Technology and Health Care in an Era of Limits (1992) / Chapter Skim
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PART III: MANAGING CARE IN THE UNITED KINGDOM AND CANADA
PART III: MANAGING CARE IN THE UNITED KINGDOM AND CANADA
Pages 77-120
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From page 77... ...
Part ITI Managing Care in the United Kingdom and Canada
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From page 79... ...
2. The NBS provides Tout go percent of aH beaMb cage far Bdtisb citizens; the phv~e sector concentrates mainly on providing elective surgery for those who wish to avoid NBS mating lists and for those Boo Tab to improve on 1be general level of hospital amenides.
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From page 80... ...
The system, however, is widely believed to be underfunded and forced to make painful decisions that it is thought could be avoided if funding could be increased. PROBLEMS OF THE BRITISH HEALTH CARE SYSTEM It will be obvious from the above that the British health care system has no problem with cost containment, if by that is meant controlling total costs.
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. Concern about costs has been left to the managers in the health authorities or in the hospitals, who, because they had little or no influence over (or even knowledge about)
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Put succinctly, medical ethics require a doctor to do no harm, to preserve life, to alleviate suffering, to respect the autonomy of the patient, to tell the truth, and to deal fairly with patients. It is accepted that these principles often conflict and that one of the skills required of doctors is to exercise appropriate judgment as to where to strike a compromise between them in any particular clinical situation.
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So at the very heart of the priority-setting process is a great information void, which renders the system vulnerable to priority setting by less appropriate means. The recent discovery and promotion of outcomes research is a belated response to this information void.
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must be provided locally, but others (especially elective surgery) might be "bought in" from hospitals outside the geographic boundaries of the purchasing health authority.
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In the British system, this is most likely to be noticed if the waiting lists for certain conditions lengthen because these cases have been squeezed out to make room for the innovative ones. Health authorities have learned, when new appointments are made, to monitor as closely as possible the likely implications of clinicians' research interests.
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From page 86... ...
Health authorities see themselves confronting collusive activity among manufacturers, practitioners, and patients, which prevents or delays systematic evaluation and leads to the weakly controlled dissemination of well-marketed but poorly evaluated new technologies. Manufacturers encourage and exploit the desire of practitioners to improve their performance by offering something that helps them resolve some diagnostic, monitoring, or therapeutic difficulty of which they are acutely aware, given the current state of the art of medical practice in their particular field.
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From page 87... ...
Each of these broad viewpoints is typically associated with a distinctive configuration of views on personal responsibility, social concern, freedom, and equality, as set out in Table 6-1. The ascendancy of either of these broad viewpoints would generate a distinctive health care system whose characteristics would be very different from those of a system shaped by the other viewpoint.
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of real opportunities of choice; Compulsion attenuates both although economic constraints are personal responsibility and less openly coercive than political individualistic and voluntary constraints, they are nonetheless expressions of social real and often constitute the concern. Centralized health effective limits on choice.
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SOURCE: Based on A Williams, "Priority Setting in Public and Private Health Care: A Guide Through the Ideological Jungle," Journal of Health Economics 7:173-183, 1988.
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9o ALAN WILLIAMS TABLE 6-2 Essential Characteristics of Idealized Health Care Systems Based on Libertarian Views (Private Systems) and Egalitarian Views (Public Systems)
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SOURCE: Based on A Williams, "Pnonty Setting in Public and Private Health Care: A Guide Through the Ideological Jungle," Journal of Health Economics 7:173-183, 1988.
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· Freedom from direct financial contributions at the point of service and the absence of risk rating enable patients to seek treatment for trivial or inappropriate conditions. · Because private insurance coverage is itself a profit seeking activity, some risk rating is inevitable; consequently, coverage is incomplete and uneven, distorting personal willingness and ability to pay.
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From page 93... ...
· It is difficult to phase out facilities that have become redundant because such an action often threatens the livelihood of some concentrated, specialized group; in addition, the people dependent on the facility can be identified, whereas the beneficiaries are dispersed and can only be identified as "statistics." · Because life expectancy is the easiest aspect of health status to measure, mortality continued
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Williams, "Pnonty Setting in Public and Private Health Care: A Guide Through the Ideological Jungle," Journal of Health Economics 7:173-183, 1988. fully.
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PRIORITY SETTING IN A NEEDS-BASED SYSTEM 95 health care prioritization a topic of continuous dialogue in the public arena, and subject to continuous review in the light of that dialogue, constitutes an important breakthrough. The entire exercise should greatly strengthen both public maturity and political accountability, which are essential to the democratic management of care and capacity in a national health service in which priorities are based on need.
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Nor is there an informed, articulate private constituency for cost containment, because private employer-based health insurance is vestigial in Canada. Although these differences have resulted in dramatically different cost experiences (Evans, 1986; Evans et al., 1991)
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WHAT MAKES CANADIAN HEALTH CARE DIFFERENT? One of the great ironies in the predicament in which health care in the United States finds itself today is that universal coverage or entitlement to benefits a key to health care system management (and cost control)
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From page 99... ...
But they will be right only because partisans of "autonomy," "pluralism," and "taxation anti-bodies"2 have used these approaches with almost religious fervor to suppress more comprehensive proposals for health care system reform and, at least so far, have restricted the policy choices to continued "disjointed incrementalism" (Kinzer, 1990~.3 Within this policy straitjacket, extending coverage to those Americans who are presently uninsured or underinsured would achieve universality but would almost certainly increase health care costs in the United States quite dramatically. Universality is not sufficient to achieve cost control.
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From page 100... ...
Unlike the United Kingdom, Canada chose to establish a collection of social insurance programs while leaving the actual provision of care largely in the hands of private "autonomous" medical practitioners. Although most hospitals are public institutions and are funded globally out of public funds, the clinical management of the patients treated in them is a matter left to private practitioners with privileges at each facility.
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appear to be emerging as a new growth industry in Canadian health care. As suggested later, however, they seem to come with more circumscribed and more realistic objectives than are found in the United States; there, managed care appears increasingly (at least to these authors)
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Political initiatives to control health care costs in Canada do not come up against the kind of need that exists in the United States to support and nurture another major set of economic activities.6 The world of technological innovation in medicine will carry on (and in all likelihood continue to prosper) regardless of what Canada does in the way of health care management.
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From page 103... ...
He emphasized that uncontrolled health care costs were now a serious drag on American prosperity and economic growth. Cooley, on the other hand, celebrated the glories of modern medicine and extolled the economic virtues of the export potential of the products and services developed and offered by the Texas medical complex (the largest such complex in the country)
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From page 104... ...
Because total health care costs are lower, the savings in private costs outweigh the extra tax payments. Provincial governments are responsible for the allocative decisions within the health care sector in each province and have a key role to play in the "pricing" of services.
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Negotiations in most provinces now have utilization "on the table" (over the protests of the medical associations) , and some medical associations appear to be willing to give up fee increases to avoid utilization or expenditure caps.
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Managing Capital The long-run viability of these Canadian approaches to managing health care costs will depend critically on the will and ability of Canadian policymakers to manage health care capital, including new technology. Health care capital comes in three basic forms: physical (bricks, mortar, machines and equipment)
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From page 107... ...
The expansionary dynamic of health care capital has roots in the explosion of the physician supply in North America and Europe over the past three decades (Schroeder, 1984; Viefhues, 1988; Evans et al., 1991~. Not only do new physicians create demands for new complementary treatment space (hospital beds and other facilities)
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It has not been particularly successful in managing its health care human capital because, unlike most physical capital, human capital is mobile. Each province is accountable for health care spending within its jurisdiction and can more or less successfully control overall levels of funding and the proliferation and diffusion of physical capital.
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Canada has not, then, to date, adequately addressed the issue of human capital management. Relative to the United States, however, it has better managed the proliferation of subspecialties.
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How successful Canada has been depends on where one sits, and on one's perception of the value of more, relative to lesser amounts, of different types of health care capital. Some American observers find much to envy in the Canadian approach (Marmor et al., 1990~.
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reduce health care costs while improving or leaving unaltered the health status of recipient patients; b. increase health care costs but produce substantial and unequivocal improvements in the functional capabilities of recipients; c.
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Life extension per se does not necessarily represent improvement in health status. The person concerned might feel, and genuinely be, "better off dead." An intervention that appears to belong in category (c)
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There is no informational counterpart to the provincial financial and managerial roles. Provincial ministries of health are loath to become involved in an organized effort to counter the claims of vendors because they fear that they cannot possibly succeed-that they will be perceived as simply projecting a message consistent with their responsibility to control costs, without much regard for outcomes.
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constitutional crisis. Given historical, federal all-party support for the Canadian medical and hospital insurance programs, the relative silence from the opposition parties suggests that they have not yet fully recognized the potential ramifications of the bill.
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emerges over the longer term, the need for such management will not disappear. THE FUTURE OF HEALTH CARE MANAGEMENT IN CANADA Despite these looming dark clouds, macromanagement is likely to continue to dominate the Canadian health care economy for the foreseeable future.
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From page 116... ...
Rather, outcomes research, the development of clinical practice guidelines, clinical competence assurance activities, and the like are seen in the Canadian context as tools for guiding resource allocation and organization within global budgets not as replacements for those budgets. No amount of micromanagement or outcomes research can tell a society how much of its scarce real resources should be devoted to health care.
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Health Affairs 8:149-157. British Columbia, Royal Commission on Health Care and Costs.
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1991. The twenty year experiment: Accounting for, explaining, and evaluating health care cost containment in Canada and the United States.
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1990. Canadian Health Care: The Implications of Public Health Insurance.
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