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March 2002 (Volume 80)
March 2002 | Bradford H. Gray
In 1995, the Israeli economist Dov Chernichovsky published an article in the Milbank Quarterly that described what he called the emerging paradigm in the financing and delivery of health care in developed nations (Chernichovsky 1995). This paradigm was a response to nations’ struggles to find an acceptable balance between individuals’ perceived needs for health care and acceptable national levels of health expenditures. The emerging paradigm sought to combine the consumer satisfaction and internal efficiency of market-competitive systems with the equity and universality of publicly financed systems. A key element of the emerging paradigm was separating the organization and management of care consumption (the OMCC function, in Chernichovsky’s terms) from financing and providing care.
In this issue, Chernichovsky extends and refines his analysis in an article entitled “Pluralism, Public Choice, and the State in the Emerging Paradigm in Health Systems.” Concerned with consumer empowerment in systems typically dominated by either government or providers, he focuses on the role of OMCC institutions. Building on Schlesinger’s (1997) notion of countervailing agency, Chernichovsky considers for whom OMCC institutions act as an agent. Schlesinger depicted health plans (OMCCs for Chernichovsky) as agents for purchasers in the United States, with patients’ interests dependent on health professionals’ acting as the agent of the patient. In other countries, Chernichovsky suggests, the OMCC’s role may be to serve as the agent of patients, providing a countervailing agency against the powerful medical profession.
OMCC institutions vary in many ways, such as the extent to which the different functions (management, primary care, hospital services) are integrated and which functions are under public control. Chernichovsky describes four OMCC models and offers hypotheses about how they relate to the system goals of expenditure control, patient satisfaction, accessibility or services, equity, and quality of care. Finally, to enhance the ability of OMCCs to help balance individual and social objectives in health care systems, he suggests some principles regarding the roles of the State and OMCCs.
The second article in this issue also is concerned with medical consumerism and the triadic relationship of patient, provider, and payer. In “Not Afraid to Blame: The Neglected Role of Blame Attribution in Medical Consumerism and Some Implications for Health Policy,” Marsha Rosenthal and Mark Schlesinger analyze several questions that arise when the payer’s role becomes more visible, as it has in the managed care era in the United States. Whom do patients blame when they suffer a bad outcome, and what determines whether they attribute responsibility to their physician or their health plan? What determines whether they will act, for example, by complaining after they have attributed blame? Rosenthal and Schlesinger develop a new conceptual framework and set of hypotheses, building on ideas ranging from attribution theory in psychology to Hirschmann’s (1970) thinking about exit, voice, and loyalty. Then they test these hypotheses using data from a survey of people with a serious mental illness and discuss the implications of their findings for medical consumerism in health policy.
In the article “Performance-Based Contracting in Wisconsin Public Health: Transforming State-Local Relations,” John Chapin and Bruce Fetter document the first attempt by a state to develop and implement a performance-based system that holds local health departments accountable. The idea of developing performance-based standards for public health agencies has attracted great interest, and the collaborative performance-standard development project of the National Public Health Performance Standards Program at the Centers for Disease Control and Prevention has now tested draft performance assessment instruments for both state and local health departments (CDC 2000, 2001). Wisconsin has been out ahead, having in 1999 become the first state to implement a system in which the state’s payments to local health departments would be linked to measured performance. The article in this issue of the Quarterlyby the state’s health officer (Chapin) and an academic historian (Fetter) describes both how the system works and the political strategies that were used to put it into place. These developments were part of the reform package championed by Tommy Thompson, the governor who is now secretary of the U.S. Department of Health and Human Services.
In “Examining the Role of Health Services Research in Public Policymaking,” John Lavis and his colleagues consider how to assess and improve the impact of researchers’ work. They report on an empirical study of how research was used in the development of a sample of low-profile policies in the health departments of two Canadian provinces, and they constructively discuss the conceptual and methodological complexities of assessing the impact of research on policy. Finding that interaction between the policy and research communities facilitates the use of research in policymaking, they analyze issues that researchers and policymakers should consider in order to improve the use of research in the development of public policy.
This issue ends with a provocative, scholarly, and witty essay, “Extending Life: Scientific Prospects and Political Obstacles,” by the gerontologist Richard Miller. Miller writes of the prospect that aging itself may be an alterable process. Thus, his topic is neither the elimination of the diseases that are major causes of mortality nor the possibility of forestalling death in the terminally ill. He first summarizes evidence from several lines of research on animals that suggests that reductions of 30 to 40 percent can be achieved in the rate of aging. In humans, similar anti-aging interventions would “produce 112-year-old people with the same, highly variable, set of abilities and disabilities seen in today’s 78-year-olds.” Notably, the period of late-life suffering would be delayed, not prolonged.
Miller then asks why so little financial support is available for anti-aging research (or what he calls applied gerontology), compared with that for disease-oriented research. His answers are insightful, intriguing, and entertaining. For example, he observes that “many members of the educated public, while frequently interested in promoting their own longevity, view improving the longevity of their fellows as vaguely distasteful and somehow unwise.” Readers will find this article stimulating even if their own work has nothing to do with questions like how we will pay for Medicare in 25 years. The scientific developments that Miller sees as likely challenge us to think about all areas of policy that would be affected by significant increases in the ordinary life span of human beings.
Bradford H. Gray Editor, The Milbank Quarterly
CDC. 2000. National Public Health Performance Standards Program: State Public Health System Performance Assessment Instrument. Version: State Tool May 2000. Draft, May 24. Atlanta: Centers for Disease Control.
CDC. 2001. National Public Health Performance Standards Program: Local Public Health System Performance Assessment. Version: Field Test 5b. Atlanta: Centers for Disease Control.
Chernichovsky, D. 1995. Health System Reforms in Industrialized Democracies: An Emerging Paradigm. Milbank Quarterly 73(3):339–72.
Hirschmann, A. 1970. Exit, Voice, and Loyalty: Responses to Decline in Firms, Organizations, and States. Cambridge, Mass.: Harvard University Press.
Schlesinger, M. 1997. Countervailing Agency: A Strategy of Principled Regulation under Managed Competition. Milbank Quarterly75(1):35–87.
Author(s): Bradford H. Gray
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Volume 80, Issue 1 (pages 1–4) DOI: 10.1111/1468-0009.00183_17 Published in 2002
Pluralism, Public Choice, and the State in the Emerging Paradigm in Health Systems
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