Moral hazard and supplier-induced demand: empirical evidence in general practice.

Changes in cost sharing and remuneration system in the Netherlands in 2006 led to clear changes in financial incentives faced by both consumers and general practitioner (GPs). For privately insured consumers, cost sharing was abolished, whereas those socially insured never faced cost sharing. The separate remuneration systems for socially insured consumers (capitation) and privately insured consumers (fee-for-service) changed to a combined system of capitation and fee-for-service for both groups. Our first hypothesis was that privately insured consumers had a higher increase in patient-initiated GP contact rates compared with socially insured consumers. Our second hypothesis was that socially insured consumers had a higher increase in physician-initiated contact rates. Data were used from electronic medical records from 32 GP-practices and 35336 consumers in 2005-2007. A difference-in-differences approach was applied to study the effect of changes in cost sharing and remuneration system on contact rates. Abolition of cost sharing led to a higher increase in patient-initiated utilisation for privately insured consumers in persons aged 65 and older. Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physician-initiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation indicate limited evidence for moral hazard.

Accountable care organizations: a primer.

Accountable care organizations (ACOs) are being hailed as a promising element of health care reform, as some believe they will be critical to improving the quality of care and holding down costs. Several state and federal ACO demonstration projects are scheduled to begin in the near future. Yet, questions abound as to what exactly an ACO is and how they work. This article describes the concept, outlines challenges to implementing ACOs, and discusses concerns about this new care delivery and payment model.

[Quality management in private practice. A nationwide survey in Germany]. / Qualitätsmanagement in der ärztlichen Praxis 2007. Eine deutschlandweite Befragung niedergelassener Arztinnen und Arzte.

Quality management (QM) will soon become mandatory for private practice physicians in Germany. We aimed to assess the knowledge about and state of implementation of QM in German private practices. In cooperation with the Stiftung Gesundheit (Foundation for Health), Hamburg, a stratified sample of 15,383 physicians was requested via e-mail in 2006 to participate in the online survey. The survey covered sources of information and experiences with QM, cost of implementing QM, and general attitudes towards QM in private health care. A total of 787 doctors (5.1% response rate) rendered useful data sets; 16% of doctors had not yet familiarized themselves with QM. The DIN-ISO QM System is by far the best-known system, with 86% of doctors having heard about it. All other systems are known by only 30% or less of the physicians. Only about 20% of private practices have already implemented QM or are about to have it implemented. The cost of QM depends heavily on the system used with DIN-ISO (5600 euros) and EFQM (2800 euros) being the more expensive, while EPA (1800 euros) and QEP (850 euros) are much less costly. All QM systems require roughly the same amount of time from staff to be implemented and maintained. Two thirds of all doctors have not yet decided which QM system to use and contacts during seminars and recommendations from colleagues are most important when selecting a system. The level of satisfaction with QM service providers is generally high. In general, the study revealed a very heterogeneous picture. As with other new technologies or organizational changes there is a group of enthusiastic "early adopters," but we also found a substantial number of physicians (about 25%) who are highly skeptical about implementing QM. They posed a challenge for health policy and service providers alike and careful market segmentation will be needed to cater for the different needs of the different groups of doctors. Moreover, the still rather technical approach towards QM might not be helpful in convincing the clinical and patient-oriented doctors of the need to install systematic and organization-based quality systems.

[Quality management in and by public health services]. / Qualitätsmanagement im und durch den öffentlichen Gesundheitsdienst.

Quality management is nowadays required by almost all organisations using public funds. Hence, quality management in public health services (PHS) first serves to make transparent the services offered, the performance, and the quality of services to comply with public demands for accountability. In addition, by following generally accepted concepts and methods of quality management, it could help to improve the performance of PHS. As a second function, quality management by PHS can be delineated. In this, PHS assumes the role of an independent quality manager of health services by reporting comparatively on regional services, their performance and the quality of care on a population basis. Considering recently introduced statutory incentives in Germany (such as disease management programmes and minimum volume thresholds for certain procedures) that could negatively affect social equity and access to health services, such a comparative quality and performance reporting by PHS is getting more and more important.

Managing costs, managing benefits: employer decisions in local health care markets.

OBJECTIVES: To better understand employer health benefit decision making, how employer health benefits strategies evolve over time, and the impact of employer decisions on local health care systems. DATA SOURCES/STUDY SETTING: Data were collected as part of the Community Tracking Study (CTS), a longitudinal analysis of health system change in 12 randomly selected communities. STUDY DESIGN: This is an observational study with data collection over a six-year period. DATA COLLECTION/EXTRACTION METHODS: The study used semistructured interviews with local respondents, combined with monitoring of local media, to track changes in health care systems over time and their impact on community residents. Interviewing began in 1996 and was carried out at two-year intervals, with a total of approximately 2,200 interviews. The interviews provided a variety of perspectives on employer decision making concerning health benefits; these perspectives were triangulated to reach conclusions. PRINCIPAL FINDINGS: The tight labor market during the study period was the dominant consideration in employer decision making regarding health benefits. Employers, in managing employee compensation, made independent decisions in pursuit of individual goals, but these decisions were shaped by similar labor market conditions. As a result, within and across our study sites, employer decisions in aggregate had an important impact on local health care systems, although employers' more highly visible public efforts to bring about health system change often met with disappointing results. CONCLUSIONS: General economic conditions in the 1990s had an important impact on the configuration of local health systems through their effect on employer decision making regarding health benefits offered to employees, and the responses of health plans and providers to those decisions.

Does competition under Medicare Prospective Payment selectively reduce expenditures on high-cost patients?

Competition and prospective payment have been widely used to control health care costs but may together provide incentives to selectively reduce expenditures on high-cost relative to low-cost patients. We use patient discharge and hospital financial data from California to examine the effects of competition on costs for high- and low-cost admissions in the 12 largest Diagnosis-Related Groups before and after the Medicare Prospective Payment System (PPS). We find that competition increased costs before PPS, but that this effect decreased afterward, especially inpatients with the highest costs. We conclude that competition and PPS selectively reduced spending among the most expensive patients and that careful assessment of these patients' outcomes is important.

Catholic social policy and U.S. health care reform: a relationship revisited.

The Roman Catholic Church is the single largest denomination in the United States and the one with the most extensive provider stake in health (and related social service) care. As a follow-up to an earlier analysis of the Catholic role in the thwarted health care reform effort of 1993-94, this article looks at the revival of interest in reform and at the rationale behind and strategy of the Catholic Church's current agenda-setting initiative. The emphasis in this article is on the delicate relationship between organized religion and social policy in a society with an officially secular culture.

Gestión del conocimiento (I) / Knowledge management (I)

Más allá de una moda, la gestión del conocimiento se constituye en una poderosa arma estratégica para la dirección de organizaciones. Se analizan los conceptos de GC, sociedad del conocimiento, trabajador del conocimiento... Introducida la importancia de la GC, establecen la vinculación del conocimiento con las bases de la política de empresa y, especialmente, la vinculación de la GC con la ventaja competitiva. Finalmente, vincula la GC con el proceso de aprendizaje ("conocimiento tácito", "socialización", "externalización", "combinación" e "internacionalización") (AU)

Health plan competition in local markets.

OBJECTIVE: To examine the structure of local health insurance markets and the strategies health plans were using to respond to competitive pressures in local markets in 1996/1997. DATA SOURCES/STUDY SETTING: Community Tracking Study site visits conducted between May 1996 and April 1997 in 12 U.S. markets selected to be nationally representative. STUDY DESIGN: In each site, 36 to 60 interviews on local health system change were conducted with healthcare industry informants representing health plans, providers, and purchasers. DATA COLLECTION/EXTRACTION METHOD: Relevant data for this article were abstracted from standardized protocols administered to multiple respondents in each site. PRINCIPAL FINDINGS: Although the competitive threat from national plans was pervasive, local plans in most sites continued to retain strong, often dominant, positions in historically concentrated markets. In all sites, in response to purchaser pressures for stable premiums and provider choice, and the threat of entry and to plans were using three strategies to increase market share and market power: (1) consolidation/geographic expansion, (2) price competition, and (3) product line/segment diversification that focused on broad networks and open-access products. In most markets, in response to the demand for provider choice, the trend was away from ownership and exclusive arrangements with providers. CONCLUSIONS: Although local plans were moving to become full-service regional players, there was uncertainty about the abilities of all plans to sustain growth strategies at the expense of margins and organizational stability, and to effectively manage care with broad networks.