GP budget holding in the United Kingdom: learning from American HMOs

Extra-market incentives in the new NHS

This paper focuses upon a number of features of the NHS reforms which are external to the new market created by the purchaser-provider split. Initially, the market and the problems associated with its operation are examined. Particular consideration is given to the extent to which these problems are likely to hinder the achievement of the Government's objective of improved efficiency in the NHS. Each of the provider, purchaser and consumer sectors of the market is then examined more closely in relation to the extra-market incentives present. It is argued that these incentives do have the potential to complement the purchaser-provider split in encouraging improvements in efficiency. However, in several instances, the incentives are either the wrong incentives or are too weak to have any real impact in changing behaviour. In conclusion, it is argued that there is a need for more direct incentive structures to be introduced if improvements in efficiency are to be realised.

Razing a Tower of Babel: a taxonomy for managed care and health insurance plans

To many, the U.S. health care system has become an unintelligible alphabet soup of three-letter health plans. There is little agreement about which characteristics distinguish one type of plan from another. In this article we chip away at what has become a Tower of Babel of managed care and health insurance terminology. We review past and current trends in the market for nontraditional health benefit plans and propose a taxonomy, or system of classification, that will aid in understanding how managed care plans differ from conventional health insurance and from one another. Also included is a comprehensive glossary of terms.

Professional autonomy and managed care in Dutch health centres: stakeholders' perceptions of a strategic option

The on-going reforms of the Dutch health care systems call for the introduction of managed care elements. Health centres in the Netherlands already bear some resemblance to health maintenance organizations in the USA. However, managed care challenges provider autonomy, and the strategic development of managed care plans may be hampered by providers' perceptions. We draw a distinction between managed care within an insurance arrangement and managed care as a package of methods. Both options are evaluated as suitable for Dutch health centres, though with differences in terms of strategic logic and cultural fit. Lastly, some general conditions are formulated that should be considered before care management processes can be implemented. These include: specify clear objectives for introduction of managed care; strengthen corporate culture; develop internal motivation for change; develop a practice criterion with health centre professionals; reduce workloads in order to provide development time; and, promote better cooperation between general practitioners and specialists.

Indices for monitoring hospital outcomes in developed countries

We discuss some of the challenges facing hospitals in developed nations, with special attention to the need to monitor and evaluate hospital performance. In particular, there is a need for quality indicators that measure the effects of treatment, and are risk-adjusted, so that valid comparisons of outcomes can be made across hospitals that treat different types of patients. Until recently, only very crude quality indicators have been available for comparing the performance of different hospitals. We describe three risk-adjusted indices for comparing the outcomes of hospital care, focusing on the construction and validation of these measures. We discuss the uses of these tools for identifying problems and for monitoring outcomes of care within a hospital, including screening medical records for peer review, identifying variations in outcomes across various subgroups of physicians, and comparing changes in outcomes following various changes in the delivery system. Possible applications at the regional, national and international levels are then discussed, with special emphasis on the use of these tools for measuring the size of the gap between the efficacy of a technology, as determined through randomized controlled trials under stringent protocols, and the effectiveness of the same technology once it is exported, and then used under true practice conditions in another country.