The use of targets to improve the performance of health care providers: a discussion of government policy.
The aim of this discussion paper is to examine the advantages and drawbacks of employing targets, or performance indicators, to improve the performance of those delivering health care services. The paper is based on an examination of two target-setting policies initiated by Government: the 1992 Health of the Nation strategy and the 1990 General Practitioners' Contract. It is argued that the introduction of both the General Practitioners' Contract and the Health of the Nation have indeed been accompanied by improvements in performance, however, there are a number of problems with targets. They tend to focus on those things that are most easily measured, and they may foster complacency on the part of providers who have already achieved upper target limits, and defensiveness on the part of those performing badly. National targets may skew local priorities; they may also be unrealistic and unattainable for particular, less privileged population groups. They may serve to widen inequalities in health, and can exacerbate the 'inverse care law' by encouraging providers to direct their efforts at the more advantaged sections of society, where such efforts are more likely to pay off in terms of overall improvements in the target level achieved. Finally, the achievement of some targets will not necessarily result in better health outcomes. The paper concludes that a target-setting approach to improving the quality of care must be based on the use of appropriate indicators, and must take account of differences between more and less advantaged sections of society. (+info)
A taxonomy of health networks and systems: bringing order out of chaos.
OBJECTIVE: To use existing theory and data for empirical development of a taxonomy that identifies clusters of organizations sharing common strategic/structural features. DATA SOURCES: Data from the 1994 and 1995 American Hospital Association Annual Surveys, which provide extensive data on hospital involvement in hospital-led health networks and systems. STUDY DESIGN: Theories of organization behavior and industrial organization economics were used to identify three strategic/structural dimensions: differentiation, which refers to the number of different products/services along a healthcare continuum; integration, which refers to mechanisms used to achieve unity of effort across organizational components; and centralization, which relates to the extent to which activities take place at centralized versus dispersed locations. These dimensions were applied to three components of the health service/product continuum: hospital services, physician arrangements, and provider-based insurance activities. DATA EXTRACTION METHODS: We identified 295 health systems and 274 health networks across the United States in 1994, and 297 health systems and 306 health networks in 1995 using AHA data. Empirical measures aggregated individual hospital data to the health network and system level. PRINCIPAL FINDINGS: We identified a reliable, internally valid, and stable four-cluster solution for health networks and a five-cluster solution for health systems. We found that differentiation and centralization were particularly important in distinguishing unique clusters of organizations. High differentiation typically occurred with low centralization, which suggests that a broader scope of activity is more difficult to centrally coordinate. Integration was also important, but we found that health networks and systems typically engaged in both ownership-based and contractual-based integration or they were not integrated at all. CONCLUSIONS: Overall, we were able to classify approximately 70 percent of hospital-led health networks and 90 percent of hospital-led health systems into well-defined organizational clusters. Given the widespread perception that organizational change in healthcare has been chaotic, our research suggests that important and meaningful similarities exist across many evolving organizations. The resulting taxonomy provides a new lexicon for researchers, policymakers, and healthcare executives for characterizing key strategic and structural features of evolving organizations. The taxonomy also provides a framework for future inquiry about the relationships between organizational strategy, structure, and performance, and for assessing policy issues, such as Medicare Provider Sponsored Organizations, antitrust, and insurance regulation. (+info)
Organizational and environmental factors associated with nursing home participation in managed care.
OBJECTIVE: To develop and test a model, based on resource dependence theory, that identifies the organizational and environmental characteristics associated with nursing home participation in managed care. DATA SOURCES AND STUDY SETTING: Data for statistical analysis derived from a survey of Directors of Nursing in a sample of nursing homes in eight states (n = 308). These data were merged with data from the On-line Survey Certification and Reporting System, the Medicare Managed Care State/County Data File, and the 1995 Area Resource File. STUDY DESIGN: Since the dependent variable is dichotomous, the logistic procedure was used to fit the regression. The analysis was weighted using SUDAAN. FINDINGS: Participation in a provider network, higher proportions of resident care covered by Medicare, providing IV therapy, greater availability of RNs and physical therapists, and Medicare HMO market penetration are associated with a greater likelihood of having a managed care contract. CONCLUSION: As more Medicare recipients enroll in HMOs, nursing home involvement in managed care is likely to increase. Interorganizational linkages enhance the likelihood of managed care participation. Nursing homes interested in managed care should consider upgrading staffing and providing at least some subacute services. (+info)
Health insurance in developing countries: lessons from experience.
Many developing countries are currently considering the possibility of introducing compulsory health insurance schemes. One reason is to attract more resources to the health sector. If those who, together with their employers, can pay for their health services and are made to do so by insurance, the limited tax funds can be concentrated on providing services for fewer people and thus improve coverage and raise standards. A second reason is dissatisfaction with existing services in which staff motivation is poor, resources are not used to best advantage and patients are not treated with sufficient courtesy and respect. This article describes the historical experience of the developed countries in introducing and steadily expanding the coverage of health insurance, sets out the consensus which has developed about health insurance (at least in Western European countries) and describes the different forms which health insurance can take. The aim is to bring out the advantages and disadvantages of different approaches from this experience, to set out the options for developing countries and to give warnings about the dangers of some approaches. (+info)
Contracting out of health services in developing countries.
Contracting out is emerging as a common policy issue in a number of developing countries. The theoretical case for contracting out suggests many advantages in combining public finance with private provision. However, practical difficulties such as those of ensuring that competition takes place between potential contractors, that competition leads to efficiency and that contracts and the process of contracting are effectively managed, suggest that such advantages may not always be realized. Most countries are likely only to contemplate restricted contracting of small-scale non-clinical services in the short term. Prerequisites of more extensive models appear to be the development of information systems and human resources to that end. Some urban areas of larger countries may have the existing preconditions for more successful large-scale contracting. (+info)
Managing the health care market in developing countries: prospects and problems.
There is increasing interest in the prospects for managed market reforms in developing countries, stimulated by current reforms and policy debates in developed countries, and by perceptions of widespread public sector inefficiency in many countries. This review examines the prospects for such reforms in a developing country context, primarily by drawing on the arguments and evidence emerging from developed countries, with a specific focus on the provision of hospital services. The paper begins with a discussion of the current policy context of these reforms, and their main features. It argues that while current and proposed reforms vary in detail, most have in common the introduction of competition in the provision of health care, with the retention of a public monopoly of financing, and that this structure emerges from the dual goals of addressing current public sector inefficiencies while retaining the known equity and efficiency advantages of public health systems. The paper then explores the theoretical arguments and empirical evidence for and against these reforms, and examines their relevance for developing countries. Managed markets are argued to enhance both efficiency and equity. These arguments are analysed in terms of three distinct claims made by their proponents: that managed markets will promote increased provider competition, and hence, provider efficiency; that contractual relationships are more efficient than direct management; and that the benefits of managed markets will outweigh their costs. The analysis suggests that on all three issues, the theoretical arguments and empirical evidence remain ambiguous, and that this ambiguity is attributable in part to poor understanding of the behaviour of health sector agents within the market, and to the limited experience with these reforms. In the context of developing countries, the paper argues that most of the conditions required for successful implementation of these reforms are absent in all but a few, richer developing countries, and that the costs of these reforms, particularly in equity terms, are likely to pose substantial problems. Extensive managed market reforms are therefore unlikely to succeed, although limited introduction of particular elements of these reforms may be more successful. Developed country experience is useful in defining the conditions under which such limited reforms may succeed. There is an urgent need to evaluate the existing experience of different forms of contracting in developing countries, as well as to interpret emerging evidence from developed country reforms in the light of conditions in developing countries. (+info)
Clinical audit and the purchaser-provider interaction: different attitudes and expectations in the United Kingdom.
OBJECTIVES: To explore and describe the views on clinical audit of healthcare purchasers and providers, and in particular the interaction between them, and hence to help the future development of an appropriate interaction between purchasers and providers. DESIGN: Semistructured interviews. SETTING: Four purchaser and provider pairings in the former Northern Region of the National Health Service (NHS) in England. SUBJECTS: Chief executives, contracts managers, quality and audit leaders, directors of public health, consultants, general practitioners, audit support staff, and practice managers (total 42). MAIN MEASURES: Attitudes on the present state and future development of clinical audit. RESULTS: Purchasers and providers shared common views on the purpose of clinical audit, but there were important differences in their views on the level and appropriateness of involvement of health care purchasers, integration with present NHS structures and processes (including contracting and the internal market), priority setting for clinical audit, the effects of clinical audit on service development and purchasing, change in behaviour, and the sharing of information on the outcomes of clinical audit. CONCLUSIONS: There are important differences in attitudes towards, and expectations of, clinical audit between health care purchasers and providers, at least in part due to the limited contact between them on audit to date. The nature of the relation and dialogue between purchasers and providers will be critical in determining whether clinical audit meets the differing aspirations of both groups, while achieving the ultimate goal of improving the quality of patient care. (+info)
Improving the quality of health care through contracting: a study of health authority practice.
OBJECTIVES: To investigate approaches of district health authorities to quality in contracting. DESIGN: Descriptive survey. SETTING: All district health authorities in one health region of England in a National Health Service accounting year. MATERIAL: 129 quality specifications used in contracting for services in six specialties (eight general quality specifications and 121 service specific quality specifications) MAIN MEASURES: Evaluation of the use of quality specifications; their scope and content in relation to established criteria of healthcare quality. RESULTS: Most district health authorities developed quality specifications which would be applicable to their local hospital. When purchasing care outside their boundaries they adopted the quality specifications developed by other health authorities. The service specific quality specifications were more limited in scope than the general quality specifications. The quality of clinical care was referred to in 75% of general and 43% of service specific quality specifications. Both types of specification considered quality issues in superficial and broad terms only. Established features of quality improvement were rarely included. Prerequisites to ensure provider accountability and satisfactory delivery of service specifications were not routinely included in contracts. CONCLUSION: Quality specifications within service contracts are commonly used by health authorities. This study shows that their use of this approach to quality improvement is inconsistent and unlikely to achieve desired quality goals. Continued reliance on the current approach is holding back a more fundamental debate on how to create effective management of quality improvement through the interaction between purchasers and providers of health care. (+info)