The growth of managed care has prompted numerous questions about its effect on the quality of health care. This paper reviews evidence on the effects of managed care on quality. Most comparisons of care for patients in different plans within similar markets suggest that there is little systematic difference in quality between HMOs and other managed care plans and non-managed-care plans. However, these studies may ignore important effects of managed care on the structure and functioning of the health care system that would be evident only across markets. We suggest that these effects could be important and provide evidence from an analysis of treatment patterns for cancer patients. We conclude by describing how more careful attention to the empirical evidence on the effects of managed care could improve current policy debates about managed care regulation.

Healthcare quality has received heightened attention over the last decade, leading to a growing demand by providers, payers, policymakers, and patients for information on quality of care to help guide their decisions and efforts to improve health care delivery. At the same time, progress in electronic data collection and storage has enhanced opportunities to provide data related to health care quality. In 1989, the Agency for Health Care Policy and Research (AHCPR, now the Agency for Healthcare Research and Quality, AHRQ) initiated the Healthcare Cost and Utilization Project (HCUP). HCUP is an ongoing federal-state-private collaboration to build uniform databases from administrative hospital-based data collected by state data organizations and hospital associations.

The HCUP quality indicator set, developed in 1994, and hereafter referred to as HCUP I, consists of 33 measures, constructed using administrative data available in the NIS. Included in the set are indicators of utilization of procedures, ambulatory care sensitive condition admissions, post-operative and other complications, and mortality.

Since the original HCUP QI development work in 1994, numerous managed care organizations, state Medicaid agencies and hospital associations, quality improvement organizations, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), the National Committee on Quality Assurance (NCQA), academic researchers and others have contributed substantially to the knowledge base of hospital quality indicators. Based on input from current users and advances to the scientific base for specific indicators, AHRQ decided to fund a research project to refine and further develop the HCUP QIs.

As a result, AHRQ charged the UCSF-Stanford Evidence-based Practice Center (EPC) to revisit the initial 33 indicator set (HCUP I QIs), evaluate their effectiveness as indicators, identify potential new indicators, and ultimately propose a revised set of indicators. This report documents the evidence project to develop recommendations for improvements to the HCUP I indicators.

Although technological change is a hallmark of health care worldwide, relatively little evidence exists on whether changes in health care differ across the very different health care systems of developed countries. We present new comparative evidence on heart attack care in seventeen countries showing that technological change--changes in medical treatments that affect the quality and cost of care--is universal but has differed greatly around the world. Differences in treatment rates are greatest for costly medical technologies, where strict financing limits and other policies to restrict adoption of intensive technologies have been associated with divergences in medical practices over time. Countries appear to differ systematically in the time at which intensive cardiac procedures began to be widely used and in the rate of growth of the procedures. The differences appear to be related to economic and regulatory incentives of the health care systems and may have important economic and health consequences.

On May 4 and 5, 2000, health care leaders, professionals, and academics convened at the Bechtel Conference Center at Stanford University for the Health Care Conference 2000. Sponsored by the Comparative Health Care Policy Research Project at the Asia/Pacific Research Center (Shorenstein APARC), in cooperation with the Center for Health Policy (CHP), the conference was held for the purpose of discussing health care policies and issues facing nations today. With the pressures of rising costs, aging populations in industrialized countries, and rapid technological advancements, the need for an accessible, affordable, and effective health care system is urgent and greater than ever. The first conference of its kind at Shorenstein APARC, the Health Care Conference 2000 established a forum for candid discussion about the past, present, and future of health care. Over sixty participants attended the conference. The panel consisted of speakers from governmental institutions, for-profit and nonprofit organizations, universities, and research institutes. The first day of the conference featured a discussion on the evolution of the health care market in the United States, while the second day focused on the effects of market forces overseas, specifically in England, Japan, the Netherlands, New Zealand, Scotland, and Singapore. The 1990s marked an era of major health care reform. For many nations with socialized health care systems, it was a decade to explore alternative systems and to move toward privatization. The implications of such changes were discussed in detail at the conference. The Health Care Conference 2000 was a successful and informative meeting, which opened the doors for future discussions on issues concerning health care around the world. These proceedings present, in edited form, the remarks of all primary conference speakers. Please contact Shorenstein APARC if you have any questions about the conference, or about the Center's work in general.

A holistic approach to the financial problems of the elderly focuses simultaneously on their expenditures that are self financed as well as those that are financed by transfers from the young (under age65). It also focuses simultaneously on paying for health care and paying for other goods and services. The income and health care expenditures not paid from personal income, provides a useful framework for empirical application of the holistic approach. In 1997, approximately 35 percent of the elderly's full income was devoted to health care; 65 percent to other goods and services. Approximately 56 percent of full income was provided by transfers from the young and 44 percent by the elderly themselves. The paper shows how these percentages might change under alternative assumptions about the growth of health care relative to other goods and services and the effect of these changes on the need for more saving and more work prior to retirement.

A biological terrorist attack probably would first be detected by doctors or other health-care workers. The speed of a response would then depend on their rapid recognition and communication that certain illnesses appeared out of the ordinary. For this reason, preparing for biological terrorism has more in common with confronting the threat of emerging infectious diseases than with preparing for chemical or nuclear attacks. Defense against bioterrorism, like protection against emerging diseases, must therefore rely on improved national and international public-health surveillance. Too often, thinking about bioterrorism has mimicked thinking about chemical terrorism, a confusion that leads to an emphasis on the wrong approaches in preparing to meet the threat.

With the backlash against managed care, medical necessity has become the focus of increasing controversy. California's health care marketplace has provided some unique opportunities to understand the role of medical necessity in managed care decisionmaking, as the legislature and stakeholders have discovered how little consensus there is on itsmeaning, ownership, and application. Nevertheless , many decisionmakers agree that medical necessity decisions generally involve authorizing treatment for an individual patient. These differ from coverage decisions, which set organizational policies regarding the coverage of treatments for populations of patients with similar conditions. Both types of decisions require medical judgment, and thus both mix considerations of payment and clinical factors.3 Differences in coverage policies and in the application of those policies to individual decisions contribute to variation in managed care decision making.

Previous research has found considerable variation in the process and criteria used for decision making in both public and private plans. The aim of our research was to understand more precisely what type of variation exists and whether more clarity and consistency in medical necessity decision making could make a difference to consumers and providers. We sought to document differences in decision-making criteria and to explain the relationship between contractual definitions and the way decisions are made in practice. Given the lack of existing information on how medical necessity decisions are made in managed care organizations, we believed that describing "best practices" as well as unacceptable variations could play a powerful role, along with consumer choice and regulatory fiat, in improving the process. Finally, we sought to produce, with stakeholders' involvement, a model contractual definition and decision-making process based on best-practices models.

Lengthy travel distances may explain why relatively few veterans in the United States use VA hospitals for inpatient medical/surgical care. We used two approaches to distinguish the effect of distance on VA use from other factors such as access to alternatives and veterans' characteristics. The first approach describes how disparities in travel distance to the VA are related to other characteristics of geographic areas. The second approach involved a multivariate analysis of VA use in postal zip code areas (ZCAs). We used several sources of data to estimate the number of veterans who had priority access to the VA so that use rates could be estimated. Access to hospitals was characterized by estimated travel distance to inpatient providers that typically serve each ZCA. The results demonstrate that travel distance to the VA is variable, with veterans in rural areas traveling much farther for VA care than veterans in areas of high population density. However, Medicare recipients also travel farther in areas of low population density. In some areas veterans must travel lengthy distances for VA care because VA hospitals which were built over the past few decades are not located close to areas in which veterans reside in the 1990s. The disparities in travel distance suggest inequitable access to the VA. Use of the VA decreases with increases in travel distance only up to about 15 miles, after which use is relatively insensitive to further increases in distance. The multivariate analyses indicate that those over 65 are less sensitive to distance than younger veterans, even though those over 65 are Medicare eligible and therefore have inexpensive access to alternatives. The results suggest that proximity to a VA hospital is only one of many factors determining VA use. Further research is indicated to develop an appropriate response to the needs of the small but apparently dedicated group of VA users who are traveling very long distances to obtain VA care.