Daniel Simonet

Cost reduction strategies for emergency services: insurance role, practice changes and patients accountability.

Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999–2000 alone. In that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to “stabilize” a patient suffering from an “emergency medical condition” before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users’ characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems.

The New Public Management Theory and the Reform of European Health Care Systems: An International Comparative Perspective

The New Public Management (NPM) Theory is a rhetorical construction with diverse intellectual roots. That diversity means that it is open to reinterpretation and shifts in implementation across countries (Sahlin-Andersson, 2001; Smullen, 2007). This overview article critically investigates NPM application in various EU health care systems. NPM led to a greater focus on market forces and competition and improved information sharing and cooperation among health care networks, and changed the way care is delivered. This article also identifies significant misfits between policy announcements and NPM implementation. NPM has taken root much more substantially in the United Kingdom (UK) than in France and Germany. The variety of capitalism and institutional systems provides an explanation for divergences in NPM implementation.

Patient satisfaction under managed care

PURPOSE In the USA, health maintenance organizations (HMOs) have pledged to control health care costs. Many patients have complained about the quality of care under the HMO regime and limits imposed on them, particularly access to care. Has quality of care been degraded under the HMO regime, resulting in an impact on patient satisfaction? There have been many studies that have compared the satisfaction of HMO patients with that of patients in the traditional fee-for-service payment system. The aim of this paper is to review HMO patient satisfaction. DESIGN/METHODOLOGY/APPROACH A review of patient satisfaction under managed care arrangements with a focus on HMOs. The article describes the US history of managed care and its effect on the satisfaction of several patient categories including the general population, vulnerable patients and the elderly. FINDINGS There is much information available on patient satisfaction with their insurers and most surveys indicate the lack of choice of a provider--a major source of discontent. Therefore, patient protection laws are necessary to avoid abuse. ORIGINALITY/VALUE Patients have little ability or are not willing to rely on the information available when selecting a provider. The paper discusses patient awareness regarding satisfaction surveys and how the latter can be used when patients are seeking care.

The New Public Management Theory in the British Health Care System: A Critical Review

This article analyzes health care reforms in the United Kingdom following the introduction of New Public Management (NPM) theory–inspired reforms. NPM has taken root deeply in the United Kingdom. This article looks at its impact on health care markets on the performance of health care organizations and on patients. It further seeks to address whether NPM prevents wastage and opportunism in health care. And finally, this article seeks to confirm whether rationality and accountability are greater under NPM or not. This article concludes that NPM reforms have failed to deliver on their own goals. There have been significant undesirable side effects and misfits between policy announcements and NPM implementation. Still, NPM adoption in health care has contributed to changing the Anglo-Saxon model of capitalism.

Healthcare reforms and cost reduction strategies in Europe: The cases of Germany, UK, Switzerland, Italy and France

PURPOSE This paper aims to analyse health reforms carried out in a sample of European countries. DESIGN/METHODOLOGY/APPROACH Using a country-specific approach, outstanding health reform features such as: greater competition between sickness funds in Germany; fund-holding practices in the UK; managed care models in Switzerland; health networks in France; and healthcare system decentralisation in Italy are analysed. FINDING There have been different approaches to controlling healthcare costs. Some states relied on public sector competition by creating quasi-markets (UK), insurance sector competition, particularly in Switzerland and Germany, organisational reforms in France by creating health networks and decentralisation in Italy. RESEARCH LIMITATIONS/IMPLICATIONS Societal and legal aspects are not discussed. ORIGINALITY/VALUE The paper compares healthcare reform effectiveness in a number of western European countries.

Assessment of new public management in health care: the French case

The French health care system embraced New Public Management (NPM) selectively, and crafted their own version of NPM using Diagnostic-Related-Group accounting to re-centralize the health care system. Other organizational changes include the adoption of quasi-markets, public private partnerships, and pay-for-performance schemes for General Practitioners. There is little evidence that these improved the performance of the system. Misrepresentation has remained high. With the 2009 Hospital, Patients, Health and Territories Act physician participation in hospital governance receded. Decision-making powers and health units were re-concentrated to instill greater national coherence into the health system.

The Vietnamese pharmaceutical market: a comparison of foreign entry strategies

Background. Entry strategies in the Vietnamese pharmaceutical market are under-researched. Aim. The first part of the paper provides an overview of the Vietnamese pharmaceutical market, and the second part a theoretical framework to understand the various foreign entry strategies. Methodology. Literature review and interviews with professionals. Contribution. Preference for one mode over another depends on market and company characteristics, the firms objectives and risk aversion level. Recommendations. There are few joint ventures. Licensing and acquisition of a local drug firm appear risky owing to lack of IP rights and cultural clash. The long-term pay-offs of wholly owned subsidiaries are higher.

Post-NPM Reforms or Administrative Hybridization in the French Health Care System?

New public management (NPM) provides an opportunity to analyze a reform trajectory that is influenced by country-specific institutional and social traditions. France adopted its own version of NPM, embracing some of its “traditional” elements such as quasi-markets and performance evaluation and rejecting others. NPM reforms in France pursued a re-centralization agenda rather than a disaggregation of public agencies. Outcomes were below expectations in core areas such as citizen participation and physician professional satisfaction. Subsequent health reforms indicate convergence toward a hybrid system rather than toward a post-NPM paradigm.

Exporting Managed Care: Asian Experiments

Following managed care saturation in the US market, and because of limited prospects in Europe, managed care made some headway in Latin America and Southeast Asia. The following paper compares a general concept, managed care, across countries, and shows that it has gained acceptance in certain territories (e.g. Hong Kong, the Philippines), but not in others. Managed care is defined as processes or techniques used by any entity that delivers, administers and/or assumes risk for health services in order to control or influence the quality, accessibility, utilization, costs and prices, or outcomes of such services provided to a defined population (American Medical Association, 1999). The first part of the paper reviews specific experiences (Indonesia, the Philippines, Malaysia, Hong Kong, Singapore), and is followed by a summary of difficulties that Managed Care encountered in Asia. Among these are rising public defiance and physician opposition.

Evaluation of downstream integration in the US pharmaceutical industry

Purpose – This paper aims to review the vertical or quasi‐vertical integration that characterized the pharmaceutical industry in the mid‐1990s. The acquisitions and vertical partnerships that linked pharmacy benefits managers and drug manufacturers modified the structure of the market at that time. What were the motivations of those agreements? Did they induce any distortion on competition in the drug market? And why did they fail to achieve their desired strategic advantages?Design/methodology/approach – The paper uses established theoretical perspectives, such as the resource‐based view and the theory of contestable markets, as the basis for a descriptive analysis, documenting strategic decisions of vertical integration using supporting literature in marketing and strategy.Findings – Vertical integration did not obtain the intended results (e.g. acquisition of competitive advantages). This perspective provides a framework to examine vertical integration strategies, applicable to other industries.Origina...