Contenu du sommaire : Numéro spécial - Innovations et régulations dans les systèmes de santé (France - USA) (Numéro préparé par Emile Lévy et Béatrice Majnoni d'Intignano).

Professor Enthoven explains why the American Health Care Organization is moving from the guild system with illimited payment to market competition. Medicare, the private insurances and private societies are introducing economic and management criterias. He asks about ethics and access to health care for everybody inside the new organization.

Comparison between the French Health System and that of other developped countries. Cross national product and Health care expenditures in the long run (1953-1985). The french approach to solve the problem of health costs increase : centralized rationing. New experiences. Too much hospitalization ? Recent problems should require a more liberal policy.

This article summarizes the evaluative research on HMOs in the United States. It consists of three parts : (1) Conceptual issues related to HMOs : their distinguishing characteristics and alternative models of operation ; (2) The performance of HMOs : how do they achieve their savings ? Do they provide better care ? Are the enrollees and physicians satisfied ? (3) Finally, a balance sheet based on a social evaluation and on an analysis of internal and external factors affecting the performance of HMOs.

In a decentralised economy, prices serve two purposes : to generate revenue and to allocate resources. However the two sides of the same coin have been separated in social security systems. On the one hand, the revenue from health insurance no longer reflects the actual cost of health services provisions. On the other hand, expenditure does not reflect marginal benefits of these services. There is no limits to the greeds of the users and the blindness of the decision makers. Freedom of choice, in effect corresponds to the right to ignore the financial implications of the decision taken. The purpose of this article is to see how this principle was introduced and whose interest it serves.

The french project concerned with reforming the medical Data Systems (Projet de Médication des Systèmes d'information or PMSI) developed by the French Hospital Administration has as an objective that of substituing the classical approach (measuring hospitalization variables such as : medical acts, hospital stays,...) for a categorisation system which separates patients into Disease Related Groups (D.R.G.). This system takes the pathology of the patient into account and its output can thus be interpreted as a production indicator. At the same time, analytical accounting is modified to obtain, within any hospital, the average cost for each D.R.G. There is a temptation to link this project to another reform, that of the «budget global» (global budgeting), which is a system concerned with the calculation of the budget awarded to each hospital by the Ministry. It is true that the calculation of each budget could be obtained from the costs of each D.R.G. and the estimation of the number of patients within each D.R.G. Such an approach has however certain limits due essentiallly to the sensitivity of budget evaluations to the different means used in calculating the costs of the D.R.G. It seems that if the project of medical Data Systems reform is to give useful information concerning the functioning of the medical system to all interested parties, the most important results can only be obtained by defining specific organizational patterns, thereby avoiding all rigidity when the new tool is put into use.

Efficient resources allocation in health area, where market failures are numerous and government regulations very large, is generally considered as requiring the support of cost-benefit, cost-effectiveness or cost-utility studies. Meanwhile many disappointments appear on the effective impact of these kinds of procedures. This article is a survey of the main methodological issues of the economic appraisal in the Health field. Study design, choice of an appropriate method and presentation of results, measurement of costs and benefits (or effectiveness or utility)... in all these aspects of an economic evaluation, many difficulties are to be solved. Better practice of economic principles is the condition for a real progress in influencing the decision making process. But it also appears that cost benefit and cost effectiveness analysis is less a substitute than a complement to market.

This article argues that the relative mix of public and private financing and provision of health services is not the decisive factor in understanding the powerful forces that are currently transforming the health sector in the United States. On the demand-side, the decisive forces of change are related to the increasing intervention of public and private health care payers in management functions. On the supply side, the growth of private non-profit as well as investor-owned multi-institutional hospital systems and the emergence of vertical integration is changing the structure of health care organization. In the future, potentially significant dichotomy would be one which distinguishes not between private versus public but rather between large horizontally and vertically integrated organizations and individual hospitals and office-based practices, whose existence is now jeopardy.