Adolf Stepan

Principal-agent problems in health care systems: an international perspective

A central feature of all health care systems is the flow of finances from the population, via a variety of agencies, to the providers of health care. Each transfer of funds within the system involves a principal-agent problem, in the sense that a principal is entrusting funds to an agent with the intention that some desired aspect of health care delivery can be secured. This paper examines within the context of a principal-agent model three key elements of the health care system: the raising of finance, the transfer of funds to hospitals, and spending by hospitals. At each of these stages there is a danger that the objectives of society for the health care system are lost. In order to illustrate the issues involved, five mature systems of health care are examined: Austria, Germany, the United Kingdom, the Netherlands and the United States of America. The paper concludes that three aspects of the flow of funds are crucial to securing adequate control: the means of controlling patient entry to hospitals; the mechanism for remunerating hospitals for additional patients; and the control of physicians by hospital management.

Priority setting in Austria

Priority setting and rationing are not yet matters of public debate in Austria. Before a discussion on rationing is undertaken, the incentive system concerning the financing of health care services needs to be reformed, especially in relation to the reimbursement of hospitals and physicians. This is necessary if a waste of scarce resources is to be avoided. Although methods and principles of priority setting and rationing are not openly discussed, several rationing techniques are already performed as organisational tools. A Eurobarometer survey of the population regarding their satisfaction with the health care system confirms the presumption that Austrians are not aware of the fact that rationing methods already exist.

Evaluating the New Activity-Based Hospital Financing System in Austria

This paper analyses the effects of the new activity-based hospital financing system on hospital performance and hospital costs in Austria. The research concentrates on differences in response among publicly-owned and privately-owned, not for profit hospitals by exploring hospital data from 1994 to 1997 with regard to credit point optimisation, shifts in performance from the inpatient to the outpatient care unit and from the outpatient care unit to physicians with their own practice, and changes in average length of stay. Techniques applied range from index figures to weighting figures and, at least, Data Envelopment efficiency scores.

Ein hierarchisches Informationssystem zur Analyse von Anreizwirkungen in Spitälern

■ Die Einfuhrung der leistungsorientierten Krankenanstaltenfinanzierung am 1.1.1997 mit Gultigkeit bis zum 31.12.2000 in Osterreich hat zu einer deutlichen Veranderung des auf die Spitaler wirkenden Anreizsystems gefuhrt. In diesem Beitrag wird mit einem hierarchischen Informationssystem analysiert, wie sich dieses geanderte Anreizsystem auf die Kosten- und Leistungsstruktur der Spitaler ausgewirkt hat. ■ Zu diesem Zweck werden mit Hilfe von Indexzahlen, Aquivalenzzahlen sowie der Data Envelopment Analysis (DEA) Hypothesen bezuglich des zu erwartenden Verhaltens der Spitaler untersucht, wobei insbesondere die Unterschiede im Hinblick auf die Tragerschaft der Krankenanstalten erforscht werden. ■ Mit Hilfe der Ergebnisse der Indexzahlen sowie der DEA konnte von 96 auf 97 ein deutlicher, creeping ‘-Effekt nachgewiesen werden. Daruberhinaus wurde mit den Aquivalenzzahlenreihen gezeigt, das Spitaler unter privater Tragerschaft fruher und in einem hoheren Ausmas am erwarteten ‚LDF-Punktewettkampf ‘ teilgenommen haben als Krankenanstalten unter offentlicher Tragerschaft.

Individual and Institutional Corruption in European and US Healthcare: Overview and Link of Various Corruption Typologies

In recent years, the fight against healthcare corruption has intensified. Estimates from the European Healthcare Fraud and Corruption Network calculate an approximate €56 billion annual loss to Europe as a result of corruption. To promote understanding of the complexity and interconnection of corrupt activities, we aim to present healthcare-related corruption typologies of the European Union and European Healthcare Fraud and Corruption Network. We subsequently link them to the typology of individual and institutional corruption introduced by Dennis Thompson in the context of investigating misconduct of US Congressional members. According to Thompson, individual corruption is the personal gain of individuals performing duties within an institution in exchange for nurturing private interests, while institutional corruption pertains to the failure of the institution in directing the individual’s behaviour towards the achievement of the institution’s primary purpose because the institutional design promotes the pursuit of individual goals. Effective anti-corruption activities not only require the enactment of anti-corruption laws but also the monitoring and, where appropriate, revision of institutional frameworks to prevent the undermining of the primary purposes of health systems or institutions. To gain further understanding of the similarities and differences of the three typologies, prime examples of corrupt activities in the health sector in the European Union and USA (along with their potential remedies) are provided. Linking corruption cases to Thompson’s typology revealed that many corrupt activities may show elements of both individual and institutional corruption because they are intertwined, partly overlap and may occur jointly. Hence, sanctioning individual actors only does not target the problem.

Hospital physician payment mechanisms in Austria: do they provide gateways to institutional corruption?

Institutional corruption in the health care sector has gained considerable attention during recent years, as it acknowledges the fact that service providers who are acting in accordance with the institutional and environmental settings can nevertheless undermine a health care system’s purposes as a result of the (financial) conflicts of interest to which the service providers are exposed. The present analysis aims to contribute to the examination of institutional corruption in the health sector by analyzing whether the current payment mechanism of separately remunerating salaried hospital physicians for treating supplementary insured patients in public hospitals, in combination with the public hospital physician’s possibility of taking up dual practice as a self-employed physician with a private practice and/or as an attending physician in private hospitals, has the potential to undermine the primary purposes of the Austrian public health care system. Based on the analysis of the institutional design of the Austrian public hospital sector, legal provisions and directives have been identified, which have the potential to promote conduct on the part of the public hospital physician that systematically undermines the achievement of the Austrian public health system’s primary purposes.

Flexible Fertigungssysteme und ihr Einfluß auf das Marktverhalten und den Wettbewerb

Jede Veranderung der Produktionstechnik fuhrt auch zu einer Veranderung der Wettbewerbsbedingungen, die sich in geanderten Reaktionsweisen von Anbietern und Nachfragern niederschlagen. Ganz besonders gilt dies fur den Paradigmenwechsel im Bereich der Fertigungstechnologie. In diesem Beitrag werden zunachst die Wechselwirkungen zwischen technischem Fortschritt und Marktverhalten von Anbietern und Nachfragern skizziert. Anschliesend wird auf die Rolle des Computer Integrated Manufacturing (CIM) im Rahmen flexibler Fertigungssysteme (FFS) eingegangen und marktverandernde Potentiale dargestellt. Abschliesend werden empirische Arbeiten zur Diffusion von FFS diskutiert.