STRAINED MERCY

Preface

PART 1   THE UTILIZATION OF HEALTH CARE

Chapter 1. Health and the Use of Health Care

Introduction: The Scope of Health Care Economics
The Health Care "Industry" in Canada: A Brief Sketch
From Data to Evaluation: How Much Is Enough?
Modelling the Health Care Utilization Process

Insurance and the Reimbursement of Health Care
Modelling the Benefits of Insurance
Private Health Insurance in Practice: Development and Limitations
Sources of "Failure" in Private Insurance Markets
    (i) Economies of Scale
    (ii) Insufficient Information for Rate-Making
    (iii) Adverse Selection
    (iv) Moral Hazard
The "Welfare Burden" of Health Insurance
Inadequacies of the "Welfare Burden" Analysis

The Social Significance of Individual Health Status
Modelling the Interpersonal Relationship
Extending the Range of Externalities
Alternative Forms of Interpersonal Effects
Policy Responses to External Effects
Subsidy Policy in the Context of Informational Asymmetry

Regulation of Health Care as Protection of Uninformed Consumers
Asymmetry of Information Between Provider and Consumer
Limits on the Professional's Role
The Agency Relationship and the Problem of Incompleteness
Professionalism as a Response to Incomplete Agency
The Implications of Informational Asymmetry for Economic Analysis
Provider Influence over Demand: Normative and Positive Implications
Empirical Evidence of "Supplier-Induced Demand"
Provider Influence and the Medico-Technical Model: Some Discrepancies
Agency and the Effect of Economic Factors on Utilization

Market Failure, Policy "Therapies," and Side Effects: A Figurative Summary
The Causal Structure of Institutional Evolution
Feedback Loops in Institutional Responses: Circles Vicious or Otherwise
Current Possibilities for Policy Response
From Positive to Normative, or "Is" to "Ought": Lerner's Rule
Over to the Supply Side

Chapter 6. Health Care Firms: Providers, Practices, and People

The Firm as Organization: Practitioners Are Not Practices
Transactions Between Firm and Environment: The Time Horizons of Decision
The "Textbook" Firm: A Single-Exit Model
Health Care Firms: A Choice of Objectives
Opening Up the "Black Box": Performance Criteria for Health Care Firms
Fuzzy Boundaries: Where Do Firms End?

The Scale of the NOFP Sector in Canada: Expenditures and Employment
Economists and the NOFP Firm: The Blind Men and the Elephant
Professions as Monopolies: Supply Restrictions
Professional Earnings: Rewards of Monopoly?
Inadequacies of the Monopoly Model
Systematic Departures from Cost-Minimization: The (Non) Use of Auxiliaries
Additional, or Alternative, Objectives for the Firm: Behavioural and Policy Implications
Evidence from Group Practices: Technical Efficiency
Provider Influence over Use: Prepaid Groups and the Exercise of Agency
Alternatives to the Exogenous Demand Curve: Professional Ethics?
Are Ethics Exogenous?
The Role of Fees when Demand Is Endogenous

The Scale and Growth of NFP Institutions in Canada
Modelling Hospital Behaviour: "Organic" NFP Firms in a Hypothetical Market Environment
Bridging the Gap from Model to Experience: Throw in More Assumptions
Making Explicit the Physician's Role: "Co-operative" Models
Transaction Models: The Hospital as a Framework for Negotiation
Hospital Reimbursement: Take the Money and ...?
Payment by Unit of Service: Lower Unit Costs, Higher Total Costs?
Reimbursement by Episode of Care
Reimbursement by Person, Not Patient, Cared For: Capitation
Wider Still and Wider ... Where Are the Boundaries of the Hospital "Firm"?

Generalizations from Experience: Induction as Well as Deduction
    (i) Hospital Cost Function Studies
    (ii) Specific Hospital Program Studies
    (iii) Population-Based Hospital Utilization Studies
Generalizations about Whose Behaviour?

For-Profit Health Care in Canada: Small Scale but Wider Significance
Beyond Good and Evil: The Economic Function of Profits
Pharmaceuticals: The Extended Bottom Line
Prescribing Appropriateness: Informing or Manipulating the Physician?
Drug Distribution: Dispensing or Retailing?
Research and Development: Does Short-Run Monopoly Buy Long-Run Progress and Competition?
Medical Equipment and Devices; Profits and Proliferation of Technology
The Shift from Professional to Commercial Diagnostic Laboratories
For-Profit Hospitals and Related Institutions: The United States Experience
Can One Mix Motivations, or Must For-Profit Firms Be All In or All Out?

Chapter 11. Evaluating Health Care Programs: Efficiency, Effectiveness, and Cost

Public Policy and Private Interests
Program Evaluation: A General Representation
Discounting, Inflation, and Consistency
Costs and Benefits to Whom? Where You Stand Depends on Where You Sit
Priceless Does Not Mean Valueless: Shadow-Pricing Life and Limb
Valuing Livelihoods: Eskimo Economics
Your Money or Your Life? Willingness-To-Pay as a Source of Shadow Prices
Cost-Effectiveness Analysis: Let the Outcome Stand for Itself
A Life Affirmed, a Death Confronted: Life Years as Outcomes
QALYs: Not All Lives Are Worth Living
Prior Considerations: If the Project Doesn't Work, Efficiency Is No Help

Investment Activities with Diverse and Non-marketed Benefits
The "New Perspective": A Public Interest in Private Lifestyles?
Communicable Behaviour: An Epidemiology of Lifestyles?
From Lifestyle Policy to Health Care Expenditure: Long Chain, Weak Links
Preventive Services in the Clinical Setting: Problems in Assessing Efficacy
Health Status and the Life Cycle of Care Use: Dead Men Use No Services
Savings at Whose Expense? The Income-Expenditure Identity Again
Preventing Poverty Among Providers?
Health Care Research: What Is the Public Interest, and How Is It Best Pursued?
Consistent Manipulation of Unknown Quantities: The Economic Analysis of Research
"Free Riding" versus National Pride: or Dr. Banting, Meet Mr. Podborski
The Profits Are in "Half-Way" Technology: Problems of Motive
After Such Knowledge, What Forgiveness?

Public Investment in Private Capital
A Polar Case: Patterns of Manpower Allocation in Pure Competition
The Principal Channels of Public Influence or Control
Informational and Interaction Problems in Public Manpower Policy
An "Activity Analysis" Planning Framework
"Magic Ratios": The Limiting Case of Activity Analysis
Manpower, Population Aging, and Utilization: Chicken or Egg?
Planning with Magic Ratios: Implicit Assumptions as to Epidemiology and Technology
Defining the Technology: Direct Measurement or the "Engineering" Approach
Statistical Observation of Performance in the Field: The "Econometric" Approach
For Whom Is Efficient Manpower Use Optimal?
The Only Things We Learn ...?

Economic Analysis to What (or Whose) Ends?
Objectives of Health Policy: A Suggested Agenda
Competing Sources of Legitimacy: Political, Professional, and Market
Constructive Inconsistency: Papering over the Cracks Can Work
If the Cracks Widen, Can More Money Fill Them?
Private Versus Public Money: User Charges, Extra-Billing, or "Patient Participation"
Dismantling Medicare: Private Funding, Private Insurance, and Private Delivery
What Happens Next? The United States Alternatives
A Professional Alternative: Control by Cartel?
Increased Public Control: How Civil a Service?
But Why Confrontation over (Allegedly) Common Objectives?
What to Do, or How to Do It: A Role for New Players?
Institutions, Incentives, and Information
What's Wrong with the Status Quo?
And a Last Word on Economics -- For Good or Ill

Bibliography 

Glossary