Proposed Changes in the Organization of Health-Care Delivery: An Overview and Critique

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.