Concordat or contract

The New Labour Government in England is seeking to promote public/private partnerships in health and social care as a key component of its political project. This article reports the findings from the first phase of an ongoing qualitative research study exploring the relationship between a private sector company and their public sector partners at four study sites. These findings indicate that organizations within the NHS do not view the development of public/private partnerships as a priority and furthermore currently have a limited ability to engage in strategic planning with the private sector. The findings are explored in the broader context of the evolution of ‘managed competition’ in health care systems and the role of partnership in that process.     

The spirit of management reforms

Abstract

The article reports on a comparative case study of the administrative cultures of the Australian (Queensland) and the Hungarian governmental administration. The basic finding of the study is that the culture profiles of the two administrative (sub-)systems are surprisingly similar. This finding is used to conclude that the organizational level of administrative culture is unlikely to play a significant role in shaping New Public Management (NPM) reforms. Moreover, this conclusion sheds a cloud of doubt onto the claim frequently found in NPM literature that NPM reforms involve a replacement of ‘outmoded, bureaucratic thinking’ with a ‘culture of efficiency and entrepreneurship’.     

Strategies for materiel management executives

With a more centralist political philosophy emulating on Capital Hill, this article focuses on potential effects on materiel management executives of a half-competitive (managed care) and a half-regulatory (Medicare and Medicaid) environment in organizing and financing health services. It predicts a far more contentious field; further cutbacks in nonpatient care personnel, including senior positions for material management executives; the centralization of tertiary services; and the possibility of additional regulatory approaches to protect the public.     

The income redistribution effects of Medicaid: Application in New York State

The efficacy of Medicaid as an income redistribution mechanism among New York State counties was examined to determine tthe degree of income shifting from higher to lower income counties. A sample of 21 counties, grouped into four discrete income classes according to 1970 per capita income was taken.Costs and expenditures (attributed to Medicaid) were allocated over all counties, adjusting for federal and state aid transfers. The data were tabulated for each of the 21 counties and six key ratios (including: Medicaid expenditures per authorized recipient, etc.) were developed as measures of income distribution.The impact of Medicaid was tested using two independent statistical techniques, goodness of fit and pooled comparisons between each pair of means for each ratio. Results indicated that no appreciable shift in income from high to low counties existed. Medicaid failed 45 of 72 mean difference tests, and the true distribution of costs and expenditures across income classes did not differ significantly from a uniform distribution in 77.7% of the cases.The results indicate that the mandated funding structure of Medicaid impinges more severely on poorer counties. Lack of an adequate health care infra-structure may seriously limit the ability of lower income counties to provide care even with Medicaid covering a large share of medical costs.     

Gender and voice in aged care: embeddedness and institutional forces

Abstract

Little is known about the role of gender in employee voice which is a particular research gap in feminised industries such as residential aged care. This article employs a multiple case study method to examine employee voice in residential aged care in New Zealand. It investigates the role of ‘embedded’ voice mechanisms, with a focus on informal voice and managerial agency as well as the impact of the external environment on organisational voice. This article questions the role of voice in maintaining low wages in residential aged care; and what role gender has in the embeddedness of voice. It finds that managerial agency is important at an organisational level, but that gender regimes influence institutional forces that have a greater influence on employee voice.     

The determinants of nursing home costs in Nebraska's proprietary nursing homes.

In the past few years nursing home care expenditures in Nebraska and the U.S. have been the fastest growing component of total health care expenditures. This rate of increase is particularly alarming in view of the fact that nursing home care is financed primarily by the Medicaid program or direct out-of-pocket payments. In fact, given the cutbacks in federal and state funds for this program, consumers will be forced to allocate a larger share of their income to meet the costs of nursing home care. Although nursing home expenditures have grown at an extremely rapid rate, relatively few empirical studies exist which analyze the cost function of nursing home providers. The purpose of this study is to identify factors which have directly influenced the cost of nursing home care in Nebraska and to evaluate the current Nebraska Medicaid reimbursement system in terms of its impact upon nursing home costs. The study was limited to a sample of 40 nursing homes in Nebraska which represents 42% of the total proprietary nursing homes in the state. The sample was limited to those facilities licensed only as an Intermediate Care Facility--I and they had to be receiving some Medicaid revenue. The data were averaged over the period of 1977-79, but the year of analysis corresponded to 1978. Multiple regression analysis was used to measure the effect of the hypothesized independent variables upon two different measures of cost--the average total cost per patient day and the average variable cost per patient day. In the first regression model 76% of the variance was explained and 71% was explained in the second equation. The results of this analysis are basically consistent with the findings of other studies and indicate that the number of staffing hours, patient mix, facility age, administrator experience and administrative intensity are significant determinants of nursing home costs. The most important finding from a policy perspective is that the current retrospective cost-related Medicaid reimbursement system does not provide incentives for minimizing costs. In fact, the present system encourages administrators to overutilize resources and charge higher prices. Considerable evidence exists which suggests that a prospective system would encourage a more efficient allocation of resources without adversely affecting the quality of care. Given the increase in the state's share of the total Medicaid budget, it would appear that a change to a prospective system is critical in order to maintain the financial accessibility to nursing home care by all Nebraska residents.     

Indigenous Peoples’ Health Care: New approaches to contracting and accountability at the public administration frontier

Abstract

This article analyses reforms to contracting and accountability for indigenous primary health care organizations in Canada, New Zealand, and Australia. The reforms are presented as comparative case studies, the common reform features identified and their implications analysed.

The reforms share important characteristics. Each proceeds from implicit recognition that indigenous organizations are ‘co-principals’ rather than simply agents in their relationship with government funders and regulators. There is a common tendency towards more relational forms of contracting; and tentative attempts to reconceptualize accountability. These ‘frontier’ cases have broad implications for social service contracting.     

Lean Production and Beyond: the System,Its Critics and the Future

Peter Wickens, who is Director of Personnel and Information Systems of the Nissan Motor Manufacturing (UK) Ltd, puts ‘lean production’ in its historical context, examines some of the criticisms of the system and considers some of the changes taking place in Japan. He goes on to suggest possible ways forward and makes the case for a system of ‘lean production’ managed by people who care about people.     

Network Incentives in Managed Health Care

This paper introduces a theory of network incentives in managed health care. Participation in the plan's network confers an economic benefit on providers; in exchange, the plan expects compliance with its protocols. The network sets a target for the number of outpatient visits in an episode of care. A provider failing to satisfy the target may be penalized by the plan's attempt to direct patients to other providers within its network. There is an equilibrium in which every provider in the network uses the target. We test the theory by observing behavior of providers before and after the introduction of managed mental health care in a large, employed population. Managed care consisted of price reductions, utilization review, and creation of a network. Quantity per episode of care fell sharply after initiation of managed care. We identify a network effect in our empirical work. The results indicate that in this case, network incentives account for most of the quantity reduction due to managed care.     

Managed Care Incentives and Inpatient Complications

Managed care organizations control costs through restrictions on patient access to specialized services, oversight of treatment protocols, and financial incentives for providers. We investigate possible effects of such practices on the care patients receive by studying frequencies of in-hospital complications. We find significant differences in complication rates between managed care and fee-for-service patients. We investigate the sources of this variation by comparing probabilities of complications among patients with different types of managed care coverage and patients treated in different hospitals. For several patient categories, the differences in outcomes we find appear to arise not from differential treatment of patients within hospitals or from heterogeneity in patients, but from variations in care across hospitals that tend to treat patients with different insurance types.     

Service Quality,Administrative Process,and Citizens’ Evaluation of Local Government in the US

Abstract

It is often assumed that citizens evaluate government based on service quality or outcomes (such as safe neighbourhoods or good schools), but aspects of administrative process (such as fairness and respect) are also important. Using data from two US surveys, this study examines how service quality and administrative process influence citizens’ evaluations of government. Results indicate that service quality matters most to ratings of the community; in contrast, administrative process is the dominant driver of trust; and both quality and process have large effects on judgements about government’s overall job performance. Implications for public management research and practice are discussed.     

Multiple Institutional Logics in Health Care: ‘Productive Ward: Releasing Time to Care’

Health care organizations are often confronted with multiple institutional logics. In this study, a longitudinal case study method was used to gain insights into the adoption decision-making and implementation process of an apparently hybrid innovative practice when multiple logics are present. The case study focuses on the adoption and implementation of ‘Productive Ward: Releasing Time to Care’ in a Dutch hospital. This is a quality improvement programme developed by the National Health Service (NHS) in the United Kingdom. The results show that institutional logics complicate the adoption and implementation process.     

A health maintenance organization design for long term care under medicaid

The rapid increase in public expenditures for long term care under Medicaid is discussed. The major cause of this increase is identified as the high and often excessive utilization of nursing home care. Health maintenance organizations (HMOs) are considered in terms of their ability to reduce health care costs by curbing unnecessary hospitalization. The HMO structure is extended to long term care, where it is argued that unnecessary nursing home care can be reduced. A health maintenance organization targeted to the Medicaid long term care population is proposed and a detail flow analysis of the HMO is presented.     

A cost-benefit analysis of prior approvals for Medicaid services in New York state.

This study investigates the costs and benefits of a prior approval mechanism instituted by the New York State Health Department to review the need for the provision of selected types of costly health care and services. The review is made prior to the provision of the service and Medicaid payment for the service is contingent upon the result of the review. Costs include program administration and form processing. Benefits include the value of services which are either denied or modified as a result of the prior approval process. The analysis indicates that three of the seven prior approval categories are cost-beneficial without regard to deterrence benefits. For the other four categories, the results of this study have been used to propose new policies.     

Combining work and informal care: the importance of caring organisations

Population ageing and rising costs of long‐term care mean that organisations will be confronted in the future with a growing number of employees who combine paid work with providing informal care to a relative or non‐kin. Combining work and informal care successfully partly depends on job and care‐related features, but more information is needed on the importance of organisational aspects in this regard. The impact of organisational support on work outcomes (work–care balance and perceived need for job adaptations) was studied among 1,991 employed informal caregivers in 50 different organisations. Multilevel logistic regression analyses revealed that a heavy care burden decreased the odds of combining work and care successfully. Caregivers who felt supported by colleagues and supervisors, and who worked in supportive organisations had higher odds of good work outcomes. The findings imply that organisations should be explicit about their concern for informal caregivers and be particularly aware of colleagues with heavy care responsibilities.     

Balancing Multiple Competing Objectives with a Balanced Scorecard

This paper investigates how multiple and competing objectives are managed within an organisation, and the role that the Balanced Scorecard (BSC) plays in balancing organisational objectives. The issue of achieving multiple objectives, those which represent the interests of various stakeholders, has come to the forefront of the corporate agenda, as companies are seen increasingly as more than a source of profit for shareholders, but rather as ‘citizens’ playing a broader role in society. This study adopts an exploratory case study approach to understand how the BSC is used in management decision and control processes to assist with the balancing of objectives. The case organisation is a state-owned electricity company, and provides a unique setting where multiple and equally important strategic objectives exist. The results demonstrate that the BSC has the potential to help in making trade-offs and balancing objectives, but there are certain requirements for this to succeed. The paper provides insights into issues of balanced strategic management, as it discusses ‘balance’ in terms of both process and outcomes.     

Why People Co-Produce: Analysing citizens’ perceptions on co-planning engagement in health care services

Abstract

The aim of this article is to comprehend the motivation of citizens to co-produce. More specifically, it considers citizens’ motivations to engage in co-planning activities of health care services. The article brings together theoretical insights and empirical data. First, we integrate insights from different strands of literature. We combine literature on citizen participation, political efficacy, co-production, volunteerism, public service motivation, and customer engagement to offer a first understanding of citizens’ motivations to actively engage as co-producers of public services. Next, empirical data are derived from one specific case: citizens participating in client councils in health care organizations. Q-methodology, a method designed to systematically study persons’ viewpoints, is used to distinguish different perspectives citizen have on their engagement in co-production. Our analysis of citizens’ motivations to engage in client councils enables us to identify four types of citizen co-producers, which we label: the semi-professional, the socializer, the network professional, and the aware co-producer. Implications for future research studying citizens’ motivations in a broader range of co-production cases are discussed.     

Getting to go in managed care

The challenge for leadership and the required changes are great. Our personal limitations include a limited view of the world and the threat of an overwhelming risk if one gets too far out on the limb. "Getting to go" will open up new and strange territories that will provide opportunity and failure for leaders. Capable leaders will pursue the opportunity. Threatened leaders will resist the change. For those leaders who feel that the managed care existing today provides the most cost-effective, quality outcome for the individual, his or her sponsor in the community, they will go no further. Unfortunately for many of us, managed care means a third party trying to micromanage patients (deductions, authorizations, and so on), employers (claims, incentives, and so forth), and providers (approvals, forums, payment, tricks, and the like). Providers need to go ahead and master efficient care. We owe that to the community and the third party nightmare of administrative overkill must be laid to rest. For those healthcare leaders who believe that managed care as a system focused on improving the health status of our communities is superior to our existing system, their individual goals and leadership focus must be changed accordingly. We cannot sit by idly and wait for the system to change us. Instead our obligation is to lead our organizations toward a new era in health care.     

Impact of the Affordable Care Act on diabetes diagnoses in the United States: A county‐level analysis

Our research examines whether there is a causal effect between expanding health insurance and diabetes incidence. Comprehensive county‐level data from the United States is used to study the effect of Medicaid expansion on diabetes rates. The analysis is based on cross‐county variation according to Affordable Care Act health care reforms, along with county share‐eligibility variation. Difference‐in‐difference and triple‐difference statistical regression specifications are employed to control for confounding variables. The results suggest a slight negative relationship between expanding health insurance and diabetes diagnoses.     

The rise of the ‘network organisation’ and the decline of discretion

This article explores the implications of ‘networked’ and ‘flexible’ organisations for the work and skills of professionals/ Drawing on material from four different case studies, it reviews work that is outsourced (involving IT professionals and housing benefit caseworkers), work that is done by teachers contracted to a temporary employment agency and work organised through an inter‐firm network (chemical production workers). In each case work that was outsourced was managed very differently to that undertaken in‐house, with managerial monitoring replacing and reducing employees' discretion. New staff in these networks had fewer skills when hired and were given access to a narrower range of skills than their predecessors. By contrast, the production staff directly employed on permanent contracts in the inter‐firm network were given (and took) significant amounts of responsibility, with positive results for both their skills and the work processed. Yet, despite the negative impact they have on skills, outsourcing and subcontracting are a far more common means of securing flexibility than organisational collaboration.