A central problem in designing effective models of provider governance in health systems has been to ensure an appropriate balance between the concerns of public sector and/or government decision-makers, on the one hand, and of non-governmental health services actors in civil society and private life, on the other. In tax-funded European health systems up to the 1980s, the state and other public sector decision-makers played a dominant role over health service provision, typically operating hospitals through national or regional governments on a command-and-control basis. In a number of countries, however, this state role has started to change, with governments first stepping out of direct service provision and now de facto pushed to focus more on steering provider organizations rather than on direct public management. In this new approach to provider governance, the state has pulled back into a regulatory role that introduces market-like incentives and management structures, which then apply to both public and private sector providers alike. This article examines some of the main operational complexities in implementing this new governance reality/strategy, specifically from a service provision (as opposed to mostly a financing or even regulatory) perspective. After briefly reviewing some of the key theoretical dilemmas, the paper presents two case studies where this new approach was put into practice: primary care in Sweden and hospitals in Spain. The article concludes that good governance today needs to reflect practical operational realities if it is to have the desired effect on health sector reform outcome.
Background: This article examines uncomfortable realities that the European hospital sector currently faces and the potential impact of wide-spread rationalization policies such as (hospital) payment reform and privatization.
Methods: Review of relevant international literature.
Results: Based on the evidence we present, rationalization policies such as (hospital) payment reform and privatization will probably fall short in delivering better quality of care and lower growth in health expenses. Reasons can be sought in a mix of evidence on the effectiveness of these rationalization policies. Nevertheless, pressures for different business models will gradually continue to increase and it seems safe to assume that more value-added process business and facilitated network models will eventually emerge.
Conclusions: The overall argument of this article holds important implications for future research: how can policymakers generate adequate leverage to introduce such changes without destroying necessary hospital capacity and the ability to produce quality healthcare.
In 2010, immediately before the United States of America (USA) implemented key features of the Affordable Care Act (ACA), 18% of its residents younger than 65 years lacked health insurance. In the USA, gaps in health coverage and unhealthy lifestyles contribute to outcomes that often compare unfavourably with those observed in other high-income countries. By March 2014, the ACA had substantially changed health coverage in the USA but most of its main features - health insurance exchanges, Medicaid expansion, development of accountable care organizations and further oversight of insurance companies - remain works in progress. The ACA did not introduce the stringent spending controls found in many European health systems. It also explicitly prohibits the creation of institutes - for the assessment of the cost-effectiveness of pharmaceuticals, health services and technologies - comparable to the National Institute for Health and Care Excellence in the United Kingdom of Great Britain and Northern Ireland, the Haute Autorité de Santé in France or the Pharmaceutical Benefits Advisory Committee in Australia. The ACA was - and remains - weakened by a lack of cross-party political consensus. The ACA’s performance and its resulting acceptability to the general public will be critical to the Act’s future.
The ongoing information revolution has re-configured the policymaking arena for tax-funded health systems in Europe. A combination of constrained public revenues with rapid technological and clinical change has created a particularly demanding set of operational challenges. Tax-funded health systems face three ongoing struggles: 1) finding badly needed new public revenues despite inadequate GDP growth 2) channeling additional funds into new high-quality provider capacity 3) re-configuring the stasis-tied organizational structure and operations of existing public providers. This commentary reviews key elements of this new information-revolution-driven context, followed by a consideration of seven specific policy challenges that it creates and/or worsens for tax-funded European systems going forward.
Physicians play multiple roles in a health system. They typically serve simultaneously as the agent for patients, for insurers, for their own medical practices, and for the hospital facilities where they practice. Theoretical and empirical results have demonstrated that financial relations among these different stakeholders can affect clinical outcomes as well as the efficiency and quality of care. What are the physicians’ roles as the agents of Chinese patients? The marketization approach of China’s economic reforms since 1978 has made hospitals and physicians profit-driven. Such profit-driven behavior and the financial tie between hospitals and physicians have in turn made physicians more the agents of hospitals rather than of their patients. While this commentary acknowledges physicians’ ethics and their dedication to their patients, it argues that the current physician agency relation in China has created barriers to achieving some of the central goals of current provider-side health care reform efforts. In addition to eliminating existing perverse financial incentives for both hospitals and physicians, the need for which is already agreed upon by numerous scholars, we argue that the success of the ongoing Chinese public hospital reform and of overall health care reform also relies on establishing appropriate physician-hospital agency relations. This commentary proposes 2 essential steps to establish such physician-hospital agency relations: (1) minimize financial ties between senior physicians and tertiary-level public hospitals by establishing a separate reimbursement system for senior physicians, and (2) establishing a comprehensive physician professionalism system underwritten by the Chinese government, professional physician associations, and major health care facilities as well as by physician leadership representatives. Neither of these suggestions is addressed adequately in current health care reform activities.
Although the concept of solidarity sits at the center of many European health sector debates, the specific groups eligible for coverage, the financing arrangements, and the range of services and benefits that, together, compose the operational content of solidarity have all changed considerably over time. In prior economic periods, solidarity covered considerably fewer services or groups of the population than it does today. As economic and political circumstances changed, the content of solidarity changed with them. Recent examples of these shifts are illustrated through a discussion of health reforms in Netherlands, Germany and also Israel (although not in Europe, the Israeli health system is similar in structure to European social health insurance systems). This article suggests that changed economic circumstances in Europe since the onset of the 2008 financial crisis may lead to re-configuring the scope and content of services covered by solidarity in many European health systems. A key issue for policymakers will be protecting vulnerable populations as this re-design occurs.
Public hospitals are well known to be difficult to reform. This paper provides a comprehensive six-part analytic framework that can help policymakers and managers better shape their organizational and institutional behavior.
The paper first describes three separate structural characteristics which, together, inhibit effective problem description and policy design for public hospitals. These three structural constraints are i) the dysfunctional characteristics found in most organizations, ii) the particular dysfunctions of professional health sector organizations, and iii) the additional dysfunctional dimensions of politically managed organizations. While the problems in each of these three dimensions of public hospital organization are well-known, and the first two dimensions clearly affect private as well as publicly run hospitals, insufficient attention has been paid to the combined impact of all three factors in making public hospitals particularly difficult to manage and steer.
Further, these three structural dimensions interact in an institutional environment defined by three restrictive context limitations, again two of which also affect private hospitals but all three of which compound the management dilemmas in public hospitals. The first contextual limitation is the inherent complexity of delivering high quality, safe, and affordable modern inpatient care in a hospital setting. The second contextual limitation is a set of specific market failures in public hospitals, which limit the scope of the standard financial incentives and reform measures. The third and last contextual limitation is the unique problem of generalized and localized anxiety, which accompanies the delivery of medical services, and which suffuses decision-making on the part of patients, medical staff, hospital management, and political actors alike.
This combination of six institutional characteristics – three structural dimensions and three contextual dimensions – can help explain why public hospitals are different in character from other parts of the public sector, and the scale of the challenge they present to political decision-makers.
Patient choice has become an increasingly visible part of publicly funded health care systems. Since the 1990s, many individuals have gained the ability to select their insurer in social health insurance funded systems, while in tax-funded health systems many patients can now select their primary care and hospital providers. Second opinions about clinical procedures are part of this broad movement toward increased patient involvement in care-related decision-making. One interesting policy question will be whether the coming period of financial austerity will strengthen or weaken the role of choice as health systems seek to deal with the inevitable mismatch of demand for and supply of medical resources.
This paper aims to develop a telehealth success model and discusses three critical components: (1) health information quality, (2) electronic health record system quality, and (3) telehealth service quality to ensure effective telehealth service delivery, reduce professional burnout, and enhance access to care. The paper applied a policy analysis method and discussed telehealth applications in rural health, mental health, and veterans health services. The results pointed out the fact that, although telehealth paired with semantic/organizational interoperability facilitates value-based and team-based care, challenges remain to enhance user (both patients and clinicians) experience and satisfaction. The conclusion indicates that approaches at systemic and physician levels are needed to reduce disparities in health technology adoption and improve access to telehealth care.