In this article, we will further the explanation of the state's changing role in health care systems belonging to the Organisation for Economic Cooperation and Development (OECD). We build on our analysis of twenty-three OECD countries, which reveals broad trends regarding governments' role in financing, service provision, and regulation. In particular, we identified increasing similarities between the three system types we delineate as National Health Service (NHS), social health insurance, and private health insurance systems. We argue that the specific health care system type is an essential contributor to these changes. We highlight that health care systems tend to feature specific, type-related deficiencies, which cannot be solved by routine mechanisms. As a consequence, non-system-specific elements and innovative policies are implemented, which leads to the emergence of "hybrid" systems and indicates a trend toward convergence, or increasing similarities. We elaborate this hypothesis in two steps. First, we describe system-specific deficits of each health care system type and provide an overview of major adaptive responses to these deficits. The adaptive responses can be considered as non-system-specific interventions that broaden the portfolio of regulatory policies. Second, we examine diagnosis-related groups (DRGs) as a common approach for financing hospitals efficiently, which are nevertheless shaped by type-specific deficiencies and reform requirements. In the United States' private insurance system, DRGs are mainly used as a means of hierarchical cost control, while their implementation in the English NHS system is to increase productivity of hospital services. In the German social health insurance system, DRGs support competition as a means to control self-regulated providers. Thus, DRGs contribute to the hybridization of health care systems because they tend to strengthen coordination mechanisms that were less developed in the existing health care systems.
Economic crises are said to challenge welfare states by forcing them to cut expenditure by pursuing reforms aimed at cost containment and efficiency enhancing strategies. The oil crises of the 1970s and early 1980s, the global financial crisis of the early 1990s, and those of the 2000s marked acute economic phases rooted within a larger period of austerity politics in which welfare states have been observed to undergo major changes. However, the question has yet to be posed as to whether decisions affecting health care policy during acute economic crises are indeed fundamentally different than what can normally be observed over the longer period of cost containment policy. Moreover, where policy differences do exist between economic periods, are these differences consistent over time and across health care systems? To answer these questions we examine changes in regulation over the past four decades for two cases of National Health Services (NHS): England and Italy. More specifically, we examine the underlying causes for reforms in order to identify whether economic crises versus 'system-specific deficits' (i.e. those deficits or sources for inefficiency lodged within the health care system itself) are the true causes for motivating change in and across NHS systems. Our findings establish that while acute economic crises create windows of opportunity for change, it is the interaction of system-specific deficits and the role of ideas and political factors that largely condition the content and timing of reforms. Regarding the nature of reforms passed, our findings reveal consistency over time and across health care systems in the types of regulatory measures adopted and advanced.s pol_786 488..505
Observations of policy convergence and the crossnational diffusion of ideas, knowledge and policies have raised the question about the ways countries might learn from their peers. This article examines the role of cross-national learning with regard to Diagnosis Related Groups (DRGs). We review the spread of this policy instrument and analyse the implementation of DRGs in three late-adopting countries: Germany, Switzerland and the Netherlands. The three cases show that the implementation of this policy instrument required intense studies, cooperation with stakeholders and adjustment to countryspecific needs. The countries learned from foreign experience, but it was only with the introduction of a regulatory framework for competition between sickness funds that DRGs came fully onto the political agenda. While Germany and Switzerland drew upon foreign DRG models, the Netherlands developed an alternative system to classify patients according to case-mix.i ssr_1344 21..40
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