Abstract: to modify the U.S. health care delivery system toward more economical patterns, encouraging preventive and ambulatory rather than costly hospital services. Evidence of HMO performance has accumulated over the years, much of it reviewed in 1969. Since then, additional evidence suggests that the "prepaid group practice" (PGP) model of HMO continues to yield lower hospital use, relatively more ambulatory and preventive service, and lower overall costs (counting both premiums and out-of-pocket expenditures) than conventional open-market fee-for-service patterns. Economies of scale in group practice per se are still not proved, but some evidence supports this theoretical hypothesis. New data point to reduced disability from the PGP model of HMO, as well as to more favorable consumer attitudes (based mainly on the economic advantages, in spite of certain impersonalities of clinics) than exist toward conventionally insured private solo practice. The medical care foundation (free choice of private practitioners with fee payments) model of HMO has yielded some evidence of economies in physician's care, but none in hospital use. HMOs entail hazards of underservicing and distorted risk-selection, but with appropriate public monitoring they constitute an approach to health planning, stressing local initiative, competition, and incentives to self-regulation.

Abstract: A "no-fault" insurance system is proposed to replace the present adversary legal system for dealing with medical malpractice. Designed to obviate inquiries into providers' blameworthiness wherever possible, the system has features which would bring certain adverse medical outcomes to light, compensate for them promptly though not lavishly, and generate incentives for providers to avoid relatively bad outcomes experience. The difficulty of specifying compensable events might dictate that, at least initially, only events which are relatively avoidable and easily identified when they occur could be made compensable, the remainder being left for adjudication under traditional principles. The system would be operated primarily by providers and would stimulate peer review, self-regulation, continuing education, and increased attention to clinical outcomes rather than inputs or processes. Direct regulation of the quality of care would be unnecessary in areas where the system proved workable, and medical decision-making would be left largely free from outside interference. Costs could appear high but would be manageable.

Abstract: stitutes of Health and the interest of private foundations in interdisciplinary research stimulated and supported the growth of medical sociology as an area of research and teaching. During the 1950s, the field developed in two directions: sociology of medicine, centered in departments of sociology in universities, and sociology in medicine, concentrated in schools of medicine and health care facilities. As training programs proliferated through the 1960s, the market for books on the subject grew quickly. Five textbooks on medical sociology are reviewed, and some suggestions are made about issues in need of study for

Abstract: Based on an extensive field study of the practitioners in a large, prepaid service contract group practice, this paper discusses how a prepaid service contract and closed-panel practice brings a new dimension into doctorpatient relations and how physicians respond to it. Unable to manage "unreasonable" demands for service by use of a fee-barrier or encouragement to "go elsewhere," as in traditional, solo, fee-for-service practice, they were particularly upset by a new type of "demanding patient" who claimed services on the basis of contractual rights and threatened appeal to higher bureaucratic authority. Modes of dealing with such patients are briefly discussed.

Abstract: Students of the American health-care delivery system are generally agreed that, under its present organization, the system will be unable to accommodate any of the more ambitious national health-insurance schemes now before Congress It is argued that the current system is actually a fragmented "nonsystem" that fails to deliver the right mix of care to the right people and at the right time As a result, it is argued, the health-maintenance services received by the average American tend to be of dubious overall quality and are unnecessarily costly To eliminate these shortcomings, a great number of reforms have been proposed, the bulk of which, however, fall into one of the following major types: (a) a shift away from the fee-for-service mode of paying for health services and toward prepayment of comprehensive health care, (b) the substitution of paramedical for medical manpower and of capital for all types of manpower, (c) the consolidation of small provider facilities (especially solo medical practices) into larger production units, and (d) the integration of provider facilities in centrally directed regional systems In this essay, the various reform proposals that have been proposed at one time or another are explored against the backdrop of pertinent empirical research available at this time This exploration leads to the disappointing conclusion that far too many of the proposed reorganization schemesparticularly the much touted idea of a nationwide network of presumably competitive Health Maintenance Organizations-appear to have been proffered more on the basis of intuition or faith than on the basis of convincing empirical evidence At the risk of appearing timid and of exasperating the impatient reformer, the author concludes that a great deal more empirical information needs to be gathered on the behavior of the participants in the health-care sector and on the technical constraints under which that sector operates before one can confidently develop and follow a coherent blueprint for a reorganization of the American health-care system

Abstract: During recent years, the health care industry has been characterized by rapid increases in the volume of services delivered. This escalation is in part unjustified by medical need, and has produced a variety of efforts on the part of payers and providers to restrict overuse. In this article the authors consider the issues and problems involved in the control of medical utilization. Five categories of control are considered in detail: supply limitations, financial disincentives, authorization requirements, review mechanisms, and legal action. The article suggests that the success or failure of these various control mechanisms hinges upon four factors: whose use is being regulated, who performs the control activities, whether the attempted control involves a judgment as to the appropriateness of treatment, and whether the attempt to control occurs before, after, or during treatment. It is concluded that most current forms of utilization control suffer from ambiguity of purpose, organizational inefficiency, and undesirable side effects. The authors offer several proposals to correct these shortcomings, but conclude that the only long-range solution to overutilization lies in a more integrated approach to medical resource allocation and a consequent change in the structure of provider and user incentives.

Abstract: This paper sounds a note of caution that regardless of the type of national health insurance program Congress will approve from among the proposals now before it, the present defects in the organization of health services in the United States may be strengthened rather than alleviated. Consequently, the reorganization and redistribution of health resources required to secure the availability of care for the greatest possible number may be hindered rather than stimulated. Strategies for change based upon a "market" and "incentives" ideology, such as those implicit in the current proposals for national health insurance (as well as those in Health Maintenance Organization proposals), will necessarily be limited in their reorganizational and redistributive effects, inasmuch as they leave untouched the locus of economic and political power in the health sector; it is argued that this very locus of power precipitated the much-quoted "medical care crisis." In order to achieve the necessary reorganization and redistribution of resources in the health sector, the author believes that the locus of power must shift from the private to the public sector, permitting the levels of federal, state, and local government to formulate a mechanism for national and regional health planning in which public agencies would be the ones primarily responsible for planning, regulating, and controlling (but not necessarily owning) the distribution of human and physical resources within the health sector. In the light of this recommendation, the present structure for national and regional planning in the United States is described and appraised.

Abstract: This paper analyzes the close nexus between professional associations and the process of state licensure. Licensure is viewed as an extension of the concern for self-regulation that characterizes professionalism. Notwithstanding the important mission of protecting the health and safety of the public, in many cases, licensure has provided a means of according status and recognition to a body of specialized knowledge, resulting in a “state-protected environment\" wherein the profession is virtually autonomous. Several recent proposals that may have far-reaching impact on the natural insularity of licensing boards are critically discussed. These include public representation, reorganization of boards, institutional licensure, and jointly promulgated regulations. In the context of a growing demand for greater public accountability and responsiveness in the credentialing of health manpower, these proposals may be of pivotal importance if innovative devel­ opments in the utilization and distribution of manpower are to be realized.

Abstract: Current interest in the development of a national health insurance in the United States invites a clear determination of objectives through identification of the problems to be resolved by a new program and an understanding of how these problems came about and why. Historical review of the background and the evolution of the current medical care scene provides perspective. Critical review may also contribute to better design of what should be intended by new undertakings and to utilization of lessons from the past in order that the specifications should minimize mistakes for the future. Here, therefore, is a review of major events and the lessons they taught (or should have taught), from the Final Report of the Committee on the Costs of Medical Care (1932) to Medicare and Medicaid (1965) and their early operational years through 1972. It is a personal review but by an author who was privileged to be a participant in many of the studies and legislative campaigns as well as a continuous observer of the evolving scene. This historical review was planned as prologue to a course of action. The author therefore comments on various current legislative proposals and indicates why he and others advocate the Health Security Bill principally because its scope embraces not only the financing of comprehensive personal health services for the whole population but, equally and simultaneously, the improvement of the medical care system as well. This review and the presentation of a rationale for action are timely, since diverse and conflicting proposals are now engaging national attention and are being debated in the Congress.

Abstract: are involved: the consolidation of the tripartite structure into a single unified system, the strengthening of management processes, and the expansion of machinery for making health services more responsive to local needs. While generally supportive of the reorganization, this assessment of the changes in policy and structure identifies a number of constraints in the form of political realities and organizational-administrative capabilities which may limit the attainment of objectives. In particular, the bias in modern medicine for hospital-based specialization, the uneven power relationships among competing professional interests, and the continued separation of health from social services are seen as restricting policy aimed at altering the balance between primary, secondary, and tertiary levels of care and between curative and "carative" services. Since the pressures underlying the reorganization of the National Health Service (NHS) reflect the broad changes accompanying social and economic development, such as the aging of the population, the shift from acute to chronic patterns of illness, and the decline in the marginal social benefit of capital-intensive medical technology, England's experience may be relevant to other highly developed countries, both as a field laboratory for the elucidation of alternatives and as a case study of the complexities inherent in any attempt to carry out large-scale organizational change. With the possible exception of Sweden's, the reorganization represents the most ambitious attempt to institute comprehensive health services planning and integrated delivery among Western capitalist countries.

Abstract: Rational approaches to policy problems of disability require some level of common agreement on both the conceptual basis and the measurement of disability. Service organizations, however, define disability in a variety of ways, depending on their interests, orientation, objectives, or jurisdiction. The limitations of specific program criteria emphasize the need for inclusive and comparable measurements of disability in order to examine the relationship to and the effects of public policy. Measurement problems are reviewed, and prevalence estimates from the Social Security Survey of the Disabled are compared to those of the National Health Interview Survey and other studies in the United States. These studies, which show a considerably higher prevalence of disability and severe disability than does the National Health Interview Survey, also indicate that the identification methods used are reliable and consistent. Disability and impairment estimates from five nations are compared, and the differences among the studies are reviewed in terms of their possible effects on the level of disability reported. Also examined are data on the differences between client populations and the disabled population at large. This paper points out the need for greater emphasis on the behavior processes of normalization and adaptation in disability. The study comparisons suggest the need for national comparative studies using common methods and criteria to provide a better basis for understanding and dealing with the problems of disability.

Abstract: The intent of this article is to present an intensive comparison of one area of health planning, viz., planning for health facilities in the United States and in Germany. In both countries federal legislation increasingly has attempted to achieve comprehensive policies through planning. Most attempts have been markedly influenced by various levels of authority which exist apart from the federal level. In the United States the notion of comprehensive health planning seems to be an indirect outcome of several isolated decisions. In Germany, on the other hand, state and local governments have long accepted health as a public responsibility and have been involved in hospitalrelated matters within certain limitations, i.e., hospitals have not been directly influenced by centralized decision making. While the German health bureaucracy remains the principal vehicle for hospital decision making, consumer advocacy planning in the American sense does not exist. Health planning in the United States under the Regional Medical Program and Comprehensive Health Planning provides an example of the interaction and interrelatedness of many political factors which influence health planning. Paradoxically, the American health planning process lacks a clear mandate from the consuming public in terms of developing fiscal, political, and legal powers over the subjects to be planned, including hospitals.

Abstract: During the academic year 1971-72, the author visited 22 American and Canadian universities in order to get acquainted with their teaching programs in community health. It was possible to place the departments of community medicine (preventive medicine, social medicine, family practice) according to clearly distinguishable variables. The most basic variable was the extent of commitment to community medicine. This ranged from medical schools in which all departments participated in providing care on a community basis to schools in which only a department of community medicine was interested in community health. The second major variable was the basic orientation of the department of community medicine. This variable is located on a continuum ranging from a basic science to a clinical orientation. Impact of the commitment to community health and of the basic orientation of departments of community medicine on teaching objectives and methods, type of client contact, student projects, and research focus is discussed.

Abstract: Health expenditures and prices have accelerated markedly in recent years, both in absolute and relative terms. The pressures for some form of governmental intervention have generated widespread debate about national health policy. Determinants of health are complex, and policy development must follow the identification of issues and review of theoretical policy analysis. Formation of a theoretical basis will have a significant impact on substantive policy outcomes. Unfortunately, past and current proposals and policies have given insufficient attention to the traditional public finance criteria for government intervention; as a result, the importance of market forces has frequently been overlooked. Before wholesale rejection of the market as a means of promoting rationality, government should examine alternatives that foster increased efectiveness of the market mechanism. Even within this context, however, some forms of regulation will be necessary; also, traditional public finance norms would allow certain kinds of expanded government intervention. Market-perfecting policy instruments would result in different kinds of government programs, and much of future policy will be shaped by political decisions about substantive health policy issues.