Health and the welfare of U.S. business

Business leaders continue to blame the skyrocketing cost of health care for jeopardizing the global competitiveness of U.S. industries, and they continue to turn to Washington for the solution. Yet after a study of 16 countries, Wharton researchers David Brailer and R. Lawrence Van Horn have discovered that health care costs do not directly hinder U.S. competitiveness. Their conclusion: there is indeed a health care crisis in the United States as well as a competitiveness crisis. But the two are unrelated, and confusing them makes it difficult to solve either one. The real problem, according to the authors, is the hands-off approach that employers typically adopt when it comes to health care. No matter how Washington responds to the health care crisis, employers must explore their own role in ensuring the health of their work force. And they must realize that their role can be a strategic one. Instead of containing costs by fine-tuning benefits packages, companies can control costs and improve health care delivery by treating health care like any other crucial component of production. Brailer and Van Horn propose three strategies for managing health care delivery: First, companies must intervene in the supply side of the health care market. This may mean creating a clinic alone or with other companies, or joining with other companies to procure health care. Second, companies need to translate corporate health benefits into the most cost-effective set of services at the local level. Finally, companies must encourage and educate employees to participate in decisions regarding health care delivery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Community health care in developing countries

Health care systems in many developing countries have shared characteristics. Government expenditures in poor countries are low for health care. The majority of people cannot easily reach a modern health facility. Most spending is for high-cost curative medicine, e.g., hospitals. Programs are often inefficient in their use of funds. The tragedy of disease in developing countreis is that many of the most serious problems are either preventable or curable by simple, inexpensive, safe methods. About 16 million children under age 5 died in 1979 in developing countries; 5 million of these deaths could have been prevented by immunization against measles, polio, tetanus, diphtheria, whooping cough, and typhoid. Many countries are establishing community-level health care facilities that use community health workers instead of doctors. A 3-tiered program is being adopted in some areas: the community health center, the rural or urban polyclinic, and the referral hospital. The community health center seeks to provide two-thirds of the needed services, including supervision of pregnancy, midwifery, care of new-born children, treatment of endemic diseases, and emergency care for injuries. Early experience has taught that it is more important for the community health worker to have practical experience and the respect of the people he serves than formal education. Improvements in nutrition, hygiene, and sanitation are needed to reach the full health potential of most communities.     

Hospital cost control: a bitter pill to swallow.

Americans delude themselves if they think that the rising tide of medical costs can be stemmed for long without sacrificing some beneficial care. Elimination of waste from the medical system can achieve large savings. But these savings cannot offset for more than a few years the cost-increasing effects of new medical technology and an aging population. Comparing the American experience with the rationing of health care in Britain, these authors conclude that though the differences are substantial between the two countries, the United States may well need to apply similar constraints, and that Americans will no longer be willing to support a system of unlimited medical care.     

The future of health futures : Another perspective

A good ‘market’ for health futures and easy access to relevant information are among the reasons that health futures is currently centred in the wealthy nations. Interest in health futures is growing in the less developed countries, however, in part because of efforts by WHO and its regional office. Many benefits can be expected if the field becomes more international, including an influx of fresh ideas about health futures study designs and about innovative approaches to health care. A shift to a more global orientation is also imperative simply because health futures deals with the well-being of human beings, and most human beings live in the less developed countries of the world.     

Household portfolio choices,health status and health care systems: A cross-country analysis based on SHARE

Health risk is increasingly viewed as an important form of background risk that affects household portfolio decisions. However, its role might be mediated by the presence of a protective full-coverage national health service that could reduce households’ probability of incurring current and future out-of-pocket medical expenditures. We use SHARE data to study the influence of current health status and future health risk on the decision to hold risky assets, across ten European countries with different health systems, each offering a different degree of protection against out-of-pocket medical expenditures. We find robust empirical evidence that perceived health status matters more than objective health status and, consistent with the theory of background risk, health risk affects portfolio choices only in countries with less protective health care systems. Furthermore, portfolio decisions consistent with background risk models are observed only with respect to middle-aged and highly-educated investors.     

Health insurance and its impact on the survival rates of breast cancer patients in Synthea

The goal of this project was to build policy modules in a synthetic health system to analyze how healthcare policy impacts breast cancer survival rates. To do any inference regarding healthcare policy, researchers need secure and protected health data, which are restricted by privacy laws and interoperability issues. Synthetic health systems generate and help investigate health data without concerns of violating legal restrictions (HIPAA). In this research, we programmed health insurance and loss‐of‐care modules into a synthetic health system simulator (Synthea) to simulate and analyze the impact of health insurance on breast cancer survival rates. Our goal was for our health insurance and loss‐of‐care implementations to be realistic and reflective of the real world, in which we were successful.     

Health care reform: universal access is feasible and necessary

While other industrial nations' health care systems have their own problems, they have more leeway to address those problems than does the United States, which spends twice as much on per capita health care as the average for other industrial capitalist democracies yet ranks average or below average in many comparative measures of health care quality. In fact, the authors of this article argue that international experience shows that assurance of universal access through expanded government involvement could provide savings while actually improving the quality of U.S. health care. In addition, universal access would recognize health care as a basic human right, not a commodity to be bartered in the marketplace and allocated based on class, race and social position.     

The Equity Market Risk Premium and the Valuation of Overseas Investments

There is little agreement among academics or practitioners about how to measure the size of the equity market risk premium, particularly when it relates to investments in emerging markets. Using monthly equity returns for 22 developed and 24 emerging markets covering the period 1976–2006, the authors find that developed capital markets have experienced significant increases in their degree of integration with the U.S. and world market indexes, while emerging markets remain at least partly segmented from those of the U.S. and the world. For countries that are reasonably well integrated into global capital markets, the authors suggest using the U.S.—based equity market risk premium. But when valuing investments in emerging markets, they recommend use of the Capital Asset Pricing Model adjusted for political risk and a measure of co‐movement between the foreign and U.S. stock markets. The authors also remind readers that the equity market risk premium is supposed to be a forward‐looking measure, and that the common practice of inferring the future from the past can be misleading, particularly in the case of rapidly developing emerging markets.     

Making medical and disability benefit plans more manageable

Good managed care health systems require two criteria for success: They must offer a set of checks and balances, and employees need to be given incentive to act in the best interest of the organization by acting in their own best interests. The authors discuss six principles that they claim are likely to reduce the complexity of making routine coverage decisions, while achieving the above two criteria.     

Pull the plug on stress

Stress is rampant, stress is growing, and stress hurts the bottom line. A 1999 study of 46,000 workers revealed that health care costs are 147% higher for those who are stressed or depressed, independent of other health issues. But what exactly is stress? It usually refers to our internal reaction to negative, threatening, or worrisome situations--a looming performance report, say, or interactions with a dismissive colleague. Accumulated over time, negative stress can depress you, burn you out, make you sick, or even kill you--because it's both an emotional and a physiological habit. Of course, many companies understand the negative impact of cumulative stress and offer programs to help employees counteract it. The problem is that employees in the greatest need of help often don't seek it. Since 1991, the authors have studied the physiological impact of stress on performance, at both the individual and organizational levels. Their goal largely has been to decode the underlying mechanics of stress. They've sought not only to understand how stress works on a person's mind, heart, and other bodily systems but also to discover the precise emotional, mental, and physiological levers that can counteract it. After working with more than 50,000 workers and managers in more than 100 organizations, the authors have found that learning to manage stress is easier than most people think. They have devised a scientifically based system of tools, techniques, and technologies that organizations can use to reduce employee stress and boost overall health and performance. In this article, they use the story of someone they call Nigel, a senior executive with whom they've worked, to describe how these techniques reduce stress in the real world.     

发达国家的农村医疗卫生制度及其对我国的启示

深化我国农村医疗卫生体制改革离不开对发达国家有益经验的借鉴。本文选取了一些有代表性的发达国家，即美国、日本和澳大利亚，对其农村医疗卫生制度进行系统考察。针对农村健康状况劣于城市的现状，美国制定出各项政策措施及立法措施，在很大程度上改善了农村医疗卫生状况，并促进了卫生公平。澳大利亚将初级卫生保健作为农村卫生发展的重要方向和目标，在保障农村居民卫生可及性和公平性等方面做出了重大努力。依托国民健康保险制度，日本针对农村地区进行积极干预和政策倾斜，达到了城乡之间医疗卫生服务的均等化。上述经验对我国农村医疗卫生体制改革具有重要的借鉴意义。     

Weak Links in the Chain II: A Prescription for Health Policy in Poor Countries

In an earlier article, the authors outline some reasons forthe disappointingly small effects of primary health care programsand identified two weak links standing between spending andincreased health care. The first was the inability to translatepublic expenditure on health care into real services due toinherent difficulties of monitoring and controlling the behaviorof public employees. The second was the "crowding out" of privatemarkets for health care, markets that exist predominantly atthe primary health care level. This article presents an approach to public policy in healththat comes directly from the literature on public economics.It identifies two characteristic market failures in health.The first is the existence of large externalities in the controlof many infectious diseases that are mostly addressed by standardpublic health interventions. The second is the widespread breakdownof insurance markets that leave people exposed to catastrophicfinancial losses. Other essential considerations in settingpriorities in health are the degree to which policies addresspoverty and inequality and the practicality of implementingpolicies given limited administrative capacities. Prioritiesbased on these criteria tend to differ substantially from thosecommonly prescribed by the international community.      

The future of therapeutics in the north

Health-care systems occupy from 6% up to 15% of developed countries' GDPs. Therapeutics, particularly hospital care, occupy the bulk of these expenditures, despite their focus on dealing with disease after it arises. In the 21st century health-care systems will focus on health gains. Therapeutics will have broadened to encompass prevention and treatment, and will be focused on each individual's unique biological, psychological and social needs. Major killers, most particularly heart disease and cancer, will be far more preventable or curable, because of changes in therapeutic paradigms to more holistic approaches as well as important biomedical breakthroughs. There are a variety of negative possibilities, including continued preeminence of the medical model, growing costs, increased inequality in access, and greater poverty and social disintegration. The movement to therapeutics more focused on health gains will be accelerated by a variety of trends, particularly the development by communities in the USA and many other countries of shared visions that guide the evolution of health care in these directions.     

Weak Links in the Chain: A Diagnosis of Health Policy in Poor Countries

Recent empirical and theoretical literature sheds light on thedisappointing experience with implementation of primary healthcare programs in developing countries. This article focuseson the evidence showing two weak links in the chain betweengovernment spending for services to improve health and actualimprovements in health status. First, institutional capacityis a vital ingredient in providing effective services. Whenthis capacity is inadequate, health spending, even on the rightservices, may lead to little actual provision of services. Second,the net effect of government health services depends on theseverity of market failures—the more severe the marketfailures, the greater the potential for government servicesto have an impact. Evidence suggests that market failures arethe least severe for relatively inexpensive curative services,which often absorb the bulk of primary health care budgets.A companion paper, available from the authors (seep. 219), offersa perspective on how government funds can best be used to improvehealth and well-being in developing countries. It gives an alternativeview of appropriate public health policy, one that focuses onmitigating the characteristic market failures of the sectorand tailoring public health activities to the government's abilityto deliver various services.      

Confronting the fear factor: the coverage/access disparity in universal health care

Since their introduction following World War II, single-payer health care systems and universally mandated health care systems have stumbled, but in their pratfalls are many lessons that apply to the universal health care proposals currently on the table in the United States. The critical and often-over-looked point is that universal coverage does not guarantee that individuals will receive needed care--In many cases guaranteed access to care is a false promise or available only on a delayed timetable. A more feasible alternative lies in providing a safety net for citizens who truly need care and financial support with an appropriate system of checks and balances--without disrupting the economic and actuarial fundamental principles of supply and demand and risk classification.     

The Impact of the International Coffee Agreement on Producing Countries

Simulations of a global coffee model incorporating a vintagecapital approach to production are run. Over the recent periodof operation of the International Coffee Agreement's exportquota system, the authors find that the quota system had a stabilizingeffect on world coffee prices. The quotas reduced real exportrevenues for most small exporting countries, but large producersgained. Most small countries gained, however, in terms of riskreduction. If a brief suspension of the quota occurs from timeto time, caused, for example, by adverse weather which resultsin a shortfall in world supply, the quota system works likea buffer stock scheme; on average, producing countries as awhole lose transfer benefits but gain risk benefits.     

Health care fraud control: understanding the challenge

The study summarized here examined the fraud-control apparatus currently used within the health care industry, and assessed the assumptions, policies, and systems that constitute the industry's current approaches to fraud control. The objective was to develop a better understanding of the strengths and weaknesses of existing approaches. Since 1992, with Health Care Reform under debate, the issue of health care fraud has received unprecedented legislative and administrative attention. Nevertheless disturbing and somewhat surprising lapses in control persist. The fraud problem shows no sign of abatement. Background knowledge of the health care fraud issue was derived from literature searches and from four years of interaction with concerned public and private organizations. Fraud control systems, policies and procedures were examined in detail at eight field sites, representing a cross section of private, not-for-profit, and public programs. The National Institute of Justice funded the study under grant number #94-IJ-CX-K004. This study finds the science of fraud control scarcely developed and little understood by industry practitioners. Academia has paid little attention to the problem. Within the health care industry, the task of fraud control is complicated by the social acceptability of insurers as targets, the invisible nature of most fraud schemes, the separation between administrative budgets and "funds", the respectability of the health care profession, and the absence of clear distinctions between criminal fraud and other forms of abuse. Existing approaches to control are more effective in controlling billing errors, overutilization, medical unorthodoxy, and other forms of abuse than in dealing with criminal fraud. The complexity of the fraud control challenge is seriously underestimated by the health care industry Existing control systems are not targeted on criminal fraud and cannot be expected to control it. Scientific measurement of the fraud problem is a prerequisite effective control.     

Prospects for account-based health plans under the Patient Protection and Affordable Care Act

Account-based health plans (ABHPs), which combine high-deductible plans with either health reimbursement arrangements (HRAs) or health savings accounts (HSAs), have gained popularity in recent years. Because there is growing evidence these plans are indeed engaging consumers and moderating cost increases, employers will need ABHP design options as they strive to bring costs under control in coming years. Some observers, however, are now concerned that benefits standards introduced by federal health care reform will undermine these plans, and many in the business community anticipate new health benefits mandates will drive up employers' total health care costs. The authors show that although the Patient Protection and Affordable Care Act (PPACA) of 2010 includes numerous provisions that will likely increase costs for employers, the law also accommodates, and may even foster, HSAs and HRAs.     

Future health of indigenous peoples A human ecology view and the case of the Amazonian Shipibo-Conibo

Health has its basis in the relationships between human societies and cultures and the environment. The health of indigenous peoples living in traditional territories is threatened today by the destruction of this environment and the introduction of new contagious diseases; those who move to urban areas suffer even worse health because of ‘civilization’ diseases and the loss of the social networks that provide personal support and health care. Contrary to expectations, an epidemiological transition has not occurred in developing countries where many of these groups live. Two apparent underlying causes—persistent poverty and political inequality—are among the factors that will affect the future health of indigenous groups, together with trends in population, urbanization, and the environment. Indigenous groups can play a major role in determining that future and are already doing so through territorial-control projects aimed at protecting the environment on which their health and well-being depend.     

Health systems futures: The challenges of technology,prevention and insurance

This article argues that the futures of health systems depend on how countries address three wider challenges that include: (a) the adoption of health innovations and quality improvements, (b) responses to new non-communicable and preventable global diseases, as well as (c) adjusting financial models to current insurance constraints. Future trends point towards an increasing dependence on productive quality improvements, the personalisation of health care and the organisation of delivery and finance to take advantage of existing knowledge. Prevention, and disease avoidance, particularly that of non-communicable diseases, will aim to reduce pressure on “care components” of the health system whilst global control of communicable risks will become apparent. Finally, trends suggest an increase in patient participation and personalisation of insurance contracts will help to realign risk sharing with cost containment and financial sustainability. Other potential challenges such as ageing are regarded as second order issues to be addressed through these aforementioned future trends.