Side Effects: A Dose of Competition and Access to Care

Department of Health Policy and Management, Columbia University, Mailman School of Public Health, USA.
Journal of Health Politics Policy and Law (Impact Factor: 1.37). 07/2006; 31(3):643-56. DOI: 10.1215/03616878-2005-011
Source: PubMed


The Federal Trade Commission and Department of Justice 2004 report Improving Health Care: A Dose of Competition argues in favor of increasing competition among health care providers. Several of the proposals within the report, however, may pose risks for access to care. The report urges that the current system of implicit cross-subsidies for indigent care be replaced with insurance expansions that provide coverage to individuals. Such a substitution would certainly enhance access, but would be very costly and likely require considerable government intervention in the health care system. In the absence of a substantial expansion in coverage, reductions in cross-subsidies could limit access to care through the existing safety net. The report argues that insurance mandates limit access to care by driving up cost and reducing choice. In some cases, such as mental health and substance abuse, however, the unregulated market may not cover a benefit at all, leaving people with less coverage and less choice. Finally, the report stresses the importance of linking costs to quality. Such a linkage is likely to lead to a health care system in which poor people obtain poor-quality care at low prices--a result that many would find disturbing.

2 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Private payers and many industry analysts claim that hospital pricing strategy typically shifts health care costs from government payors to private payors. Economists believe, however, that hospitals would have maximized prices with previous market power, preventing any current opportunity to increase prices and shift costs. Economists have more recently claimed that a lack of competition is the reason for any cost shifting that may be occurring. Given issues such as hospital mission and governance, and the responses of hospitals to changing industry conditions, both parties may be correct in their cost-shifting assessment. Furthermore, understanding both viewpoints may be necessary to address adequately the cost-shifting issue and the future financing of health care.
    Journal of health care finance 02/2007; 34(1):64-71.
  • [Show abstract] [Hide abstract]
    ABSTRACT: The aim of this retrospective study was to assess the feasibility and outcome of day case thyroidectomy in an ambulatory surgery centre in Hong Kong. Patients with day case thyroidectomy carried out between July 2005 and December 2006 were retrospectively reviewed. Day surgery was offered to patients satisfying the selection criteria for day case and having from benign unilobular thyroid disease. Fifty patients had hemithyroidectomy carried out during the study period. There were 6 men and 44 women and the mean (standard deviation SD) age was 45.6 years (7.4 years). All patients were American Society for Anesthesiologists grade I (76%) or II (34%). The mean (SD) operative time was 79.5 min (17 min). Twelve patients had episodes of postoperative nausea and vomiting. The mean (SD) analgesic requirement was 0.7 tablets (0.5 tablets) of combination acetaminophen and phenyltoloxamine citrate before discharge. The mean (SD) time to discharge was 7.5 h (0.7 h). The overall discharge rate was 98% and the complication rate was 8%. One patient was observed overnight because of postoperative haematoma. One patient had recurrent laryngeal nerve injury. There were no unplanned readmissions postoperatively. Three patients had unsuspected thyroid malignancy on histopathology. This study showed the feasibility and safety of day case thyroidectomy. The setting was not associated with any increase in morbidity or mortality and has the potential in reducing hospital costs.
    ANZ Journal of Surgery 11/2008; 78(10):864-6. DOI:10.1111/j.1445-2197.2008.04681.x · 1.12 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The 2006 Enthoven-inspired Dutch health insurance reform, based on regulated competition with a mandate for individuals to purchase insurance, will interest U.S. policy makers who seek universal coverage. This ongoing experiment includes guaranteed issue, price competition for a standardized basic benefits package, community rating, sliding-scale income-based subsidies for patients, and risk equalization for insurers. Our assessment of the first two years is based on Dutch Central Bank statistics, national opinion polls, consumer surveys, and qualitative interviews with policy makers. The first lesson for the United States is that the new Dutch health insurance model may not control costs. To date, consumer premiums are increasing, and insurance companies report large losses on the basic policies. Second, regulated competition is unlikely to make voters/citizens happy; public satisfaction is not high, and perceived quality is down. Third, consumers may not behave as economic models predict, remaining responsive to price incentives. Finally, policy makers should not underestimate the opposition from health care providers who define their profession as more than simply a job. If regulated competition with individual mandates performs poorly in auspicious circumstances such as the Netherlands, how will this model fare in the United States, where access, quality, and cost challenges are even greater? Might the assumptions of economic theory not apply in the health sector?
    Journal of Health Politics Policy and Law 01/2009; 33(6):1031-55. DOI:10.1215/03616878-2008-033 · 1.37 Impact Factor