Managed care has no standard definition, but its basic structure is as follows:
1) Relationship between doctor and insurer
a. Managed care standardizes medical treatment.
b. Using a method called“monitoring and incentive,” it induces the doctor to select standardized medical treatment.
c. It constructs a doctor & hospital network focussed on the insurer.
2) Relationship between patient and insurer.
a. Managed care puts a restriction on the patient's selection of medical institutions.
b. It systemizes the patient as insured.
Managed care can be regar d ed as an institutional innovation that, by using those setups, improves the two types of inefficiency seen in the medical system (a. inefficiency resulting from a socially superfluous medical demand, and b. inefficiency resulting from the inability to optimally allocate medical resources either spatially or time-wise).
Looking at man aged care performance in the USA (especially HMO), we can see a trend toward the following: a. lower hospital admission rates, b. shorter hospital length of stay, c. less use of expensive procedures, d. greater use of preventive services, e. lower satisfaction with services, and f. higher satisfaction with costs.
On the other hand, the following problems are pointed out: a. lower service quality, b. exclusion of high-risk persons, and c. breakdown of good doctor-patient relationship.
When considering the introduction of the managed care concept and method into the public medical insurance institution of Japan, important factors are as follows:
a. Maintaining an information system that functionally links the medical treatment content to the cost information so that medical treatment standardization can be conducted with evidence based.
b. The necessity of making a system to form the consensus of“standardized medical treatment.”
c. The necessity of establishing an institutional setup for the insurer to act as agent on behalf of the patient.
If managed care is a dopted hastily without solving those issues, its side effects may defeat its purpose.

View full abstract

As we approach the 21st century, all advanced nations are striving to build a healthcare system capable of providing high-quality healthcare to every citizen.
Particularly, the healthcare system of the United States continues to challenge essential issues with their original approaches, while also facing the problems of a considerable number of uninsured citizens and higher healthcare costs than any of the other countries.
Since 1980, managed care in the United States has been expanding at a pace rapid enough to bring about radical changed to the various healthcare systems, but it seems vague due to its variety and variation. It was born and developed in a private-insurance-centered system unique to the United States. It does not seem to easily apply to other healthcare systems in other countries, for example, in the social-insurance-centered healthcare system of Japan.
However, from the standpoint of a provider, an insurer, a consumer and a payer, we have found the possibility of effectively applying the concept and method of managed care in various configurations and forms while preserving the advantages of the Japanese healthcare system. In this article, I will introduce the e fforts of providers, insurers and consumers in Japanese-style managed care, look at each element of the managed care system of the United States, and examine the feasibility of adapting it more broadly to the Japanese healthcare system.

View full abstract

The rapid spread of managed care is a major reason behind the slowing of the health care cost growth rate in the US. Managed care organizations (MCOs), particularly HMOs, are increasingly being held accountable for the quality of health care delivery by their contract providers, and are reporting more information about the quality of health care delivered. HMOs have introduced the use of management tools such as evidence-based guidelines, gatekeeping, and capitation to improve the cost-effectiveness of care delivered by their contract providers.
Primary care physicians (PCPs) are playing an important rolein the delivery of managed health care, and now bear part of the financial risk through mechanisms such as gatekeeping and capitation. This paper looks at some recent reports of PCP satisfaction with this new role. PCPs in the role of gatekeeper were found to have lower satisfactions due to increased administrative work associated with gatekeeping, though most physicians felt that quality of care was unaffected. About half of PCPs are reported to have at least one capitated contract, far more than specialists. Larger physicians groups were also found to be more likely to have capitated contracts than smaller groups. PCPs were generally found to be less satisfied with treating their patients covered by capitated contracts than in their practice as a whole, though satisfaction increased with increasing proportion of capitated patients. However, another study showed that total physician visits, hospital days, and total costs were unaffected by physician compensation method. This suggests that it is the system of health care delivery and not care at the level of the physician/patient interaction that is affected by managed care.

View full abstract

Managed care dynamics centered around the private sector. The influence of managed care is beginning to emerge in the 1990s. Five trends are becoming clear:
1) Managed care-discounted fee-for-service and capitation-is becoming the norm, while full-choice indemnity coverage is nearly obsolete in many areas o f the country. In response to consumers' desire for a wider product choic e, plans are shifting to mixed models, particularly IPA-type arrangements and POS options. Managed care has the increase in health premium and governme nt program costs; however, the long-term impact of managed care on h ealth cost growth still remains unclear.
2) Merger and acquisition activity continues in full swing. Especially the need for capital to enhance competitiveness is a strong driver in the market. For th i s reason, for-profit conversions among providers continue. In the absence of regulatory controls, investments in the provider sector are going to skirt th e line of clear conflict of interest-e. g., pharmaceutical firm investments in physician management companies.
3) The public is generally ignorant of these evolving changes. There is little understanding of managed care concepts. People continue to want full provider choice simultaneously with strict cost containment. They also fear that health care is becoming purely a commercial enterprise.
4) For the federal government, Medicare's short-term problems are a relatively easy fix; the much larger problem is the impact of the baby boom gen e ration's imminent retirement on an already overburdened system. The g overnment has not done a very good job of readying the American public for th e sacrifices necessary to keep the program financially viable.
5) The uninsured remains powerless in the managed care movement. Although their numbers appear to have stabilized, welfare reforms threaten the M edicaid safety net that has contained their growth, and without mandates, em ployers will continue to reduce coverage to improve their competitive position. Although profitability is at an all-time high, hospitals do not h a ve the traditional surplus from private payers to cover the bills for the uninsure d and the public sector is not producing an alternative.

View full abstract

Managed care has been mainly fostered in the field of US private health insurance. However, the system and concept of managed care have recently been actively introduced to the US social health insurance system, such as Medicare, Medicaid. The Japanese health-care system, which has an established social health insurance system, may be able to follow the US line in adopting managed care systems in the social health insurance field.
Firstly, this paper examines the system and issues of managed care systems in the US social health insurance field. The specific models for discussion are Medicare and Medicaid managed care model (primary case management model, HMO model), and the number of people joining these systems has increased very rapidly since 1990. Although there still remain some issues to be addressed regarding these systems, it is believed that they will steadily expand in the future.
Secondly, this paper examines the effectiveness and issues of the manage d care system on the assumption that the managed care system was introduced to Japanese health-care system in a similar way as it was introduced to the US social health insurance system. Consequently, although the cost containment effect of managed care may be promising, the magnitude of the effect in Japan seems to be less than that of the US. The effect of the quality improvement is difficult to predict.
Two kinds of issues are recognized; the same issues w h en managed care was introduced to the US social health insurance system; the general issues on managed care. The latter includes the possibility of too-little-care and the incompatibility of the doctor-patient relationship in Japan.

View full abstract

The evaluation of the appropriateness of medical interventions is one of the most important subjects in a maneged care environment. The “appropriateness study”, developed by the RAND corporation, is carried out through the following two steps; First, consensus-based appropriateness criteria for various conditions are set, integrating opinions from several specialists through a modified delphi method. Second, medical charts are retrospectively reviewed based on these criteria, and an appropriate rate is evaluated. The author attempted to develop Japanese appropriateness criteria for the indications of two major cardiovascular procedures, i. e. percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG), and compared our criteria with those of the Swedish survey. The agreement rate with the Swedish results was not so high; 43.2% for the appropriateness of PTCA,54.0% for the appropriateness of CABG, and 64.8 % for the preference between PTCA and CABG. Although the method of the appropriateness study, which has been used internationally, was thought to be applicable to our country, several issues to be considered were identified. For example, an accurate grasp of the causes of the disagreement between the Japanese and Swedish results, e. g. the technological advances during the period between the two studies, the differences of practice pattern, and/or biases derived from the survey method, should be examined.

View full abstract

This paper examines the ethical issues regarding neonatal care focusing on two aspects, “parental refusal of medically indicated treatment to the child” and “discontinuation of treatment by choice”.
Several characteristics un i q ue to the relationship between the parent (s) and the newborn are noted; 1) substantial time is not yet shared as a family,2) it is impossible to know the patient's (i. e., the newborn's) wishes,3) it is difficult to gain a through understanding of the child's disorder (s),4) the legal system to protect the rights of the child is inadequate.
In the United States, the Chi l d Abuse Prevention and Treatment Act (CAPTA)was amended to include a provision regarding the withholding of medically indicated treatment from disabled infants following the “Baby Doe” incident in 1982. However, the issue of “parental refusal of medical treatment to the child”has not yet been sufficiently discussed in Japan.
Medical professionals often make de c isions to discontinue treatment to help ease the feelings of guilt the parents and family may suffer if they make the decision by themselves. This paternalistic practice is commonly utilized in Japan. However, rather than having one of the two parties decide alone, it is believed to be more important for them to share information and come to a unified conclusion. Furthermore, it is also believed to be important to allow clinical psychologists to assist in the decision-making process so that the parents and family are able to come to the best possible conclusion.

View full abstract

In the social history of the HIV/AIDS epidemic, one of the remarkable characteristics has been the emergence and development of thousands of private sector voluntary and community-based AIDS organizations devoted to social services, education, advocacy, and policy assessment. These organizations successfully serve communities affected by HIV/AIDS, whose people are often alienat ed from mainstream health care institutions. In the face of neglectful health care systems at all levels, which were reluctant or unable to provide a broad range of human and social services for people with AIDS in the early years of the epidemic, voluntary and community-based AIDS organizations which rely primarily on volunteer labor arose to fill such an enormous institutional gap. However, as the history of the HIV/AIDS epidemic moves into its second decade, community-based AIDS organizations have faced problems that threaten their effective continuity: institutionalization and formalization accompanied by the disempowerment of the affected communities, and the loss of a strong connection to the communitie s which the organizations claim to represent. Social scientists need to offer critical assistance for strengthening community-based AIDS service organizations by providing the necessary knowledge for strategic planning of organizational development which will determine their continued effectiveness.

View full abstract

Marketing is a form of communication between consumers and companies, and advertising is a means through which companies to communicate. The pharmaceutical industry has rarely been a subject for study not only in the field of advertising, but also in the field of marketing. No other industry, however, has a higher proportion of advertising expenses to sales than the pharmaceutical industry, and this essay considers the role of advertising in the pharmaceutical industry.
The pharmaceutical industry was able to free itself from the traditional advertising paradigm at an earlier date than other industries, since regulations were made on advertising in the pharmaceutical industry by the government in 1967after the case of the cold ample. Therefore, this essay examines the new paradigm for advertising in the pharmaceutical industry from the viewpoint of the formation of brands.

View full abstract