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Training health services managers: improving health by more health economics?
Health Policy, 9 (1988) 25-37 Elsevier
25
HPE 00184
Training health services managers: improving health by more health economics? Reiner Leidl lnstitut
fiir Medizinische
Gesellschaft F.R.G. Accepted
lnformatik
fiir Strahlen-
20 September
und Systemforschung
und Umweltforschung
(MEDIS),
mbH (GSF), Neuherberg,
1987
Summary In times of rising health expenditures and imminent health problems, efficiency is a crucial element for maintaining and improving health care and, finally, health. One major support measure is the effective management of health services. This paper considers possible improvements of health care by training health services managers in health economics. It surveys the current state of health economics training, presents approaches towards the key issues of health economics, discusses the impact of health economics by two examples, and considers management aspects of health economics training. Health economics
training;
Health services management
Introduction When Hippocrates, who lived on the Greek island of Kos around 460 BC, formulated his oath, which has often been quoted in medical ethics since, he also included some economic rules: “Physicians”, he said, “should promise to share their livelihood with their teachers, to support them in times of hardship, and to teach their children - upon request and without remuneration -the art of medicine” [l].
Address for correspondence: Health Planning and Health 016%8510/88/$03.50
0
Dr. Reiner Economics,
1988 Elsevier
Leidl. MEDIS-Institute/GSF.WHO-Collaborating IngolGdter LandstraBe 1. 8042 Neuherberg,
Science
Publishers
B.V. (Biomedical
Division)
Centre F.R.G.
for
26
Of course, this is only a small aspect out of the multitude of economic aspects of health and health care. But up to now, the relevance of economics in health care is still controversial in many a physicians’ opinion. As an economist, Alan Maynard has pinpointed the strained relationship between medicine and economics by formulating yet another moral principle: inefficiency is unethical [2]. So economics must and can provide its share to health and health care; it is a necessity in the support of public health. Health economics training can be looked upon as one instrument to promote the contribution made by economics. It will be discussed specifically for the group of health services managers. Health economics as a knowledge basis for problem recognition and solving, its training programmes and some aspects of the effectivity of both will be dealt with. First an overview is given on the current state of health economic training programmes. Then key issues in health economics for health services managers are investigated. As examples for possible effects of health economics, two case-studies are presented. A last part discusses planning and evaluation of health economics and its training from a (social) management perspective.
Current state of health economics training Health economics as an academic discipline has a much shorter history than the introduction might suggest. A 1951 meeting of the American Economic Association on the ‘Economics of Medical Care’ [3] can be considered as a starting point after World War II. An uncountable number of papers, publications and meetings followed, certainly with a significant increase accompanying cost developments in about the last two decades (for annotated bibliographies, see [4,5]). The expansion of research work was supplemented by a growth of education and training in health economics. Recent cross-sectional surveys conducted in 26 countries from Asia, Australia, Europe and Northern America revealed almost 700 courses in this field ([6]; for the European region, cf. [7]). In the Federal Republic of Germany, for example, there were 58 courses rePorted for the academic year of 1983/84. They were taught in diverse faculties such as economics, medicine, business, law, administration, sociology, political science, and industrial engineering. The scope of the courses ranged from 100% health economics to applications of economic debates (e.g. competition vs regulation), programmes in social policy, and others. Nine non-academic institutions provided another 29 courses at the same time. All in all, health economics could be characterized as a problem-oriented, applied and interdisciplinary science [8]. But in spite of the fact that health economics was spread quite well in the Federal Republic of Germany, it lacked the symbols of acknowledgement such as own institutes or being part of academic exams at the time of the survey. In 1986, however, it was the title of the annual meeting of the German ‘Verein fur Socialpolitik’ [9], which may indicate the respect of the economic profession for this field. As an example for what and how issues are thought of in health economics, some
Case studies Group discussion Expert lectures
Source:
own survey
Master in health policy and management (U.S.A.) 2 years
(1985).
Comprehensive theoretical and empirical analysis of health care systems
Cost-benefit and -effectiveness analysis, quality assessment. decision analysis
and
Competition/regulation, priority-setting/ planning/strategy implementation, cost-containment techniques, non-economic theories
and
Hospital management accounting
Cost theory calculation
hospital fiand planning systems’ com-
German nancing system, parison
Hospital tration (F.R.G.) 2 years
adminis-
Case studies Expert lectures
Health care goods and markets, health (care) measurement, equity. clinical budgeting, DRGs
Principles, techniques and application of economic appraisal
Theoretical analysis: incentives, doctors’ payment, alternative organisation
Health service administration (Ireland) 10 days
Case studies In-service Training
Expert lectures Planning game
Budget allocation. investment credits. DRGs, role of social security insurance
assessment
Quality
Case studies Working group Discussions
and
Special teaching methods
Other health economics; related issues
Organisation of hospital/health care system in the Netherlands systems’ comparison
evalua-
Hospital administration (Netherlands) 9 days
Economic tion Hospital accounting management
and
for health services managers
Economic evaluation of hospital activities
System description analysis
training
Evolution of the Greek health care system
Country. of course
of health economics
Hospital administration (Greece) 80 hours
Course, Length
Five examples
Table 1
Post-graduate academic programme; Health economics oriented towards research/application
Very broad-based fulltime study; Health economics oriented towards financing
Comprehensive academic course; Full scale health economics
Programme especially oriented towards country context and policy issues; Applied economics
Broad-based introductory programme; Basic economics for problem solving
Type of course; Role of health economics
28
programmes for health services or hospital managers are examined more closely. Table 1 shows 4 courses from European countries and one program from a school of public health in the United States, which are compared for the issues covered and for special teaching methods; further, their general type and the role of health economics in the course is characterized. Three courses are especially designed for hospital managmenent. Health economics has not always been included in the courses as an own field of study, and it differs remarkably in its economic comprehensiveness and in its methodological depth. Some courses are designed more systematically and analytically, others are oriented towards descriptive purposes. Three courses are short-type programmes and last about 10 days, the other ones are full-time studies and last two years. With respect to special teaching methods, most of the programmes offer case studies. Applications which are problem-oriented and relevant to the professional environment of managers represent the preferred teaching method, as it has also been recommended for the training of health services managers [ 10,111. Quantitatively and qualitatively, health economics may thus be featured as a wide field of study, which is diverse, but hardly definite. Even for a certain target group like health services managers, its practical orientation leads to manifold variations. Concepts and criteria to plan and evaluate health economics training must therefore be considered.
Key issues of health economics training What are the key issues of health economics for health services or hospital managers? One common approach would be to investigate the relevance of health economics textbooks with respect to health services management. Such textbooks [12-181 cover general problems in the economic analysis of health care; some pay special attention to health care sectors like hospital care. Others are devoted only to economic problems of the hospital [19-211. However, most of these books do not include specific applications for different target groups, and might not be representative for all country contexts. They might also be found to be too comprehensiveto be dealt with in short courses, or not specific enough in the introduction to ee6nomic methods relevant to a target group (e.g. for economic appraisals in health care as a tool for priority setting and the support of decision making [22,23]).
WHO-modules
for health services managers
Fortunately, a systematic approach, which has been developed in a problem-oriented way, is available to describe key elements of health economics for health services managers: the results from an international study group on health economics. This group, which was initiated by the World Health Organization (WHO), tried to develop comprehensive sets of health economic issues. Five sets were identified and labelled as ‘modules’ (for details on teaching units, economic con-
29
cepts used, and the background literature see [24], or for short discription [S]). The modules are to be used selectively with respect to a country context and a target group. In the last meeting of the Study Group in Dubrovnik, June 1985, the application of the modules was discussed for three target groups. For one of them, the ‘administrators’, some of the conclusions and teaching units which were found to be essential are reported briefly. - Module I covers the relationships between health, the health care sector and the economy. It seemed quite important to introduce the relationship between the economy and health care expenditures to the administrators, and to describe external economic determinants on the financial capacity of the health care sector. As regards the influence of the health sector on the economy, a hospital closure exercise would be an appropriate role-playing approach in all systems where hospital capacities are cut down. In addition, some information on the statement that health essentially depends on other factors besides health care, especially on the economic development, could be provided, but this might be going too far in a short course for busy administrators. - Module 2 concerns the impacts of health policy implementation and performance for different patients and providers. From the different perspectives of patient or provider groups, the outcomes of alternative health care systems or policies are to be discussed on the basis of empirical data. While in long-term studies, market-oriented systems could be compared with systems of the public health care type in a comprehensive approach (i.e. for outcomes in terms of effectiveness, efficiency and equity), it could be necessary to cut down exercises to a comparative debate on the specific outcomes of current policy issues in short courses. - Module 3 covers the harmonization of consumer and provider interests. It is the central one in understanding the economic structure of the system in which health services managers or administrators are working. The incentive structure in the health care markets is analysed by applied microeconomic techniques. For the economic understanding of administrators, it seems most important to analyse the incentives set for the hospital or other institutions by financing and capacity planning, the incentives set for the patients (e.g. by their insurance coverage), and the incentives set for the physicians in a hospital. For example, one teaching unit is especially concerned with the reimbursement of hospitals. An incentiveanalysis of the institutional organisation of the health care system (e.g. if only services, or services including health insurance are provided) or a unit on the competition versus regulation debate could be added to this module. - Modufe 4 deals with economic techniques for priority setting and strategy selection. These techniques comprise economic appraisal and evaluation of projects or programmes like cost-, cost-effectiveness-, cost-utility-, or cost-benefit-analyses. It might be too extensive to go into details of evaluation techniques in short courses, but at least the critical use of evaluative studies and the assessment of economic appraisals should be covered. For target groups, who frequently have to decide on the allocation of resources, problem-oriented case-studies of economic evaluations could be provided (e.g. the assessment of new technologies
30
for hospital managers, the allocation of resources to patient groups for regional managers, or options for the development of geriatric care in hospitals for health planners). In addition to the economic results of an evaluation, other, non-economic, influences could be included. - Module 5 deals with equity problems, equality, and the reduction of status differentials. An introduction to equity definitions, value judgements and the measurement of equity (e.g. in quality-adjusted life-years) seems to provide important tools for all health care managers. Teaching applied analysis of equity problems - with respect to regional equity, to equity impacts of health systems or health policy measures (like a change in cost-sharing), to equity among health care providers, or to equity and efficiency trade-offs - could rather depend on its relevance in the health care system of the target group. This short survey on key issues may give first ideas of the comprehensiveness of the modules and ways to shape and extend programmes according to the needs of specific target groups. Besides the key issues, the question of how technical health economics is taught should be considered. With the exception of the first module, the economic concepts and instruments needed mostly comprise applied microeconomics. In many cases, arguments can be derived either verbally, graphically, or mathematically; teaching methods are shapeable for each level of education. Mathematical tools, for example, can be necessary for an economic evaluation or appraisal, but might be found unnecessary for administrators when coming to the analysis of economic behavior, when a verbal explanation of incentive effects is understood more easily. Other instruments that could prove to be useful for analytic capabilities are the building of models or - when lacking empirical data simple simulation techniques. Another aspect of training are the skills of evaluating and using empirical results. Theoretical arguments may sometimes seem easily understandable, while the results expected do not occur in the evidence due to many interfering factors. On the other hand, empirical data sometimes may not be interpretable as indicators of effects expected theoretically. It might be going too far to include sophisticated empirical techniques; here, the consultation of experts could be proposed. To support more rational advice for decision-making in health services management, however, some critical comparison of empirical results should be provided in addition to theoretical reasoning (e.g. discussing a survey of the empirical analysis of hospital regulation in the United States [25], or results from the field of cost-sharing [26,27]).
Case-studies
of health economics implications
If training programmes were effectively performed, what effects could be expected from an increase in health economics knowledge and applications? For simplicity and significance, two case-studies of sizeable, recent ‘health economics movements’ will be discussed as one first approach to answer this question - instead of deriving the effects of training programmes directly. The two examples
31
come from the hospital field, one from the Federal Republic of Germany, and one from the United States. The results from such implementations of health economic skills and knowledge can be reconsidered in the promotion of effective health economics training. (1) The reform of the German
hospital financing
system
A few years after 1972, when the basic law that regulates hospital financing was passed in the Federal Republic of Germany, disincentives set by the system and deficiencies to cope with necessary adaption processes induced ample criticism from hospitals as well as from health insurances: the .financing side claimed unconstrained increases of expenditures, the hospitals claimed unmet capital needs because of too low investment budgets. The need for reform seemed clear from all sides, and the analysis of the system’s deficiencies and the proposals for reform also were discussed intensively among health economists. Commissions on the reform were founded; they included academic experts as well as hospital professionals, which gave the discussion a broad basis and started problem-oriented health economics applications. In contrast to the more competitive environment of the hospital system in the United States, the comprehensive planning and financing system in the F.R.G. only leaves a small scope and little incentives for businessstyle decision-making of hospital managers. Therefore, the discussion focussed on the analysis of the constraints set by the system rather than on the development of economic advice to manage the hospitals more effectively. The discussions in the literature and in the expert commissions - which, by the way, were theoretical and hardly used empirical results - produced a clear diagnosis: the basic problems were considered to be the splitting of investment and operating financing, the fullcost reimbursement principle and the lump-sum daily rate as the payment unit. The resulting proposals for reform have also been compared in economic categories [2&30]. Health economics thus can be seen as one rational approach in the reform of the hospital financing system. Improvements in the economic management of the hospital system were suggested by defining new constraints. In spite of this promising approach, however, a good deal of the basic deficiencies of the system that were identified by the economic debate simply survived the political bargaining process for the reform of the financing law. Up to now, the analyses and proposals for reform neither in hospital financing nor in hospital management have produced any revolutionary changes. In addition, more concrete economic analyses on how hospital managers were to transpose new incentives (like a prospective budgeting) into more efficiency (e.g. by the development of internal budgeting systems) could have improved the implementation of reform attempts. (2) The diagnosis-related
groups (DRGs)
The story of the DRGs in the United States is an impressive example for health economics applications and its effects. What was the innovation by DRGs? Be-
32
fore, there was no widely accepted output-measure for the products provided by the hospital, and each economic analysis of hospital activities, each comparison of lengths of stay or reimbursement rates had to admit that differences in the types of patients treated - and thus in the services needed and rendered - could not be controlled for. The DRGs were a technical solution to this problem that proved to be applicable nationwide. They were empirically developed and define the hospital product in 468 medically meaningful categories with homogeneous resource consumption (measured by the length of stay). They established a new instrument for the economic analysis of hospital systems, of individual institutions, of wards, or of services rendered to specific patient groups. They were used for the reimbursement of hospitals by - simplified - prospectively budgeting per case. On the management side, they involved more physicians in hospital management decisions and strengthened activities on the strategic and operational level of managing product lines [31,32]. A series of economic analysis followed; early examples are the analyses on substitutive behaviour of hospitals trying to supply more profitable treatment categories [33], or analyses of physicians’ discretionary behaviour, or of hospital costs, losses and profits [34]. Of course, DRGs also stimulated critical views, e.g. because of inner-group variations of resource consumption and casemix severity, or data quality problems [35]; they stipulated other specifications of the hospital’s product too [36]. Summarizing the effects of the DRGs, they promoted an extensive health economics movement in the hospital field; worldwide attempts are made to follow the American experience [37]. By supplying a missing tool at the right time, DRGs promoted a broad, also empirically based economic discussion, and changes in hospital financing, organisation, and management. Made to be medically meaningful, they innovated the relation between hospital administrators and doctors [31] and integrated clinical, managerial and financial information. All these effects are probably more than applied health economics could ever wish to achieve. However, the economic impact of the DRG-approach on the societies’ health and on the resources used for care is not completely understood; not all compensating effects may.have been fully accounted for yet. Examples are substitutions by later hospitalizations, by outpatient, nursing home and home care, or effects on the quality or distribution of services. For countries with less advanced information systems, the evaluation of an early DRG-experiment in New Jersey should be remembered, which had reported a considerable increase in costs associated with the introduction of the system. The evaluators then concluded that ‘it is hoped that they (the DRGs) will ultimately generate substantial gains in efficiency [31]. From a society’s point of view and from a public health standpoint, the outcome of this health economics movement is not yet clear.
Health economics training reconsidered:
management
aspects
According to a 1984 survey in the Federal Republic of Germany, hospital-employed physicians reported that most economic interventions made by the hospital
33 often
never
sometimes
drugs
occupancy
laboratory
64.2
med-tech
I
0
I
I
I
I
20
40
60
80
1
100
percentage Fig. 1 Perceived economic influences of hospital administration MEDIS-survey (n = 361). Federal Republic of Germany. 1984.
on decisions
of hospital
physicians.
administration would happen with respect to drug therapy. Fields of less influence were bed occupancy, the use of laboratory diagnostics and of technical equipment (see Fig. 1). While expenditures for drugs only amount for about 5% of a hospital’s total operating costs, drugs seem a priority issue in the economic control of hospitals. However, more than one-third of the physicians reported no interventions in this field, and half of the interviewees never experienced any with respect to occupancy. These results present some empirical evidence on the role of economics in the process of hospital care. They show areas where economic discussions are going on, but high-cost issues where more control could be initiated and significant fields where little or even no economic interventions take place. The latter may of course result from perfect efficiency, or from economic constraints like the fullcost-reimbursement principle and the property rights of hospital administrators, or from a lack of economic consciousness and knowledge. Would health economics training then be able to increase the effectiveness and efficiency of care, and to promote health? How could it promote these objectives most effectively? And what would be indicators for an improvement? These questions lead us to discuss health economics training from a management perspective. Objective (i). To improve managerial contributions to effectiveness and efficiency of health care, health economics training is supposed to provide knowledge about economic principles and techniques, and skills to apply it. This comprises the economic understanding of the health care system, evaluation and incentivesetting for efficiently managing the system, and skills for efficiently changing or designing it. Besides, managers should be made aware of the health effects of decisions
even outside
their own institution,
and motivated
to participate
more fully
34
in health policy activities. From a market-oriented point of view, however, the pure supply of education is not very meaningful. The analyst of economic behaviour rather looks upon the objectives and the constraints of the agents than upon their skills and knowledge. In the classical market nobody needs to know how the system works. The efficient management of health care units might be promoted by strengthening the economic capabilities of individual agents, but much more by an improvement of the incentive structures. Objective (ii). From a health management perspective, health economics can be looked upon as one contribution among others to promote and achieve health. It would support the targets of ‘a health strategy - e.g. the Health for All Program by the World Health Organisation [38] - and would have to be evaluated by its contribution to public health. In this case, a social instead of an institutional or individual perspective of effectiveness and efficiency would have to be emphasized, Health economics then must be more than a tool to control costs or expenditures of a single institution; the intention could neither be to teach managers how to shift costs from their institution to others, nor to train them in expanding their revenues or profits when this would not be in line with social efficiency and public health. This would certainly include the analysis of adverse effects of costcontainment on health [39]. Program design. People managing health services are a very heterogeneous group. Participants of health economics training may include managers, who more or less are the policy-makers of a health care system, head physicians of large hospitals, subordinate administrators only responsible for the financial affairs, or, last but not least, the group of people planning to become managers. Health economics may be taught at university and thereafter, or on the job. The type, the amount and methods of health economics depend very much on the definition of the target group, their level of education, and their specific needs. The economic skills suitable for a hospital manager in a competitive environment [40] do not necessarily cover those needed in a regional budgeting environment; they vary according to the constraints the managers are exposed to. For effective health economics, programmes have to match the needs of target groups, and relevant groups have to be able to attend specific programmes. Implementation. Health economics does not comprise all managerial tasks; it does not include managerial skills like strategic management, institutional organisation, planning techniques, or knowledge in statistical techniques, information systems and electronic data processing. Most of these tools are needed when applying health economics analysis or implementing its results. Interrelations with management can be introduced easily by special teaching methods like case-studies, role-playing and scenario techniques. Skills for managing health programmes or even health systems are discussed; for example, in courses like the Managerial Process for National Health Development by the World Health Organization [41]. Feasibility. As the first case-study showed, the political feasibility of health economics can be a crucial constraint. There is more to health policy and health services management than economic analysis; to be of relevance, health economics must always think about feasibility and include political, psychological, legal, his-
35
torical, and institutional determinants. Another aspect is the time needed for effectively influencing a health system by better education: a broad introduction of knowledge, or changes in attitudes like from bureaucratic behaviour to businessstyle management seem at least a generation’s task. Evaluation. What are the indicators for the effectiveness of health economics training? Structural indicators could refer to institutionalisations of health economics or to qualifications of management personnel; process criteria to publications, meetings, committees or public debates, or to selected data on the economic performance of health care institutions or systems. At least in the health management’s perspective, outcome indicators in the evaluation of managerial activities would have to be health-oriented. While this may seem quite theoretical, health economics could imply significant problems for the individual patient: if economic calculus is spelled out as a decision criterion in individual health care, it surely would be very inconvenient for those outruled by the calculus. Further, depending on the health care system, interest groups and technocrats could be strengthened instead of strengthening patients’ participation. Evaluation seems a necessity. Future trends. What are possible developments for health economics, where could its institutional background be and who really provides its constituency? In the future, health economics may become one instrument in an interdisciplinary ensemble of health systems research oriented towards public health. It could be integrated more closely with epidemiology (for priority setting and effect measurement), with biomedical research (for cost-effectiveness assessment of these technologies), or with data-processing technologies and management sciences (e.g. for the control of health systems by indicator systems). Some training programmes have made advances in this direction [42]. In the development of sciences, integrations may be enforced by imminent health problems like AIDS, which - rather than cost-containment, a previous determinant of health economics - is acknowledged to be of public concern and to demand interdisciplinary collaboration [43].
Conclusion Health economics is supposed to provide rational advice in the social regulation of health care and to promote health. The training programmes support these objectives by improving the managerial contribution to the efficiency of health care. Health economics is but one instrument to health services management. To effectively improve health and health care, other determinants like clinical, technical and political ones, have to be considered and integrated. In the future, this may innovate health economic research and education. From a wide variety of issues and teaching methods, training programmes in health economics have to be shaped adequately for specific target groups. It seems useful for health services managers to be able to analyse their health care system and current policy issues in economic terms, and to know how an economic evaluation is performed. Health economics training could increase managerial skills and opportunities for creative participation in the dynamics of the health system. But
36
in addition to promoting training programmes, health economics should be considered.
evaluations
of the effectivity of
Acknowledgements The author would like to thank his colleges at the MEDIS-Institute and an anonymous reviewer for their helpful comments, and Drs. Heesters (Utrecht), O’Shea (Dublin) and Yfantopoulos (Athens) for their information on hospital management courses. The U.S. program came from Harvard School of Public Health, the German one from Deutsches Krankenhausinstitut.
References 1 Pschyrembel, W., Klinisches Worterbuch, 255 ed., Berlin New York, 1986. 2 Maynard, A., Budgeting health care systems. Effective Health Care, 2 (1984) 41-49. 3 American Economic Association, Economics of medical care, American Economic Review, 41 (1951) 617-696. 4 Culyer, A.J., Wiseman, J. and Walker, A., An Annotated Bibliography of Health Economics, English Language Studies, New York, 1977. 5 Griffith, A., Rigoni, R., Tacier, P. and Prescott, N., An Annotated Bibliography of Health Economics, Western European Studies, Oxford, 1980. 6 Hersh-Cochran, MS., Survey on Education and Training Programmes in Health Economics, World Health Organisation, Publication JCPiMPN 503isO1, Copenhagen, 1986. 7 Berman, P.C. (Ed.), Health Services Administration, Education and Research. A Directory of the Membership, 2nd edn., European Association of Programmes in Health Services Studies, Dublin, 1985. 8 Schwefel, D., Zollner, H., Neubauer, G. and Leidl, R. (Eds.), Ausbildung und Fortbildung in Gesundheitsokonomie, GSF-Bericht 6/87, Neuherberg, 1987. 9 Gafgen, G. (Ed.), Gkonomie des Gesundheitswesens, Berlin, 1986. 10 Hepner, J.O. and Ameiss, A.P., Survey and recommendations point to need for improving financial management education in graduate health administration programmes, Hospitals, 56 (1982) 91-92. 11 White D., Training health service managers. In International Hospital Federation (Ed.), Official Yearbook, 1985. 12 Evans, R.G., Strained Mercy, Toronto, 1984. 13 Feldstein, P.J., Health and Health Economics, 2nd edn., New York, 1983. 14 Jacobs, P., The Economics of Health and Medical Care, Baltimore, MD, 1980. 15 Cullis, J.G. and West, P.A., The Economics of Health, Oxford, 1979. 16 Newhouse, J.P., The Economics of Medical Care, Massachusetts, 1978. 17 Migue, J.L. and Belanger, G., The Price of Health, Toronto, 1974. 18 Sorkin, A., Health Economics, Lexington, 1975. 19 Sloan, F.A. and Steinwald, B., Insurance, Regulation and Hospital Costs, Lexington, 1980. 20 Dowling, W.L., Hospital Production, Lexington, 1976. 21 Berki, S., Hospital Economics, Lexington, 1972. 22 Drummond, M.F., Stoddart, G.L. and Torrance, G.W., Methods for the Economic Evaluation of Health Care Programmes, Oxford, 1987. 23 Drummond, M.F., Principles of Economics Appraisal in Health Cares, Oxford, 1980. 24 Brenna, A., Drummond, M.F. and Stoddart, G. (Eds.), Development of Health Economics Training, World Health Organization, Copenhagen, 1987, in press. 25 Steinwald, B. and Sloan, F.A., Regulatory approaches to hospital cost containment: a synthesis of
37
26
27 28 29 30 31 32 33 34 35 36 37 38
39 40 41 42 43
the empirical evidence. In Olson, M. (Ed.), A New Approach to the Economics of Health Care, Washington/London, 1981. Lohr, K.N., Brook, R.H., Kamberg, C.J.. Goldberg. G.A.. Leibowitz, A., Keesey, J., Reboussin, D. and Newhouse, J.P., Use of medical care in the RAND insurance experiment, Medical Care. 24 Suppl. (1986). Ven, van de. W., Effects of cost-sharing in health care, Effective Health Care. 1 (1983) 47-58. Robert Bosch Stiftung (Ed.), Krankenhaustinanzierung in Selbstverwaltung - Kommisionsbericht, Beitrage zur Gesundheitsokonomie 20, Stuttgart, 1987. Neubauer, G. and Unterhuber H., Failures of the hospital financing system of the Federal Republic of Germany and reform proposals. Effective Health Care, 2 (1985) 161-171. Studienstiftung der Verwaltungsleiter deutscher Krankenanstalten e.V. (Eds.), Zentrallehrgang 1984, Mtihlheim, 1984. May, J.J. and Wasserman, J., Selected results from an evaluation of the New Jersey diagnosis-related group system, Health Services Research. 19 (1984) 547-559. Kukla. S.F. and Bachhofer. H.J.. Building up reporting systems. In International Hospital Federation (Ed.), Official Yearbook. 1985. Simborg, D.W.. DRG-creep. A new hospital acquired disease. New England Journal of Medicine. 304 (1981) 1602-1604. Wennberg, J.E., McPherson, K. and Caper. P., Will payment based on diagnosis-related groups control hospital costs? New England Journal of Medicine, 3 II (1984) 295-300. Fetter. R.B., The DRG methodology: pitfalls and adverse effects. Paper presented at the V. Jornadas De Economia Da Saude. Lisbon, Portugal, May (1985). Leidl, R., Die fallbezogene Spezifikation des Krankenhausprodukts. Ein methodischer und empirischer Beitrag, Berlin/Heidelberg/New York, 1987. Jenkins, L. (Ed.), Diagnosis Related Groups Newsletter, CASPE Research, 14 Palace Court, London W24HS, June (1986). World Health Organisation, Targets for Health for All. Targets in support of the European regional strategy for health for all. World Health Organisation, Regional Office for Europe. Copenhagen, 1985. Schwefel, D.. Towards the containment of containment policies in healt care or: From cost containment to effect-assessment, World Health Forum No. 6 (198.5) 17-19. Himmelsbach, W.A.. Competition in health care: strategies from other industries, Health Progress 65 (1984) 2&30. World Health Organisation, Managerial Process for National Health Development, Geneva, 1081. Heidenberger, K., Die Ausbildung in Gesundheitspolitik und -management an der Harvard School of Public Health, Das Sffentliche Gesundheitswesen 48 (1986) 19-24. Institute of Medicine, Confronting AIDS. Directions for Public Health, Health Care and Research, Washington. 1986.
25
HPE 00184
Training health services managers: improving health by more health economics? Reiner Leidl lnstitut
fiir Medizinische
Gesellschaft F.R.G. Accepted
lnformatik
fiir Strahlen-
20 September
und Systemforschung
und Umweltforschung
(MEDIS),
mbH (GSF), Neuherberg,
1987
Summary In times of rising health expenditures and imminent health problems, efficiency is a crucial element for maintaining and improving health care and, finally, health. One major support measure is the effective management of health services. This paper considers possible improvements of health care by training health services managers in health economics. It surveys the current state of health economics training, presents approaches towards the key issues of health economics, discusses the impact of health economics by two examples, and considers management aspects of health economics training. Health economics
training;
Health services management
Introduction When Hippocrates, who lived on the Greek island of Kos around 460 BC, formulated his oath, which has often been quoted in medical ethics since, he also included some economic rules: “Physicians”, he said, “should promise to share their livelihood with their teachers, to support them in times of hardship, and to teach their children - upon request and without remuneration -the art of medicine” [l].
Address for correspondence: Health Planning and Health 016%8510/88/$03.50
0
Dr. Reiner Economics,
1988 Elsevier
Leidl. MEDIS-Institute/GSF.WHO-Collaborating IngolGdter LandstraBe 1. 8042 Neuherberg,
Science
Publishers
B.V. (Biomedical
Division)
Centre F.R.G.
for
26
Of course, this is only a small aspect out of the multitude of economic aspects of health and health care. But up to now, the relevance of economics in health care is still controversial in many a physicians’ opinion. As an economist, Alan Maynard has pinpointed the strained relationship between medicine and economics by formulating yet another moral principle: inefficiency is unethical [2]. So economics must and can provide its share to health and health care; it is a necessity in the support of public health. Health economics training can be looked upon as one instrument to promote the contribution made by economics. It will be discussed specifically for the group of health services managers. Health economics as a knowledge basis for problem recognition and solving, its training programmes and some aspects of the effectivity of both will be dealt with. First an overview is given on the current state of health economic training programmes. Then key issues in health economics for health services managers are investigated. As examples for possible effects of health economics, two case-studies are presented. A last part discusses planning and evaluation of health economics and its training from a (social) management perspective.
Current state of health economics training Health economics as an academic discipline has a much shorter history than the introduction might suggest. A 1951 meeting of the American Economic Association on the ‘Economics of Medical Care’ [3] can be considered as a starting point after World War II. An uncountable number of papers, publications and meetings followed, certainly with a significant increase accompanying cost developments in about the last two decades (for annotated bibliographies, see [4,5]). The expansion of research work was supplemented by a growth of education and training in health economics. Recent cross-sectional surveys conducted in 26 countries from Asia, Australia, Europe and Northern America revealed almost 700 courses in this field ([6]; for the European region, cf. [7]). In the Federal Republic of Germany, for example, there were 58 courses rePorted for the academic year of 1983/84. They were taught in diverse faculties such as economics, medicine, business, law, administration, sociology, political science, and industrial engineering. The scope of the courses ranged from 100% health economics to applications of economic debates (e.g. competition vs regulation), programmes in social policy, and others. Nine non-academic institutions provided another 29 courses at the same time. All in all, health economics could be characterized as a problem-oriented, applied and interdisciplinary science [8]. But in spite of the fact that health economics was spread quite well in the Federal Republic of Germany, it lacked the symbols of acknowledgement such as own institutes or being part of academic exams at the time of the survey. In 1986, however, it was the title of the annual meeting of the German ‘Verein fur Socialpolitik’ [9], which may indicate the respect of the economic profession for this field. As an example for what and how issues are thought of in health economics, some
Case studies Group discussion Expert lectures
Source:
own survey
Master in health policy and management (U.S.A.) 2 years
(1985).
Comprehensive theoretical and empirical analysis of health care systems
Cost-benefit and -effectiveness analysis, quality assessment. decision analysis
and
Competition/regulation, priority-setting/ planning/strategy implementation, cost-containment techniques, non-economic theories
and
Hospital management accounting
Cost theory calculation
hospital fiand planning systems’ com-
German nancing system, parison
Hospital tration (F.R.G.) 2 years
adminis-
Case studies Expert lectures
Health care goods and markets, health (care) measurement, equity. clinical budgeting, DRGs
Principles, techniques and application of economic appraisal
Theoretical analysis: incentives, doctors’ payment, alternative organisation
Health service administration (Ireland) 10 days
Case studies In-service Training
Expert lectures Planning game
Budget allocation. investment credits. DRGs, role of social security insurance
assessment
Quality
Case studies Working group Discussions
and
Special teaching methods
Other health economics; related issues
Organisation of hospital/health care system in the Netherlands systems’ comparison
evalua-
Hospital administration (Netherlands) 9 days
Economic tion Hospital accounting management
and
for health services managers
Economic evaluation of hospital activities
System description analysis
training
Evolution of the Greek health care system
Country. of course
of health economics
Hospital administration (Greece) 80 hours
Course, Length
Five examples
Table 1
Post-graduate academic programme; Health economics oriented towards research/application
Very broad-based fulltime study; Health economics oriented towards financing
Comprehensive academic course; Full scale health economics
Programme especially oriented towards country context and policy issues; Applied economics
Broad-based introductory programme; Basic economics for problem solving
Type of course; Role of health economics
28
programmes for health services or hospital managers are examined more closely. Table 1 shows 4 courses from European countries and one program from a school of public health in the United States, which are compared for the issues covered and for special teaching methods; further, their general type and the role of health economics in the course is characterized. Three courses are especially designed for hospital managmenent. Health economics has not always been included in the courses as an own field of study, and it differs remarkably in its economic comprehensiveness and in its methodological depth. Some courses are designed more systematically and analytically, others are oriented towards descriptive purposes. Three courses are short-type programmes and last about 10 days, the other ones are full-time studies and last two years. With respect to special teaching methods, most of the programmes offer case studies. Applications which are problem-oriented and relevant to the professional environment of managers represent the preferred teaching method, as it has also been recommended for the training of health services managers [ 10,111. Quantitatively and qualitatively, health economics may thus be featured as a wide field of study, which is diverse, but hardly definite. Even for a certain target group like health services managers, its practical orientation leads to manifold variations. Concepts and criteria to plan and evaluate health economics training must therefore be considered.
Key issues of health economics training What are the key issues of health economics for health services or hospital managers? One common approach would be to investigate the relevance of health economics textbooks with respect to health services management. Such textbooks [12-181 cover general problems in the economic analysis of health care; some pay special attention to health care sectors like hospital care. Others are devoted only to economic problems of the hospital [19-211. However, most of these books do not include specific applications for different target groups, and might not be representative for all country contexts. They might also be found to be too comprehensiveto be dealt with in short courses, or not specific enough in the introduction to ee6nomic methods relevant to a target group (e.g. for economic appraisals in health care as a tool for priority setting and the support of decision making [22,23]).
WHO-modules
for health services managers
Fortunately, a systematic approach, which has been developed in a problem-oriented way, is available to describe key elements of health economics for health services managers: the results from an international study group on health economics. This group, which was initiated by the World Health Organization (WHO), tried to develop comprehensive sets of health economic issues. Five sets were identified and labelled as ‘modules’ (for details on teaching units, economic con-
29
cepts used, and the background literature see [24], or for short discription [S]). The modules are to be used selectively with respect to a country context and a target group. In the last meeting of the Study Group in Dubrovnik, June 1985, the application of the modules was discussed for three target groups. For one of them, the ‘administrators’, some of the conclusions and teaching units which were found to be essential are reported briefly. - Module I covers the relationships between health, the health care sector and the economy. It seemed quite important to introduce the relationship between the economy and health care expenditures to the administrators, and to describe external economic determinants on the financial capacity of the health care sector. As regards the influence of the health sector on the economy, a hospital closure exercise would be an appropriate role-playing approach in all systems where hospital capacities are cut down. In addition, some information on the statement that health essentially depends on other factors besides health care, especially on the economic development, could be provided, but this might be going too far in a short course for busy administrators. - Module 2 concerns the impacts of health policy implementation and performance for different patients and providers. From the different perspectives of patient or provider groups, the outcomes of alternative health care systems or policies are to be discussed on the basis of empirical data. While in long-term studies, market-oriented systems could be compared with systems of the public health care type in a comprehensive approach (i.e. for outcomes in terms of effectiveness, efficiency and equity), it could be necessary to cut down exercises to a comparative debate on the specific outcomes of current policy issues in short courses. - Module 3 covers the harmonization of consumer and provider interests. It is the central one in understanding the economic structure of the system in which health services managers or administrators are working. The incentive structure in the health care markets is analysed by applied microeconomic techniques. For the economic understanding of administrators, it seems most important to analyse the incentives set for the hospital or other institutions by financing and capacity planning, the incentives set for the patients (e.g. by their insurance coverage), and the incentives set for the physicians in a hospital. For example, one teaching unit is especially concerned with the reimbursement of hospitals. An incentiveanalysis of the institutional organisation of the health care system (e.g. if only services, or services including health insurance are provided) or a unit on the competition versus regulation debate could be added to this module. - Modufe 4 deals with economic techniques for priority setting and strategy selection. These techniques comprise economic appraisal and evaluation of projects or programmes like cost-, cost-effectiveness-, cost-utility-, or cost-benefit-analyses. It might be too extensive to go into details of evaluation techniques in short courses, but at least the critical use of evaluative studies and the assessment of economic appraisals should be covered. For target groups, who frequently have to decide on the allocation of resources, problem-oriented case-studies of economic evaluations could be provided (e.g. the assessment of new technologies
30
for hospital managers, the allocation of resources to patient groups for regional managers, or options for the development of geriatric care in hospitals for health planners). In addition to the economic results of an evaluation, other, non-economic, influences could be included. - Module 5 deals with equity problems, equality, and the reduction of status differentials. An introduction to equity definitions, value judgements and the measurement of equity (e.g. in quality-adjusted life-years) seems to provide important tools for all health care managers. Teaching applied analysis of equity problems - with respect to regional equity, to equity impacts of health systems or health policy measures (like a change in cost-sharing), to equity among health care providers, or to equity and efficiency trade-offs - could rather depend on its relevance in the health care system of the target group. This short survey on key issues may give first ideas of the comprehensiveness of the modules and ways to shape and extend programmes according to the needs of specific target groups. Besides the key issues, the question of how technical health economics is taught should be considered. With the exception of the first module, the economic concepts and instruments needed mostly comprise applied microeconomics. In many cases, arguments can be derived either verbally, graphically, or mathematically; teaching methods are shapeable for each level of education. Mathematical tools, for example, can be necessary for an economic evaluation or appraisal, but might be found unnecessary for administrators when coming to the analysis of economic behavior, when a verbal explanation of incentive effects is understood more easily. Other instruments that could prove to be useful for analytic capabilities are the building of models or - when lacking empirical data simple simulation techniques. Another aspect of training are the skills of evaluating and using empirical results. Theoretical arguments may sometimes seem easily understandable, while the results expected do not occur in the evidence due to many interfering factors. On the other hand, empirical data sometimes may not be interpretable as indicators of effects expected theoretically. It might be going too far to include sophisticated empirical techniques; here, the consultation of experts could be proposed. To support more rational advice for decision-making in health services management, however, some critical comparison of empirical results should be provided in addition to theoretical reasoning (e.g. discussing a survey of the empirical analysis of hospital regulation in the United States [25], or results from the field of cost-sharing [26,27]).
Case-studies
of health economics implications
If training programmes were effectively performed, what effects could be expected from an increase in health economics knowledge and applications? For simplicity and significance, two case-studies of sizeable, recent ‘health economics movements’ will be discussed as one first approach to answer this question - instead of deriving the effects of training programmes directly. The two examples
31
come from the hospital field, one from the Federal Republic of Germany, and one from the United States. The results from such implementations of health economic skills and knowledge can be reconsidered in the promotion of effective health economics training. (1) The reform of the German
hospital financing
system
A few years after 1972, when the basic law that regulates hospital financing was passed in the Federal Republic of Germany, disincentives set by the system and deficiencies to cope with necessary adaption processes induced ample criticism from hospitals as well as from health insurances: the .financing side claimed unconstrained increases of expenditures, the hospitals claimed unmet capital needs because of too low investment budgets. The need for reform seemed clear from all sides, and the analysis of the system’s deficiencies and the proposals for reform also were discussed intensively among health economists. Commissions on the reform were founded; they included academic experts as well as hospital professionals, which gave the discussion a broad basis and started problem-oriented health economics applications. In contrast to the more competitive environment of the hospital system in the United States, the comprehensive planning and financing system in the F.R.G. only leaves a small scope and little incentives for businessstyle decision-making of hospital managers. Therefore, the discussion focussed on the analysis of the constraints set by the system rather than on the development of economic advice to manage the hospitals more effectively. The discussions in the literature and in the expert commissions - which, by the way, were theoretical and hardly used empirical results - produced a clear diagnosis: the basic problems were considered to be the splitting of investment and operating financing, the fullcost reimbursement principle and the lump-sum daily rate as the payment unit. The resulting proposals for reform have also been compared in economic categories [2&30]. Health economics thus can be seen as one rational approach in the reform of the hospital financing system. Improvements in the economic management of the hospital system were suggested by defining new constraints. In spite of this promising approach, however, a good deal of the basic deficiencies of the system that were identified by the economic debate simply survived the political bargaining process for the reform of the financing law. Up to now, the analyses and proposals for reform neither in hospital financing nor in hospital management have produced any revolutionary changes. In addition, more concrete economic analyses on how hospital managers were to transpose new incentives (like a prospective budgeting) into more efficiency (e.g. by the development of internal budgeting systems) could have improved the implementation of reform attempts. (2) The diagnosis-related
groups (DRGs)
The story of the DRGs in the United States is an impressive example for health economics applications and its effects. What was the innovation by DRGs? Be-
32
fore, there was no widely accepted output-measure for the products provided by the hospital, and each economic analysis of hospital activities, each comparison of lengths of stay or reimbursement rates had to admit that differences in the types of patients treated - and thus in the services needed and rendered - could not be controlled for. The DRGs were a technical solution to this problem that proved to be applicable nationwide. They were empirically developed and define the hospital product in 468 medically meaningful categories with homogeneous resource consumption (measured by the length of stay). They established a new instrument for the economic analysis of hospital systems, of individual institutions, of wards, or of services rendered to specific patient groups. They were used for the reimbursement of hospitals by - simplified - prospectively budgeting per case. On the management side, they involved more physicians in hospital management decisions and strengthened activities on the strategic and operational level of managing product lines [31,32]. A series of economic analysis followed; early examples are the analyses on substitutive behaviour of hospitals trying to supply more profitable treatment categories [33], or analyses of physicians’ discretionary behaviour, or of hospital costs, losses and profits [34]. Of course, DRGs also stimulated critical views, e.g. because of inner-group variations of resource consumption and casemix severity, or data quality problems [35]; they stipulated other specifications of the hospital’s product too [36]. Summarizing the effects of the DRGs, they promoted an extensive health economics movement in the hospital field; worldwide attempts are made to follow the American experience [37]. By supplying a missing tool at the right time, DRGs promoted a broad, also empirically based economic discussion, and changes in hospital financing, organisation, and management. Made to be medically meaningful, they innovated the relation between hospital administrators and doctors [31] and integrated clinical, managerial and financial information. All these effects are probably more than applied health economics could ever wish to achieve. However, the economic impact of the DRG-approach on the societies’ health and on the resources used for care is not completely understood; not all compensating effects may.have been fully accounted for yet. Examples are substitutions by later hospitalizations, by outpatient, nursing home and home care, or effects on the quality or distribution of services. For countries with less advanced information systems, the evaluation of an early DRG-experiment in New Jersey should be remembered, which had reported a considerable increase in costs associated with the introduction of the system. The evaluators then concluded that ‘it is hoped that they (the DRGs) will ultimately generate substantial gains in efficiency [31]. From a society’s point of view and from a public health standpoint, the outcome of this health economics movement is not yet clear.
Health economics training reconsidered:
management
aspects
According to a 1984 survey in the Federal Republic of Germany, hospital-employed physicians reported that most economic interventions made by the hospital
33 often
never
sometimes
drugs
occupancy
laboratory
64.2
med-tech
I
0
I
I
I
I
20
40
60
80
1
100
percentage Fig. 1 Perceived economic influences of hospital administration MEDIS-survey (n = 361). Federal Republic of Germany. 1984.
on decisions
of hospital
physicians.
administration would happen with respect to drug therapy. Fields of less influence were bed occupancy, the use of laboratory diagnostics and of technical equipment (see Fig. 1). While expenditures for drugs only amount for about 5% of a hospital’s total operating costs, drugs seem a priority issue in the economic control of hospitals. However, more than one-third of the physicians reported no interventions in this field, and half of the interviewees never experienced any with respect to occupancy. These results present some empirical evidence on the role of economics in the process of hospital care. They show areas where economic discussions are going on, but high-cost issues where more control could be initiated and significant fields where little or even no economic interventions take place. The latter may of course result from perfect efficiency, or from economic constraints like the fullcost-reimbursement principle and the property rights of hospital administrators, or from a lack of economic consciousness and knowledge. Would health economics training then be able to increase the effectiveness and efficiency of care, and to promote health? How could it promote these objectives most effectively? And what would be indicators for an improvement? These questions lead us to discuss health economics training from a management perspective. Objective (i). To improve managerial contributions to effectiveness and efficiency of health care, health economics training is supposed to provide knowledge about economic principles and techniques, and skills to apply it. This comprises the economic understanding of the health care system, evaluation and incentivesetting for efficiently managing the system, and skills for efficiently changing or designing it. Besides, managers should be made aware of the health effects of decisions
even outside
their own institution,
and motivated
to participate
more fully
34
in health policy activities. From a market-oriented point of view, however, the pure supply of education is not very meaningful. The analyst of economic behaviour rather looks upon the objectives and the constraints of the agents than upon their skills and knowledge. In the classical market nobody needs to know how the system works. The efficient management of health care units might be promoted by strengthening the economic capabilities of individual agents, but much more by an improvement of the incentive structures. Objective (ii). From a health management perspective, health economics can be looked upon as one contribution among others to promote and achieve health. It would support the targets of ‘a health strategy - e.g. the Health for All Program by the World Health Organisation [38] - and would have to be evaluated by its contribution to public health. In this case, a social instead of an institutional or individual perspective of effectiveness and efficiency would have to be emphasized, Health economics then must be more than a tool to control costs or expenditures of a single institution; the intention could neither be to teach managers how to shift costs from their institution to others, nor to train them in expanding their revenues or profits when this would not be in line with social efficiency and public health. This would certainly include the analysis of adverse effects of costcontainment on health [39]. Program design. People managing health services are a very heterogeneous group. Participants of health economics training may include managers, who more or less are the policy-makers of a health care system, head physicians of large hospitals, subordinate administrators only responsible for the financial affairs, or, last but not least, the group of people planning to become managers. Health economics may be taught at university and thereafter, or on the job. The type, the amount and methods of health economics depend very much on the definition of the target group, their level of education, and their specific needs. The economic skills suitable for a hospital manager in a competitive environment [40] do not necessarily cover those needed in a regional budgeting environment; they vary according to the constraints the managers are exposed to. For effective health economics, programmes have to match the needs of target groups, and relevant groups have to be able to attend specific programmes. Implementation. Health economics does not comprise all managerial tasks; it does not include managerial skills like strategic management, institutional organisation, planning techniques, or knowledge in statistical techniques, information systems and electronic data processing. Most of these tools are needed when applying health economics analysis or implementing its results. Interrelations with management can be introduced easily by special teaching methods like case-studies, role-playing and scenario techniques. Skills for managing health programmes or even health systems are discussed; for example, in courses like the Managerial Process for National Health Development by the World Health Organization [41]. Feasibility. As the first case-study showed, the political feasibility of health economics can be a crucial constraint. There is more to health policy and health services management than economic analysis; to be of relevance, health economics must always think about feasibility and include political, psychological, legal, his-
35
torical, and institutional determinants. Another aspect is the time needed for effectively influencing a health system by better education: a broad introduction of knowledge, or changes in attitudes like from bureaucratic behaviour to businessstyle management seem at least a generation’s task. Evaluation. What are the indicators for the effectiveness of health economics training? Structural indicators could refer to institutionalisations of health economics or to qualifications of management personnel; process criteria to publications, meetings, committees or public debates, or to selected data on the economic performance of health care institutions or systems. At least in the health management’s perspective, outcome indicators in the evaluation of managerial activities would have to be health-oriented. While this may seem quite theoretical, health economics could imply significant problems for the individual patient: if economic calculus is spelled out as a decision criterion in individual health care, it surely would be very inconvenient for those outruled by the calculus. Further, depending on the health care system, interest groups and technocrats could be strengthened instead of strengthening patients’ participation. Evaluation seems a necessity. Future trends. What are possible developments for health economics, where could its institutional background be and who really provides its constituency? In the future, health economics may become one instrument in an interdisciplinary ensemble of health systems research oriented towards public health. It could be integrated more closely with epidemiology (for priority setting and effect measurement), with biomedical research (for cost-effectiveness assessment of these technologies), or with data-processing technologies and management sciences (e.g. for the control of health systems by indicator systems). Some training programmes have made advances in this direction [42]. In the development of sciences, integrations may be enforced by imminent health problems like AIDS, which - rather than cost-containment, a previous determinant of health economics - is acknowledged to be of public concern and to demand interdisciplinary collaboration [43].
Conclusion Health economics is supposed to provide rational advice in the social regulation of health care and to promote health. The training programmes support these objectives by improving the managerial contribution to the efficiency of health care. Health economics is but one instrument to health services management. To effectively improve health and health care, other determinants like clinical, technical and political ones, have to be considered and integrated. In the future, this may innovate health economic research and education. From a wide variety of issues and teaching methods, training programmes in health economics have to be shaped adequately for specific target groups. It seems useful for health services managers to be able to analyse their health care system and current policy issues in economic terms, and to know how an economic evaluation is performed. Health economics training could increase managerial skills and opportunities for creative participation in the dynamics of the health system. But
36
in addition to promoting training programmes, health economics should be considered.
evaluations
of the effectivity of
Acknowledgements The author would like to thank his colleges at the MEDIS-Institute and an anonymous reviewer for their helpful comments, and Drs. Heesters (Utrecht), O’Shea (Dublin) and Yfantopoulos (Athens) for their information on hospital management courses. The U.S. program came from Harvard School of Public Health, the German one from Deutsches Krankenhausinstitut.
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