Physicians' views of the relative importance of thirty medical innovations.

In response to a mail survey, 225 leading general internists provided their opinions of the relative importance to patients of thirty medical innovations. They also provided information about themselves and their practices. Their responses yielded a mean score and a variability score for each innovation. Mean scores were significantly higher for innovations in procedures than in medications and for innovations to treat cardiovascular disease than for those to treat other diseases. The rankings were similar across subgroups of respondents, but the evaluations of a few innovations were significantly related to physicians' age. The greatest variability in response was usually related to the physician's patient mix.

The future of health economics.

This paper discusses health economics as a behavioral science and as input into health policy and health services research. I illustrate the dual role with data on publications and citations of two leading health economics journals and three leading American health economists. Five important and relatively new topics in economics are commended to health economists who focus on economics as a behavioral science. This is followed by suggestions for health economists in their role of providing input to health policy and health services research. I discuss the strengths and weaknesses of economics, the role of values, and the potential for interdisciplinary and multidisciplinary research. The fourth section presents reasons why I believe the strong demand for health economics will continue, and the paper concludes with a sermon addressed primarily to recent entrants to the field.

Health care for the elderly: how much? Who will pay for it?

Health care expenditures on the elderly tend to grow about 4 percent per year more rapidly than the gross domestic product (GDP). This could plunge the nation into a severe economic and social crisis within two decades. This paper describes recent growth in age/sex-specific health care utilization by the elderly and discusses the important role of technology in that growth. It also explores the potential for the elderly to pay for additional care through increases in work and savings. Efforts to "save Medicare" will prove to be "too little, too late" unless they are embedded in broader policy initiatives that slow the rate of growth of health care spending and/or increase the income of the elderly.

Overview: the next step.

If we are going to reform our healthcare system, we will have to start by providing access to basic care for everyone. This can be done through embracing a strategy that is built around integrated healthcare delivery systems. Payment should be via a universal tax for the basic plan, and there should be ways in which to pursue options beyond the basic plan, to be paid for by individuals. What is provided by way of care will need to be evaluated through a central technology assessment institute. The system will have to slow the rate of growth of spending in an intelligent way, not using price controls, caps, or repressive methodologies. The trick will be to still preserve a certain amount of freedom and flexibility, and include the capacity for change. There will have to be a significant reorientation of what has been our traditional approach to malpractice. Through the course of this symposium there has not been a great deal to be positive about. There are many physicians today who are well described by the English poet A. E. Housman's line, "A stranger and afraid in a world I never made." Change is inevitable; it is here and more is coming. The great medical historian Henry Sigerist noted that: "The physician's position in society, the task assigned to him, and the rules of conduct imposed on him changed in every period. They were determined primarily by the social and economic structure of society and by the technical and scientific means available to medicine at the time."(ABSTRACT TRUNCATED AT 250 WORDS)

A conversation about health care reform. Interview by Linda Hawes Clever.

Professor Victor R. Fuchs is the Henry J. Kaiser Jr Professor at Stanford (California) University, where he applies economic analysis to social problems of national concern, with special emphasis on health and medical care. He holds joint appointments in the Economics Department and the School of Medicine's Department of Health Research and Policy. Professor Fuchs is a Distinguished Fellow of the American Economic Association and a member of the American Philosophical Society, the American Academy of Arts and Sciences, and the Institute of Medicine of the National Academy of Sciences. He was the first economist to receive the Distinguished Investigator Award of the Association for Health Services Research and has also received the Baxter Foundation Health Services Research Prize. Professor Fuchs is president-elect of the American Economic Association. His latest book, The Future of Health Policy, was published by Harvard University Press in 1993. The following edited conversation between Professor Fuchs and Linda Hawes Clever, MD, Editor of the journal, took place on April 8, 1994.

The Clinton plan: a researcher examines reform.

The Clintons are commended for bringing health care reform to the top of the domestic policy agenda. Their plan's basic elements are summarized and critiqued, with emphasis on the problems posed by its complexity. Five false assumptions that underlie most reform proposals are examined. They concern the burden of health care costs, the significance of firm size, the effect of health care costs on global competitiveness, the relation between insurance coverage and expenditures, and the implications of health care reform for the health of the population. Three critical issues for the future of health policy are discussed: the disengagement of health insurance from employment, the taming of technologic change, and coping with an aging society.

Hospital expenditures in the United States and Canada.

BACKGROUND: Expenditures per capita for hospitals are higher in the United States than in Canada. If the United States had the same spending pattern as Canada, the annual savings in 1985 would have exceeded $30 billion. METHODS: We used data from published sources, computer files, and institutional reports to compare 1987 costs for acute care hospitals on three levels: national (the United States vs. Canada), regional (California vs. Ontario), and institutional (two California hospitals vs. two Ontario hospitals). Expenditures per admission were adjusted for the case mix of patients, prices of labor and other resources, and outpatients visits. RESULTS: The United States had proportionately fewer hospital beds than Canada (3.9 vs. 5.4 per 1000 population), fewer admissions (129 vs. 142 per 1000 population), and shorter mean stays (7.2 vs. 11.2 days). Higher costs per admission in the United States were explained in part by a case mix that was more complex by 14 percent and by prices for labor, supplies, and other hospital resources that were higher by 4 percent. Hospitals in the United States provided relatively less outpatient care, particularly in emergency departments (320 vs. 677 visits per 1000 population). After all adjustments, the estimate of resources used for inpatient care per admission was 24 percent higher in the United States than in Canada and 46 percent higher in California than in Ontario. The estimated differences between the two pairs of California and Ontario hospitals were 20 and 15 percent. CONCLUSIONS: Canadian acute care hospitals have more admissions, more outpatient visits, and more inpatient days per capita than hospitals in the United States, but they spend appreciably less. The reasons include higher administrative costs in the United States and more use of centralized equipment and personnel in Canada.

America's children: economic perspectives and policy options.

American children are worse off than those in the previous generation in several important dimensions of mental, physical, and emotional well-being. During the 1960s cultural changes adversely affected children while their material condition improved substantially. By contrast, material conditions deteriorated in the 1980s, especially among children at the lower end of the income distribution. Public policies to improve the material condition of children require a transfer of resources from households that do not have children to those that do. Government programs such as tax credits and child allowances are more efficient and equitable than employer-mandated programs.