Making competition in health care work

Health care reform in the United States is on a collision course with economic reality. Most proposals focus on measures that will produce one-time cost savings by eliminating waste and inefficiency. But the right question to ask is how to achieve dramatic and sustained cost reductions over time. What will it take to foster entirely new approaches to disease prevention and treatment, whole new ways to deliver services, and more cost-effective facilities? The answer lies in the powerful lessons business has learned over the past two decades about the imperatives of competition. In industry after industry, the underlying dynamic is the same: competition compels companies to deliver constantly increasing value to customers. The fundamental driver of this continuous quality improvement and cost reduction is innovation. Without incentives to sustain innovation in health care, short-term cost savings will soon be overwhelmed by the desire to widen access, the growing health needs of an aging population, and the unwillingness of Americans to settle for anything less than the best treatments available. The misguided assumption underlying much of the debate about health care is that technology is the enemy. By assuming that technology drives up costs, reformers neglect the central importance of innovation or, worse yet, attempt to slow its pace. In fact, innovation, driven by rigorous competition, is the key to successful reform.     

Finding a lasting cure for U.S. health care

In "Making Competition in Health Care Work" (July-August 1994), Elizabeth Olmsted Teisberg, Michael E. Porter, and Gregory B. Brown ask a question that has been absent from the national debate on health care reform: How can the United States achieve sustained cost reductions while at the same time maintaining quality of care? The authors argue that innovation driven by rigorous competition is the key to successful reform. A lasting cure for health care in the United States should include four basic elements: corrected incentives to spur productive competition, universal insurance to secure economic efficiency, relevant information to ensure meaningful choice, and innovation to guarantee dynamic improvement. In this issue's Perspectives section, eleven experts examine the current state of the health care system and offer their views on the shape that reform should take. Some excerpts: "On the road to innovation, let us not forget to develop the tools that allow physicians, payers, and patients to make better decisions." I. Steven Udvarhelyi; "Health care is not a product or service that can be standardized, packaged, marketed, or adequately judged by consumers according to quality and price." Arnold S. Relman; "Just as antitrust laws are the wise restraints that make competition free in other sectors of the economy, so the right kind of managed competition can work well in health care." Edward M. Kennedy "Biomedical research should be considered primarily an investment in the national economic well-being with additional humanitarian benefits." Elizabeth Marincola.     

Phytoplankton Productivity and Standing Crop in the Vicinity of the Lake Huron-Saginaw Bay Front

Continuous underway sampling was used in four research cruises near the mouth of Saginaw Bay in order to locate the bay-lake front, where eutrophic bay water mixes with oligotrophic Lake Huron water. Although mixing between these water masses normally occurs in outer Saginaw Bay, the distribution was variable, depending on wind force and direction as well as water temperature. Large algal crops in inner Saginaw Bay had reduced soluble nutrients, particularly silicate and nitrate-nitrogen, in the outer bay to levels lower than the adjacent lake water. Nonetheless, outer bay water supported high algal biomass (up to 14 μg/L chlorophyll a) and ¹⁴C uptake (up to 73 μg /L/h). The phytoplankton community at the nutrient front between bay and lake waters was characterized by high chlorophyll a biomass ($\overline{x}$ = 4.47 μg/L), low ¹⁴C uptake ($\overline{x}$ = 7.12 μg/L/h), and high bacterial activity (V_max$\overline{x}$ = 1.33) indicating the presence of a senescent assemblage. Decomposition and settling of phytoplankton in the vicinity of the front apparently served to remove much of the bay plankton from the water column before mixing into the open lake. But, during mid-summer, occasional large inputs of nutrients and/or phytoplankton from the bay into the open lake were observed.     

Spatial distribution and habitat characterization of schistosomiasis host snails in lake and land habitats of western Kenya

Intermediate host snails of schistosomiasis were surveyed in this study to determine their abundance and distribution in the lake and land aquatic habitats of Lake Victoria basin of Kenya. Several sites were sampled at eight locations, both in the lake and on the land. The habitat and/or vegetation type (i.e. open water, hippo grass, hyacinth, ambatch trees, other vegetation, stream, swamp, pond, dam) of the sampled aquatic sites within the locations were also differentiated, water physicochemical parameters were determined, and the abundance of different species or taxa of phytoplankton and zooplankton were enumerated and correlated with the abundance of schistosomiasis snails in the sites. The results indicated significantly more Biomphalaria sudanica snails than Bulinus africanus snails in different physical habitats on land (Student's t‐test, P < 0.05), as well as in different locations on land (Student's t‐test, P = 0.026). Regression analyses revealed that several physicochemical parameters, including dissolved oxygen (R² = ?0.659; n = 8; P = 0.014), pH (R² = 0.728; n = 8; P = 0.007) and turbulence (R² = ?0.616; n = 8; P = 0.02), were predictive of Biomphalaria spp. abundance, while pH (R² = 0.610; n = 8; P = 0.02) and turbulence (R² = ?0.578; n = 8; P = 0.028) were predictive of Bulinus spp. abundance in different locations in the lake. Cyanobacteria (R² = 0.638; n = 8; P = 0.02) and chlorophyceae (R² = ?0.50; n = 8; P = 0.05) were shown to be predictive of both Biomphalaria spp. and Bulinus spp. abundance in different locations in the lake. Zooplankton abundance varied significantly between different locations in the lake (One‐way anova , P < 0.001). Bosmina spp. were found to be predictive of both Biomphalaria spp. (R² = ?0.627; n = 8; P = 0.01) and Bulinus spp. (R² = ?0.50; n = 8; P = 0.05) in different locations in the lake. The results from this study will help inform policy regarding control measures for schistosomias and intermediate snail hosts in Lake Victoria waters, as well as in adjacent terrestrial aquatic habitats and even beyond.     

Transjurisdictional Water Pollution Management in China: The Legal and Institutional Framework

The current study shows that the recent diesel price hike had an insignificant impact on irrigation costs incurred by diesel well owners in eastern India. Further, analysis of the farming enterprises of diesel well owners and water buyers from both diesel and electric wells confronted with a differential cost of irrigation water showed that farmers would be able to cope with a very high rise in irrigation costs through irrigation efficiency improvements and allocating more area to crops that give higher returns per unit of land and water. By doing this, they are able to maintain the farm returns.     

Groundwater quality monitoring overview

A study was made to develop an approach to designing a groundwater-quality network for implementation by Mexico's Comisión Nacional del Agua (CNA) under support funding from The World Bank's (1996) PROMMA program. The network-design conceptualization and guidelines were based in part upon review of CNA's past and existing monitoring programs in measurement of water levels as well as measurements and analyses of groundwater quality. The principal focus used for this network-design framework rather was derived from identification of specific monitoring-program information needs. Also, a detailed review has been made of available reports and technical materials describing the nature, extent, and management of Mexico's groundwater resources and groundwater-quality impacts. This physical-based approach complemented a socioeconomic-based methodology being developed concurrently. Specific selection criteria and recommendations were made regarding network design components, in terms of monitoring locations, scheduling, and variables (parameters). Understandably, this preliminary design methodology, when implemented, should take into consideration somewhat realistic levels of effort that are judged to be fiscally sustainable by CNA over the near term. Moreover, some guidance also is provided in the case of fiscal or capacity-building limits of monitoring-program efforts.     

Irrigation infrastructure development in the Limarí Basin in Central Chile: implications for adaptation to climate variability and climate change

One option to deal with climate variability in agriculture is to build irrigation infrastructure, although this may lead to the overdevelopment of water resources, leading to ‘basin closure’. The Limarí Basin, in central north Chile, has relied on irrigation infrastructure over the last 30 years to increase water supply reliability and extend irrigated acreage, especially for permanent crops. This situation has reduced adaptation opportunities in the basin, which is currently experiencing a severe drought that, according to climate change projections, is expected to persist in the future, with important consequences for the sustainability of agriculture production.     

Urbanisation and Shallow Groundwater: Predicting Changes in Catchment Hydrological Responses

The impact of urbanisation on catchment hydrological response was investigated by using a process-based coupled surface water–groundwater model (MODHMS). The modelling estimated likely changes in river discharge as a result of land-use change in the Southern River catchment in Western Australia, underlined by a highly transmissive aquifer, has permeable soils and a shallow watertable. A significant increase in total annual discharge was predicted as a result of urbanisation area with the runoff coefficient rising from 0.01 to more than 0.40. In contrast with urban areas elsewhere, these changes were mainly due to a shift in the subsurface water balance, leading to significant reduction in evaporative losses from the soil profile and shallow watertable after urbanisation (from nearly 80 % of infiltration to less than 20 %). The infiltration of roof and road runoff and establishment of subsurface drainage adopted in local construction practice leads to higher groundwater recharge rates and subsequently groundwater discharge to the urban drainage network. Urban density and groundwater abstraction for urban irrigation most strongly influence the urbanisation impact on catchment fluxes. The results shows that urban development leads to a production of ‘harvestable’ water; and depending on local needs, this water could be used for public and private water supply or to improve environmental flows.