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Introduction to Healthcare Policy*
Overview--Where We've Been in Healthcare Policy and Where We're Going
(Please Note: Figures and any other illustrations mentioned in the following text refer to the print edition of this work, and are not reproduced here.)
(*The phrase "healthcare policy," while in common usage to designate policies affecting the financing, delivery, quality, cost, and regulation of medical care services, is actually misleading. In this lecture we discuss the policies that shape the world doctors, nurses, administrators, and payers face with medical care. Healthcare is a euphemism and is a much broader concept than medical care. Hence the chapter uses "medical care" to refer to the policies cited above.)
Why should physicians and healthcare managers care about healthcare policy? This serious question deserves careful reflection. The past 10 years have without a doubt produced great changes in the world of healthcare financing, as well as significant changes in the perception of the healthcare professions. Is this a revolution? How are we to make sense of these changes? What do they auger for the future? In answering these questions, I will suggest some ways of understanding the volatile context within which you will be practicing your profession. This requires a step back, to think about American healthcare as a whole.
To begin, we need to describe the arrangement of financing, delivering, organizing, and overseeing healthcare in the United States, what some people ambiguously call the healthcare system.
Because of significant changes in the past two decades, we must examine not only the different elements, but also how they relate to each other (Figure 1.1). As this diagram shows, American healthcare is an amalgamation of public, for-profit, and nonprofit institutions, operating with private and public finance, and marked by both competition and regulation. One way to think about this complex mix is to consider separately the sources of finance, the payment methods for services, the structure of insurance intermediaries, and how care is organized and delivered.
Sources of Finance
From where do the resources originate that ultimately finance healthcare? The first thing to notice in answering this question is that, contrary to popular shorthand, the American system is not one of private sector, free enterprise. Rather there exist enormously significant public, as well as private, sources of financing. General tax revenues provide the lion's share of financing for over 70 million Americans in Medicare (40 million), Medicaid (25 million), and the Veteran's Administration/Department of Defense (5 million). Combine this direct public funding for 70 million individuals with the tax treatment of medical insurance premiums for the 150 million Americans covered by employment-related plans (where the premiums are nontaxable to the recipient and tax-deductible to the employer) to see that public funding comprises a large share of American healthcare. (You surely knew this before, but probably not the magnitude of public funding.) Turning to the private sources of finance, we find self-purchased plans, individual Medicare premiums, employee premiums, and pretax employer premiums. Looking at the complex and varied sources of funding, you can describe the U.S. system as a fragmented mix of public and private sources. Or you can say America has a balance between public and private finance. (Note the difference in connotation.)
Not only is there a complex mix of funding sources, but also a diversity of institutions operate between those sources of finance and the delivery of care. This category--all too familiar to medical professionals and administrators--includes indemnity plans, HMOs, PPOs, POSs, and still other acronyms. When analyzing any insurance plan, it helps to think in terms of three important dimensions. One dimension is the location of financial risk. The second dimension comprises the degree of regulation in services provided--from zero or neutral (no interference for services provided that are not prone to fraud) to 10 (the plan evaluates whether the activity should have been done and at what price the activity should have been done).
The third dimension categorizes the organizational form, ranging from prepaid, group practice to solo practice and so on. All three dimensions together characterize the fundamental ways in which healthcare insurance operates. This does not, I should emphasize, constitute a full description of health insurance; it is rather an initial guide to understanding.
Modes of Payment
Much controversy in recent years involves changes in how medical professionals are paid for their services. For all the controversy, there are really only three ways to pay for professional work. One can be paid by the act (fee for service). One can be paid based on the person for whose care (or organ system) one is responsible (capitation), or paid by time (salary or sessional). Most important, every form of payment has distinctive virtues and concomitant vices. This is essential, especially now when there are so many false or misleading claims about payment. (By that I mean false or misleading in the representation of the advantages of any one method of payment.)
A closer examination of each payment method reveals the potential vice that accompanies its virtue. Fee for service payment, for instance, rewards those who work hard. However, that very virtue simultaneously creates an incentive to produce more actions than necessary. The method that rewards energy can reward the possible misapplication of that energy as well.
What of capitation? This payment method disconnects the professional's treatment decision from immediate financial awards. It permits the professional to focus on the medical necessities--for an individual or a group of patients--independent of the immediate reward structure. What is the vice of this payment virtue? The more patients on your list, the better you do financially. It is not simply: The better care you provide those patients, the more you earn.
Let me dwell on the positive side of capitation for a moment. Current disputes (related more to the level of reimbursement and particularly the structure of bonus payments) can obscure capitation's positive incentives. When I visit my physicians at a prepaid, group practice financed by per capita payments, they and I have no obvious and direct monetary connection. Nor is there any connection between their providing more or less medical service to me and a financial reward to them. This permits my doctors to decide, given other constraints, what is most important among the competing claims of their patients. The vice of this virtue is its inherent incentive to take on too many patients, each of whom gets less and less time with physicians, and to do (i.e., spend) less on each patient in the way of tests and procedures. By its nature, capitation creates a tension between independence to allocate care among patients and the flip-side incentive to take on too many patients. That is why in parts of the world where capitation is widespread (e.g., the United Kingdom and Holland) those institutions financing care pay less per capita as the number of patients increases. This is precisely to avoid the risk of the economic incentive just discussed.
What of payment by salary? Take my situation as a professor. Receiving a salary has the great professional merit of keeping my financial well-being independent of my efforts to assist my students. This means dealing with students can be guided by my own conception of appropriate professional conduct. This seems like the professional ideal: The core of the professional's duty is to identify the interests of the client (or patient) and act as their agent. That, in principle, justifies professional autonomy, licensure, and substantial professional rewards. However, salary payment neither rewards doing the right thing (providing more and better care for patients) nor penalizes doing the wrong thing (providing less and worse care). Both behaviors are compatible with payment by salary. Salary systems assume a large set of nonfinancial social and/or occupational constraints to ensure adequate professional performance--doing nothing and doing the right thing are equally compensated with salaries. As I hope this discussion has shown, no one method of payment is self-regulating. Each has vices as well as virtues and that, incidentally, helps to explain the mix of payment methods we increasingly find used in contemporary industrial democracies.
The American Healthcare System--Facts and Figures
As Figure 1.2 illustrates, U.S. spending on healthcare as a percentage of gross domestic product (GDP) has climbed rapidly over the last 40 years, from somewhat over 5 percent to the present 14 percent level. What does this chart mean? Does it indicate the United States spends too much? Not necessarily. As the next chart shows (Figure 1.3), one must also consider the impact of inflation. The inflation in healthcare costs has largely tracked the movement of general changes in the consumer price index (CPI). Periods of high relative inflation in the CPI are also periods of high relative inflation for healthcare. What is important to remember here is to be attentive to the difference between real and nominal increases--real increases deflate the effect of general inflation.
Another point worth noting about U.S. health spending over the last 40 years is the extent to which public spending increased as a percentage of the total, from approximately 25 percent of total spending in 1960 to over 40 percent today. Over that same time period, the federal government assumed a larger role in the payment for medical services. The Health Care Financing Administration (HCFA) became the dominant public actor, creating Diagnostic Related Group (DRG) and Resource Based Relative Value System (RBRVS) payment methods in the 1980s, which in turn were adopted and modified by private insurers. In private-health spending, we witnessed a shift from out-of-pocket spending to prepaid insurance. In 1960, over 65 percent of private spending was out-of-pocket, compared with under 40 percent today. Where have these healthcare dollars gone? Since 1960, the physician's share of the healthcare dollar has remained fairly constant, while hospitals have been pressured to reduce costs and length of stays over the past two decades, and nursing homes have received a larger percentage of the healthcare spending pie (Figure 1.4).
One final note about what the facts and figures do not show: Contrary to assertions in the press and by some politicians, demography is not destiny. From 1970 to 1990, Canada and the United States aged identically. During that time, U.S. outlays rose from 7 percent of GDP in 1970 to 11.5 percent in 1990. Canadian outlays over the same period increased from 7.1 percent to 9.3 percent. Assertions that the aging of the population alone is responsible for U.S. spending growth are simply not true.
How to Make Sense of the U.S. System
New Vocabulary and Persuasive Definitions
Having framed the context, it is time to make sense of the present state of American medical affairs. What is a useful toolbox for understanding where we are? First, I want to discuss standard ways of characterizing medical care and whether those descriptive labels are useful. There have been undeniably dramatic changes in American medicine over the last 30 years. But one major change has been the transformation of the vocabulary with which healthcare is described. Thirty years ago there was a common way of describing medical institutions, one that did not imply a judgment about the quality of the care provided. So, for example, one would describe medical arrangements by the type of patient (e.g., Boston Children's Hospital), the hospital's (often religious) ownership (e.g., St. Vincent's, Mt. Sinai, St. Barnabas), or by a specialty area (e.g., Menlo Park Orthopedic Center). Such descriptions would not, however, convey any overall conclusion. They would not allude to modes of payment, nor necessarily point to anything about the quality of the medical providers. That mode of description in part represented an implicit ideology--medical professionals need complete freedom from interference by nonmedical professionals in order to perform their roles. Notice too that the descriptions left judgments of quality to demonstration, not definition.
In contrast, we now regularly speak of health systems, with frequent claims that they are integrated in the provision and financing of care. Instead of calling a set of medical institutions by a neutral name or the title of a sponsoring religious group, a different vocabulary is now regularly employed. It is a vocabulary comprised of both business school jargon and advertising hyperbole. Take, for instance, the medical institutions in Minnesota now known by the label, Alina. Where once the institutions that make up this medical conglomerate were known by names like Group Health, or Abbott-Northwestern Hospital, the marketing teams devise terms that suggest rather than name. So, to take this particular example another step, Alina is not only to be thought of as an integrated health delivery system, but also one where the incentives of the units are supposedly aligned with those of the patients (or potential customers).
This illustrates a persuasive definition. How do you know an integrated system works well? What can one say about whether incentives are compatible on the basis of a label? The name supposedly says it all--surely you wouldn't want a fragmented system, a nonaligned one! Would you want unmanaged care? One needs to be alert to this associational thinking so as not to be blindly persuaded by labels. Calling something a health maintenance organization does not, in and of itself, mean the organization is in fact operating (or is even designed to operate) to promote health.
The Fallacy of Financial and Professional Independence
The traditional ideal of the learned professional holds that doctors can properly perform their jobs only if they are completely independent financially and professionally. According to this older view, dominant in North America and Western Europe before the Second World War, there should be no intermediaries between physicians and their patients. The ideal presupposes that professionals, certified as competent by self-regulation or by the state, offer their services to patients, who typically spend their own money out-of-pocket. The threat of patient exit (finding another doctor) is supposed to serve as an additional discipline on the professional. This ideal of financial autonomy (charge whatever you decide) and professional autonomy (do whatever you think is right) simply cannot be achieved in the contemporary world of modern democracies, where it is widely believed access to care ought to be available and largely independent of ability to pay. These are the foundational principles of, for example, the Canada Health Act, the legislation setting up the National Health Service, and the statutes governing national health insurance in general. What is incompatible between the traditional professional ideal and contemporary ideas about fair access to healthcare? Access under the traditional model depends on ability and willingness to pay for healthcare, which necessarily conflicts with responding to medical need as defined by ability to benefit. For all its appeal, the traditional professional vision of complete independence in its pure form is simply not viable in any modern democracy, including the United States.
Medical Care--Like Food in a Restaurant?
In recent years, many enthusiastically applied the lessons of free markets to new areas, including medical care. In formal theory and in much practice, free markets allocate capital efficiently because well-informed consumers demand that suppliers produce desired goods or services of high quality at acceptable cost. Transactions between willing buyers and sellers produce an allocation of goods and services that beats the alternatives. Is this way of thinking applicable to medical care? Is it useful in some areas and not others? To answer those questions, we must clarify the presumptions behind free markets, and critically examine them in terms of medical care as the economic good. As I detail in the following, such an examination reveals that healthcare markets do not generally meet these ideal conditions. Market incentives, to be sure, affect the distribution of medical services. But medical care differs in so many ways from the typical market good, wariness is the appropriate stance.
A common free market analogy for medical care is food. Food, the argument goes, is at least as much a necessity as medical services. Yet no patron dictates to restaurants what they must serve, how much they can charge for their meals, or limits the number of restaurants allowed to do business. Nor does anyone sensibly suggest there should be any regulation of where, when, and how often people should be allowed to go to restaurants. (We do, of course, assume some public-health regulation of restaurant conditions is necessary because ordinary customers are not in a position to know a restaurant's hygienic status.) Individuals know when they are hungry, what food they like, and how much they are willing to pay relative to other claims on their budgets. This, according to standard defenses of markets, allows for an efficient allocation of food, so why not use the same type of market for medical care?
The analogy is provocative, but incomplete. There are three important ways in which the analogy breaks down, and the response to each difference underscores the ways in which medical care is not comparable to other economic goods and services.
Certainty of Need The first difference is that although you know when you're hungry, you don't always know when you are in medical danger. Everyone knows they will experience hunger and they must eat regularly. For health, one does not necessarily know in advance what one's needs are or will be.
Completeness and Symmetry of Information The second difference that undermines the analogy of medical care to other goods and services involves the distribution of crucial health information. In the case of the restaurant, individuals are uniquely knowledgeable about food preferences and can gather comprehensible information on restaurant alternatives (e.g., read restaurant reviews and ask acquaintances with similar tastes). Note, however, that even if a citizen knowingly requires medical care, he is unlikely to know the specific kind and amount. There is an expected asymmetry of knowledge between the patient (consumer) and the medical professional (provider). By definition, the professional possesses greater knowledge of symptoms, diagnoses, options, and consequences. This imbalance creates a subordinate position for the patient; it requires an element of trust in the physician's application of superior knowledge to the patient's circumstances. The doctor-patient relationship is qualitatively different from that between even the best chef and the most uninformed restaurant patron. This difference in information is significant in identifying why medical care should not be allocated by market principles.
Private versus Community Interest There is a third way in which the analogy to ordinary economic goods and services is flawed, and that concerns the degree to which community interests are implicated in medical services allocation. One's choices about where and what to eat have little or no affect on others. There is no reason why I should worry or care if someone eats at a restaurant three times a week or once a month. But I should worry if they have a contagious disease and don't get treatment. This direct impact on others of communicable diseases (e.g., tuberculosis) has no counterpart in food, clothing, or housing, essential as those may be. Community interest illustrates yet another way in which the analogy of medical care as a standard economic good is flawed. But the public-health rationale does not begin to exhaust the grounds for policy interventions in the medical world. For a wide variety of reasons--ranging from charitable concerns for the poor, to utilitarian concerns for healthy societies, to egalitarian notions advocating equal access as crucial to medicine--every modern democracy (and most nondemocracies) provides for medical care to be available on some other basis than willingness and ability to pay. Although views range widely in the United States about what care people should receive if they are sick and on what precise terms, the long-standing support for the provision of some medical services regardless of ability to pay (charity care at hospitals, free clinics, prenatal care, vaccinations, etc.) underscores the conviction that medical care is different from a classic economic good.
How Is Medical Care Different?
Modern societies have all responded to these differences in ways that illustrate just how unique medical care actually is economically. The response to the patient's uncertainty of need for medical services has been health insurance. To address the issues about completeness and asymmetry of knowledge, there exist professional standards, licensing, malpractice law, and reimbursement policies. To address community interests in public health and the allocation of care, American policy makers legislated health departments locally, public health-insurance programs (e.g., Medicare and Medicaid), and subsidies. However, like the virtues and vices of payment methods, the responses to medicine's distinctive features can create their own problems.
Health insurance, which correctly recognizes that sick people are not shoppers, at the same time does reduce a typical consumer's caution about outlays. Professional standards and sanctions recognize the asymmetry of information between patient and physician. But the high barriers to entry into the medical profession (the long years of training for professionals and the high cost of creating medical facilities) mean that response to change is slow. Public programs and subsidies designed to address the community's interest in a basic level of medical care also creates free rider problems and issues of unequal access (e.g., someone on disability gets Medicare coverage, while many workers in low-income jobs have no health coverage of any kind).
Some regard the nonprofit form of medical care delivery (in hospitals especially) as a response to market failures, in particular the limited access to care that rationing by income entails. Could a nonprofit provide free or subsidized care to meet the needs of those not served under the current medical system? The categories nonprofit and for-profit are easily subject to distortion and misrepresentation. The technical definition of a nonprofit institution is simply that ownership cannot convey an equity interest in the assets of the institution. So, for example, the Ford Foundation cannot issue stock or sell its assets and distribute them to shareholders. That undeniable restriction on a form of wealth acquisition does not, however, mean that nonprofits can ignore the laws of economics. For any institution to survive, it must have resources available roughly equal to its expenditures or claims on its activities. Thus it is not surprising to find that in the 1970s and 1980s, although for-profits provided less free care, on average, than nonprofits, both offered less free care in response to increasing financial pressures than they had in earlier decades. The nonprofit organizational form cannot, in and of itself, meet the demand for free care in the face of pressures to hold down expenditures.
Medical Care As Political Football--Explaining the Past and Predicting the Future
We might ask whether there is anything in the broader world of public-policy analysis that might enlighten our analysis of medical care. Are there useful guides on how to characterize, explain, predict, and evaluate the actions of actors whose decisions have a major impact on our lives, whether Medicare, Medicaid, insurance carriers, or professional review boards? Over the last 25 years, analysts of public policy have developed a variety of models to help understand and explain decision making by large organizations. One model is particularly useful.
The Rational Unitary Actor
Graham Allison's model of decision making suggests three ways to analyze a particular course of action taken (or to be taken). The first model, called the rational unitary actor, treats large organizations as unitary and rational. According to it, actors choose policies and actions because they offer the best alternative for the given problem. This model focuses on an action--say, the decision to build a children's hospital--and asks why it made sense.
This model is useful in characterizing problems and establishing potential policy responses. It helps make sense of arguments by analysts who use cost-benefit approaches to evaluation. However, the model is misleading in suggesting that most decisions are made in a unitary, rational way (it is descriptively inaccurate). It also fails to explain the timing of most decisions or provide an adequate account of decisions not taken. Anyone involved in the building of a new medical facility understands how the unitary, rational model fails to capture the diversity of agendas and efforts within an organization, as well as the nonrational elements that come into play.
This model focuses on an organization's past behavior as the best predictor of its future behavior. According to this view, organizations do similar things in time t + 1 as in time t because routines and standard operating procedures drive day-to-day life. It is not simply that inertia is at work or there are organizational stakes at play (for example, bureaucracies like to grow). In most organizations, the method of decision making involves articulating standard operating procedures. The very nature of this approach implies big organizations don't change rapidly, and knowing the habits and routines of the organization you work for is crucial in predicting what will happen tomorrow and beyond.
This model provides only part of the answer about why a given policy action is taken or not. For some decisions, the model provides a very accurate description of the present and prediction for the future. However, it fails to provide explanations for radically new policies that appear to conflict with the routines of the organizations involved. Moreover, it ignores the role of misunderstandings and personalities in the making and unmaking of policy decisions.
The third approach described by Allison is the bureaucratic politics (or micropolitics) model. This model emphasizes determining who gets what, when and how. It is similar to a journalist's account of an event or decision. Several individuals or groups have conflicting desires; they bargain and/or fight, and the outcome is the result of their tactics, intensity, and influence (as well as luck). The model examines the individual players and each person's stakes and interests. This can be quite useful in understanding any decision, particularly when the question is the timing of a policy choice or the way in which a decision emerged.
For example, in order to understand Medicare policy, one needs to consider the role of the House Ways and Means and the Senate Finance Committees. Since its inception, these committees have been directly involved in overseeing Medicare. Even with fairly stable membership on both committees, however, their decisions have varied considerably. The organizational politics model alone can't explain this. And while the rational unitary actor model might set the parameters of actions the committee could have taken, the bureaucratic politics model is more likely to provide the best explanation (for example, the inclusion of the Medicare provisions in the Balanced Budget Act of 1997).
Again, this third model is incomplete. Not all actions can be explained by the behavior of particular parties, unaffected by either an assessment of what is possible, or by the standard orientation of the relevant organizations. To use the Balanced Budget Act of 1997 as an example, the inclusion of HMO provisions for Medicare was in part a reflection of a persistent intellectual movement for over 20 years touting the benefits of market mechanisms in medical care. Simply examining the rise of Newt Gingrich as Speaker of the House and the shift in the partisan control of House committees would not fully explain those dramatic 1997 changes.
Overall, these three models provide a variety of lenses through which to view the world. The type of lens determines the level of detail one can see, and it shapes the patterns of description (what one finds) of explanation (what relieves puzzlement). By extension, it shapes one's anticipation. Because each model suggests different ways of understanding outcomes, they ought to have some impact on how one views a particular situation. In this sense, they can shape our view of the nation's leaders.
Change in the Public Image of Physicians
Of all the changes over the last 30 years, perhaps the most striking in health policy has been the public image of physicians. The traditional conception is that physicians are instruments of improvement in their patients' lives, whether they cure patients of illness or mitigate the consequences of their ailments. The rising, new conception views physicians as simply professionals who treat sick people. According to this view, physicians' claims to superiority and independence demonstrate a conspiracy against laymen. This view holds that much of what physicians do can be duplicated by a computer. Attempts to convince the layman otherwise are simply efforts to protect the economic interests of the physicians' guild.
These two conceptions now exist side by side. Several changes are, however, quite clear. These are charges against all professionals, not just physicians. It exemplifies a view of professional organizations as groups seeking special privileges under guild status, trying to confuse ordinary people about their alleged superior knowledge.
Within the medical field, the growth of medical knowledge has become so rapid, no physician can know all pertinent information in his or her field, let alone relevant developments outside that field. As a result, the traditional notion of a sole practitioner or independent professional and the individual patient in a sealed doctor-patient relationship with no interaction with anyone or anything else is increasingly unrealistic.
In perhaps the most striking change of the last 25 years, the traditional ally of the medical world--big business--has in many instances turned against physicians. Business, driven in part by the rising real and relative cost of care (remember, 150 million Americans are covered in part by employer health plans), has joined the attack on physicians as a cottage industry. They pose this guildlike arrangement is archaic and has insufficiently responded to the industrialization of the possibilities of medical care, the world of computerization and information technology. This breakdown of a solid coalition opposed, for example, to national health insurance, is really quite important.
The combination of these factors has led to a striking shift in public perception of the medical professions. Surprisingly, the medical community has been largely unresponsive to this dramatic shift in public opinion. Consider, for example, the reaction of the medical community to Clinton's health-reform proposal. In the course of that frustrating fight, enormous changes took place outside national politics, especially among private insurers misleadingly called managed-care firms. As a result, there was a great deal of public talk about choice, but no policy change occurred in the end. At the same time, a great deal of change was implemented without choice (consolidation of insurers, reductions and restrictions in benefits, changes in compensation methods).
Challenge of the Future
There has been little, if any, response in the past few years by actors in the public arena to the complaints and concerns of the American medical establishment. Why is this so? I believe it relates in large part to a failure by the medical community to understand the impact of the constant attack on (1) guildlike behavior, (2) the claim of medical competence to do things uniquely that others arguably could do, and (3) the profession's apparent opposition to any type of reform. Without understanding the impact of these attacks, it is difficult to understand how both professional and financial autonomy--so central to the traditional concept of the decent professional--have both become so threatened.
As physicians go forward, they need to hear the critiques of their profession from the media and others and not be defensive. As a society, we have shifted from adulation to skepticism without reflection. You, as doctors, must take part in righting that balance and achieving that reflection.
Table of ContentsIntroduction: Physicians and Management (S. Rimar).HEALTHCARE SYSTEMS.Introduction to Healthcare Policy (T. Marmor).How to Change Healthcare Policy from the Office (S. Rimar).Management Strategy and Health Economics (W. White).How to Expand a Practice and Retain Control (S. Rimar).FINANCIAL MANAGEMENT.Introduction to Accounting (R. Antle).How to Talk about Money (S. Rimar).Healthcare Financial Management (E. Bradley).How to Convince Someone an Idea Is Worth the Money (S.Rimar).An Introduction to Economic Evaluation (A. Paltiel).How to Evaluate a Proposal (S. Rimar).ORGANIZATIONAL MANAGEMENT.Leadership Style: Managing the Decision-Making Process (V.Vroom).How to Be a Leader (S. Rimar).Leading and Managing a Negotiation Process (C. McCusker).How to Negotiate (S. Rimar).Contemporary Marketing in Healthcare (J. Wack & W.Gombeski).How to Position a Practice to Get More Business (S. Rimar).ESSENTIAL MANAGEMENT SKILLS.The Business Plan (S. Rimar).How to Develop a Plan for a Practice (S. Rimar).Selling an Idea (S. Rimar).How to Make an Oral Presentation (S. Rimar).Index.