Information needs in a changing health care system: capitation and the need for a population-oriented view.

Information systems needed for managing the health care of populations under at-risk (capitation) contracts must be designed differently than those used in fee-for-service practice. Under capitation, providers must deliver health care to enrollees with financial resources that are fixed in advance. Therefore, the information systems they use must enable them to understand the health status of health plan enrollees and how health care is provided. These systems should facilitate the detection of underservice and of inadequate quality of health care as well as overuse of health care resources. They should permit clinical-epidemiologic and statistical analysis; facilitate disease management and the adoption of preventive programs, and lend themselves to use by planners, group leaders, and practicing physicians.

Managed competition that works.

President Clinton has advocated managed competition within a global budget as a long-term strategy for simultaneously controlling health care costs and expanding access to medical care to all Americans. This proposal is intended to show how these two seemingly conflicting goals can be simultaneously accomplished. Managed competition, as it has been conceptualized to date, is primarily a strategy for reforming the system of providing health services. To work, it must be joined with a strategy for reforming our system of financing and paying for those services and of limiting overall system capacity. "Managed Competition That Works" is a proposal that would create a single trust-funded national system of health insurance, implemented through a system of vouchers to individuals. Global budgeting would be accomplished through establishment of the voucher's value each year. The trust fund would pay health plans for all medical care by capitation, but health plans would be free to negotiate a variety of payment arrangements with physicians, hospitals, and other providers. All plans would be required to offer a standard package of benefits, but would have great flexibility in offering benefits beyond the scope of the standard package, if those benefits replace high-cost with lower-cost services or permit the plan to compete more effectively for market share. This proposal would establish firm but acceptable national budget limits; provide universal, comprehensive, and uniform insurance coverage; eliminate cost shifting; encourage competition; reward efficiency-improving innovation; greatly reduce the need for centralized micromanagement of medical care; and retain local determination and a somewhat reduced level of consumer choice. Although this proposal is written as a national plan, trust funds could be implemented at the state level, if problems associated with portability of benefits among states could be solved.

The year after Kobuleti: what difference does it make?

Following and pursuant to a conference held in Kobuleti, Soviet Georgia in April, 1990, a paper describing proposed principles for legislation establishing a health insurance system for the U.S.S.R. and Union Republics was published. It proposed supplementing the existing publicly financed medical care system with a system of regionally based 'health insurance' funds, as well as formally recognized direct payments to health care providers. While creating the opportunity for insurance funds which were to be regionally based, the system was to be centrally directed. Since the publication of that paper, the reforms it envisions have progressed more slowly than expected. This is due to at least three factors. First, the general state of the Soviet economy, coupled with a strengthening of the movement toward greater autonomy for the Soviet Republics and an accompanying reluctance on the part of the Republics to contribute to the Union budget, has resulted in a greater reduction of that budget (and a greater budget deficit) than anticipated. Second, due in part to perverse financial incentives, the capacity of the Soviet health care system to increase production, even if the financial resources were available, is limited, and has deteriorated during the past year. Third, the patience of health care workers with their working conditions is wearing thin, resulting in less willingness on their part to cooperate with anything less than total and fundamental reform than has been the case in the past. At this point, it appears that any reform of Soviet health care will emphasize autonomy at the levels of the Republics, and a diminution of central power and control. There is a growing feeling that anything short of a significant improvement in the general Soviet economy linked with total reform of health care financing and delivery will fail to reverse the deterioration of the Soviet health care system.

Approaches to the measurement of effectiveness and efficiency in medical care: the use by employers of community-wide population-based patterns of care.

One of the major problems currently facing health care purchasers and providers is the difference in perspective each brings to the health care debate. Clinicians tend to think in terms of individual patients. Health care policy analysts in both public and private sectors, hospital and health maintenance organization managers, insurance executives, business purchasers of health care, and epidemiologists tend to think in terms of defined populations. This difference makes communication difficult. The routine epidemiologic surveillance of medical care, using modern microcomputer techniques, can be an important tool in improving communications among these parties. An example of a project which accomplished that goal at General Electric is described. The implications of variations in population based per capita rates of medical care in various settings are described.