Models for Organizing Health Services and Implications of Legislative Proposals

Many organizational blueprints have been submitted as the basis for restructuring the United States health system, but only three basic models have a reasonable chance of being implemented: (1) the Professional Model, the name I have applied to the existing American health system, (2) the Central Planning Model, which is sometimes called the “political economy model,” and (3) the Competitive Health Maintenance Organization (HMO) Model, which could also be called the “market economy model.” Conceivably, any of these organizational arrangements (or even a combination of them) could form the basis of health care delivery in the future, since each has a cadre of active supporters, and since economic and social forces are at work portending change in the system as it now exists. The structure and performance of the Professional Model are well known. The performance of the Central Planning Model is probably less familiar, however, even though it is the most prevalent pattern of organizing health care delivery among Western European nations and, until recently at least, has been preferred by most health planners. The HMO model is found exclusively in the United States, and has become much better known in recent months. Yet no one can say for certain what a truly competitive health market would be like, because in no instance do HMOs command a large enough segment of the health market to make their competitive influence felt. In a general way, the effectiveness of these models can be compared simply by examining their working examples in this country and abroad. However, it is more difficult, if not impossible, to quantitatively assess and compare their effectiveness in optimizing the cost, quality and distribution of health care, because of the differing conditions in which they function and the varying populations they serve, and because models do not exist in pure form. This paper represents a first attempt to set forth ideas in a systematic way that by themselves are not new. Its aim is to describe alternative models for organizing the delivery of health care and the assumptions on which they are based, and to lay bare the implications of specific legislative and administrative decisions and proposals, in terms of their relation to these models and to the larger issue of national health policy. It will become clear that the paper is merely an unfleshed outline of related ideas. In part, this is by design, in deference to the purposes of the symposium and to the charge given each speaker to provide a stimulus and organizational framework for the deliberations. But the paper's sketchiness is also attributable to the fact that some of its ideas cannot be substantiated by objective research, even though the factual basis for much of what it says is either self-evident, or well known and widely accepted. These gaps in information illustrate the “flat-earth” state of the program and policy-making art in health delivery, and help to explain why the task of designing corrective measures to amend existing problems and deficits in health care delivery is both difficult and hazardous. Yet we have arrived at a critical juncture in health delivery, in which the opportunity has never been more favorable for revamping the nation's health industry—an industry that thus far has successfully resisted reform.