Physician relations in Canada: shooting inward as the circle closes

Budgetary targets as cost-containment measure in the Swiss healthcare system? Lessons from abroad

Growing healthcare expenditure is a major concern for policy makers and calls for effective cost containment measures. For the decentralized Swiss healthcare system, ranking second among OECD countries in healthcare spending, a group of experts has proposed budgetary targets as key measure. In order to substantiate this proposal, we review the literature and analyse experiences with budgetary targets in comparable social health insurance systems, such as Germany and the Netherlands. Budgetary targets raise the cost responsibility and prompt providers to give greater weight to cost-benefit considerations. Our analysis suggests that the involvement of all principal healthcare players and clear decision-making and negotiating structures are key to successful implementation. Risks of rationing, lower quality incentives or conservation of structures have to be countered with taking into account age-related morbidity and medical progress when setting the budgetary targets. Accompanying measures such as incentive-compatible remuneration schemes and quality monitoring are of paramount importance.

Phantoms in the snow: Canadians' use of health care services in the United States

To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians' use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994-1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.

Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model

In this paper we revisit and add elements to our earlier conceptual framework on shared treatment decision-making within the context of different decision-making approaches in the medical encounter (Charles, C., Gafni, A., Whelan, T., 1997. Shared decision-making in the medical encounter: what does it mean? (or, it takes at least two to tango). Social Science & Medicine 44, 681 692.). This revised framework (1) explicitly identifies different analytic steps in the treatment decision-making process; (2) provides a dynamic view of treatment decision-making by recognizing that the approach adopted at the outset of a medical encounter may change as the interaction evolves; (3) identifies decision-making approaches which lie between the three predominant models (paternalistic, shared and informed) and (4) has practical applications for clinical practice, research and medical education. Rather than advocating a particular approach, we emphasize the importance of flexibility in the way that physicians structure the decision-making process so that individual differences in patient preferences can be respected.

Targets and systems of health care cost control

Discussion of health care cost control policy and politics tends to focus on terms such as "market," "government," and "managed care" that are either too general or too value laden to encourage sound analysis. This article proposes an alternative framework for classifying cost control policies. It first distinguishes targets from systems of control. Targets can then be divided into categories of service (e.g., hospital care, pharmaceutical treatment) and components of cost (e.g., price and volume). Systems can be classified in terms of the degree of pooling of finance, ranging from no insurance to a single pool of funds, and how payment of providers is organized, ranging from all payers paying all providers on the same terms to extensive selective contracting among payers and providers. The article analyzes examples of target policy and politics, system policy and politics, and how system choices can influence which targets are targeted how well, so as to show that both policy consequences and political alignments become clearer by using these terms. As one instance, discussions of "managed care" are often confused because the term has two meanings, one referring to target policy and one to system policy.

Dynamics of a changing health sphere: the United States, Britain, and Canada

Different patterns of change in the American, British, and Canadian health care systems in the 1990s result from the particular logic of each system. Different balances of influence across major categories of actors, and different mixes of hierarchical, market-based, and collegial instruments have different implications for lines of accountability and for information costs, and thus create different incentives that shape behavior. Market instruments functioned differently when introduced into Britain's system of "hierarchical corporatism" than in the American mixed-market system. Profession/state accommodations in Britain and Canada tempered the pace of change, while the entrepreneurial logic of the U.S. system generated a turbulent transformation.