Introduction

• Economic analysis of health care is not a new phenomena

  • Cost benefit studies existed in the 1930s and 1950s (Donabedian, 1985)

• Since the mid-1980s all the major players in US health care have called for expansion of measurement efforts including cost benefic analysis, and have argued that the measurement of costs and benefits should underlie the allocation of health care resources

• Health Care Financing Administration (the US Federal agency overseeing Medicare):

  • Desire to “purchase value, the optimal mix of high quality and reasonable cost” (Roper and Hackbarth, 1988)

• Early advocates of Diagnosis Related Groupings (DRGs) argued that the introduction of DRGs would lead to better information about costs and benefits

• Several accounting researchers have suggested that it is important to study accounting numbers as they appear in situ

  • i.e. in real institutions and debates

  • e.g. Cooper and Sherer (1984), Hopwood (1987)

• Cost benefit analysis involves a particular way of informing and/or justifying resource allocations

• Cost benefit studies as texts which have both a surface, “common-sense” meaning and a less apparent meaning which reflects the institutions are structures surrounding their production, content and distribution

• The importance of cost benefit analysis is not just that it might be a way of co-ordinating physician behavior at a distance, or that it reflects the way physicians take up the language of economists

  • But that physicians take up this technology to protect and construct authority over resources

Examination of the Production and Transmission or Diffusion of Messages: Cost Benefit Studies in the Current US Context

• All of the studies we examine were published in the USA during 1987-1990

• Two themes emerge from discussions of health care during this period:

  • 1) Provision of health care in the USA is in crisis and chaos

  • 2) Perception of physicians under siege

A Discourse of Crisis and Chaos

• Few individuals pay for all their health care costs directly, although many pay part of the bill for hospitalization, drugs and office visits

• Frequently the term “consumer” refers to employers concerned about the costs of providing employees with health insurance benefits

• “It is consumer groups and large purchasers of care who will ultimately exert the strongest pressures for cost-effective care” (Bunker, 1988)

• Much of the support for President Clinton’s health care policy comes from US businesses concerned about their own share of health insurance expenditures (Arnold et al., 1994)

• Health Maintenance Organizations (HMOs)

  • Sometimes operate their own hospitals and hire their own physicians

• The Veterans Administration runs hospitals but is also fiscally responsible for the care of US military veterans

• Boundaries of health care system in the US is unclear

  • Creates a system in which interests, activities and discourse become very jumbled and in which terms like “consumer”, “provider” and even “cost” and “benefit” become layered with multiple meanings

    • This jumbled system controls and distributes access to health services without a central body such as a government agency which is responsible for planning

• Rising costs and limited access to health care resources is a current unifying them in the discourse of crisis and chaos

• The public is also worrying over major diseases which appear to be out of control

• Measurement of costs and benefits are frequently a central issue

  • Approx. 400 articles in the Medline Index fro 1987 to July 1990 were on cost-benefit, cost effectiveness and quality of care issues

• Issues are also widely discussed in the mainstream press

Physicians under Siege

• Media discussions of the US health care crisis often cite physicians as a major culprit

  • Time Magazine (1988) noted that under pressure to reduce some fees “doctors find ways to protect their incomes from corporate budget cutters”

  • Los Angeles Times (1989) editorial argued that physicians have incentives to do more to earn more under the current system

    • Inherent conflict of interest in fee-for-service medicine

• In their own discussions, physicians describe themselves as under siege from government policy makers and third-party payers who intrude into the physician’s practice

  • American Medical Association’s (AMA) own texts often pose this theme

    • “Physicians become victims of Bottom Line” (AMA, 1990)

• Widespread agreement that the US health care system is in crisis, and that rising costs are central to this crisis

• There is a repeated them about conflict between the parties involved in health care

  • The press and the federal government blame physicians for rising costs

  • The AMA chastises both the government and private insurers for interfering in medical practice

• Various conflicting descriptions of the motivations driving the system

• Physicians also begin to argue that they must now reconcile “social responsibilities” with clinical decisions

  • They cite the efforts to monitor and measure clinical outcomes and costs as an infringement on their autonomy

    • Autonomy which they see as socially positive

• AMA argues that business acumen is required if physicians are to preserve quality of care and physician autonomy

• Economic analysis becomes socially responsible when it furthers these goals and when it is controlled by...

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