The development of market approaches in Russia

In the late 1980s, it became clear that poor outcomes of the Russian health system were caused not only by underfunding but also by inadequate management of health care. Some features of the system led to great inefficiency in medical care provision and an irrational structure of medical care. The recognition of this fact has intensified the search for new methods of finance and management. The underlying idea of health care reforms in Russia is to weaken providers' dominance, to make them more responsive to consumer preferences, and to change the structure of medical care. The main developments of the reform parallel the reforms in Western countries. These are primarily the separation of finance and provision of medical care, with the shift from an integrated to a contractual model of relationships between payers and providers. But the specific characteristics of the health care situation, primarily the great underfunding and the absolute dominance of state-owned medical facilities, make the reform in the Russian health sector more radical. This paper highlights the issues of the current and planned developments in the Russian health sector. After presenting the main characteristics of the current health systems, it addresses economic experiments which are underway in several regions of the new Russian Federation. They are designed to introduce elements of market relations into a highly bureaucratic system. The main features and the impact of the experiments are discussed. Then the new model of finance, which is based on a transition from tax-financed to the health insurance system, is presented.

What kind of healthcare 'internal market'? A cross-Europe view of the options

Many governments are trying to invent new types of 'internal' healthcare market that will expose health services to competitive pressures to innovate, contain costs, raise service quality, and respond better to consumer demands; but not expose them to 'market failures' which prejudice universal access to 'basic' health services. Policy debates in this area are muddled and constricted by a failure to differentiate the variants of internal market that are available. This article outlines a taxonomy of the main types of internal market: primary doctor purchasing; managed competition; competitive bidding; social insurance; and compulsory private insurance. It notes their main structural characteristics and differences. Although internal market reforms have been intended to support the commercialization of healthcare, the idea of designing new types of economic structure to avoid market failure in healthcare has wider and more radical implications than most policy-makers intend.

Reforming health care in The Netherlands

Health reforms in The Netherlands have been introduced into a very different environment but with similar aims: efficient, effective, high quality care that addresses the needs of individual patients. Anne-Marie te Maarssen and Richard Janssen outline progress so far.

Management challenges and markets

The scarcity of resources in healthcare systems has general causes and country-specific causes. Common to most healthcare systems is a strong emphasis on management and an increased attention to the role of the market. Management and market are concepts which need clarification: management applies not only to individual institutions but to systems of institutions. Market implies not only the pursuit of individual interests but also the assumption of responsibility. The design or redesign of healthcare systems must take into account the level of management skills which each system and its institutions can rely on. Cost patterns in a healthcare system develop around its institutional design. Different factors produce varying levels of costs in different healthcare systems. The same applies to the effort needed to reach a certain degree of effectiveness in output. An outline of strengths and weaknesses of options for the design of healthcare systems is presented in the final part of the article. These should always be considered together with the specific features of each country.

Market competition and the quality of nursing home care

This article identifies factors influencing the degree of competition in the nursing home market. Using data obtained from the 1987 Medicare and Medicaid Automated Certification Survey, the relationship between competition and structural and process measures of quality (registered nurse staffing and resident care management practices) is estimated by weighted two-stage least squares regression. Results suggest that the quality effects of indicators of competition vary and that market concentration may not diminish quality-based competition. Proposals for nursing home reimbursement reform are evaluated with respect to their incentives for enhancing quality, particularly in the Medicaid market segment.

The market and health sector reform

A new international orthodoxy has developed on health sector reform. The dominant theme of the orthodoxy is the alleged benefits of market style reforms for health development. This is shaping changes formulated, and being implemented, in the British NHS and other European health services (including Central and Eastern Europe), Latin America and a number of developing health systems in Africa and Asia. Sets out a ten-point description of the orthodoxy. Contends that the orthodoxy is showing distinct signs of restricting the analysis and development of health management and planning. This is a matter for considerable concern as the adoption of market-style reforms can generate unforeseen and, in some cases, negative consequences. There is clearly a need for strengthening management research and development as a basis for effective health sector reform.

Competitive strategies for faculty practice plans in the 1990s

The upsurge in clinical revenue of faculty practice in academic centers over the last decade may be succumbing to RBRVS growth in managed care plans. Author Alan M. Zuckerman, FAAHC, investigates this possibility in his article.

Monopoly medicine?

"Integrated" health plans, which tie together doctors, hospitals and other services, are being touted as a remedy for the nation's ailing health system. But in Minnesota, where such plans are relatively well established, a side effect has appeared: a rash of mergers and acquisitions that could undermine competition in the health care market.

Integrated delivery systems reposition for reform

As policy-makers debate the ultimate design for health care reform, the pace of change in the fundamental structure for health care financing and delivery is accelerating, writes John Cochrane. State governments, employers, HMOs, insurers, hospitals, physicians and vendors are aggressively changing the way they are organized and do business. Cochrane's message to anyone involved in health care: "The revolution is now!"