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Microcomparison, or single-component analysis, of health care systems offers a potentially better basis for reform than traditional macrocomparison analysis of aggregate elements. Using macroanalysis, available evidence shows that Germany provides cheaper but more effective hospital care than the United States. To find the causes for this outcome, we developed a microanalytic model of hospital administrators' perceptions, financial ratios, medical outcomes, and pharmaceutical costs. However, only data on pharmaceutical costs were available and similar in both countries. Our significant outcome was development of a microcomparative model that gives world medical care providers new criteria for analyzing and improving cost to care ratios.

The community-oriented primary care (COPC) model of health care presents a practical means of reintroducing elements of cost containment and humanitarianism to medicine. The current health care system is fragmented and depersonalized. It emphasizes biotechnology and acute hospital care over health status and patient outcome. The three main problems facing the health care system are skyrocketing costs, inadequate access to care and inappropriate or ineffective care. Lawmakers are aware of the public's dissatisfaction with the system and are realizing that true reform will come only with comprehensive revisions in the financing, organization and provision of care. The COPC model requires a primary care practice based in the community, an identifiable population that will receive the services and a process for evaluation. COPC is socially responsive and would control costs., The current high-cost health care delivery system, which places greater emphasis on acute hospital care than on community-based primary and preventive care, is no longer viewed by policymakers, politicians, and the -American public as the ideal model for organizing and providing health care services. Americans want change; however, politicians are responding with a barrage of disjointed finance and cost-containment proposals that fail to address the organization and provision of health care services. Nevertheless, to adequately address problems of cost, access, and quality, reform proposals will need to consider delivery models that create a balance between medical care and health care, between public health and personal health services, and between curative and preventive care. The community-oriented primary care model and the discipline of community and socially responsive medicine is a process for making a health care system more rational, accountable, appropriate, and socially relevant to the public. Consequently, this model, which is now at a pivotal point in its evolution, may serve as a paradigm for reforming the organization and provision of health care services in America. (JAMA. 1993;269:2544-2547)

Managed competition is the type of health care reform supported by President Clinton. This strategy aims to control health care costs while ensuring access to care for all. The proposal as it stands now would depend on altered tax incentives and market forces to contain costs. These measures, however, ignore the increasing demand for health services and the growing stratification according to income in access to health insurance. 'Managed Competition That Works' is a proposal to reform not only the provision of services but also the financing of the health care system. This plan would set community spending levels but would not restrain specific services, encouraging communities to be creative and efficient in distributing their resources. It would establish a single trust fund similar to Social Security, and then distribute health care vouchers, adjusted for age, sex and health status, to everyone., President Clinton has advocated managed competition within a global budget as a long-term strategy for simultaneously controlling health care costs and expanding access to medical care to all Americans. This proposal is intended to show how these two seemingly conflicting goals can be simultaneously accomplished. Managed competition, as it has been conceptualized to date, is primarily a strategy for reforming the system of providing health services. To work, it must be joined with a strategy for reforming our system of financing and paying for those services and of limiting overall system capacity. "Managed Competition That Works" is a proposal that would create a single trust-funded national system of health insurance, implemented through a system of vouchers to individuals. Global budgeting would be accomplished through establishment of the voucher's value each year. The trust fund would pay health plans for all medical care by capitation, but health plans would be free to negotiate a variety of payment arrangements with physicians, hospitals, and other providers. All plans would be required to offer a standard package of benefits, but would have great flexibility in offering benefits beyond the scope of the standard package, if those benefits replace high-cost with lower-cost services or permit the plan to compete more effectively for market share. This proposal would establish firm but acceptable national budget limits; provide universal, comprehensive, and uniform insurance coverage; eliminate cost shifting; encourage competition; reward efficiency-improving innovation; greatly reduce the need for centralized micromanagement of medical care; and retain local determination and a somewhat reduced level of consumer choice. Although this proposal is written as a national plan, trust funds could be implemented at the state level, if problems associated with portability of benefits among states could be solved. (JAMA. 1993;269:2524-2526)

Reforming the nation's health care system promises to be a long, challenging, divisive battle. While most Americans see the need for fundamental changes, there is no consensus on how to proceed. The two basic issues any health care proposal must address are improving access for all and controlling escalating costs. Other reform elements include reducing administrative hassles and costs, encouraging primary care, ensuring quality of care, promoting disease prevention and maintaining necessary physician and patient autonomy. One of the most difficult tasks will be identifying futile services and reducing the money spent on unnecessary and marginal medical care. Cutting back on such services as unnecessary diagnostic tests and procedures will also require that professional liability be limited.

The quality and accessibility of mental health services will be radically improved under plans set out in a consultation document. New Horizons outlines a ten-year blueprint for England that will [...]