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This paper examines the changes in equality of health and health care in China during its transition from a command economy to market economy. Data from three national surveys in 1985, 1986, and 1993 are combined with complementary studies and analysis of major underlying economic and health care factors to compare changes in health status of urban and rural Chinese during the period of economic transition. Empirical evidence suggests a widening gap in health status between urban and rural residents in the transitional period, correlated with increasing gaps in income and health care utilization. These trends are associated with changes in health care financing and organization, including dramatic reduction of insurance cover for the rural population and relaxed public health. The Chinese experience demonstrates that health development does not automatically follow economic growth. China moves toward the 21st century with increasing inequality plaguing the health component of its social safety net system. Keywords: Equity; Health care; Economic transition; China; Health sector reform; Health financing

The establishment of the Medicare Fee Schedule on Jan. 1, 1992, has given physicians the authority to dictate the costs for a wide range of medical services except for payments for multiple surgery which are still based on existing policies and conventions. Studies show that there are significant economies of scope in performing this class of medical precedures. These findings indicate the need for new policies which will reduce the cost of secondary procedures by as much as 50% while retaining existing policies for subsequent operations.

The Medicare fee schedule for repayment of physicians' services inequitably allocates funds, favoring invasive procedures over medical services. The Medicare fee schedule in use since 1992 is based on the resource-based relative-value scale which uses a monetary-conversion factor to translate relative-value units into dollars. Using the monetary-conversion factor and the Medicare fee schedule, the simulated net income for different medical specialties was determined. If all payments had been made according to the 1992 Medicare fee schedule, pediatricians would have earned $35,000, family physicians would have earned $40,000 and thoracic surgeons would have earned $241,000. Furthermore, medical specialists would have been shortchanged in the reimbursement of their actual practice costs by 25% to 40% while surgeons would have been over-compensated for their costs.

The article discusses issues on health services education and research in the U.S. and the proposed integrated delivery system (IDS) to address them. Topics include the costs of inefficiencies and wastes in the healthcare delivery system, the historical health services delivery issues, and the performance of health maintenance organizations (HMO).

An article on the emphasis of international health policy debates on efficiency-driven rather than equity-drive approaches is evaluated. It is argued that the dichotomy between equity and efficiency is similar to the one the exists between market-driven and centrally-planned health care systems, both of which are unsuccessful. It is also suggested that improving equity rests on the development of an efficient public health sector.

ABSTRACT: This article presents the overall results of the Resource-Based Relative Value Scale (RBRVS) study. We present resource-based relative values for selected services in each of the 18 specialties we studied. We found that preservice and postservice work represents close to 50% of total work for invasive services and 33% of total work for evaluation/management services. We also found that the work per unit time (a measure of intensity) for invasive services is about three times that of evaluation/management. We developed a simple model and simulated an RBRVS-based fee schedule for the Medicare program under a "budget-neutral" assumption. Results for 30 commonly performed services show that office visit fees for evaluation/management could rise by 70%, while some surgical fees could drop by 60%. We also simulated what the Medicare outlays would have been in 1986 for categories of medical services under an RBRVS-based fee schedule. We found that total Medicare payments for evaluation/management services would have increased by about 56%. Invasive, imaging, and laboratory services would have decreased by 42%, 30% and 5%, respectively. We also discuss implementation issues related to an RBRVS-based fee schedule, such as the determination of a monetary conversion factor, practice costs, billing codes, and the need to evaluate the potential impacts of an RBRVS-based payment system on the cost and quality of health care.