Managed competition

The way the health system is organised is a critically important social determinant of health. Australia's current health system funding arrangements contain serious barriers to effective health promotion and chronic disease management. The consequences are most evident among disadvantaged people. Major health system reform is needed in Australia to rectify this problem. This paper describes current mechanisms for funding health care in Australia and examines a recent reform experiment, the Co-ordinated Care Trials. It discusses why the trials were unsuccessful and identifies key criteria for future success. Three existing proposals for health system reform are assessed against these criteria - managed competition, a Commonwealth takeover of health and medical saving accounts. Successful reform of Australia's health system will need to ensure that more flexible services are delivered, changes are made on a large scale to affect demand and strong incentives to use cost-effect...

The way the health system is organised is a critically important social determinant of health. Australia's current health system funding arrangements contain serious barriers to effective health promotion and chronic disease management. The consequences are most evident among disadvantaged people. Major health system reform is needed in Australia to rectify this problem. This paper describes current mechanisms for funding health care in Australia and examines a recent reform experiment, the Co-ordinated Care Trials. It discusses why the trials were unsuccessful and identifies key criteria for future success. Three existing proposals for health system reform are assessed against these criteria - managed competition, a Commonwealth takeover of health and medical saving accounts. Successful reform of Australia's health system will need to ensure that more flexible services are delivered, changes are made on a large scale to affect demand and strong incentives to use cost-effect...

On March 23, 2010, Section 3022 of the Patient Protection & Affordable Care Act (PPACA or ACA) established the Medicare Shared Savings Program (MSSP). The MSSP depends on Accountable Care Organizations (ACOs) to coordinate care for large groups of Medicare beneficiaries and reduce their overall costs while maintaining quality.' ACOs are a critical part of the PPACA. If they succeed, they could be a model of care coordination critical to cost reductions, quality improvements, and expanded access to care both within and beyond the Medicare program.2 Their failure would not bode well for the wide array of pilot programs promoted and funded by the PPACA.3 Seton Hall was the first law school to host a conference on

Market-oriented strategies, embodied in managed competition, have become the primary focus of contemporary U.S. health policy. This dominance reflects the emergence of a bipartisan coalition of support among political elites. This study traces the historical evolution of elite support for the market and suggests that the consensus favoring managed competition is deceptively fragile, with support riven by cleavages in the values used to judge fairness in the allocation of medical care. A unique data set of matched questions asked of both policy elites and the general public is used to document these differences in ethical norms. The implications of these cleavages help to explain three puzzling aspects of contemporary U.S. health policy: (1) the persisting inability to translate the principles of managed competition into politically feasible reforms, (2) the repeated failures to implement demonstration projects intended to test competitive pricing within the Medicare program, and (3) the inability of state regulations to assuage the public's concerns about managed care. Some prescriptions for a more revealing and effective treatment of market reforms in health policy conclude this study.

Market-oriented strategies, embodied in managed competition, have become the primary focus of contemporary U.S. health policy. This dominance reflects the emergence of a bipartisan coalition of support among political elites. This study traces the historical evolution of elite support for the market and suggests that the consensus favoring managed competition is deceptively fragile, with support riven by cleavages in the values used to judge fairness in the allocation of medical care. A unique data set of matched questions asked of both policy elites and the general public is used to document these differences in ethical norms. The implications of these cleavages help to explain three puzzling aspects of contemporary U.S. health policy: (1) the persisting inability to translate the principles of managed competition into politically feasible reforms, (2) the repeated failures to implement demonstration projects intended to test competitive pricing within the Medicare program, and (3) the inability of state regulations to assuage the public's concerns about managed care. Some prescriptions for a more revealing and effective treatment of market reforms in health policy conclude this study.

Résumé

L’article présente une comparaison des modes de régulation des services à domicile au Québec et en Ontario à partir d’une approche empruntée au cadre conceptuel de l’économie solidaire et plurielle en tenant compte des dispositions permettant aux usagers d’exprimer leurs préférences quant à l’organisation des services. Après avoir tracé le portrait des transformations des services à domicile au Québec et en Ontario au cours des quinze dernières années, nous mettons en relief le caractère déterminant des modes de régulation dans la structuration des services dans les deux provinces. Si l’Ontario a expérimenté avec plus d’intensité la régulation concurrentielle en mettant en place un système de managed competition, le modèle québécois, quant à lui, reste ancré de manière dominante dans une régulation tutélaire, malgré un intérêt plus récent pour la logique concurrentielle. Malgré leurs différences, le choix des usagers dans l’organisation des services reste toutefois peu considéré dans les deux modèles.

Abstract

This paper compares modes of regulating in-home services in Quebec and Ontario based on an approach borrowed from the conceptual framework of the plural, solidarity economy, taking into account provisions that allow users to express their preferences regarding the organization of services. After outlining how the delivery of in-home services has changed in Quebec and Ontario over the last 15 years, we highlight the modes of regulation as the decisive factor in structuring services in the two provinces. While Ontario experimented more intensely with competitive regulation by setting up a system of managed competition, Quebec has stuck with a supervisory regulation model, despite more recent interest in a competition-based approach. Notwithstanding the differences between the two systems, users’ freedom to make choices about the organization of services is given little consideration in either model.

This article provides a comparative conceptual framework for understanding why so many governments found economic policies based on managed competition attractive and yet dangerous to implement. The framework conceptualizes governments as a kind of organizational complex and thus governments as an international population of organizations, each embedded in a state that tries to harness and direct behaviour through what Foucault called "governmentality". This nascent concept is made more robust here and joined with Fligstein's historical research on the response of leading organizations when fundamental change threatens a population of organizations, by embracing a new conception of control that allows them to re-establish their control and pre-eminence. Fligstein studied corporations, but his model can be fruitfully extended to governments. Economic sociology has not to date been able to do much comparative research on institutional responses to economic policy; but th...