In contrast with the foregoing models, the set of problems of care models is strictly medical and health-related. In other words, this is the most specifically technical dimension of the health care sector. The questions involved are those linked to: i) what care is to be provided? ii) how and where is it to be provided?

2.3.1. LIMITATION TO THE PROVISION OF MEDICAL CARE

Medical and technical knowledge is occurring at dizzying rates. Insurance companies, however, cannot include in their coverage plans all the medical applications offered by medical science and the technology assisting health services. The principal reason for this restriction is economic. No health insurance in the world covers absolutely everything because the cost would tend to be infinite. The question, then, is the criteria to use to put a limit to the amount and variety of care covered by insurance.

In traditional private insurance - those plans not tied to the providers and which merely reimburse the insured for their health care expenses-limitations do not follow medical criteria, but simply establish a maximum amount to be reimbursed to the patient covered. In other words, in an insurance plan that controls only the financial flow, the problem of rationing is not the care model but the financing model.

In managed care models, like the prepaid drug companies, and in the greater part of social insurance plans, the problem of limits acquires a technical nature. Insurance plans try to operate with implicit as well as explicit limits. Explicit limits are those usually established by social insurance plans through standards and lists. Lists may be positive (goods and services actually covered) or negative (goods and services not covered by insurance). Implicit limits are those that pertain to clinical decisions, i.e., remain at the micromanagement level. Part of the more recent reforms of health systems have concentrated on the achievement of models of care that allow a broader range of control of the use of resources.³⁶

^36. Perhaps the most paradigmatic case has been the implementation of general practitioners as health fund administrators [fundholders] in the UK's National Health Service, which makes primary care physicians responsible for the use of resources, supplying them with a budget from which they would have to purchase services from specialists and hospitalize their own patients.

The strategy of social insurance involves a single coverage plan, while the axis of competition in private insurance is the diversification of plans. That means that social insurance will tend to have a single rationing scheme, while private insurers may adopt different criteria in each plan.

There are various technical models to establish coverage priorities and limits to the provision of medical care. However, since the publication of the Report on World Development in 1993 by the World Bank, which proposed the implementation of basic health care "baskets" on the basis of a model of evaluation of the cost-effectiveness of health care provision, various countries have taken steps along that line. The Report deals with the implementation of morbidity studies that allow the selection of medical provisions to be covered in terms of the possible impact that such provisions would have on the health of the population, and their costs.

2.3.2. ORGANIZATION OF MEDICAL PROVISIONS

It is a case of defining what providers must be responsible for in the provision of services in the sense of the levels of complexity or the adequacy of the quality of the services. What are the criteria or patterns they must operate with? Questions involving quality involve technical dimensions in which medical knowledge is essential.

In the same way, medical knowledge is necessary to establish where and how supply must be distributed. What criteria of reference and counter reference must be adopted?

On the other hand, an insurance company may opt for an open or a closed plan model for the organization of its medical services. Open plans are characteristic of traditional private insurance. In this case there is no contract between the insurer and the service provider. When demanding a service the beneficiary or insured goes directly to a private provider and pays the latter for services provided. Insurance then reimburses the insured totally or partially for the amount paid out. Closed plans allow the insurance company better control over the providers since the supply of medical treatment is limited to the set of institutions and professionals authorized by the insurance plan to provide medical care to its members. This model involves a contract between the insurance company and the care providers. In this case, when an insured person demands a service he consults a service provider included in the handbook. The listed professional is remunerated by the insurance company through different payment schemes.

In systems where the provision of services and the financing are separate or indirect, an intermediary usually appears to assume a series of responsibilities through a contract establishing the method of payment. In consequence, distinct possible combinations involving the form of payment contracted and the professional are produced that characterize the provider model and influence not only the use of service but the results of the medical care. Table 5 describes the characteristics of each modality.

Table 5:

Source: Tobar, Rosenfeld, Reale, 1998

In summary, in the case of closed plans two situations may be identified: a) contracts with providers, b) direct provision of medical services through the vertical integration model. Vertical integration is typical of public insurance plans centered on a scheme to finance supply, where the insurance owns the health establishments and maintains a staff of professionals in a dependent relation.

Further, co-payments may be incorporated into closed plan models. In that case the insurance finances a part of the medical service and the insured pays the rest.