Suchergebnisse

"There's class warfare, all right, but it's my class, the rich class, that's making war, and we're winning." (Warren Buffett, five years ago.) Last year's Occupy Wall Street movement suggested that people are finally catching on. Note, making war: Buffett meant that there was deliberate intent and agency behind the huge transfer of wealth, since 1980, from the 99% to the 1%. Nor is the war metaphorical. There are real casualties, even if no body bags. Sadly, much Canadian commentary on inequality is pitiably naïve or deliberately obfuscatory. The 1% have captured national governments. The astronomical cost of American elections excludes the 99%. In Canada, parliamentary government permits one man to rule as a de facto dictator. The 1% don't like medicare.

The fall in Shoppers Drug Mart shares last April 8 gave a crystal-clear demonstration of the link between health expenditures and health incomes. Reacting (finally) to the excessive retail prices of generic drugs, the Ontario government effectively halved the rate of reimbursement of ingredient costs and banned the "professional allowances" (kickbacks) paid to pharmacies by generic manufacturers. Taxpayers and private payers will save hundreds of millions of dollars, and pharmacy revenues will fall by an equivalent amount. Patients will still get their drugs, with no loss of quantity, quality or even convenience; no one's health is threatened. But investor profits will fall. There are similar savings opportunities throughout the health system. Health costs are primarily a political, not an economic, problem.

A paper by Selden and Sing (2008) reminds us of what was at stake 45 years ago, when Emmett Hall recommended universal public medical insurance over private–public alternatives. While focusing exclusively on the United States, it also helps to explain why universal pharmacare is being diverted into that same private–public dead end through public "catastrophic" coverage. Governments finance, through many different programs, most US health expenditure. Spending programs – Medicaid, Medicare and others – primarily benefit the unhealthy and unwealthy. However, benefits of the largest program, the tax exemption for private insurance, are heavily tilted towards the highest incomes and are essentially unrelated to health. This pattern (also found in Canada) may help explain political support for private insurance, despite its excessive administrative cost and inability to cover those in greatest need.

On June 1, 2009 the town of McAllen, Texas rose to brief prominence on the American political stage. With the highest (bar Miami) per-beneficiary costs in the entire US Medicare program, it was featured in an essay in The New Yorker by Atul Gawande, then seized upon by President Obama: "This is what we have to fix." Behind the headlines were decades of documentation of clinical practice and analysis of regional variations by John Wennberg, Elliott Fisher and their colleagues, and by Leslie and Noralou Roos and theirs. The implications for health systems were grasped over 30 years ago and have been confirmed by more recent work. Efforts to understand these variations within standard economic theory have, however, had limited success.

Incomes in Canada, as in many other countries, are becoming increasingly unequal. In North America this process has several notable features. First, after 40 years of stability, income has since 1980 been increasingly concentrated in the hands of the top 0.01% of earners. Second, this concentration correlates with an explosion in the relative earnings of corporate CEOs, a sort of "corporate kleptocracy." Third, the top earners have appropriated most of the productivity gains over this period. The resources and political influence of the super-rich underlie the growing prominence of the "elite" agenda: lower taxes, smaller government and privatization or shrinkage of social programs. The marketing of this agenda may explain much of the nonsense that contaminates health policy debates.

Most economic relationships are either arm's-length exchange transactions, each party seeking his or her own interest, or command structures, such as a firm or public agency, integrating joint efforts toward a common goal. The health care industry, however, displays a pattern of incomplete vertical integration—relationships which are neither truly arm's-length nor completely hierarchical. The doctor-patient relationship is archetypical. Physicians appear to sell services in private markets; yet they reach through the exchange process to direct the consumer-patient's utilization decisions, implicity undertaking to act in the patient's interest, and thus integrate forward. But they also integrate backward to control the public regulatory process—self-government—and some forms of insurance. The health care systems of different countries—Canada, the United Kingdom, and the United States—can be interpreted as different patterns of incomplete integration among five basic classes of transactors: consumer-patients, first-line providers, second-line providers, insurers, and governments. Each system of linkage has characteristic strengths and weaknesses. Nowhere, however, do we find a predominance of arm's-length market relationships. Where they exist, markets in health care are usually pseudomarkets dominated by one side of the transaction. The rhetoric of market relationships serves principally to obscure political struggles over shifting patterns of integration.

Most economic relationships are either arm's-length exchange transactions, with each party seeking his or her own interest, or command structures, eg, a firm or public agency, integrating joint efforts toward a common goal. The health care industry, however, displays a pattern of incomplete vertical integration -- relationships that are neither truly arm's-length nor completely hierarchical. The MD-patient relationship is archetypical. MDs appear to sell services in private markets; yet they reach through the exchange process to direct the consumer-patient's utilization decisions, implicitly undertaking to act in the patient's interest, & thus integrate forward. However, they also integrate backward to control the public regulatory process -- self-government -- & some forms of insurance. The health care systems of different countries -- Canada, the UK, & the US -- can be interpreted as different patterns of incomplete integration among five basic classes of transactors: consumer-patients, first-line providers, second-line providers, insurers, & governments. Each system of linkage has characteristic strengths & weaknesses. Nowhere, however, is there a predominance of arm's-length market relationships. Where they exist, markets in health care are usually pseudomarkets dominated by one side of the transaction. The rhetoric of market relationships serves principally to obscure political struggles over shifting patterns of integration. 4 Figures. HA.

This paper was written for the Fourth Annual Medical Workforce Conference, San Francisco, November 4-7, 1999. The organizers intent was to have the conference papers published, and to have the discussants for the papers in each session contribute a synthesis paper for that session. The papers synthesized here are: Harding, John, and Warwick Conn, 'Workforce Productivity in the Australian Medical workforce', Watanabe, Mamoru, Lynda Buske and Jill Strachan, 'Canadian Physician Workforce Productivity', Maynard, Alan and Karen Bloor, 'Workforce Productivity in the U.K. NHS: Measurement, Variation and Incentives'. Unfortunately the organizers plans for publication did not materialize. This paper reached the antepenultimate stage of being circulated to the session participants for comment and possible revisions, after which references were to have been added. But the overall project was abandoned before any comments were received, and the paper was never completed for publication. The broader issue of physician productivity has, however, re-emerged in Canada. I believe that the paper offers a useful analytic framework for addressing that topic along with fairly detailed illustrative examples of its application to the descriptive material, institutional and statistical, provided in the session papers. Much has changed since; no attempt has been made to up-date those papers. But the process of applying the analytic framework to the world as it then was (said to be) provides, I think, a clear guide for a similar application to present circumstances. ; Arts, Faculty of ; Vancouver School of Economics ; Medicine, Faculty of ; Population and Public Health (SPPH), School of ; Unreviewed ; Faculty