Inquiries and innovations in Healthcare Financial Management.

FOREWORD

This issue of RESEARCH IN HEALTHCARE FINANCIAL MANAGEMENT (RHFM), presents six articles with differing levels of analyses. Four are physician focused and come from the USA, one compares three European Community countries and comes from The Netherlands and one reports on a community based effort in India. Each article challenges the status quo of their healthcare finance environment and asks how can this be done better? The authors are not content to simply review the literature and say, "It is what it is." Rather, these inquiries lead the reader to say, "Why is it what it is? Why can't it be different?" We are asked to be active, not passive readers and to engage in questioning assumptions.

Accordingly, the articles in this issue of RHFM begin with a critical review of the literature related to management control and application to US medical practice by Louis J. Stewart. This article examines how technology, deregulation and managed care organizations have forced physicians to move from small business models of practice to large, corporate medical group models. From a management perspective, attempting to control physician behavior in these new models has often been difficult and frustrating. Stewart offers us a framework for future research in this area using contingency theory perspective and challenges us to apply what is learned.

Then, Raef Lawson provides a study that explodes the myth about the costs of training physicians in HMOs. For years everyone has heard from HMO executives that it is too costly to train medical students in HMOs. "They slow down productivity, they get underfoot and they ruin the bottom line! We just can't afford to have them step one foot in our HMOs!" Lawson's elegant comparison of costs of training third-year primary care medical students in HMO and non-HMO health centers demonstrates that "it ain't necessarily so."

Moving from the macro level of analysis of a risk-adjusted database to the micro level of identifying and educating "less efficient" physicians in a regional medical center setting is the subject of the next article. Dale Buchbinder, Clifford F. Melick, David P. Coil and Sylvia Moore are a team of two physicians, a researcher and an administrator who decided to tackle this tough and ticklish question. They provide tangible examples of how to utilize data to achieve significant cost savings.

Then, Patricia G. Ketsche, William J. Miller and Susan A. McLaren challenge the deep seated belief that Primary Care Case Management (PCCM) programs reduce costs and utilization of high cost, chronically ill Medicaid recipients. Ketsche, Miller and McLaren conducted analyses of utilization and expenditures of high cost Medicaid enrollees, comparing PCCM enrollees to a control group. The authors demonstrated that there was little impact of the PCCM program on expenditures and no impact on utilization, uprooting another unproven assumption.

Traveling from the USA to the EC, Marco Varkevisser and Stephanie A. van der Geest offer a case study of competition among social insurers in The Netherlands, Belgium and Germany. The authors question the economic conviction that competition enhances efficiency. If that is the case, they wonder, then how can all the efforts in these three countries to increase competition have been ineffective? This groundbreaking article reveals how equity considerations in health insurance can influence efficiency despite efforts to increase competition.

This issue concludes with a "must read" paper. Siddarth Agarwal describes an exciting innovation in community-based health. CARE India worked with village women to collect funds to market safe delivery kits and oral rehydration salts. From these simple beginnings grew the basis of the Community Based Organizations, which now help to purchase medicines, vaccines, and other medical supplies that have been unavailable previously. This paper demonstrates that rural, village women can be empowered to act collectively to make decisions for their health.

It is with great pleasure and pride that we present these articles to you. We ask you to continue to inquire, to question assumptions and to innovate.

Sharon Bell Buchbinder
Towson University (USA)

Address for correspondence: Sharon Bell Buchbinder, Department of Health Science, Towson University, 8000 York Road, Towson, MD 21252-0001 USA, [e-mail].