The Health Planning Predicament

France, Quebec, England, and the United States
By Victor G. Rodwin
       Health planning is in trouble. Health care costs are out of control. Access to services is inadequate, and too many people fail to receive the right services at the right time, at the right place, and for the right reason. Little consensus exists about what is "right," and even when experts agree on the need to redistribute health resources away from hospitals to community-based health and social services, such goals are rarely implemented. These problems constitute what Victor G.Rodwin calls the health planning predicament.
       How did this predicament come about? What are alternative strategies to cope with these problems? Are there lessons we can draw from experiences with health planning in other Western industrialized nations? Dr. Rodwin examines the evolution of health planning efforts in France, Quebec, and England and compares these experiences with that of the United States.
       France is an example of a European national health insurance (NHI) system that covers public and private hospitals as will as private practice. Quebec is an example of a new NHI system characterized by major institutional renovation. England is the exemplar of a national health service: hospitals are controlled by the state, and physicians are reimbursed on the basis of salaries and capitation fees. In each of these different environments, Dr. Rodwin emphasizes how health planners have challenged the model of hospital-centered medical care. He concludes that attempts to redistribute health resources have been hobbled by a central shortcoming: health planning has not been linked effectively to health care budgeting and the financial incentives that influence hospitals and physicians.
       In the United States, the health planning predicament has provoked controversial proposals to dismantle the formal health planning system and replace it by a strategy of encouraging competition in the health sector. But whether health planning strategies reply on regulation, competition," Rodwin argues that the critical policy issue is the design of a reimbursement system that would encourage hospitals and physicians to pursue society's interest as well as their own. This will involve not just technical innovations but political initiatives that overcome the resistance of powerful groups such as organized medicine, and reconcile deep differences in political philosophy.
       This comparative study of national health planning will broaden the debate about health policy in the United States today. It is sure to be of interest to physicians, health planners, and all those concerned with health systems and medical care.
 

Contents

Foreword

xi

PART 1. INTRODUCTION

1. The Nature of Health Planning

Two Images of Health Planning
Doctrinal Controversies in Planning
The Plan and Themes of This Study

 1

2
4
8

PART 11. BACKGROUND AND APPROACH

2. Health Planning and the State

Health Planning as A Response to Change
The Role of the State: Contrasting Perspectives
Implications for Health Planning
Implications for This Study

 13

14
19
27
38

3. Health Planning and Implementation

The Health Planning Predicament
Medical Care Systems Behavior and the Options for Planned Intervention
The Need for and the Problems of Linking Health Planning and Financing

40

40
47

56

PART 111. CASE STUDIES

4. Profiles of Health Systems

Health Systems Compared: An Overview
Financing and Organization
Provider Reimbursement

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63
70
77

5. Health Planning under National Health Insurance: France

84
Origins of Health Planning
Health Planning as Hospital Construction and Modernization
Health Planning as Rationalization
Evaluation of French Health Planning

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90
97
113
6. Health Planning amid Institutional Renovation: Quebec

Origins of Health Planning
Health Planning as a Strategy for Social Change: The Castonguay- Nepveu Commission
Health Planning as Legislative Reform
Evaluation of Health Planning in Qu6bec

 117

118
121

123
143

7. Health Planning in a National Health Service: England

Origins and Early Years of Health Planning
Health Planning as Reorganization
Health Planning as Resource Allocation
Evaluation of English Health Planning

 148

149
156
165
177

PART IV. COMPARATIVE EVALUATION AND CONCLUSIONS

8. Health Planning: American Style

Central Problems and Early Health Planning Efforts
Health Planning as A Strategy of Decentralized Intervention
Evaluation of Health Planning in the United States
Alternative Strategies for Health Planning: Competition, Regulation, and Regulated Competition
On Linking Health Planning and Financing

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184
186
192

195
203

9. Comparisons and Interpretations

Expansion and Containment
Rationalization and Linkage
Barriers to Implementation
Emerging Trends

212

213
218
221
231

Appendixes

1. Comparative Health Systems: Notes on the Literature
2. Key to Acronyms
Notes
Acknowledgments
Index

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