Managed care, quality of care, and patient rights

The growth of managed care has been accompanied by calls for increased government regulation because HMOs and other forms of managed care are seen by the public as more concerned about controlling costs than with protecting the rights of patients to quality care. This paper applies a theory of health care rights and clinical evidence of managed care quality in an analysis of public opinion about managed care. The paper concludes that there is no persuasive evidence that managed care has resulted in a general deterioration in the quality of care and that, with one exception, restrictions imposed by managed care plans are consistent with a theory of health care rights. The paper concludes with the recommendation that public policy should dispense with attempts to fine tune managed care and address an unquestionable violation of health care rights, the failure to guarantee a minimum standard of care to some 43 million Americans.     

On the Transaction Cost Determinants of Vertical Integration

The transaction cost approach to the organization of firms hasbeen among the most significant advances in industrial organizationin the last 25 years. Much of this work has taken the transactioncost economics view of Williamson (1975, 1979, 1985) and Klein,Crawford, and Alchian (1978) in which high levels of quasi-rentsare taken to increase the likelihood of vertical integration.More recently, however, the more formal property rights theoryof Grossman and Hart (1986) and Hart and Moore (1990) has receivedconsiderable attention as a theory of integration. This articleexplores the predictions of property rights theory to assesswhat the extensive supporting evidence on transaction cost economicstells us about the property rights theory's empirical relevance.The article concludes that this evidence sheds little lighton the relevance of the property rights theory and discusseshow we might try to learn more.     

Does contracting out increase the efficiency of government programs? Evidence from Medicaid HMOs

State governments contract with health maintenance organizations (HMOs) to coordinate medical care for nearly 20 million Medicaid recipients. Identifying the causal effect of HMO enrollment on government spending and health care quality is difficult if, as is often the case, recipients have the option to enroll in a plan. To estimate the average effect of HMO enrollment, this paper exploits county-level mandates introduced during the last several years in the state of California that required most Medicaid recipients to enroll in a managed care plan. The empirical results demonstrate that the resulting switch from fee-for-service to managed care was associated with a substantial increase in government spending but no corresponding improvement in infant health outcomes. The findings cast doubt on the hypothesis that HMO contracting has reduced the strain on government budgets.     

管理医疗模式的影响差异——来自加州医疗救助的经验证据

国际上越来越多的健康保险(医疗保险)采用了管理医疗的方式,目的在于保证健康服务质量并节约成本。尽管该方式在控制成本方面的效果有目共睹,但对于其保证健康服务质量方面的评价则颇为困难。本文使用独特的大样本数据,利用美国加利福尼亚州医疗救助项目(美国最大的公共健康保险之一)从传统按次偿付方式到多种管理医疗模式的转变,来识别不同管理医疗模式对健康服务的使用及服务质量的影响。这对于我国公共健康保险制度(如新型农村合作医疗)的探讨具有一定的借鉴意义。     

Female political representation and substantive effects on policies: A literature review

The share of women in political offices has increased considerably over the past few decades in almost every country in the world. Does this matter for policy outcomes? This is the first paper to provide a literature review on the substantive effects of female representation on policies. In developing countries, the increase in female political representation has caused a better provision of public goods, especially with regard to education and health. In developed countries, higher female representation has not affected public policies as measured by spending patterns. However, more recent evidence shows that female representation has induced changes in parliamentary deliberations and specific policy choices (e.g. more public child care) that may not be reflected in the observable composition of public spending. Finally, higher female representation has improved institutional quality by reducing corruption and rent-extraction by those in power.     

Economics,Ethics and Thanatology: Lessons from the Ancients

The normative presuppositions motivating rational choice decision-making based on optimizing objectives amount to a thin account of ethical economic behavior. Ancient thought offers insights that can provide a firmer basis both for personal, individual choice as well as for public policy. After a brief review of Epicurean and Stoic ethical principles, a comparison is made of modern economic and Hellenistic conceptions of rationality and rational behavior. These competing conceptions are then applied to an examination of a contemporary public policy problem, namely health care, particularly as this applies to “end-of-life” issues. The argument concludes that decision-making based on a eudaimonic conception of the good has the potential to provide us with a more efficient health care system as well as one that more satisfactorily addresses the needs of the chronically ill and dying patients who account for a highly disproportionate share of health care expenditures.     

Stern measures

Andy Stern, new head of the Service Employees International Union, has set his sights on the nation's health care industry, linking workers' rights with consumer protection. The union's strategy is on display in California, where managed care has made dramatic inroads and financially pinched hospitals are shedding workers.     

Ambulatory care registered nurse performance measurement

On March 1-2, 2010, a state-of-the-science invitational conference titled "Ambulatory Care Registered Nurse Performance Measurement" was held to focus on measuring quality at the RN provider level in ambulatory care. The conference was devoted to ambulatory care RN performance measurement and quality of health care. The specific emphasis was on formulating a research agenda and developing a strategy to study the testable components of the RN role related to care coordination and care transitions, improving patient outcomes, decreasing health care costs, and promoting sustainable system change. The objectives were achieved through presentations and discussion among expert inter-professional participants from nursing, public health, managed care, research, practice, and policy. Conference speakers identified priority areas for a unified practice, policy, and research agenda. Crucial elements of the strategic dialogue focused on issues and implications for nursing and inter-professional practice, quality, and pay-for-performance.     

Focus on quality assessment: the need for evaluation

There is growing concern among purchasers and consumers of health care as well as among regulators that managed care has meant that quality has been sacrificed in the name of cost saving. Employers, as major purchasers, should demand that the managed care organizations they utilize demonstrate high-quality/low-cost care.     

Why managed care has gone too far

Managed care has not solved employers' problems with rising health care costs; instead, it has created another set of problems, this author maintains. She suggests steps that employers can take to enhance the quality of health care for their employees and prevent further damage from the excesses of managed care.     

The effectiveness of government spending on education and health care in developing and transition economies

Recent studies show that corruption is associated with higher military spending [Eur. J. Polit. Econ. 17 (2001) 794] and lower government spending on education and health care [J. Publ. Econ. 69 (1998) 263]. This suggests that policies aimed at reducing corruption may lead to changes in the composition of government outlays toward more productive spending. However, little empirical evidence has been presented to support the claim that public spending improves education and health indicators in developing and transition countries. This paper uses cross-sectional data for 50 such countries to show that increased public expenditure on education and health care is associated with improvements in both access to and attainment in schools, and reduces mortality rates for infants and children. The education regressions are robust to different specifications, but the relationship between health care spending and mortality rates is weaker.     

GRAZING ON PUBLIC RANGELANDS: AN EVOLVING PROBLEM OF PROPERTY RIGHTS

Competition for publicly owned natural resources may be intensified when property rights are incomplete. Incomplete delineation of these rights among claimants to the various resource attributes of the public rangelands of the western United States has resulted in high transaction costs for capturing and/or protecting unassigned rights. This paper addresses how changes in the values society places on the public land resources have resulted in changes in the relative positions of various interest groups with respect to resource allocation decisions. The paper concludes by discussing implications of the property right approach for land management policies and grazing fees.     

社会医疗保障改革的福利效应:以中国城镇为例

This paper evaluates Chinese public health insurance reform enforced since 1998 in terms of its welfare effects. We evaluate China health insurance reform since 1998 using the China Health and Nutrition Surveys (CHNS) data with relevant econometric models. The results of empirical studies show that the public health insurance status has significant impact on medical service utilization and expenditure. The reform reduces the positive effect of public health insurance on medical service utilization, meaning the utilization gap is narrowed after the reform. However, the empirical studies find that the medical expenditure growth of the sample individuals in urban China has not been controlled after the Basic Medical Insurance (BMI) program even if a new co-payment is enforced. Two main reasons for this failure might be the rising cost of medical service and physician’s severe moral hazard, while both of them come from no managed care mechanism for medical service providers in China.      

公立医院公益性问题研究

近年来,公众之所以会对"公立医院是否具有公益性"产生疑问,是源于社会上对"公立医院收费使它们丧失了公益性"的批评,而这种批评又混淆了公立医院提供医疗服务应不应当收费和医疗费用最终应当由谁支付这两个不同的问题。因此,文章在综合各种公益性概念并对公益性给出一个确切定义的基础上,分别梳理了目前国际上医疗费用筹措与医疗服务提供的几种主要方式,分析各自的优缺点,指出了增加公共医疗支付的必要性。文章最后提出,目前我国一些城市试行的"按病种付费"的体制,可望根据实际情况进行改进以后在更大的范围内推广。     

Distress financing of out‐of‐pocket health expenditure in India

In the absence of a universal health insurance mechanism, the increasing burden of out‐of‐pocket (OOP) health expenditure has become a growing concern in India. To cope with the cost of illness, people use either their savings and income, or they have to rely upon distress means of finance such as depletion of household assets, borrowings from banks and moneylenders, and contributions from family and friends. This paper analyses the changes that have taken place in the incidence and covariates of distress financing in India by using data from National Sample Survey Organisation for the years 2004 and 2014. Results indicate that during this period the incidence of distress sources as a means to finance OOP health expenditure has hovered around 50%. Further, the results reveal a significant socioeconomic gradient in the incidence of distress financing. Socioeconomic and health‐related covariates significantly impact the likelihood of distress financing as a means to cope with OOP health expenditure. The results indicate the need for government action to formulate a comprehensive plan through an increase in public spending on health care that will improve the quantity and quality of the public health‐care system and enhance the scope of health insurance in India.     

The comparative advantage of public ownership: evidence from U.S. electric utilities

Abstract.  Studies of the performance effects of public vs private ownership have found mixed evidence. This paper draws on theory suggesting that public enterprise may have an advantage in producing goods and services whose quality attributes are difficult to specify a priori. Using a comprehensive data set of U.S. electric utilities to estimate cost functions, we find that while privately owned systems achieve lower costs in generation, public systems generally have an advantage in the end‐user‐oriented distribution function with its more non‐contractible quality attributes. Other evidence on quality differences by ownership type and by enterprise size supports this distinction. JEL classification: L33, L94     

The importance of measuring patient satisfaction

Managed care has demonstrated its ability to contain costs. Its emergence as a dominant factor in the health care marketplace has raised concerns about measuring health care quality. As the field of quality assurance is evolving, it is becoming clearer that patient satisfaction surveys should be an integral component of assessing care.     

URBANIZATION AND HEALTH CARE IN RURAL CHINA

Strong economic growth has led to remarkable urbanization in China. Using the China Health and Nutrition Survey, this study provides the first empirical evidence documenting the impact of urbanization on rural health care and insurance. The primary finding is that urbanization leads to a significant and equitable increase in insurance coverage, which in turn plays a critical role in access to care. In addition, adverse selection exists in the demand for insurance. Income is also a significant determinant of insurance coverage. This study concludes that urbanization can help make substantial changes in rural health care and insurance status.     

The political economy of public education

I study the relationship between income inequality and public spending in education in a voting model. Voters collectively choose the uniform quality level of public education, the amount of a public good, and the tax rate on labor income. Parents can decide to opt-out of the public education system by purchasing private education at the desired quality level, and children’s expected income is assumed to be increasing in the quality of education. I show that higher income inequality is associated with higher governmental spending in education if and only if the expected marginal returns to education are larger for the children of relatively low income parents. In turn, better public education tends to reduce future inequality. These results are consistent with most findings in the empirical literature about public investment in education. Lastly, I show that for other kind of publicly provided goods, such as health care, the relationship with income inequality exhibits an ambiguous or opposite sign.