Audit as Leviathan: Constructing Quality Registers in Swedish Health Care

This paper explores the rise of an audit practice: the national quality registers in Swedish health care. Based on actor‐network theory, the study tells the story of an actor‐network formed by physicians in the 1970s who mobilized themselves around a common object; to develop the knowledge‐base of medical professionals. However, over time more actors became persuaded of the potential of the network and associate themselves with it, resulting in reformed registers. The study shows how the network develops into a macro‐actor, a Leviathan in health care, how this macro‐actor comes to affect health care practices and how it contributes towards maintaining a new governance regime.     

THE IMPACT OF FUNDHOLDING ON PRIMARY HEALTH CARE: ACCOUNTS FROM SCOTTISH GPS

At the inception of the internal market in health care GP fundholding was seen rather as a 'sidesho' to the main reforms. But as the reforms have worked through, GP fundholding has emerged as pivotal to the purchaserlprovider agenda and the changes now associated with GP fundholding will be major issues in directing future health care policy initiatives. Drawing on empirical data from three Scottish regions, this paper argues that fundholding is now significant because GPs perceive benefits for primary health care. The paper uses the data collected from the case studies in the regions to assess these gains on two levels: the 'micro' impact of fundholding on primary health care processes and the 'macro' issues raised for health care policy by involving GPs more closely in resource management. Some GPs wish to use resource management as a vehicle for enhancing equity within the NHS, others are more concerned to manage resources so as to expand their practices into sites which combine primary, secondary and community health care, still others envisage developing the market to include monetary rewards for 'efficient' practices.     

美国医疗保险扩面改革之路的里程碑

虽然美国有两大类三大层次的医疗保险体系,但没有实现如其他大多数发达国家那样的全民医保,缺乏一张覆盖全国的社会医疗网络,始终是美国近10年来备受诟病的社会问题.没有医疗保险的问题始终处于社会政策争议的前沿和核心.之前克林顿总统失败的改革方案核心就是实现全民医保,15年后,奥巴马新医改方案又明确将扩大覆盖面作为其改革的重中之重.然而,历经波折得以通过的奥巴马医改法案却依然面临诸多反对和抗议,其中最为核心的是关乎强制参险的条款.2012年6月28日,美国最高法院裁定奥巴马医疗保险改革的大部分条款合乎宪法,最具争议的强制参险也得以保留,这意味着美国在实现全民医保时代的进程中向前迈出了一大步.     

Comparing the Impact of News: A Tale of Three Health Care Sectors

Abstract:   This paper examines the impact of news on the volatility of equity returns in three sectors of the health care industry – health care service providers, producers of drugs and supplies, and third‐party payors. The news impact is found to be asymmetric in that bad news (i.e., a negative shock) has a significantly greater effect on volatility than good news. Intra‐industry differences in health care equity market performance are documented and are consistent with the fundamental attributes of these sectors including the degree of price and cost pressures facing firms, the physical capital requirements of firms, the search behavior of health care customers, and the presence of alternative market opportunities.     

碎片化医保制度设计弊端与农民工医保模式路径选择

我国二元社会保障模式的构建思维一直影响我国保障制度的建设,导致我国医保制度建设呈现碎片化趋势,农民工医保制度也受这一传导机制影响。鉴于碎片化医保制度存在的诸多弊端和单独构建农民工医保模式存在的制度缺陷,农民工医保模式的路径选择应该是纳入现有保障制度框架。当前最关键和最紧迫的问题是提高现有医保制度统筹层级、解决三大医保制度接续以及加强农民工医保制度的配套建设。     

印度的医疗卫生融资改革

印度公共医疗卫生支出水平较低,且在各邦之间分布不均。中央政府拨款对于各邦政府自身医疗卫生支出具有替代性。本文认为,要推进印度医疗卫生事业改革,必须扩大公共医疗卫生支出,提高政府支出效率,并重新设计转移支付制度。     

Policy Making on Reserves of Dutch University Hospitals: A Case Study

Organizations in the health care sector are increasingly managed and judged on the basis of economic criteria. Because they are faced with growing risks, reserves need to be sufficiently high. This paper entails a case study on policy making regarding reserves in a particular segment of the Dutch health care sector, i.e. university hospitals. After describing the various major risks of health care organizations, the three stages of the case study will be presented. First, we developed, in collaboration with experts from the university hospitals, a model for establishing sufficient reserves. Second, an advisory committee of the Dutch government formulated guidelines for policy making on this issue. Finally, after the recommendations of this committee became the basis for policy making on reserves, we examined the changes in the actual reserve policy of the university hospitals. The way in which health care organizations can cope with their perceived risks by establishing sufficient reserves or by taking other actions is hardly covered in the literature on public sector or not–for–profit organizations. This paper endeavours to raise relevant questions and to suggest preliminary answers by describing and critically appraising a case study on this subject.     

United we stand,divided we fall: the failure of an accounting information system in a major radiology provider

This article explores the way in which a major Australian radiology organization implemented a complex accounting information system and how workers in the 72 radiology practices that had to use it resisted the change. The study reports on the issues that led to the circumvention of the system by individuals and, after only three years, complete withdrawal of the accounting information system by the parent organization. This article has implications for firms in the health care and other sectors considering implementing new accounting information systems. Organizations need to incorporate change management techniques and provide open communication to all stakeholders to minimize disruption and potential problems.     

The Design and Use of Management Accounting Systems in Process Oriented Health Care – An Explorative Study

Process orientation has made its entrance in Health Care Organizations (HCOs). The purpose is to improve patients’ journeys through the health care system. One factor that potentially affects process orientation is the design and use of Management Accounting Systems (MAS). In the literature there are worries that process orientation often is not supported by a well designed and used MAS but, on the contrary, is counteracted by a MAS designed for other purposes than supporting processes. This study contributes to the existing knowledge in that it shows how the introduction of process orientation within health care is accompanied by the development of horizontally oriented MAS (HMAS) which is used in different ways and by different actors. Generally, the use of HMAS for diagnostic control is limited. The main use of HMAS is for the purpose of mastering the events and interactive control, and the main users are the persons connected to the processes. The observation in earlier research that the existence of vertically oriented MAS may be a threat to process orientation is to some extent corroborated in the paper.     

论商业健康保险在新医疗保障体系中的地位

国务院新公布的《关于深化医药卫生体制改革的意见(征求意见稿)》引发了社会各界的高度关注,方案中明确提出在新的医疗保障制度构建中要积极发展商业健康保险。国际经验表明,要建立一个高效率运行和可持续发展的医疗保障体系,商业健康保险是不可或缺的重要组成部分。本文从经济学理论和医疗保障的实践结果两个角度出发,论述商业健康保险与社会医疗保险合理配合的必要性,以及商业健康保险在医疗保障体系中的优势和特殊作用,并对进一步确保我国商业健康保险发展提出相应的政策建议。     

经合组织国家医疗融资结构的收敛：经验与启示

摘要：医疗融资是医疗体制中的一个重要组成部分,具有募集资金、分担与降低风险、购买医疗服务等功能。文章基于17个OECD国家1972—2010年间的医疗融资数据,采用公共融资占医疗总融资的比例和人均公共融资作为收敛检验指标,利用盯收敛和p收敛两种判定收敛的方法,结果显示,总样本中这两项指标均发生了收敛现象,收敛的程度随医疗体制类型和时间段的不同而不同,且并非总是单调的。文章的结论虽只是初步的,但深入研究医疗融资结构收敛及其成因和效果,必将对我国医疗体制改革尤其是医疗融资政策设计具有重要意义。     

MEASUREMENT AND HEALTH CARE MANAGEMENT

Over recent decades many health care organisations have 'modernised' their management accounting systems by using the balanced scorecard (BSC). However, public health care involves multi-dimensional goals and resolving conflicts of interest. The question is whether a management control system based on measurements is suitable in a health care context. Light can be shed on this question using a study of the application of a BSC over a ten-year period at Högland Hospital. The study shows that the BSC and measurements of output and behaviour became a way of approaching unanswered questions about processes and quality development. Medical professionals with management responsibility, in co-operation with medical professionals responsible for different specialities, determined measures and targets and the measurements were integrated into activity processes and affected activities.     

论人人享有基本卫生保健之改革

本文通过分析"看病贵、看病难"原因而导致的阻碍人人享有初级卫生保健的主要因素,提出必须深化卫生体制改革,发展基层社区卫生服务、建立覆盖全民的基本医疗保障制度以及实行均等化的公共卫生服务和基本药物制度,以实现人人享有初级卫生保健的目标。     

A BUDGETHOLDING EXPERIMENT IN NEW ZEALAND

This paper provides a case study of a New Zealand health centre which embarked on a budgetholding (similar to UK fundholding) trial in 1992. The case study is grounded in the changes underway in the New Zealand public sector and in the management and organisation of health care. The case discusses the impact of the budgetholding trial on the practice and reflects on the future of budgetholding in New Zealand. Initial indications are that general practitioners are moving away from practice based budgetholding and are combining into Independent Practice Associations (IPAs) to facilitate contract negotiations and to provide additional leverage in dealing with secondary care providers.     

城乡居民医保逆选择的破解——一个基于不同人口年龄需求的设计

逆选择困扰了我国城乡居民医保事业的可持续发展.在原有的大病和重病保障之外,基于不同人口年龄需求设计一个有条件、有限度和有年龄差别的特殊医保待遇方案,让参保者在没有享受到大病重病医保待遇的情况下,也可获得一些与年龄相称的医保待遇.这一设计除了能增加参保的弹性,让各年龄群体都自愿积极参保,还可增强居民的健康意识,提高居民的健康水平,减少居民和医保的医药开支.此外,它还能促进基层医疗服务业的发展.     

我国省际公共卫生与基本医疗服务供给状况评估

公共卫生与基本医疗作为一项保障和促进公众健康的社会公益事业,与公众的基本生命安全息息相关,是我国基本公共服务的重要内容.本文运用层次分析法,构建出公共卫生与基本医疗供给状况评估的指标体系,并对2009年我国31个省区市的供给状况进行综合评价.结果表明,我国的公共卫生与基本医疗供给状况与地区经济发展水平无严格的正相关关系,但存在一定联系,且省际间差异明显,供给状况较不平衡.未来工作重点在西部省份及个别东中部省份的状况改善.     

Integrating Management Control and Human Resource Management in Public Health Care: Swedish Case Study Evidence

The debate on management reforms in the public health care sector has largely overlooked the role of human resource management (HRM) and its potential interaction with traditional management control (MC) mechanisms. This paper explores which factors associated with the integration between MC and HRM may foster organisational learning in a public health care setting. A case study in a public dental practice is used for examining this issue. Apart from highlighting the influence of various task characteristics, the case study suggests that the vertical as well as horizontal dimensions of integration are important to consider in this context. Implications for further research are discussed.     

Opting Out of Public Insurance: Is It Socially Acceptable?

The privatization of social services is being increasingly discussed. The market of social services is often characterized by market failures, like informational asymmetries, externalities, distributional problems, which all justify public intervention. But the quality of services provided by public authorities or by private insurers in the context of health insurance is different and could be observable. The public reimbursement of health care is often conditional on rules, like the choice of the physician or the hospital, that induce a disutility of using social insurance instead of private insurance. An alternative solution to a complete privatization is to allow some individuals to opt out. We can imagine that the government allows and even in some cases favors part of the population leaving the public health insurance system. We analyze the situations where the opting out is welfare improving. We then study the optimal policy depending on the characteristics of the economy considering a Rawlsian criterion.     

全民健保战略目标下的医疗救助理念研究——浙江省新型社会救助体系的启示

在全民健保的战略目标下,医疗救助的地位被弱化,只是对因病致贫人员和特殊群体实行的临时性救助。然而,以缴费型保险为主的医疗保障体系不能从根本上解决贫困人口的医疗费用问题。因此,从目前过渡到全民健保阶段,医疗救助的地位不应该被削弱。目前我国医疗救助的理念定位不清,没有充分化解贫困人口的疾病风险。本文以全民健保的战略目标和医改为背景,对基本风险、最低需求、政府责任这几个基本概念加以界定;并从医疗救助化解的社会风险出发,分析全民健保战略目标下仍需医疗救助处理的基本风险;再以浙江省分层分类的覆盖城乡的新型社会救助体系为例,阐述医疗救助理念定位需要重点解决的两个关键问题,反思医疗救助与社会医疗保险的关系和医疗救助水平,促进公平和效率。