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Name your poison or name your reality
POLICY WATCH
monthly insurance premium for benefits that may or may not be needed. Another barrier to increasing coverage through the small business sector is the fact that when employers offer health insurance benefits, they are automatically expanding their labor costs at a time when firms can only survive by limiting their labor costs as much as possible. And, finally, the young feel invincible. A large portion of the uninsured are young adults who cannot imagine themselves having a serious injury or disease. Thus, they elect not to pay for health insurance. In spite of these obstacles, the projects gave affordability their best shot. They limited benefits and provider networks, they sought premium subsidies, and they arranged provider discounts. Still, it was not enough to entice a significant portion of the targeted small business market to offer the plans to their employees. This is important information with respect to the present debate over employer mandates as a mechanism for expanding access to health insurance. Given that the percent of the work force employed by Fortune 500 companies has decreased in the past 20 years and the growth in employment has occurred in the small business sector of the economy (i.e, businesses that employ fewer than 100 employees), this means we can expect to see a continuing increase in the number of working uninsured. In times of high unemployment when jobs with benefits are dwindling and competition for jobs has intensified, workers will not demand health insurance as a condition of employment. The authors conclude that the major policy implication from these projects is that efforts to expand the current employerbased insurance system are not likely to achieve universal finan-
cial access to health care unless there is a legal mandate. And they argue that it is not fair to require employees in small firms to pay more for their health insurance than they would if they were employed in large firms. Yet, that is the disparity between the large group/small group markets. At the outset of the projects, the Robert Wood Johnson Foundation’s Health Care for the Uninsured Program had underestimated the operational complexities of achieving reform. If universal access to health insurance is the goal, voluntary employer-sponsored health insurance is not the means to reach it.-MEG
Name Your Poisonor Name Your Reality [Hillman AL. Managing the physician: rules versus incentives. Health Aff (Millwood) 1991; 10: 138-46.1
T
his provocative commentary discusses one aspect of the new environment facing health care, specifically, managed care and controls placed on physician behavior. Hillman maintains there are two primary ways being used by organizations to affect physician practice patterns-the instigation of clinical rules or the implementation of incentives. Each of these places limitations on physician autonomy and clinical decision making, and each affects the physician’s relationship as the patient’s agent. In theory, the physician acts in the best interest of the patient without interference from any third party. But in reality, interference of one type or another has existed for many years. The fee-
for-service reimbursement system encouraged additional services to be provided which led to more payment. Managed-care systems encourage efficiency and quality, which may imply fewer services. According to Hillman, there are advantages to clinical rules over incentives as a way to affect physician behavior. They help in the dissemination of new knowledge; they have explicit criteria for evaluation of conditions and may help provide explanation for the patient; and they may lead to more standardization in the treatment of certain medical conditions. By providing clear parameters, clinical rules tell the physician how to respond to a specific set of clinical conditions. Unfortunately, however, there is little research on how clinical rules affect the cost and quality of medical care. The other primary approach to the control of physician clinical decision making is the incentive approach. Incentives can take several forms, but the most common is the financial incentive where the physician is exposed to some risk or some reward for certain actions. Financial incentives for reducing hospital use are one of the more prominent applications of this mechanism for controlling costs. Both rules and incentives limit a sense of professional autonomy by physicians. If rules are established properly, however, with appropriate physician involvement and adequate updating, they may lead to higher quality of care and to establishing new standards of care. On the other hand, there is great potential for conflict that may arise from the use of financial incentives which pit the patient’s interests against the interests of the organization or group practice. Hillman’s advocating the evaluation of new systems that bal-
October 1992 The American Journal of Medicine
Volume 93
Ill
ante the use of rules and incentives is appropriate. He states that “several HMOs are experimenting with systems in which payment to primary care physicians is based partly on quality assessments . . . including chart reviews for adherence to clinical protocols, patient satisfaction surveys, and reviews of providers’ adherence to certain predetermined administrative standards of care.” These quality assessments along with external review of the HMO lead to greater accountability of the physician. And, as always, there is great need for research to evaluate the impact of rules and incentives on physician behavior and on the health care system.-AM
Chaos in the High=Rise [Mullan F. Missing: a national medical manpower policy. Milbank Q 1992; 70: 381-6.1
T
wo supply-side factors account in large measure for the successes of national health programs in countries like Canada and England. First, income differentials between generalists and specialists are less
IV
than in the U.S., and second, the percentage of Canadian and English physicians who are generalists exceeds 50%, well above the U.S. supply. The first issue-income disparities-is being addressed in the U.S. to the degree currently feasible by the Resource-Based Relative Value Scale (RBRVS). In essence, the RBRVS will reduce income differentials by making reimbursement more related to the level of resources applied directly by the physician, i.e., time spent managing a patient’s care. This should provide an incentive for more students to choose primary care specialties. However, addressing the second issue, the percent of training slots in primary care, will require a significant change in graduate medical education. Dr. Mullan likens graduate medical education to a high-rise apartment with the 150 or so medical schools occupying the ground floor. The more than 1,500 postgraduate residency training programs reside on the floors above, each occupying a small space with its own landlord. The relationship of the upper floor tenants to the medical schools on the first floor is informal and “disarticulated.” Medical schools may try to influence postgraduate training se-
October 1992 The American Journal of Medicine
Volume 93
lection, albeit halfheartedly, but are simply overwhelmed by the number of disparate programs, each answering to a different set of pressures, both real and imagined. Consequently, efforts by medical schools to make primary care appear more attractive are thwarted by training programs with totally different agendas. Vertical integration of the medical schools with the training programs would quickly reduce chaos in the high-rise. While a number of different scenarios are possible, Mullan suggests regional medical education consortia composed of a medical school and regionally affiliated training programs. Primary care manpower targets could then be established by the federal government and gradually phased in over a several-year period. Federal funding of graduate medical education, which will total $5.3 billion in 1992, is the obvious incentive to make the consortia comply with the primary care goals. Such an intrusion into the domain of graduate medical education will appear too much like regulation to many interested parties. But if the supply-side issues of national health reform are to be adequately addressed, “gentle, but firm, intrusiveness will be necessary to gain control....“-MM
monthly insurance premium for benefits that may or may not be needed. Another barrier to increasing coverage through the small business sector is the fact that when employers offer health insurance benefits, they are automatically expanding their labor costs at a time when firms can only survive by limiting their labor costs as much as possible. And, finally, the young feel invincible. A large portion of the uninsured are young adults who cannot imagine themselves having a serious injury or disease. Thus, they elect not to pay for health insurance. In spite of these obstacles, the projects gave affordability their best shot. They limited benefits and provider networks, they sought premium subsidies, and they arranged provider discounts. Still, it was not enough to entice a significant portion of the targeted small business market to offer the plans to their employees. This is important information with respect to the present debate over employer mandates as a mechanism for expanding access to health insurance. Given that the percent of the work force employed by Fortune 500 companies has decreased in the past 20 years and the growth in employment has occurred in the small business sector of the economy (i.e, businesses that employ fewer than 100 employees), this means we can expect to see a continuing increase in the number of working uninsured. In times of high unemployment when jobs with benefits are dwindling and competition for jobs has intensified, workers will not demand health insurance as a condition of employment. The authors conclude that the major policy implication from these projects is that efforts to expand the current employerbased insurance system are not likely to achieve universal finan-
cial access to health care unless there is a legal mandate. And they argue that it is not fair to require employees in small firms to pay more for their health insurance than they would if they were employed in large firms. Yet, that is the disparity between the large group/small group markets. At the outset of the projects, the Robert Wood Johnson Foundation’s Health Care for the Uninsured Program had underestimated the operational complexities of achieving reform. If universal access to health insurance is the goal, voluntary employer-sponsored health insurance is not the means to reach it.-MEG
Name Your Poisonor Name Your Reality [Hillman AL. Managing the physician: rules versus incentives. Health Aff (Millwood) 1991; 10: 138-46.1
T
his provocative commentary discusses one aspect of the new environment facing health care, specifically, managed care and controls placed on physician behavior. Hillman maintains there are two primary ways being used by organizations to affect physician practice patterns-the instigation of clinical rules or the implementation of incentives. Each of these places limitations on physician autonomy and clinical decision making, and each affects the physician’s relationship as the patient’s agent. In theory, the physician acts in the best interest of the patient without interference from any third party. But in reality, interference of one type or another has existed for many years. The fee-
for-service reimbursement system encouraged additional services to be provided which led to more payment. Managed-care systems encourage efficiency and quality, which may imply fewer services. According to Hillman, there are advantages to clinical rules over incentives as a way to affect physician behavior. They help in the dissemination of new knowledge; they have explicit criteria for evaluation of conditions and may help provide explanation for the patient; and they may lead to more standardization in the treatment of certain medical conditions. By providing clear parameters, clinical rules tell the physician how to respond to a specific set of clinical conditions. Unfortunately, however, there is little research on how clinical rules affect the cost and quality of medical care. The other primary approach to the control of physician clinical decision making is the incentive approach. Incentives can take several forms, but the most common is the financial incentive where the physician is exposed to some risk or some reward for certain actions. Financial incentives for reducing hospital use are one of the more prominent applications of this mechanism for controlling costs. Both rules and incentives limit a sense of professional autonomy by physicians. If rules are established properly, however, with appropriate physician involvement and adequate updating, they may lead to higher quality of care and to establishing new standards of care. On the other hand, there is great potential for conflict that may arise from the use of financial incentives which pit the patient’s interests against the interests of the organization or group practice. Hillman’s advocating the evaluation of new systems that bal-
October 1992 The American Journal of Medicine
Volume 93
Ill
ante the use of rules and incentives is appropriate. He states that “several HMOs are experimenting with systems in which payment to primary care physicians is based partly on quality assessments . . . including chart reviews for adherence to clinical protocols, patient satisfaction surveys, and reviews of providers’ adherence to certain predetermined administrative standards of care.” These quality assessments along with external review of the HMO lead to greater accountability of the physician. And, as always, there is great need for research to evaluate the impact of rules and incentives on physician behavior and on the health care system.-AM
Chaos in the High=Rise [Mullan F. Missing: a national medical manpower policy. Milbank Q 1992; 70: 381-6.1
T
wo supply-side factors account in large measure for the successes of national health programs in countries like Canada and England. First, income differentials between generalists and specialists are less
IV
than in the U.S., and second, the percentage of Canadian and English physicians who are generalists exceeds 50%, well above the U.S. supply. The first issue-income disparities-is being addressed in the U.S. to the degree currently feasible by the Resource-Based Relative Value Scale (RBRVS). In essence, the RBRVS will reduce income differentials by making reimbursement more related to the level of resources applied directly by the physician, i.e., time spent managing a patient’s care. This should provide an incentive for more students to choose primary care specialties. However, addressing the second issue, the percent of training slots in primary care, will require a significant change in graduate medical education. Dr. Mullan likens graduate medical education to a high-rise apartment with the 150 or so medical schools occupying the ground floor. The more than 1,500 postgraduate residency training programs reside on the floors above, each occupying a small space with its own landlord. The relationship of the upper floor tenants to the medical schools on the first floor is informal and “disarticulated.” Medical schools may try to influence postgraduate training se-
October 1992 The American Journal of Medicine
Volume 93
lection, albeit halfheartedly, but are simply overwhelmed by the number of disparate programs, each answering to a different set of pressures, both real and imagined. Consequently, efforts by medical schools to make primary care appear more attractive are thwarted by training programs with totally different agendas. Vertical integration of the medical schools with the training programs would quickly reduce chaos in the high-rise. While a number of different scenarios are possible, Mullan suggests regional medical education consortia composed of a medical school and regionally affiliated training programs. Primary care manpower targets could then be established by the federal government and gradually phased in over a several-year period. Federal funding of graduate medical education, which will total $5.3 billion in 1992, is the obvious incentive to make the consortia comply with the primary care goals. Such an intrusion into the domain of graduate medical education will appear too much like regulation to many interested parties. But if the supply-side issues of national health reform are to be adequately addressed, “gentle, but firm, intrusiveness will be necessary to gain control....“-MM