The health care system. Black box or Bermuda Triangle. Four essays on economically desirable health care system characteristics.

摘要

This volume consists of four papers addressing the issue of optimal system design, where optimality is evaluated on the basis of care effectiveness, and cost containment.;The extent to which patients' behaviour and payers' decisions motivate doctors to exert diagnostic effort is investigated. Two major results are found. First, when a larger proportion of patients reject treatment recommendations, doctors are less likely to be diligent. This result holds when patients are not informed about their condition. Second, in a capitation system, patients choosing to return from additional care after initial failure create an incentive to choose diagnostic effort. The capitation system creates a higher proportion of diligent doctors than the fee for service system. While under-prescription increases, over-prescription is curbed to a greater extent.;Second, two empirical papers are presented, investigating the methods available for estimation of health system efficiency, and estimation of its underlying causes. In 2000, the World Health organization estimated the efficiency of health systems around the world and provided a ranking for 191 countries. Since then, several authors have commented on the shortcomings of the model used in the original study. Follow up studies modified the original model to show the resulting changes in efficiency estimates and rankings. The remaining gap in literature is an investigation of determinants of health system inefficiency. A related strand of literature focuses on health system characteristics as determinants of health expenditures. Focus on health care costs, with no consideration of health outcome, is an incomplete economic study, as many point out at the microeconomic level of health program evaluation. This paper discusses the same health system characteristics, but as determinants of health system efficiency.;Two methods of analyzing sources of health system inefficiency are applied, a two stage stochastic frontier approach, and a one stage stochastic frontier approach. Data used encompasses 21 OECD countries over 23 years. While efficiency estimation and subsequent ranking of health systems are quite volatile to choice of model, results with respect to desirable health system characteristics are consistent between models.;First, a microeconomic model of the health care market is presented, in which doctors act as agents to uninformed patients. Diagnostic effort is required on the part of the doctor to correctly identify the patient's condition. Hence a failure on the part of the doctor to prescribe the appropriate most effective treatment is attributed not the monetary gain from delivering too much treatment, as is suggested by the demand inducement hypothesis. Rather, a doctor may lack the financial and altruistic incentive to exert necessary diagnostic effort, therefore recommending in appropriate treatment.;Results indicate that efficiency is higher in public contract systems, defined as one where an agreement exists between health care providers and third party payers. Efficiency also increases with the number of acute care beds available coupled with shorter stays in those beds. Capitation of physician reimbursement leads to greater efficiency as opposed to fee-for-service arrangements.;Results of this volume, both theoretical and empirical, strongly favour capitation forms of physician reimbursement over fee for service systems. (Abstract shortened by UMI.)