Volume 5, No. 4 Wintermiver 1992

Book Review

B y Godwin 0. Eni, PhD

Book Title: How do w e g e t there from here?

Edited by : Raisa B. Deber and Gail G. Thompson Toronto: The University of Toronto Press, 1992,420 pp.

he authors have put together, from tape record- ings, oral presentations and conference papers, a T book representing the proceedings of the fourth

Canadian Conference on Health Economics that was held in Toronto in August 1990. Thirty-six papers on a variety of topics, ranging from paying the doctor to health promotion, quality of medical care, governance, economic evaluation, the US . influence on Canadian health care, and the report of the various royal commis- sions on health care among others, are used to gauge the future direction of the Canadian health services sys- tem. Recognizing that, perhaps, ”the Canadian health care system is becoming a victim of its own success”, and that “medical care may be necessary for health, (but) in some cases it may not even be necessary” (p. xi), the book uses research findings, and some opinions of experts and practitioners, to examine the past, the present, and what may happen in future.

The reader will find the presentations simple and to the point, and in many cases, devoid of technical details which tend to discourage non-academic inter- ests. Each presentation is further examined by a panel via question, answers and debates which reflect the variety of opinions currently being expressed about the Canadian health care system. In these discussions, some of the terminologies applied to a given issue can be problematic. For example, a physician participant at the conference asked the following question to one of the presenters: ”Do you think you can turn utilization around and make it a good word, rather than the four- letter word that your panel has painted it this morn- ing?”

The response was: ”I agree with you. That’s why I would like the term ’utilization management’ to disap- pear. It has a bad history, which means control, sup- press, cut/reduce, diminish - we are talking about what 1 am calling clinical resource management. We are talking quality. We‘re talking guidelines for quality care.” (p. 44)

There are 13 key areas of discussion which the reader will find very informative, and I recommend

these discussions to health care management executives charged with managing aspects of the sys- tem while trying to make sense of policy-relevant re- search findings. Although no consensus in direction emerged as to “how we get there from here”, the reader will find the various differences of opinion quite informative with respect to the reasons behind each rationale. Take for example the argument, by one of the presenters, that there is an emerging shift from a Canadian consensus on health care toward indi- vidualism as in the United States because of economic competitiveness and the ”changing nature of democracy” (p. 5), which earned this response from another presenter: ”Why on earth do we think we want to abandon the cheaper form in order to take on the more expensive form, in order to make ourselves more competitive? Why do we want to make the thing worse?” (p. 144) Such exchange of views keeps the reader on the lighter side while grappling with the more fundamental issues of pertinence to the struc- tures and policies that govern the system.

A reader interested in the relationships between medical care policies and utilization of physician ser- vices should read the chapter on the preliminary results of an ongoing study in British Columbia. The authors examined the 10-year dita on the outcome of three government policies in British Columbia; name- ly, fee negations with physicians, M.D. supply and dis- tribution, and utilization caps. Among some of the initial findings were that (a) over a nine-year period “fees for general practitioners increased an average of 85%” compared to the ”average increase for all fee items” of 71% which was quite close to the consumer price index (p. 15). The authors were able to show that G.P.s had the most fee increase while some diagnostic specialists did less well; (b) the largest increases in utilization were associated with the smallest fee in- creases; and (c) utilization trends appeared to fall as the policies to cap expenditures (constant dollar expen- ditures per capita) became reality.

Gestion des soins de sante ~

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Wintermher 1992 Volume 5, No. 4

Perhaps there is a lesson somewhere for other provincial jurisdictions and health service administrators.

- provincial and federal - have concluded the review of their health care systems by royal commis- sions. The exception was British Columbia which com- pleted its own review afterwards. The book also examined the composition, objectives and findings of the nine royal commissions. There were no great surprises! They were all concerned with fiscal matters followed by human resources, organization, manage- ment and other matters in that order. In order to reduce fiscal pressures on the system the commissions want the number of acute care hospital beds reduced, a freeze on new hospital construction plans, develop- ment of incentive programs for hospitals to become more efficient, global budgeting, increase in out- patient and community-based services, and the use of lower cost drugs, among other recommendations.

Health care managers will be particularly interested in some of the commissions' findings. For example, recommendations to improve management include:

At the time this book was written, nine governments

"cross-representation of Medical Advisory Commit- tees and Management Boards of hospitals"; "active in- volvement of physicians and nurses in the management of hospitals"; "monitoring performance by making utilization reviews a regular component of management practice" as well as peer review; the use of multi-unit management concept to manage "hospi- tals, nursing homes, and other facilities in the same geographic area; and "allowing hospitals the flexibility to trade-off programs and services as part of the changed emphasis in organization". (p. 59)

specific Canadian issues but also some views on developments in the United Kingdom. For example, in his presentation "The Empire Strikes Back" (p. 317), Culyer discusses hospital competition in the United Kingdom and suggests a possible framework for the "demand-side" organization of the National Health Service!

I recommend this book to health services admini- strators, health care professionals, program managers, teachers, students and those charged with policy development. There is something for everyone.

The reader will find not only some discussion of

I 1 Book Review

B y Pamela Ann Azad, MsHA (PhD candidate - UBC)

Book Title: Health Care Quality Management for the 21st Centu y

Edited by :James B. Couch, MD, JD, FACPE Tampa, Florida: Hillsboro Printing Company, 1991,494 pp. ..

his book is an edited collection of 20 essays about health care quality management (QM) T and focuses on the issue of "quality care" vs.

"quantity of care". Written by some of today's leaders in QM, this book emphasizes the importance of or- ganizational quality management as a means to en- hance customer (patient) service and to decrease costs.

In general, the authors strive to bridge the gap be- tween theory and practice with respect to "the best way" of providing health care services. Secondly, they seek to clarify common misconceptions that quality management has garnered over recent years. Thirdly and most importantly, the authors focus their energies on illustrating how quality improvement may result in

lower health care costs thereby allowing greater access to health care services. Whether or not their attempt is successful is up to the individual reader.

Health Care Qualify Management is well written and provides basic information to anyone interested in either establishing or further developing a hospital im- provement program. The book's strength lies in its numerous case studies and illustrations and offers a comprehensive perspective of health care QM in a single source.

There are six parts to this book. The first section reviews the historical foundations of health care quality management and discusses QM from the health care economics perspective. Whde this section

56 Healthcare Management FORUM