Answer questions

Explain the difference between Traditional Managed Care and Network Managed Care.
List and explain two of Managed Care’s achievements.
List and explain two of Managed Care’s unmet goals.
Briefly, explain the three complaints depicted in the article.
According to the article, why are health care costs still rising?
Explain the difference between Traditional Managed Care and Network Managed Care.
List and explain two of Managed Care’s achievements.
List and explain two of Managed Care’s unmet goals.
Briefly, explain the three complaints depicted in the article.
According to the article, why are health care costs still rising?

Answer all five questions using the uploaded article

Managed care: the US experienceNeelam K. Sekhri1

This article provides an overview of managed health care in the USA — what has been achieved and what has not —and some lessons for policy-makers in other parts of the world. Although the backlash by consumers and providersmakes the future of managed care in the USA uncertain, the evidence shows that it has had a positive effect onstemming the rate of growth of health care spending, without a negative effect on quality. More importantly, it hasspawned innovative technologies that are not dependent on the US market environment, but can be applied in publicand private systems globally. Active purchasing tools that incorporate disease management programmes,performance measurement report cards, and alignment of incentives between purchasers and providers respond to keyissues facing health care reform in many countries. Selective adoption of these tools may be even more relevant insingle payer systems than in the fragmented, voluntary US insurance market where they can be applied moresystematically with lower transaction costs and where their effects can be measured more precisely.Keywords:managed care programmes; quality of health care; review literature; United States.Voir page 841 le re ́ sume ́ en franc ̧ ais. En la pa ́ gina 842 figura un resumen en espan ̃ ol.IntroductionManaged health care as it has developed in the USA,aand the current backlash against it, must be viewed inthe context of the traditional US health care system.This system of employer-based, indemnity insuranceand fee-for-service health care conditioned bothproviders ’and patients ’expectations of unlimitedresources and unrestrained choice. As Uwe Re-inhardt has aptly stated, it was the ‘‘fairyland tale ofthe proverbial free lunch’’ (1). Not surprisingly, theconstraints and controls imposed by managed carehave resulted in outrage by doctors and their patients(and by doctorsthroughtheir patients).Although the response is predictable given thelimits on provider compensation and consumerexpectations of unrationed care, the methods usedby managed care organizations have undoubtedlycontributed to the furor. That the US Administration isnow being asked by the public to step in and ‘‘regulate’’the health care market is an irony which HillaryClinton, who led the last ill-fated government attemptto reform the US health care market, must findparticularly amusing. Managed care in the USA findsitself under attack from all sides. Consumers complainvocally about denials of care; and they and their lawyersclaim that managed care organizations provide sub-standard quality of care for the sake of cutting costs,citing anecdotal evidence of negligence on the part ofhealth plans. As a result, several US states have passedlaws allowing health plans to be sued for malpractice,and the team of lawyers that successfully brought thetobacco industry to its knees has now turned itsattention to managed care.Providers complain about unsustainable re-ductions in compensation, unfair labour practicesthat can dismiss physicians if they provide care that istoo expensive in the view of the health plan, andunethical intrusion by health plans into the practice ofmedicine. Physicians are ready to unionize and theAmerican Medical Association, in an unprecedentedmove, supports this. Many US states have passed‘‘any willing provider’’ laws requiring a health plan tocontract with any and all physicians who are willing toaccept its contract. This runs counter to thefundamental managed care tenet of selective con-tracting and protects the system’s excess supply ofphysicians, particularly specialists.The managed care industry might be able towithstand these criticisms if it were actually makinghuge profits, a charge levelled by providers and thepublic. In fact, although managed care enrolment hascontinued to grow, the net income of most managedcare organizations has plummeted. In 1997, forexample, they reported collective losses of almostUS$ 1 billion (2). As a result, health plans have postedsignificant employer premium increases for the thirdyear in a row, and now find their previous allies, thefunders of care, frustrated and antagonistic (3, 4).Despite provider reactions, ‘‘horror’’ stories in themedia, and government rhetoric, neither US employ-ers nor government funders are willing to return todouble-digit annual percentage increases in health carecosts (3). Medicare, the largest government funder,which provides coverage to those aged over 65 years, isrequired by the Balanced Budget Act of 1997 tosignificantly reduce spending and extend the life of theMedicare trust fund. Employers, still protected by the1Founding Partner, Healthcare Redesign International,875-A Island Drive #381, Alameda, CA 94502, USA(email: nsekhiri@hcredesign.com).aUnless otherwise specified, the terms health plan and managedcare organization are used interchangeably in this article to refer toan entity providing or arranging for coverage of health services neededby members of a plan for a fixed, prepaid premium.Ref. No.00-0607Special Theme– Health Systems830#World Health Organization 2000Bulletin of the World Health Organization, 2000,78(6)

booming US economy, have been able to absorb risinghealth care premiums so far, but foresee a day fastapproaching when increases in premiums will bepassed down to employees or will force employers tostop providing health care coverage (5). This can onlylead to a further swelling of the ranks of the 44 millionuninsured people in the USA (6).What is the truth behind the complaints aboutmanaged care? What is the evidence that US healthcare quality is suffering due to an overemphasis oncost containment? This article provides an overviewof the state of managed care in the USA today, what ithas achieved and what it has not; and some lessonsfor policy-makers in the USA and elsewhere.Brief overview of the US health caresystemThe US health care system is unique among wealthyindustrialized countries in the extent of its reliance onthe private sector for the financing, purchasing anddelivery of health care services. Public expenditures— through federal, state and local governments —total 45% (Fig. 1) of overall health spending,primarily for purchasing health services for specificpopulations (e.g. the elderly, disabled, veterans, andthe poor). The large majority of US residents receiveshealth insurance benefits through their employersand accesses services delivered by the private sector.Employers receive a significant tax subsidy forproviding private insurance to employees and theirfamilies, and employees often share in the cost ofbenefits. However, almost 44 million people are notcovered by any continuous public or private healthinsurance scheme and have limited access to privatemedical resources. They receive care through publiclyoperated clinics and hospitals or pay out of pocket forservices to private providers (7).At 13.5%, the USA devotes a higher percentageof its gross domestic product (GDP) to health care thanany other country. This percentage has remainedessentially flat since 1992 (8), which is attributable tothe strong US economy, the Balanced Budget Act of1997, and the dramatic shift away from indemnityinsurance into managed care plans. Although annual percapita health expenditures in 1998 of US$ 4094 (9, 10)were still well above those of other OECD countries,they are growing at a much slower rate than in the past.Fig. 2 provides an overview of the US healthcare system: the funders, purchasers and providers ofcare are generally distinct entities. Some managedcare organizations, however, serve as both purcha-sers (pooling the risk) and providers of care; 89% ofemployees are now enrolled in plans with some formof managed care (11). Provision of health services ispredominately through private providers, includinghospitals,bintegrated health care organizations(which link physicians, hospitals and other provi-ders), and physicians. Almost 70% of US hospitals arecommunity-based, non-profit institutions.Most physicians in the USA, both primary carepractitioners and specialists, are in some form ofprivate practice; 39% operate single practices and 61%are in group practices of two or more physicians (12).cThe USA has a higher ratio of specialists to primarycare physicians than most OECD countries. With therapid spread of managed care, the demand for primarycare providersdhas grown; today, they account foralmost 40% of the physician supply in the USA.What is managed care?Under traditional indemnity insurance, the moneyfollows the patient. Patients select health careproviders and visit them as they choose. Providersthen bill the private insurer or public payer and arereimbursed on a fee-for-service or per case basis.Most indemnity plans attempt to limit demandthrough financial barriers to the patient, such asdeductibles and co-insurance, rather than constraintson the provider. Many also require the patient to paythe provider directly and seek reimbursement fromthe insurer, often with payments less than charges.This form of insurance is rapidly disappearing, withonly 11% of employees currently enrolled inindemnity plans (11).Traditionalmanagedcare.In traditionalmanaged care plans (e.g. Health MaintenanceOrganizations (HMOs)) the money follows the‘‘member’’, whether ill or not. Although there aremany definitions of managed care, generally the termdescribes a continuum of arrangements that integratethe financing and delivery of health care. Purchaserscontract with (or ‘‘own’’) selected providers to delivera defined set of services at an agreed per-capita orper-service price. In practice, managed care encom-passes a wide range of arrangements, some of whichresemble discounted fee-for-service (e.g. preferredprovider organizations, in which the memberreceives better benefits with lower co-payments byusing contracted providers rather than ‘‘non-preferred’’ providers) and others (e.g. some HMOs)using capitation and ‘‘gatekeepers’’ — primary carephysicians serving as patients ’initial contacts formedical care and referrals — to manage patient careand authorize referrals.eMost managed care organi-zations offer a wide array of benefit designs thatinclude HMO products, preferred provider organiza-tions, and direct access products that allow patients toself-refer to specialists. This variety of arrangementsand payment mechanisms makes it difficult to drawbThe designation ‘‘private’’ for hospitals can sometimes be misleadingsince many US hospitals are non-profit community organizations.These hospitals, however, are generally not controlled and managedthrough government agencies.c1995 figures for non-federal physicians.dPrimary care providers usually include general practitioners, familypractitioners, internists, and paediatricians; sometimes alsoobstetricians/gynaecologists and nurse practitioners.eWith the recent backlash, many health plans are eliminating the‘‘gatekeeper’’ model, even in their more managed HMO products.Managed care: the US experience831Bulletin of the World Health Organization, 2000,78(6)

conclusions about the effectiveness of managed care.As the saying goes, ‘‘if you have seen one managedcare plan, you have seen one managed care plan’’.Managedcareprinciples.Managed care in itscurrent forms has evolved in response to purchaserdemands to control costs. However, the principlesbehind this system are intended to provide high-quality, cost-effective health care to a population(13). These principles represent the vision of itsproponents to change fundamentally the fragmentedFig. 1.Breakdown of health costs in USA, 1998Fig. 2.Flowchart illustrating organization of the US health care systemSpecial Theme– Health Systems832Bulletin of the World Health Organization, 2000,78(6)

delivery system in the USA. In this vision, a managedcare organization is responsible for managing the careof a population through a health care system that:– monitors and coordinates care through the entirerange of services (primary care through tertiaryservices);– emphasizes prevention and health education;– encourages the provision of care in the mostappropriate setting and by the most appropriateprovider (e.g. outpatient clinics versus hospitals,primary care physicians versus specialists);– promotes the cost-effective use of servicesthrough aligning incentives (e.g. by capitation ofproviders, cost-sharing by consumers).Most health plans in the USA have implemented thisvision only partially. Such ‘‘managed cost’’ plans haveconcentrated on negotiating price discounts withproviders (5), and using restrictive pre-authorizationprocedures rather than employing the more sophis-ticated managed care tools such as disease manage-ment, aligning incentives, prevention, healtheducation. It is important to distinguish thesemanaged caretoolsfrom managed caresystemsinwhich competing insurers use some managed carepractices.fIt is these tools that have the greatestpotential for use in both public and private systemsglobally.From uncontrolled fragmentationto managed complexityTraditional modelMost people envision a managed care organization asthe traditional staff/group model HMO epitomizedby Kaiser Permanente or Harvard CommunityHealth Plan. In this model the risk-pooling orinsurance function (the ‘‘health plan’’) is linked toan integrated system of hospitals and physicians,covering the continuum of health care services.gThe physicians in such a system are eitheremployees of the health plan or members of amedical group that contracts exclusively with thehealth plan. The health plan, in turn, contracts withpurchasers of care (public or private) to provide adefined set of services at a prepaid per capita price(capitation) on a per member, per month (pmpm)basis. Mutual exclusivity between the physicians andhealth plan is a key feature that distinguishes thismodel from the network models described below. Inthis type of plan, the system as a whole receives acapitation payment from the funder, but providersare paid in a variety of ways. The physicians, as agroup, may receive a capitated payment, whileindividual physicians receive either a salary or acombination of salary and incentive payment.Physician specialties and hospitals may receive aglobal budget; or hospitals may be paid on a per case,per diem or even fee-for-service basis. Governance inthis model is most often shared between physiciansand administrators and decision-making is collabora-tive, with physicians managing the clinical aspects ofcare and the health plan managing the information,administrative and insurance functions. As straight-forward as this model appears, it is the least commonorganizational form in the USA. The reasons for thiscan be traced to the historically fragmented healthcare system, in which there were multiple privateinsurers, over 6000 independent community hospi-tals, and physicians practising primarily as singlepractitioners or in small groups of a single specialty.As managed care became popular, this fragmentedsystem found ways to create linkages withoutincurring the costs or making the fundamentalchanges needed for vertical integration.Network modelsThe most common managed care model is forindependent health insurers to contract with hor-izontally integrated (14), often loosely affiliatedprovider networks on a non-exclusive basis. Themost popular version of a provider network is theIndependent Practice Association, in which physi-cians join together for the sole purpose of contractingwith health plans (Fig. 3). Physicians continue topractise in their independent settings, but are paidthrough the association’s structure. Such associationsusually establish Management Services Organizationsto perform the administrative functions of contract-ing and managing payments; some form linkages withhospitals resulting in further horizontal integration.The provider environment is made more fluid by thefact that an individual physician may belong to severalindependent practice associations, because a singleone may not have enough health plan contracts (and,therefore, members) to sustain the physician’spractice. In most cases, the physician will also havedirect contracts with health plans, as well as receivefee-for-service payments. The associations receive acapitation payment, but each individual physician ispaid in a variety of ways. Although capitation is at theheart of aligning incentives between providers andpurchasers, it is not the predominant means ofreimbursing physicians in managed care. It isparticularly rare for individual physicians to receivea capitation payment for services other than thosethey directly provide. The predominant form ofpayment is still discounted fee-for-service; althoughmore mature organizations have found that pay-ments based on a blend of capitation and fee-for-service are more effective in creating targetedincentives for cost-effectiveness and quality(Fig. 4). A common model, which is also widelyused in the United Kingdom to pay generalpractitioners, is to give the GP a capitation paymentfor curative services and a fee-for-service paymentfCompeting systems are at the centre of ‘‘managed competition’’,a concept distinct from ‘‘managed care’’.gEven in these generally vertically integrated organizations, someservices such as hospital care may be provided through contractualrelationships rather than direct ownership.Managed care: the US experience833Bulletin of the World Health Organization, 2000,78(6)

Fig. 3.Flow-chart illustrating horizontally integrated managed care systemsFig. 4.Flow-chart illustrating how the monies flow in a well-developed, horizontally integrated systempmpm = per member, per monthSpecial Theme– Health Systems834Bulletin of the World Health Organization, 2000,78(6)

for screening, immunizations and other preventiveservices that the system wishes to encourage.Physicians may also share in a ‘‘risk pool’’ forreferrals to specialists and hospital admissions, inwhich money is set aside from the capitation paymentto provide an incentive to control utilization. Thereare many variations in structuring compensation forphysicians and hospitals and there is much on-the-ground experimentation in this area (15).In markets with high managed care enrolment,most physicians contract with most health plans,heither through physician networks or directly, and it isnot difficult for an individual to change health plansevery year, but retain the same primary care provider.This enhances patient choice, but adds to the cost andcomplexity of selective contracting and provides adisincentive to health plans to invest in prevention.This year’s healthy member may belong to anotherplan next year, or, put another way, the populationwhose health the plan is seeking to manage isconstantly changing.Proliferation of productsNew products offered by health plans to respond tocomplaints about restrictive referral practices andlimited choice add further complexity to this scene.There is an ‘‘alphabet soup’’ of these products (suchas triple option plans offering employees a choicebetween an HMO, preferred provider organizationor indemnity plan, and point of service plans, whichallow those covered by them to receive services fromparticipating or non-participating providers), eachwith differing levels of patient co-payments depend-ing on whether the patient sees a physician in theprimary network, outside of the primary network, isself-referred, or is referred by her primary careprovider. For the physician in a network, each type ofproduct may involve a different payment mechanismand amount. So, for example, a physician may receiveUS$ 50 for a routine office visit when treating apatient who has chosen the restrictive HMO productfrom Health Plan X, US$ 65 for the patient who iscovered through Health Plan X’s point of serviceplan, or she may receive a US$ 15 pmpm capitationfor each member in Health Plan Y. For the individualphysician this can create a very complicated web ofrules and payment schemes. Far from the clearincentives to reduce treatment and generate a surplusthrough ‘‘less care’’, as the detractors of managed careclaim, the real economic impact to the physician isconfusing and the administrative burden is substan-tial. In addition to multiple revenue sources withdifferent incentives, each health plan also has variousprocedures for authorizing treatments and determin-ing to whom the physician can make referrals(depending on the specific contracted network ofphysicians), as well as the drugs that can be prescribed(health plans each have separate drug formularies).The resulting transaction costs of all thiscomplexity and choice are significant. A typicalhealth plan spends between 12–20% of its premiumson administration; a typical IPA spends 6–8% of thecapitated amount it receives on administration;individual physicians ’offices hire staff to manageauthorizations and referrals; and hospitals have entiredepartments devoted to contracting with health plansand contesting denials of payment. The fact that,despite this, managed care has saved money isreflective of the high costs of the previous indemnityinsurance system in which patient and provider couldfreely spend what they thought was someone else’smoney — the insurer’s and the employer’s.iWhat has managed care achieved?In attempting to understand what can be borrowedfrom the US experience, it is useful to examine thecomplaints against managed care organizations andpractices. The most commonly expressed complaintscan be grouped into the general categories shownbelow.Complaint 1. Cost savings. Cost savings claimedby managed care are either not real, or areunsustainable.Complaint 2. Provider reimbursement.Hospitalreimbursement and physician compensation levelsare too low to provide adequate health care.Complaint 3. Quality of care. The quality of careprovided by managed care organizations is substan-dard. This category includes denials of care, restrictedaccess to specialists, and limits on the length of stay inhospital.The available evidence is examined below todetermine whether it supports these complaints,although the complexity of models makes it difficultto distinguish reality from myth. Irrespective ofwhether the data justify the anti-managed carebacklash or not, as with most complaints there isoften a germ of underlying truth that constitutes the‘‘the real problem’’.Complaint 1. Cost savings‘‘Structural changes centered around the expansionof managed care have been the major transformativeforce in health markets in recent years and haveplayed a major role in restraining growth in healthspending’’ (16).In a recent survey of consumers, 60% said thatmanaged care had either not made a difference inhealth care cost containment or had actually beenresponsible for increasing health care costs (13).Providers claim there has been an overemphasis oncost containment which threatens the quality ofmedical care in the USA. What is the truth behindthese seemingly contradictory views held by two keyconstituencies?

for screening, immunizations and other preventiveservices that the system wishes to encourage.Physicians may also share in a ‘‘risk pool’’ forreferrals to specialists and hospital admissions, inwhich money is set aside from the capitation paymentto provide an incentive to control utilization. Thereare many variations in structuring compensation forphysicians and hospitals and there is much on-the-ground experimentation in this area (15).In markets with high managed care enrolment,most physicians contract with most health plans,heither through physician networks or directly, and it isnot difficult for an individual to change health plansevery year, but retain the same primary care provider.This enhances patient choice, but adds to the cost andcomplexity of selective contracting and provides adisincentive to health plans to invest in prevention.This year’s healthy member may belong to anotherplan next year, or, put another way, the populationwhose health the plan is seeking to manage isconstantly changing.Proliferation of productsNew products offered by health plans to respond tocomplaints about restrictive referral practices andlimited choice add further complexity to this scene.There is an ‘‘alphabet soup’’ of these products (suchas triple option plans offering employees a choicebetween an HMO, preferred provider organizationor indemnity plan, and point of service plans, whichallow those covered by them to receive services fromparticipating or non-participating providers), eachwith differing levels of patient co-payments depend-ing on whether the patient sees a physician in theprimary network, outside of the primary network, isself-referred, or is referred by her primary careprovider. For the physician in a network, each type ofproduct may involve a different payment mechanismand amount. So, for example, a physician may receiveUS$ 50 for a routine office visit when treating apatient who has chosen the restrictive HMO productfrom Health Plan X, US$ 65 for the patient who iscovered through Health Plan X’s point of serviceplan, or she may receive a US$ 15 pmpm capitationfor each member in Health Plan Y. For the individualphysician this can create a very complicated web ofrules and payment schemes. Far from the clearincentives to reduce treatment and generate a surplusthrough ‘‘less care’’, as the detractors of managed careclaim, the real economic impact to the physician isconfusing and the administrative burden is substan-tial. In addition to multiple revenue sources withdifferent incentives, each health plan also has variousprocedures for authorizing treatments and determin-ing to whom the physician can make referrals(depending on the specific contracted network ofphysicians), as well as the drugs that can be prescribed(health plans each have separate drug formularies).The resulting transaction costs of all thiscomplexity and choice are significant. A typicalhealth plan spends between 12–20% of its premiumson administration; a typical IPA spends 6–8% of thecapitated amount it receives on administration;individual physicians ’offices hire staff to manageauthorizations and referrals; and hospitals have entiredepartments devoted to contracting with health plansand contesting denials of payment. The fact that,despite this, managed care has saved money isreflective of the high costs of the previous indemnityinsurance system in which patient and provider couldfreely spend what they thought was someone else’smoney — the insurer’s and the employer’s.iWhat has managed care achieved?In attempting to understand what can be borrowedfrom the US experience, it is useful to examine thecomplaints against managed care organizations andpractices. The most commonly expressed complaintscan be grouped into the general categories shownbelow.Complaint 1. Cost savings. Cost savings claimedby managed care are either not real, or areunsustainable.Complaint 2. Provider reimbursement.Hospitalreimbursement and physician compensation levelsare too low to provide adequate health care.Complaint 3. Quality of care. The quality of careprovided by managed care organizations is substan-dard. This category includes denials of care, restrictedaccess to specialists, and limits on the length of stay inhospital.The available evidence is examined below todetermine whether it supports these complaints,although the complexity of models makes it difficultto distinguish reality from myth. Irrespective ofwhether the data justify the anti-managed carebacklash or not, as with most complaints there isoften a germ of underlying truth that constitutes the‘‘the real problem’’.Complaint 1. Cost savings‘‘Structural changes centered around the expansionof managed care have been the major transformativeforce in health markets in recent years and haveplayed a major role in restraining growth in healthspending’’ (16).In a recent survey of consumers, 60% said thatmanaged care had either not made a difference inhealth care cost containment or had actually beenresponsible for increasing health care costs (13).Providers claim there has been an overemphasis oncost containment which threatens the quality ofmedical care in the USA. What is the truth behindthese seemingly contradictory views held by two keyconstituencies?hIn California, a typical physician contracts with 15 different healthplans (20).iIn reality, of course, the employee ultimately pays for this throughreduced wages (20).Managed care: the US experience835Bulletin of the World Health Organization, 2000,78(6)

Healthexpenditures.Between 1995 and 1998,the Consumer Price Index (CPI) for medical servicesshowed the lowest rate of increase in medical costs onrecord, rising at an average of 3.3% annually (17).jThis was part of a 5-year trend during which overallgrowth in health spending increased by 31%, lessthan half the increase during the previous period,1988–92 (67%) (18).kThe producer price index(PPI) for health services, a more accurate reflectionof medical inflation,lgrew at an even lower rate(<2%) per year from 1995 to 1998 (17). Personalhealth care expenditures,mas a percentage of GDP,remained steady between 1992 and 1998, actuallyfalling from 13.7% to 13.5% (8).For the three largest components of healthexpenditures (hospital care, physician services, anddrugs), both hospital services and physician serviceshave shown significant reductions in rates of growth(Table 1). Spending for drugs, on the other hand, hasnot shown similar trends. Since 1992 the annual ratesof growth have ranged from a low of 7.0% in 1994, toa high of 12.3% in 1998 (19). Despite toughnegotiations with drug companies and the use offormularies, increases in drug spending have,ironically, been fuelled by generous drug benefitcoverage and low out-of-pocket co-payments of-fered by managed care plans (8). At the same time,pharmaceutical manufacturers have significantlyincreased spending on direct-to-consumer advertis-ing; for example, in 1998 a total of US$ 1.3 billion wasspent on direct advertising, an increase of 55% overthe previous year. There is clear evidence that thisadvertising has been effective, with the ten mostheavily advertised drugs accounting for more than20% of the increase in prescription drug spendingbetween 1993 and 1998 (8). In response to greaterconsumer pressure for drugs, health plans are movingtowards tiered pharmacy benefit programmes whichimpose higher co-payments for brand drugs anddrugs that are not on the health plan’s formulary.Healthcarepremiums.Trends in health carespending can also be measured through the cost toemployers of purchasing private health benefits.Since 1993, health insurance premiums — theamounts paid to a carrier to provide coverage undera contract — have stopped their double-digit annualpercentage increases and premiums have remainedalmost flat for several years. Premiums increased<2% between 1994 and 1996 (11). In California, forexample, premiums for large purchasers and groupsdoubled between 1987 and 1992, but remained flatbetween 1992 and 1998 (20). In fact, when adjustedfor inflation, one of the largest purchasing groups inCalifornia experienced a 13% decrease in premiumsbetween 1992 and 1997 (20).The trend has recently reversed, however, withcosts of health benefits increasing by 7.3% in 1999,almost three times the rate of general inflation (4).Projections show health expenditures increasingfrom the current US$ 1200 billion to overUS$ 2000 billion in 2007, which will represent anestimated 14.9% of the US GDP (18). Despite theseincreases, the effects of managed care are still evident,particularly in areas with high managed care penetra-tion. In California, HMO premiums remain 17%below the national average despite one of the highestcosts of living in the USA. (20). Case-adjustedhospital costs in California are 25% less than thenational average (21), and the State’s 2.4 hospital bedsper 1000 population are well below the nationalaverage (22).Therealproblem.The evidence shows thatmanaged care has had an impact on stemming theescalating growth of US health care costs. There arealso indications that rates of growth may once againbe climbing. Experts disagree on whether the factthat health care costs and premiums are again on therise indicates that managed care has outlived itsusefulness or whether this is a market correction thatmay lead to organizations using more sophisticatedpopulation health management tools.In this first phase of managed care, employershave relied on moving employees from indemnityplans to less expensive managed care plans as theirprimary method for controlling the costs of healthbenefits. Health plans have relied on exploiting thesystems ’over-capacity through selectively contract-ing and controlling use of specialists and hospitals. Inmany markets they have shifted risk to providersthrough full capitation arrangements.Almost 90% of employees now belong to amanaged care plan and, although there is littlelikelihood that the old indemnity system will return,jThe units of service change with managed care, which is not capturedin the CPI or PPI.kDuring this same period, the CPI minus medical care rose byan average of 2.3%.lThe PPI measures transaction prices (prices paid by third partypurchasers), whereas the CPI measures retail prices which areoften undiscounted.mPersonal health expenditures do not include investments forresearch and construction, or expenses for prepayment, administrationand government health activitiesTable 1.Personal health care expenditures in the USA, by typeof serviceaExpendituresCumulative % changein 1997(US$ x 109) 1975–821983–871988–921993–97Hospital care371.198435722Physician’s217.684816924servicesDrugs and108.981625953other medicalnon-durablesaPersonal health expenditures do not include costs for research, construction, prepayment,and administration and government health activities.Source: US Health Care Financing Administration, Office of National Health Statistics, 1998.Special Theme– Health Systems836Bulletin of the World Health Organization, 2000,78(6)

there is clearly a trend towards indemnity-in-drag —plans which provide greater freedom of choice forpatients and reimburse providers on a fee-for-servicebasis. With the disintegration of physician groups (seebelow), the ability of providers to take risk throughcapitation is also in question. It may be that the oldtechniques have generated the cost savings of whichthey are capable.Sustainable cost containment in the USA isunlikely without structural changes in the health carefinancing and delivery system, which requiresconfronting difficult issues of consumer and provi-der expectations. US consumers have not yet under-stood the effects of unrestrained spending onaffordability of health insurance and on other aspectsof the economy. In a recent survey, 62% of USresidents strongly agreed that health plans should payfor medical treatment even if it were to involve costsof US$ 1 million per person (13). With the recentbacklash, providers anxiously anticipate a return tothe autonomy of fee-for-service medicine and areunprepared to grapple with the realities of con-strained resources. Funders, purchasers and provi-ders can explore innovative ways to deliver cost-effective care but, ultimately, they must make theconsequences of spending more transparent to thepublic.Complaint 2. Provider reimbursementThis complaint has two dimensions: hospital profit-ability, and physician compensation. As far ashospitals are concerned, administrators are worriedabout profitability or surplus for reinvestment, andconsumers are worried about the threat of hospitalclosures. Few things stir as much public outcry as theprospect of closing a community hospital. Yet excesscapacity in a system is a natural cost driver and mostsingle-payer systems have used capacity constraintsto restrain growth in health spending. Managed careorganizations have attempted to create capacityconstraints indirectly through pre-authorization andutilization reviews and have been successful inreducing hospital utilization, although actual facilityclosures have been rare.The USA has witnessed a modest decrease inoverall bed capacitynduring the past 20 years, but thisshift may be attributable more to Medicare’simplementation of case ratesothan to managed care;however, in California’s most highly penetratedmanaged care markets, the number of hospitalsdecreased by 19% between 1983 and 1993 (23). Asshown in the previous section, growth in hospitalcosts has slowed since 1992. Inpatient surgicalprocedures decreased 33% between 1983 and 1993,but these decreases were offset by a 168% increase inoutpatient surgical procedures (24, 25); in manycases this simply marked a shift from one part of thehospital to the other, since most hospitals nowprovide ambulatory surgery and other outpatientservices. Although ambulatory services have lowerprofit margins than hospital days, hospital profitmargins have continued to climb over the pastdecade, reaching 6.9% in 1998, at the height ofmanaged care.Physician compensation, the other major boneof contention, is growing at a slower rate than in thepast. In 1996 the mean net income for US physicianswas US$ 199 000p(22). Although this incomecontinues to be the envy of most of the world’sdoctors, the rate of growth has slowed considerably,and inflation-adjusted mean net income remained flatbetween 1993 and 1997 (8). Incomes for primary carephysicians have increased, however, rising by 27%between 1994 and 1996 to an average annual salary ofUS$ 140 000 (22).qTherealproblem.Managed care has had animpact on slowing rates of growth in the costs of twomajor health care producers: hospitals and specialistphysicians. There is little evidence to suggest,however, that current levels of reimbursement areinadequate to provide care.Although it is difficult to accept limits on growthin compensation after years of significant increases,what ultimately drives the outrage by providers mayhave less to do with total reimbursement and more todo with what the hospital and physician mustundertake for this reimbursement. For both hospitalsand doctors, sources of revenue have shifteddramatically since 1960: in 1960, over 20% of hospitalcharges were paid for out of pocket, whereas in 1996,almost 97% of hospital payments came through thirdparties (over 60% from government payers) (25) whodemand complex accounting of charges, have pre-authorization processes, and can review retrospec-tively and deny claims for reimbursement.For physicians, the situation can be even morefrustrating. Physicians derive over 50% of theirincome from private insurers (26); with the demise ofindemnity insurance, these insurers carefully scruti-nize all claims. By layering managed care processes ona disintegrated system, physicians are required tocomply with multiple authorization procedures,prescribe from multiple formularies, refer to multiplenetworks of physicians, and manage a complexrevenue stream from multiple sources, based onmultiple formulae. This has significantly increasedthe physician’s administrative burden and requiresmanagement and financial skills for which fewphysicians are trained. In 1996 over 20% of the costsof running a physician’s practice were for ‘‘otherservices’’, including administrative structures forjoint contracting, complying with authorizationsand referral processes, and billing and collections(26, 27). The business complexity of managed careand capitation has led to the demise of manynBetween 1983 and 1993, the number of community hospitals inthe USA decreased by 9%.oThe prospective payment system enacted in 1983 introducedpayment through diagnostic related groups.pMean net income is the income after expenses and before taxes.qIncludes general practice, family practice and paediatrics(1996 figures).Managed care: the US experience837Bulletin of the World Health Organization, 2000,78(6)

independent practice associations and other looselyconfigured networks. In California, several majorphysician networks are facing insolvency.Whether this implies that provider compensa-tion levels are unsustainable is a question for debate.It is clear, however, that the assumption of riskthrough capitation requires sophisticated businessskills for which physicians are ill prepared. It alsosuggests that loose affiliations of physicians for thepurposes of collective contracting, rather than clinicalmanagement, like traditional medical groups, has notbeen successful. If providers are to regain control ofthe health care system, network models such asindependent practice associations must evolve intostronger medical group organizations that not onlyaccept risk but can also assume the financial andclinical accountability for managing the care of thepopulation they serve.Complaint 3. Quality of careMuch recent legislation and many legal reforms havebeen aimed at preventing managed care’s perceivedquality abuses. The Patient Bill of Rights, which hasbeen heavily debated in Congress, defines, amongother things, the rights of consumers with complexconditions to access directly a qualified specialist,continuity of provider for patients who are underregular treatment, and self-referral to certain types ofspecialists (e.g. obstetricians–gynaecologists)(20, 28). Many US states have passed legislation thatoverrides health plan guidelines by recommendingspecific lengths of stay for certain procedures, such ascaesarian sections and normal deliveries (29). InCalifornia, over 90 managed care bills were con-sidered in 1997, many of them seeking increasedaccess to specialists and less restrictive length-of-staypractices (20, 28). A 1998 survey found that 7 out of10 doctors were against managed care. Almost one-third of the physicians responding to this survey saidthat they were ‘‘being pressured to withhold specificpatient services that could improve care’’ (30).rDenials of care by health plans serve as red flagsto providers and consumers because they imply that a‘‘corporate entity’’ is second-guessing what thedoctor feels is best for his patient, intruding on thesacrosanct doctor–patient relationship. In fact,although the pre-authorization process is cumber-some and limits physician and patient autonomy,denials of care are not common, and are made byphysicians in the medical management departmentsof health plans. United Health Care, which recentlyeliminated its prior authorization process for referrals(a process of obtaining prior approval of theappropriateness of a service or medication) says thatonly 1% of medical decisions are overturned, yet theycost the company over US$ 128 million annually inutilization review staff (31).Although denials of care capture media atten-tion, there is a growing body of evidence that thequality of care in managed care organizations is asgood as that provided in traditional fee-for-servicesettings (32). In a rigorous review of the literature,Miller & Luft (33) reported that 14 out of 20 studiesthat measured quality of care showed either better orsimilar results for HMO patients, compared with fee-for-service patients.sThe authors concluded that,‘‘The evidence shows no pattern of worse HMOquality of care’’ (33). A analysis of the literature onmanaged care performance since 1980 cites sixstudies which show that HMO plan enrollees receivemore preventive tests, examinations, and healthpromotion services than indemnity plan enrollees(34). Managed care’s coverage of preventive visitsand screening may be particularly beneficial tovulnerable populations; as part of the RAND HealthInsurance experiment, researchers found that chil-dren assigned to an HMO had a 40% greater numberof routine preventive visits and 50% more officevisits than a control group assigned to a fee-for-service plan (32). Some surveys, however, haveshown that vulnerable populations are less satisfiedwith the care they receive through HMOs (33).Several studies suggest that managed care mayalso be effective in preventing over-treatment whichcan have a negative effect on health. For example, a1998 study comparing clogged artery treatmentdecisions for three groups (Medicaid patients, thosecovered in fee-for-service plans, and those coveredby HMOs) showed that fee-for-service patients were2.3 times more likely to have coronary bypass surgeryor angioplasty than Medicaid patients. HMO patientswere 1.5 times more likely than Medicaid patients tohave these procedures, but their mortality rates werelower than the fee-for-service group. The authorssuggest that this indicates ‘‘a more appropriate use ofprocedures in HMOs’’ (35).Despite the vocal backlash by consumers,enrollees ’satisfaction with managed care tends to behigh. A survey of over 3000 Medicare patients foundthat 87% would recommend their HMO for standardcare (36). A survey, commissioned by California’sManaged Care Health Care Improvement Task Forcein 1997, found that although 42% of respondentsreported one or more problems with their health planin the past year, over 75% were actually satisfied orvery satisfied with their health plan (20). Othersurveys of California residents confirm these find-ings. A survey of disabled Medicare patients showedhigh rates of satisfaction with their HMO; 41%reported that the care they received was excellent;almost 53% said it was good or very good; and only6% rated the care as fair or poor (37).Therealproblem.Measurement of quality inhealth care is a highly debated issue, and bothproponents of managed care and its critics can findevidence to support their views (38–44). Althoughmanaged care models differ, there is little evidence tosuggest that overall, managed care systems providerThe MEDSTAT Group and JD Power & Associates conductedthis survey on 30 000 physicians in 150 health plans in 22 areas.s‘‘Similar’’ results also include those studies which showedmixed (both better and worse) results.Special Theme– Health Systems838Bulletin of the World Health Organization, 2000,78(6)

substandard quality. In most areas, the same physi-cians who treat fee-for-service patients treat managedcare patients. With the exception of denials ofnecessary care by a health plan’s medical managerthat resulted in a bad outcome (of which there are fewdocumented cases), the quality of care of a health planshould reflect the quality of care of the generalprovider community. For example, a study by theAgency for Health Care Policy and Research reportedthat managed care patients spent two fewer days in theintensive care unit than patients with fee-for-serviceinsurance, with the average stay for managed carecosting US$ 8000 less and with no difference inmortality between the two groups. Patients were caredfor by the same intensive care specialists (45).Physician concerns about quality of care inmanaged care organizations may more accuratelyreflect the loss of professional autonomy throughrigidly applied pre-authorization procedures by non-physicians, and the imposition of medical practiceguidelines which have not been developed inconsensus with treating physicians. The most widelyused guidelines, developed by Milliman & RobertsonInc., recommend what many doctors and patientsconsider unreasonable rules, e.g. a one day stay for anormal delivery, two days for a caesarian section, andfor procedures such as certain mastectomies to beperformed on an outpatient basis (29).Although these guidelines were developed incollaboration with and by physicians, they were notdeveloped by the physicians who use them and maynot reflect local practice norms and consumerexpectations. To the public, which is often unedu-cated about variations in practice patterns, becausetheir doctors find guidelines restrictive, they serve toundermine confidence in the managed care system.When asked how they felt about managed care plansrequiring doctors to follow guidelines, 56% ofconsumers said that they thought this was a badpractice because they believe that decisions abouttreatment should be made exclusively by thedoctor (13).At the heart of the public’s concerns aboutmanaged care tools, such as guidelines and pre-authorization procedures, is that these approachescreate fear that patients will not be taken care of bytheir health plan when they are sick (13). A recentsurvey found that the most important criterion forchoosing a heath plan was the consumer’s perceptionof how well the plan takes care of sick members (13),and not its prevention programmes, screenings orhealth education components. The growth of for-profit health plans adds to concerns that thecustomer being served is the shareholder, not thepatient.By not adequately recognizing the importanceof providing a sense of ‘‘security’’ in the minds ofconsumers, health plans have ignored a basic preceptof insurance. It must come as an unhappy realizationto health plan executives that the public rates thembelow oil companies and only slightly above tobaccocompanies in how well they serve consumers (13).What have we learned from managedcare?The evidence on managed care shows that overall ithas had a positive impact on controlling growth inhealth care costs without a negative effect on quality.Some of the methods that it has used, however, haverankled providers and consumers and generated abacklash that will be difficult to manage withoutpromoting another round of medical cost escalation.Managed care is clearly at a crossroads in theUSA today. How this version of managed care willmetamorphose, and whether the USA will graduallysee a shift towards a single payer systemtwill becomeapparent in the coming years. What is clear, however,is that there are many innovations and lessons fromthe managed care experiment which will betterinform the future health policy debate in the USAand may have relevance for other countries as theyundertake their own health care reforms.Managed care as it has been implemented in theUSA is a product of the market. What it has done welland what it has failed to do reflect, to a certain extent,what markets (particularly real life, imperfect mar-kets) do well and what they do poorly. Markets arenot particularly good at providing for social goodssuch as universal health coverage, and the growingnumber of uninsured individuals in the USA atteststo this. Markets are good, however, at innovation andexperimentation and managed care has spawnedconsiderable innovation in how medical care can bedelivered, how quality can be measured andimproved, and how incentives can be aligned at alllevels of the health care system.The tools that managed care has developedhave applicability for both public and private systems.Many publicly funded systems are in the process ofseparating funding from purchasing of health careservices, and these systems could benefit from theactive purchasing techniques employed in the USA.Many of the practices described below will havebetter acceptability in publicly funded systems inwhich consumers have accepted the reality of healthcare rationing. Waiting times for specialists andelective admissions in most managed care planscompare very favourably with public systems in theUnited Kingdom and other OECD countries. Withinthe limits imposed by constrained resources, mana-ged care has been able to implement practices thatimprove hospital and physician efficiency to serveconsumers who have been raised on a diet ofunlimited choice and personalized service.Disease managementManaging disease through the continuum of care hasbeen an exciting area of development in the USA.tPresident Clinton’s State of the Union message in February 2000proposed significant expansion of public programmes that wouldincrease the public sector’s coverage of large groups of Americans.Managed care: the US experience839Bulletin of the World Health Organization, 2000,78(6)

Shifting from fee-for-service in which providers arepaid for sickness, to capitation in which they makemoney when they keep people well, has generatedinnovative practices focused on better managing thequality and costs of the chronically ill. Valuable evidencehas accumulated on the most effective treatmentprotocols, how to involve patients and families in thecare of chronic illnesses, and how to promotecompliance with drug and treatment regimens. Seniorcitizens and the poor have benefited as niche managedcare organizations have specialized in improving waysto care for them. Other major targets for diseasemanagement programmes have included paediatricasthma, diabetes, spinal cord injury, lower back pain,chronic renal disease and mental health. It can be arguedthat many of these programmes lead the world inproviding high quality and comprehensive care fordifficult chronic syndromes at a reasonable cost (46).Quality measurementSeveral techniques used by managed care firms, suchas guidelines based on clinical best practices, qualityreport cards that provide information on providerand health plan performance, and evidence-basedmedicine that incorporates the latest clinical findingsand cost-effectiveness data, are steps towardsimproving the quality of health care services.Although to individual physicians the application ofguidelinesmaybeintrusive,widevariationsintreatment patterns for the same diseases betweengeographical areas and physician practices (29, 47)indicate the need for sharing best practices on how totreat particular illnesses. Clinical protocols developedby providers in integrated HMOs have had a positiveeffect on reducing variation and improving quality(47). Evidence-based medicine requires this type ofguidance to promote quality of care, and bothphysicians and patients can be brought into thediscussion of the benefits of information in improv-ing treatment decisions.The Health Plan Employer Data and Informa-tion Set (HEDIS) has created a core set ofperformance measures to assist purchasers inmeasuring the value of the services they are buying.This permits comparison of health plan and providerTable 2.Selected performance areas in a quality report cardaPerformance areaWhat is measured?Why is it important?Childhood immunizationAre 2-year-olds up to date on allrecommended vaccinations?Prevents measles, mumps, poliomyelitis,and other debilitating diseasesAdolescent immunizationDid children receive recommended shotsby the age of 13 years?Prevents serious diseases such as mumps,measles, and rubellaBreast cancer screeningDid women aged 52–69 years have aPap smear test within the last 3 years?Detects breast cancer in its early stages whenit is easier to treatAntenatal careDid antenatal care start within the first3 months of pregnancy?Reduces the risk of pregnancy complicationsand illness in babiesCheck-ups after deliveryDid women who delivered a baby receivea check-up within 8 weeks after delivery?Evaluates progress of mother and allowsfor assistance to be provided, if necessaryCholesterol managementafter acute cardiovasculareventsDid adults who had a heart attack, bypasssurgery, or coronary angioplasty havetheir cholesterol level tested between2 months and one year after the event?Reduces the risk for future heart problemsby identifying and treating those with highcholesterolAnti-depressantmedication managementDid adults with a new diagnosis of depressionand who were treated with antidepressants:Have at least three follow-up contacts witha health care provider during the 12 weeksfollowing diagnosis?Remain on an anti-depressants duringthe12 weeks following diagnosis?Remain on anti-depressants for atleast 6 months following diagnosis?Reduces the likelihood of a recurrenceof depression by appropriate treatmentwith anti-depressantsAdvising smokersto quitDid smokers aged518 years receive adviceto stop smoking when they visited theirprovider during the past year?Reduces the risks of smoking, includingcancer, heart disease, and early deathaSource: Pacific Business Group on Health, Quality Report Card, 1999 at http://www.calpers.comSpecial Theme– Health Systems840Bulletin of the World Health Organization, 2000,78(6)

group performance on quality, access and satisfactionmeasures. Many purchasers have refined this data setto develop quality report cards that report onpreventive measures such as childhood immuniza-tion rates, breast and cervical cancer screening rates,and care of those with chronic conditions (Table 2).These data are combined with patient satisfactionsurveys and shared publicly. Although data gatheringand comparison methodologies still need to berefined, they have served as a catalyst for populationhealth management and measurement programmes.Aligning incentivesManaged care has generated a variety of experimentalapproaches in how best to pay providers andstructure incentives for cost-effectiveness, produc-tivity and quality. Of particular global interest arestructures that contain costs by limiting unnecessaryor inappropriate use of the health care system.Internationally, there have been three main ap-proaches to this problem:– creating queues or waiting lists through limitingsupply;– putting providers at risk through some form ofcapitation or prepayment for services;– cost-sharing with patients through co-paymentsor co-insurance.In the USA, the queuing mechanism is not politicallyacceptable, but much evidence has been gathered onthe other two approaches mentioned above(15, 48, 49). For example, a recent study on theimpact of financial incentives on the use and cost ofprescription drugs found that the introduction of aUS$ 10 co-payment was ‘‘almost as effective atcontrolling drug spending as is switching physicianpayment from fee-for-service to a capitated riskpayment’’ (48).ConclusionThe US health care system is continuously inter-nalizing the lessons from both the positive and thenegative experiences of managed care. The politicallycharged managed care backlash may slow progress ina number of areas in the country, but innovation andexperimentation will remain strong.From an international perspective, managedcare may have more to offer than has beenrecognized. Ten years ago, the US health care systemwas often used by health policy-makers from othercountries when they became seriously ill, but onewhich did not hold much appeal as a model to beemulated in their own countries. The systemappeared to be grossly expensive, uncontrollable,and lacking any expression of social solidarity orequity; values which are important in the health caredebates of many countries, but not in the USA.Today, many managed care practices haverelevance for reforms in a wide variety of circum-stances. Active purchasing and selective contractingwhich exploits overcapacity can be powerful tools inmany parts of the world. These experiences arerelevant and applicable across a wide range of healthcare systems in countries of the European Union,Eastern Europe and Latin America. In addition, theemerging economies of Asia, with their implementa-tion of private health insurance, could do well byintroducing managed care practices which limitunnecessary demand through provider and patientincentives.Regrettably, in some countries, managed carehas come to be associated with a completely private,competitive, profit-driven model. Even in the USA,however, government payers (e.g. Medicare) areadopting managed care methods to provide quality,cost-effective health care for their beneficiaries.Itcan be argued that selective adoption of managedcare technologies is even more relevant and moreeasily applied in single-payer systems than in thefragmented, voluntary insurance market of the USA.These tools can be applied more systematically, withlower transaction costs, and their effects can bemeasured more precisely when implemented incountries that finance health care for the totalpopulation.Performance monitoring, outcomes measure-ment, reducing clinical variation, managing chronicdisease, and aligning incentives have become ubiqui-tous components of health policy debates in manycountries. These innovations are not dependent onthe US market environment and were not allpioneered in the USA. However, in the last decadethis country has provided and will continue toprovide a laboratory for experimentation from whichthe rest of the world will wish to benefit.nRe ́ sume ́Gestion des soins de sante ́ : l’expe ́ rience des Etats-Unis d’Ame ́ riqueLes principes qui sous-tendent la gestion d’un syste`medesoins visent a` fournir a` une population des soins de sante ́de qualite ́ , ayant un bon rapport couˆ t/efficacite ́ . Cetarticle donne un aperc ̧ u de la gestion des soins de sante ́aux Etats-Unis d’Ame ́ rique – de ce qui a e ́te ́re ́ alise ́etdece qui n’a pu l’eˆ tre – et pre ́ cise les enseignements quepeuvent en tirer les de ́ cideurs de ce pays et d’autresparties du monde. Cependant, dans la pratique, lagestion des soins englobe un large e ́ventail dedispositions qui font qu’il est difficile d’en tirer desconclusions sur le plan de l’efficacite ́.Il est important de faire la distinction entre lesoutilsde gestion des soins et lessyste` mesde gestion dessoins, dans lesquels ce sont des organismes prive ́ s qui sefont concurrence pour attirer des adhe ́ rents. Les outilsont toutes les chances d’eˆ tre utilise ́ s aussi bien dans lesManaged care: the US experience841Bulletin of the World Health Organization, 2000,78(6)

syste` mes publics que prive ́ s partout dans le monde. Nousexaminons ici les principales critiques formule ́ es et lesfaits dont on dispose pour mieux comprendre ce que l’onpeut emprunter a` l’expe ́ rience ame ́ ricaine. Si les faitsmontrent que la gestion des soins a permis de mettre fin a`l’escalade des de ́penses de sante ́ aux Etats-Unisd’Ame ́ rique, il y a peu de chance qu’on puisse parvenira` endiguer les couˆ ts de fac ̧ on durable sans proce ́ der a` desmodifications structurelles du financement et de lafourniture des soins de sante ́ , pour lesquelles il va falloirfaire face a` la question difficile des aspirations desconsommateurs comme a` celles des dispensateurs.Les organismes de gestion de soins ont limite ́ lesmoyens d’action par le biais d’un syste` me d’agre ́ mentpre ́ alable et d’une analyse de la consommation des soinset ils ont re ́ussi a`re ́ duire la consommation des soinshospitaliers, mais les fermetures d’e ́ tablissements desante ́ ont e ́te ́ rares. Rien ne permet de penser que lessyste` mes de remboursement actuels soient insuffisantspour la fourniture des soins. Toutefois, l’e ́ valuation desrisques a` laquelle proce` de un dispensateur de soins desante ́ par le biais de la capitation – c’est-a` -dire dusyste` me dans lequel on paie une somme donne ́ e paradhe ́ rent, en ge ́ne ́ ral de fac ̧ on mensuelle, au dispensa-teur afin de couvrir le couˆ t de tous les services de sante ́fournis a` la personne couverte par le contrat – exige descompe ́ tences gestionnaires sophistique ́ es auxquelles lesme ́ decins et les hoˆ pitaux sont mal pre ́ pare ́s.Tout porte a` croire que la qualite ́ des soins desante ́ offerts par les organismes de gestion de soins estaussi bonne que celle offerte dans les institutionstraditionnelles de re ́ mune ́ ration a` l’acte. Dans la plupartdes re ́ gions, ce sont les meˆ mes me ́ decins qui traitent lespatients soumis au paiement a` l’acte et ceux adhe ́ rant a`un syste` me de soins ge ́re ́ s. Malgre ́ les tempeˆ tes deprotestations des consommateurs, avec les soins ge ́re ́s,la satisfaction des clients a tendance a`eˆ tre e ́ leve ́ e. Chezles me ́ decins, les pre ́ occupations relatives a` la qualite ́dessoins sont peut-eˆ tre le reflet de la manie` re dont ilsressentent leur perte d’autonomie professionnelle, dueaux proce ́ dures rigoureuses d’agre ́ment pre ́alableapplique ́ es par des non-me ́ decins, et a` l’e ́ laboration dedirectives relatives a` la pratique me ́ dicale qu’on leurimpose sans avoir recueilli de consensus chez lesme ́ decins traitants.De nombreuses innovations et enseignements del’expe ́ rience ame ́ ricaine de la gestion des soins sontapplicables a` d’autres pays. En dehors des outils quipeuvent eˆ tre applique ́ s aussi bien dans le syste` me publicque dans le syste` me prive ́ , il y a des enseignementspre ́ cieux a` tirer des protocoles de traitement les plusefficaces, de la fac ̧ on de faire participer les patients et lesfamilles aux soins des maladies chroniques, et de la fac ̧onde promouvoir l’observance de la prise des me ́ dicamentset des sche ́ mas the ́ rapeutiques. Les principaux pro-grammes de prise en charge the ́ rapeutique sont lessuivants : asthme pe ́ diatrique, diabe` te, le ́ sions de lamoelle e ́ pinie` re, lombalgies basses, maladie re ́ nalechronique et sante ́ mentale.Plusieurs techniques, par exemple directivesbase ́ es sur les meilleures pratiques cliniques, cartesd’information qualitative fournissant des renseigne-ments sur les re ́ sultats obtenus par le dispensateur etla planification sanitaire, et me ́ decine factuelle incorpo-rant les dernie` res perce ́ es cliniques et donne ́ es ayant unbon rapport couˆ t/efficacite ́ , sont autant de progre` s pourame ́ liorer la qualite ́ des services de soins de sante ́. Lagestion des soins a ge ́ne ́re ́ beaucoup d’expe ́ rimentationsquant a` la fac ̧ondere ́ mune ́ rer au mieux les dispensateurset de structurer les mesures d’incitation en faveur d’unbon rapport couˆ t/efficacite ́ , de la productivite ́etdelaqualite ́ . Toutefois, beaucoup des pratiques utilise ́ es dansla gestion des soins seront davantage acceptables dansdes syste` mes finance ́ s par des fonds publics et dans dessituations ou` les consommateurs ont accepte ́lare ́ alite ́durationnement des soins. Au Royaume-Uni et dansd’autres pays de l’OCDE, dans la plupart des plans desoins ge ́re ́ s, les de ́ lais d’attente pour consulter lesspe ́ cialistes et pour les admissions non urgentessoutiennent tre` s bien la comparaison avec ceux dessyste` mes publics.ResumenAtencio ́ n de salud gestionada: la experiencia de los Estados UnidosLos principios en que se basa la atencio ́ n de saludgestionada esta ́ n orientados a prestar a la poblacio ́ n unaasistencia sanitaria eficiente y de calidad. Este artı ́culoofrece una visio ́ n general de la atencio ́ n sanitariagestionada en los Estados Unidos – lo que se ha logradoy lo que no –, ası ́ como algunas lecciones va ́ lidas parainstancias normativas de los Estados Unidos y de otroslugares del mundo. Sin embargo, la atencio ́ n sanitariagestionada abarca en la pra ́ ctica una gran variedad dearreglos, por lo que es difı ́cil extraer conclusiones sobresu eficacia.Es importante diferenciar losinstrumentosdeatencio ́ n gestionada y lossistemasde atencio ́ngestionada en que intervienen organizaciones privadascompetidoras. Los instrumentos son potencialmente ma ́su ́ tiles para los sectores pu ́ blico y privado en todo elmundo. En el presente informe se estudian los principalesmotivos de queja y los datos disponibles para poderdiscernir que ́ parte de la experiencia de los EstadosUnidos puede aprovecharse. Si bien hay indicios de quela atencio ́ n gestionada contribuyo ́ a contener el continuocrecimiento de los gastos de atencio ́ n sanitaria en losEstados Unidos, difı ́cilmente se conseguira ́ frenar deforma sostenible esos gastos si no se introducen cambiosestructurales en la financiacio ́ n y la prestacio ́n deasistencia, para lo cual hay que afrontar los complejosproblemas planteados por las expectativas de losconsumidores y los proveedores.Las organizaciones de atencio ́ n gestionada hanimpuesto lı ́mites a la capacidad mediante la preautori-zacio ́ n y los estudios de la utilizacio ́ n, y han logradoreducir el uso de los hospitales, pero el cierre de centrosSpecial Theme– Health Systems842Bulletin of the World Health Organization, 2000,78(6)

sanitarios ha sido excepcional. Apenas hay pruebas deque los reembolsos actuales sean insuficientes paraprestar atencio ́ n sanitaria. Sin embargo, la aceptacio ́ndelos riesgos por parte de un proveedor de atencio ́nsanitaria mediante la capitacio ́ n (procedimiento por elque se paga al proveedor una suma per ca ́ pita, por logeneral mensualmente, para cubrir los costos deprestacio ́ n de todos los servicios sanitarios que recibeel beneficiario conforme a las condiciones estipuladas enel contrato del proveedor) requiere aptitudes comercialescomplejas, de las que suelen carecer los me ́ dicos yhospitales.Cada vez hay ma ́ s pruebas de que las organiza-ciones de atencio ́ n sanitaria gestionada prestan unaatencio ́ n sanitaria de calidad comparable a la proporcio-nada en las instituciones tradicionales que cobranhonorarios por servicios prestados. En la mayorı ́a delos sectores, los mismos me ́ dicos que tratan a pacientesque se acogen a este u ́ ltimo sistema tratan tambie ́n apacientes del sistema de atencio ́ n gestionada. A pesar delas protestas de los consumidores, los clientes suelenestar bastante satisfechos de los servicios de atencio ́ngestionada. La preocupacio ́ n de los me ́ dicos por lacalidad de la asistencia puede obedecer a la sensacio ́ndepe ́ rdida de autonomı ́a profesional que se deriva de losestrictos procedimientos de preautorizacio ́ n aplicadospor personal no me ́ dico, ası ́ como a la elaboracio ́n eimposicio ́ n de directrices de pra ́ctica me ́dica noconsensuadas con los me ́ dicos tratantes.Muchas de las innovaciones y las lecciones quecabe extraer de la experiencia de los Estados Unidos en ela ́ mbito de la atencio ́ n de salud gestionada revistenimportancia para otros paı ́ses. Adema ́ s de los instru-mentos que pueden aplicarse en sistemas tanto pu ́ blicoscomo privados, pueden extraerse lecciones valiosassobre los protocolos terape ́ uticos ma ́ s eficaces, sobre lamanera de implicar a los pacientes y las familias en laatencio ́ n prestada a los enfermos cro ́ nicos, y sobre co ́mofomentar la observancia de la medicacio ́n y lostratamientos prescritos. Entre los principales programasde manejo de enfermedades cabe citar los dedicados alasma infantil, la diabetes, los traumatismos de lacolumna vertebral, la lumbalgia, la nefropatı ́a cro ́ nica ylos trastornos mentales.Te ́ cnicas que representan un avance en la mejorade la calidad de los servicios asistenciales son porejemplo las directrices basadas en las pra ́ cticas clı ́nicaso ́ ptimas, las fichas de seguimiento de la calidad, queproporcionan informacio ́ n sobre el desempen ̃ o de losproveedores y del plan de salud, y la medicina basada enpruebas cientı ́ficas que incorpora los u ́ ltimos datosaportados por las investigaciones clı ́nicas y los ana ́ lisis decosto-eficacia. La atencio ́ n gestionada ha propiciadonumerosos experimentos encaminados a hallar lafo ́ rmula ido ́ nea para pagar a los proveedores yestructurar los incentivos que potencien la eficacia enrelacio ́ n con los costos, la productividad y la calidad. Sinembargo, muchas de las pra ́ cticas utilizadas en el a ́ mbitode la atencio ́ n gestionada sera ́n ma ́ s aceptables en lossistemas financiados con fondos pu ́ blicos cuando losconsumidores hayan aceptado la necesidad de racionarla atencio ́ n sanitaria. En la mayorı ́a de los planes deatencio ́ n gestionada, los tiempos de espera para lasvisitas a especialistas o los ingresos hospitalarios sonmucho menores que en los sistemas de salud pu ́ blica delReino Unido y de otros paı ́ses de la OCDE.References1.Reinhardt UE.The predictable managed care kvetch on the rockyroad from adolescence to adulthood.Journal of Health Politics,Policy and Law, 1999,24: 897–910.2.Four-year trends show drop in HMO net income despite steadyrises in enrollments, revenues.New Jersey, Best Week InsuranceNews & Analysis, 1998 (Internet Communication, 9 November1998, at http: //www.bestweek.com.html).3.Galvin RS.An employer’s view of the US health care market.Health Affairs, 1999,18: 166–170.4.Passing health plan cost increases to employees not an optionfor firms struggling with labor shortages.New York, William M.Mercer Inc., 1999 (Internet Communication, 14 December 1999,at http: //www.wmercer.com).5.Halvorson GC.Health plan’s strategic responses to a changingmarketplace.Health Affairs, 1999,18: 28–29.6.Kronick R, Gilmer T.Explaining the decline in health insurancecoverage, 1979–1995.Health Affairs, 1999,18(2): 30–47.7.Myths of the uninsured.Washington DC,Newsweek, 1999(Internet Communication, 8 November, 1999, athttp://www.newsweek.com).8.Levit K et al.Health spending in 1998: signals of change.HealthAffairs, 2000,19: 124–132 (Internet http://www.projhope.org).)9.Highlights national health expenditures, 1998.Baltimore, MD,Health Care Financing Administration, 2000 (InternetCommunication, 10 January 2000, at http://www.hcfa.gov).10.Personal healthcare expenditures aggregate and per capitaamounts and percent distribution, by source of funds: selectedcalendar years 1960–98.Baltimore, MD, 2000 Health CareFinancing Administration, Office of the Actuary: National HealthStatistics Group. (Internet Communication at http://www.hcfa.gov).11.Jacob JA.Premium costs rise as more employees choose PPOs.American Medical News, 2000 (Internet Communication,3/10 January 2000 at http://www.ama_assn.org).12.Center for Health Policy Research.Physician marketplacestatistics, 1995.Chicago, IL, American Medical Association, 1996.13.Blendon RJ et al.Understanding the managed care backlash.Health Affairs.17(4): 80–93.14.Robinson JC.The future of managed care organization.HealthAffairs, 1999,18(2): 7–24.15.Robinson JC.Blended payment methods in physicianorganizations under managed care. Journal of the AmericanMedical Association, 1999,282: 1258–1263.16.National health expenditures projections: 1998–2008.Baltimore,MD, Health Care Financing Administration, 1999 (InternetCommunication, 12 July 1999, at http://www.hcfa.gov).17.Percent change in medical prices from same period a year ago:1995–99.Washington, DC, United Sates Department of Labor,Bureau of Labor Statistics: CP/ Detailed Report, 1999(Internet Communication at http://www.hcfa.gov).Managed care: the US experience843Bulletin of the World Health Organization, 2000,78(6)

18.Vincenzino JV.Medical care costs: trends and outlook.StatisticalBulletin, October-December 1999: 28–33.19.National health expenditures aggregate amounts and averageannual percent change, by type of expenditure: selectedcalendar years 1960–98.Baltimore, MD, Health Care FinancingAdministration, Office of the Actuary, National Health StatisticsGroup, 1999 (Internet communication at http://www.hcfa.gov).20.Enthoven AC, Singer SJ.The managed care backlash andthe Task Force in California.Health Affairs.17(4): 95–110.21.The impact of managed care on US markets.New York, KPMGPeat Marwick LLP, 1996.22.Health Care Financing Administration.1998 datacompendium.Baltimore, MD, US Department of Health andHuman Services, Health Care Financing Administration, 1998.23.Robinson JC.Decline in hospital utilization and cost inflationunder managed care in California.Journal of AmericanMedical Association, 1996,276: 1060–1064.24.Selected community hospital statistics: 1995–1999.Chicago, IL,American Hospital Association, Trend Analysis Group: NationalHospital Panel Survey Reports, 1998 (Internet communicationat http://www.hcfa.gov).25.Hospital care expenditures aggregate and per capita amountsand percent distribution by source of funds: selected calendaryears 1960–98(Internet communication at http://www.hcfa.gov).26.Physician service expenditures aggregate and per capitaamounts and percent distribution, by source of funds:selected calendar years 1960–98(Internet communicationat http://www.hcfa.gov).27.Center for Health Policy Research.Physician marketplacestatistics, 1995.Chicago, IL, American Medical Association, 1998.28.Highlights of the legislative accomplishments of 1998.Sacramento, CA, 1998 (Internet communication athttp://www.sen.ca.gov/sor/98 highs.htm).29.Reinhardt UE.A social contract for 21st century health care:three-tier health care with bounty hunting.Health Economics,1996,5: 479–499.30.National study finds seven of 10 physicians are anti-managed care,HMO’s rank highest among physicians in several markets.Managed Care On-line: Surveys, 1998, (Internet Communication,14 September 1998, at http://www.mcareol.com).31.Heimoff S.What if they threw a revolution and no healthplans showed up?Managed Care, December 1999,athttp://www.managedcaremag.com.32.Platt BD, Stream LD.Dispelling the negative myths of managedcare: an analysis of anti-managed care legislation and the qualityof care provided by Health Maintenance Organizations.FloridaState University Law Review, 1996:23:489–510.33.Miller RH, Luft HS.Does managed care lead to better orworse quality of care?Health Affairs, 1997,16(5): 7–25.34.Miller RH, Luft HS.Managed care plan performance since 1980.Journal of the American Medical Association, 1994,271:1512–1516.35.Langa KM, Sussman EJ.The effect of cost containmentpolicies on rates of coronary revascularization in California,New England Journal of Medicine, 1993,329: 1784–1787.36.Most Medicare HMO patients are satisfied with plans.Washington, DC, Physicians Weekly, 1996 (Internetcommunication, 21 October 1996, at http://www.physweekly.com).37.Gold M et al.Disabled Medicare beneficiaries in HMOs.Health Affairs, 1997,16(5): 149–161.38.Eddy DM.Performance measurement: problems and solutions.Health Affairs, 1998,17(4): 7–25. (Note: several articles inthis issue discuss quality measurement.)39.Galvin RS.Are performance measures relevant?Health Affairs,1998,17(4): 29–31.40.Sennet C.Moving ahead, measure by measure.Health Affairs,1998,17(4): 36–37.41.Lansky D.Measuring what matters to the public.Health Affairs,1998,17(4): 40–41.42.Glynn EA.Six challenges in measuring the quality of health care.Health Affairs,1997,16(3): 7–21.43.Enthoven AC, Vorhaus CB.A vision of quality in health caredelivery.Health Affairs, 1997,16(3): 44–57.44.Gosfield AG.Who is holding whom accountable for quality?Health Affairs, 1997,16(3): 26–39.45.Research in action strengthening managed care.Rockville, MD,Agency for Health Care Policy and Research, 1999 (Internetcommunication, 6 January 2000, at http://www.ahcpr.gov).46. TheHealthcare Demand & Disease Managementseries offerexcellent reviews of disease management programmes. Atlanta,GA, National Health Information.47.Newcomer LN.Physician, measure thyself.Health Affairs,1998,17(4): 32–35.48.Hilman AL et al.Financial incentives and drug spendingin managed care.Health Affairs, 1999,18(2): 189–199.49.Reinhardt UE.Spending more through ‘‘Cost Controls’’: ourobsessive quest to gut the hospital.Health Affairs, 1996,15(2):145–154.Special Theme– Health Systems844Bulletin of the World Health Organization, 2000,78(6)