Health care efficiency and cost: Is bigger government better?

Recent research on health care delivery in the UK has reported on the advantages that decentralized systems of care have over more centralized ones. Namely, the idea that systems based in smaller health trusts or states, rather than nationally centralized systems, can provide care that is better tuned to local context, culture and challenge.

A new study from Mexico, however, has reached the opposite conclusion. Using the variables of out-of-pocket cost and utilization of preventive services, researchers from the UCLA School of Public Health took advantage of an unusual delivery and funding system that exists in Mexico. In 17 Mexican states, dual, non-competing health care systems currently coexist: One administered by the central government, and one by the state government. By comparing the two, the researchers found that the state-run system cost nearly 40% more out-of-pocket, and used 7% fewer preventive care than the centralized, federal system.

Though it is unfortunate that no outcomes measures were used to see which system provided better care, it does suggest that different health care delivery models may have different strengths and weaknesses based on the details of their design, and their operational contexts.

The authors theorize that there are four attributes that may be contributing to the centralized system's seeming greater efficiency:

* Type of service: Enhanced ability to provide the standard types of primary care services that dominate the care profile.

* Quality of care: Access to greater resources, and incentives tied to quality improvement.

* Experience: Centralized systems are better established, and therefore have had more time to iron out the wrinkles in their care delivery processes.

* Local capacity: The high level managerial skills needed to run efficient health care systems are more likely to exist in centralized systems.

One thing that this study does appear to emphasize is the importance that health care delivery and management skills play, at least in the provision of lower cost, prevention-leaning care.

The research was published in the September issue of the Journal of Social Science and Medicine.