Rolling back third-party intrusions in the practice of medicine.

Formerly vaunted projections about the triumph of managed care over the provider-controlled health services industry now appear overly optimistic as consumer and provider opposition stiffens. Popular dislike of managed care and purchaser disenchantment over its failure to deliver on promises to control health insurance spending have created a strategic opening for rolling back third-party interference in medical practice. Employer frustration over rising premiums, compounded by workers' antagonism toward benefits restrictions and worry over the loss of government protection against managed care litigation, signals a radical overhaul in the way health insurance is offered. For many employers, substituting defined contribution for defined benefit plans and transferring ownership rights and responsibilities to employees is an attractive solution. Along with the growth of consumer-friendly health plans and a relaxation of onerous managed care practices, physicians can look forward to a restored doctor-patient relationship. This article identifies the forces pushing health care purchasers to adopt defined contribution plans and discusses the implications of such a movement on the physician-patient relationship.

A blended strategy using competitive and regulatory models.

Whether the health field in the United States should have more competition or more government regulation is now at the center of the public policy debate. After examining the market-driven and regulatory models to constrain cost and improve access to care, this article argues against supporting either extreme and instead favors a blended approach where the emphasis is on practicality rather than ideological exactness. Such a mixed strategy is predicted to eventually gain acceptance, legitimacy, and momentum, since such a hybrid design is more consistent with America's cultural and political values.

The new management competencies: a global perspective.

How will tighter controls over health expenditures, an increased supply of qualified doctors, and clinical acumen becoming more critical in allocating health resources under market-driven, capitated payment-type plans affect physicians? Throughout the world, they will play a greater role in the management of health facilities and services. To train doctors to provide leadership in these new, more market driven environments, education should focus more on the integration and coordination of clinical and managerial processes, an approach outside the scope of most curricula now offered. New managerial competencies will be required by the paradigm shift away from simply delivering quality health services to tighter cost containment efforts. Physicians will play an increasing role in how medical facilities and services are organized and financed--the blending of clinical and managerial-financial-information science processes will be paramount in these educational pursuits.

Making health reform work without employer mandates.

Requiring employers to furnish health insurance may be a politically expedient way to expand coverage to the uninsured, but it will surely undermine economic competitiveness and contribute to greater unemployment at a time when the U.S. is struggling to regain its economic strength. In the present environment, a wiser course of action would require that individual households, not employers, become the entity responsible for obtaining health insurance. Under such a scenario, limits would be established on the percentage of after-tax income devoted to health insurance, subsidies would be granted to low-income individuals to purchase insurance, and a basic benefit package would be developed that limits payments to services meeting efficacy and cost-effectiveness criteria.

Universal access to health care: a practical perspective.

Policy disconnected from economic reality is bad policy. Neither government financed health insurance nor an employer mandated health insurance approach are in the national interest. Higher national priorities compel a reallocation of resources from consumption to investment. This need not, however, cause an abandonment of efforts to deal with the problems of the uninsured and other health reforms. Successful health care reform is achievable provided it is responsive to higher priorities for economic growth. A strong economy and the production of wealth are indispensable to economic justice. Toward this end, a program of universal access is proposed whereby families and individuals are required to pay for their own health insurance up to a fixed percentage of disposable personal income before public payments kick in. Government's chief role is to establish a standard package of cost-effective benefits to be offered by all insurance carriers, the cost of which is approximately 40 percent less than conventional insurance coverage because of the elimination of reimbursement for clinically non-efficacious and cost-ineffective services. Public financing is relegated to a residual role in which subsidies are targeted on the needy. Much of the momentum for cost control is transferred to consumers and private insurers, both of whom acquire a vested interest in obtaining value for money. Uniform rules for underwriting, eligibility, and enrollment practices guard against socially harmful practices such as experience rating and exclusion of preexisting conditions. The household responsibility and equity plan described herein could free up as much as $90 billion or more for public investment in economic growth and national debt reduction while assuring access to health care regardless of ability to pay. Economic revitalization will be assisted by changes in household savings. With health care no longer a free good and government social programs concentrated on the truly needy, individual propensity to save will increase, thereby enlarging the pool of capital for financing investments in economic growth. Putting more responsibility for health care financing on households with an ability to pay also serves to reinforce and expand the work ethic. Privatizing responsibility by severing health insurance from the workplace connection improves the geographic and occupational mobility of labor, diminishes employer tendencies to discriminate against hiring the disabled and older employees, and eliminates a major source of labor unrest.(ABSTRACT TRUNCATED AT 400 WORDS)

National health insurance reconsidered: dilemmas and opportunities.

Changing social and economic constraints are precipitating a reformulation of the role of government in the provision of social welfare services. The authors conclude that government intervention in the health sector is bound to expand rather than contract because centralization is the key to reconciling otherwise divergent political demands for spending controls and greater equality of access to quality care for the increasing number of uninsured or underinsured persons. In the past eight years, the federal government has unleashed competitive market principles that have had negative side effects on the nation's health services. Payers, providers, and consumers will likely seek to protect themselves by forming coalitions, as happened recently in Massachusetts where the law now requires employers to provide minimum health insurance benefits to their employees. Escalating pressures to correct the damages from short-term piecemeal solutions to problems of health finance and delivery will provide the chief dynamic for universal health insurance in the United States. New economic, social, and political realities suggest, however, an eclectic strategy for attaining this goal that bears little resemblance to the conventional wisdom that guided health policy throughout the postwar period.