T. Getzen – Health Economics and Financing (Fifth edition)

Описание

Health Economics and Financing is a primer for the economic analysis of medical markets. Its
intended audiences are students of medicine, public health, policy, and administration who
wish to engage the central economic issues of their field without prolonged preparatory work;
beginning students in economics who wish to study an applied area in detail without recourse
to extensive mathematical manipulation; and more advanced students in economics who may
be familiar with analytical techniques but lack knowledge of the many institutional features that
make the study of health and health care so unique and rewarding.1 This book draws upon the
work of many scholars, but in keeping with its design as a primer for introducing students to the
principles and concepts of health economics rather than its literature and research methods,
the use of attribution, footnotes, and references is purposely limited. Suggestions for additional
reading and more advanced source materials and databases are listed at the end of each chapter
and are available on the text website at www.wiley.com/college/getzen or from the author at
getzen@temple.edu.
The first eleven chapters use a flow-of-funds approach to investigate the sources and uses of
financing and to explore the incentives and organizational structure of the health care system.
Transactions between patients and physicians (and others) are examined to see how profits are
made, costs covered, contracts written (or implied), and regulations formed. The long-term
consequences of exchanging services for money in a particular way are revealed by exploring
the historical development of those distinctive features that characterize the industrial organization
of health care: licensure, third-party insurance, nonprofit hospitals, and government
regulation. The last seven chapters take a wider macroeconomic perspective in order to explore
the dynamics of change within the health care system and to explicitly consider determinants
of national health spending and the role of governments in public and private health.
The introductory chapter lays out the overall flow of funds, schematically presents the
complexity of medical care transactions, and introduces the basic principles that form the
toolkit for economic analysis. Chapter 2 examines the economic concept of demand and compares
it to the medical concept of need. Chapter 3 applies the basic principles of supply and
demand, marginalism and equilibrium, using a cost–benefit approach in a clinical context.
The more detailed investigation of medical care organization begins in Chapters 4 and 5 on
insurance and third-party reimbursement, which has become the dominant source of funds in
medical care. The physician whose role as the patient’s agent and a central player in all medical
care transactions is the subject of the next two chapters. Chapters 8 and 9 cover the reimbursement,
regulation, and cost structure of hospitals. Nursing homes, long-term care, and the
effects of aging on medical costs are covered in Chapter 10. In Chapter 11, pharmaceuticals
provide an exemplar of the modern “information economy,” where the fixed costs of research
and marketing outweigh the cost of production and where competition relies on continuous innovation. In Chapter 12, the means and consequences of access to capital for health care
providers are briefly reviewed, with particular attention to the implication of nonprofit status
and ownership structure.
To understand the interactions between component parts of the system, it is necessary to
place health care in a macroeconomic context that includes redistribution, taxation, inflation,
and growth. The dynamics of national health expenditure are presented in Chapter 13 as an
application of the permanent income hypothesis. Chapter 14 explores the role of government,
public goods, and public health. The economic history of health is traced in Chapter 15, drawing
on the contributions of demography and the cliometric work of Fogel and North. Chapter 16
provides international comparisons of health and medical care expenditures, taking Ghana,
Sudan, China, Mexico, Poland, Germany, and Japan as illustrative examples. Health policy,
reform, and the Patient Protection and Affordable Care Act of 2010 are described and discussed
at length in Chapter 17. A final chapter addresses the probable trends in health care spending,
suggesting that the primary barrier to increased effectiveness and efficiency is poor allocation
and problems of effective political alignment.
Health economics is fascinating to study, but it is not easily summarized or readily captured
in neat equations. In part, this is because the study of health economics is relatively new and still
in the process of refinement, but primarily it is because the transactions made by doctors and
hospitals are not simple, and they cut to the heart of what it means to be human. What is the
value of life? Who pays the price of pain, and what does it mean to trust a surgeon who profits
because of a crisis? Because most medical care is funded through taxes and insurance, there is no
direct linkage between the amount paid and the resources used in treatment. As a consequence,
“prices” become more ambiguous and are often of less immediate relevance to the trading
parties than ongoing relationships of trust and professional behavior. It is important to understand
how economic forces continue to operate when markets are indirect and inefficient, and
how other organizing principles (professionalism, licensure, agency, regulation) act as substitutes
for prices. Although most of the special features of medical markets are there to make
people better off, they have also been shaped by groups who had the power to modify the rules
in their own interest, subject to the controls of economic and political competition. Tracing the
economic rationale and development of medical care licensure and organization and making
those forces more clearly visible and amenable to analysis is the purpose of this book.