ABSTRACT
Health care reform has become the ‘buzzword’ of the 1990s and recommendations for change are being proposed by consumers, providers and policymakers alike. Health care reform is a complex concept, involving both structural and operational revisions to the system, and in its ideal form represents a change in the fundamental relationships among the stakeholders within the system. Although cost effectiveness is one, and only one, piece of reform, it has been the driver of most if not all of the changes proposed or implemented in jurisdictions in much of the industrialized world. Debt and deficit preoccupation has undoubtedly caused this determination to control health care costs which in Ontario, for example, represent roughly one-third of the provincial budget. The bulk of the activity in Canada and in North America has been focused on controlling costs through managing the supply side of the picture and in that way decreasing utilization. Thus, there is considerable attention directed at numbers and mix of providers, decreasing the numbers of hospitals and measuring the outcomes of various clinical interventions. As yet, the evidence is inconclusive as to the size of the effect that can be expected from this approach to controlling costs. What is clear, however, is that the public values Medicare in Canada and is wary and often angry at the prospect of its close-to-home services being reduced and even eliminated. The inability of policy-makers to balance public anger with reduction in costs has led them to consider demand management strategies directed to controlling and reducing the demand for services.
