Care Access in Rural Areas: WhatLeverage Mechanisms Do RegulatoryAgencies Have in a Public System?

Nassera Touati

Andre-Pierre Contandriopoulos

Jean-Louis Denis

Charo Rodriguez

Claude Sicotte

Abstract: Based on observations of the government’s vital role in enhancing rural

health care accessibility, in this article, we analyze solutions implemented by

Quebec’s public health system by highlighting the limitations in incentives used to

remedy the dearth of rural medical resources and the consequent interest in

ameliorating health care accessibility through service integration. The current

challenge lies in fostering cooperation between health care institutions not

subject to market incentives and integrating private practice physicians into

the public system. To this end, regulatory agencies in public systems use four

main leverage mechanisms: formal power, economic power, influence, and

commitment, as illustrated in an experiment conducted in rural Quebec.

The problems rural areas face in regard to theprovision of health care services are remarkablysimilar to those in all health care systems.1

These problems involve a shortage of medical resources,a lack of specialized services, the threat of the dis-

appearance of overcapacity hospitals, and so on, all ofwhich lead to lack of access to quality services in ruralareas. This, in turn, raises the issue of fairness in accessto health care. The solution to these problems is farfrom obvious. Aside from efforts by health care pro-viders, who these days use promising technologies suchas telemedicine,2,3 the integration of health care servicesappears to be an effective way to make services moreavailable to rural populations. This applies equally toprivate health care systems, as has been witnessed in theUnited States,4–7 and public systems, as in the case ofQuebec.8 Therefore, the real issue involves understand-ing how to promote such integration.9 Public and pri-vate systems each favor different leverage mechanismsto attain this goal: One chooses regulation and the otherchooses the market.

By examining a Quebec case study, we intend to

� explain why public systems tend to look beyondconventional methods for improving access to carethrough better distribution of resources; henceforth,

July–September � 2004 249

Health Care Manage Rev, 2004, 29(3), 249-257A 2004 Lippincott Williams & Wilkins, Inc.

Key words: accessibility, integrated health care systems,public system, regulatory agencies, rural health

Nassera Touati, PhD, is Associate Researcher, Centre de recherche,Hopital Charles-Lemoyne, Quebec, CanadaAndre-Pierre Contandriopoulos, PhD, is Professor, Administrationde la sante, Universite de Montreal, Quebec, CanadaJean-Louis Denis, PhD, is Professor, Administration de la sante,Universite de Montreal, Quebec, CanadaCharo Rodriguez, MD, PhD, is Professor, Faculty of Medicine,Department of Family Medicine, McGill University, Quebec, CanadaClaude Sicotte, is Professor, Administration de la sante, Universitede Montreal, Quebec, Canada

the integration of health care services appears to bea more effective way to improve accessibility;

� illustrate how the method public systems favor forintegrating health care services, that is, state regu-lation, differs from the market dynamic in force inprivate health care systems;

� describe the leverage mechanisms that regulatoryagencies can adopt to improve integration in a publicsystem. Following a theoretical review, we illustratethese using examples drawn from an experiment per-formed in a rural area of Quebec;

� examine what the Quebec case study can teachhealth care systems (particularly those closely linkedto the Canadian system) concerned about improvingaccess to care in rural areas.

SOLUTIONS TO IMPROVE RURAL ACCESSTO HEALTH CARE

Public health care systems have explored severalsolutions to improve access to health care in rural areas.One such solution is the integration of health careservices as an alternative to measures promoting betterdistribution of resources.

We might think a priori that public health caresystems could easily solve problems related to healthcare accessibility in rural areas, especially in view oftheir potential ability to organize medical staff andresources. The Quebec experience clearly indicatesthat the solution is less simple than we might think.In fact, the organization of medical resources has itslimitations, because in Canada, physicians constitute aprofession that is very independent. Although itsmembers must negotiate their incomes with thegovernment, they retain full control in the area ofclinical practice10 and enjoy the freedom to choosewhere they will practice. The Quebec government has,of course, introduced various incentive measures toencourage physicians to practice in outlying regions.Among them are economic measures (bonuses, prefer-ential rates of pay) and disincentives (financial penaltiesfor new physicians who decide to practice in urbanareas). Unfortunately, these measures have achievedlimited success.11,12 In fact, some studies have shownthat economic incentives play only a secondary role inphysicians’ choice of practice location.13 In response tothe limitations of economic incentives, the government,in organizing medical staff planning, has employed othermeans to remedy the shortage of medical specialists inoutlying regions, which is by far the most crucialproblem. In this regard, certain positions for residentsare open to candidates who promise to practice outsidemajor urban centers (it should be noted that Quebecregulates the number of physicians by imposing quotason training programs).

The government has also introduced regional quotasto restrict the choice of location for medical practices.The medical establishment has taken advantage ofvarious loopholes to circumvent these measures, includ-ing an orientation toward general practice and politicalpressure to modify objectives, citing shortages of certainmedical specialists.11,12

We must conclude that the incentives resorted toby the Quebec government to solve the problem ofphysician availability in rural areas have not really beenvery successful; this is, of course, to be expected, giventhe complexity of the problem.14 As shown in a studyanalyzing stability factors regarding physicians inoutlying regions,13 practice conditions (e.g., solo orgroup practice and proximity to a hospital) are the mostmotivating factors. Other Canadian provinces havereached the same conclusion and are promoting morecomprehensive solutions to the problem of access tohealth care in rural areas.15

Clearly, it is not sufficient to address only the issuesof recruitment and stabilization of medical teams.We must also seek other ways to employ the meansat our disposal. In this respect, the integration ofhealth care services within the context of a pub-licly funded system offers interesting possibilities forimproving access to care. In fact, integrated systems,described here as ‘‘networks of interdependent organ-izations, coordinated functionally, clinically, andfinancially,* and responsible for the health of a givenpopulation to which they provide ongoing servicesadapted to its needs’’ [this citation is not an officialtranslation]16 would have to be more efficient, moreeffective,17,18 and thus more accessible.

METHODS FAVORED BY PUBLICSYSTEMS FOR INTEGRATINGHEALTH CARE SERVICES:GOVERNMENT REGULATION

Public health care systems prefer that the governmentplay a strong role, rather than resorting to a search forthe lowest bidder to integrate services more effectively.However, this does not mean that a market dynamiccannot be introduced through various mechanisms (e.g.,separating the care buyers from the providers andstrengthening the role of the consumer). However, as

*Functional integration refers to the coordination of supportfunctions (information systems, human resources management,financial management, etc.) associated with organizations withinthe system. The integration of physicians is evaluated by theirdegree of economic dependency upon the system and participa-tion in its administration. Lastly, clinical integration correspondsto the degree of coordination of health care services throughoutall job positions, care units, care providers, and so on.

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we see in the case of Great Britain,19,20 which introducedthis market dynamic into its health care system whilemaintaining public funding, the government must retaincontrol as guarantor of compliance with quality carestandards and as a key player in the dynamics ofknowledge (e.g., feedback on performance and guidelinesfor clinical practitioners). In the public systems, thismarket ‘‘dynamic,’’ which we reiterate does not result inprice competition, is only one way to promoteintegration of health care services. As we will see,government uses other leverage mechanisms to attainthis objective.

The situation is different in the case of private healthcare systems. More specifically, in the United States, theintegration of health care services in rural areas is oftenattributed (even though some studies question thishypothesis21) to the introduction of ‘‘managed care,’’5,22

in part because of stronger competition in urban areasand other market characteristics (e.g., population pro-file, care providers, and government policies23). Careproviders are thus joining forces to increase their bar-gaining power when negotiating with funding agencies,in response to cost-saving constraints on their rates ofpay, and ultimately to be able to offer a range of healthcare services.5 In short, this is primarily a matter ofmarket dynamics. That said, the government also has arole to play in supporting the integration of services. Forexample, it can intervene legally24 to overcome barrierscreated by antitrust laws or soften restrictions on equityfor the network of health care providers who assumefinancial risk. This, of course, raises the issue of de-termining an accurate definition of rurality.25

As we can see, private and public health care systemsalike can use both the market dynamic and the gov-ernment regulation to promote the integration of healthcare services in rural areas. Nevertheless, the two sys-tems differ in how intensely they use these two mech-anisms and above all in the type of leverage mechanismsthey each employ. In the following, through analysis ofa Quebec case study, we first intend to clarify the na-ture of regulation in the context of a public system,particularly that used to promote greater integration ofhealth care services.

LEVERAGE MECHANISMSREGULATORY AGENCIES CAN USETO PROMOTE GREATER INTEGRATIONOF SERVICES IN A PUBLIC HEALTHCARE SYSTEM: ANALYSIS OF AQUEBEC CASE STUDY

Before beginning our analysis of these leverage mech-anisms, it would be useful to describe the Quebec healthcare system briefly, in order to clarify the context.

OVERVIEW

Most health care services in Quebec are funded bythe government through taxpayer contributions. Theseservices are provided by the following:

� Public institutions, for instance, acute-care andlong-term care hospitals and frontline communityorganizations, commonly known as CLSCs (see def-initions in Table 1). They are funded through in-dependent fixed budgets and are run by boards ofdirectors, some of whose members represent thegeneral population.

� Physicians in private practice, who are paid on a fee-for-services basis, or physicians in institutions (e.g.,in a CLSC), who are paid either on a fee-for-servicesbasis or by the hour. Of course, doctors may workconcurrently in several types of practice.

Control of the system operates on two levels:

� The macroscopic level: The provincial governmentdetermines the extent of coverage under the medicalinsurance scheme, the population insured, the di-vision of powers between decision-making levels,and the definition of areas of practice for the vari-ous professionals, and signs collective agreementsgoverning human resources management and workorganization.

� The mesoscopic level: This refers more specifically toorganizing the provision of health care services. InQuebec, as in other health care systems aroundthe world,26,27 this responsibility falls to regionalregulatory agencies. Decisions are made by a board ofdirectors that represents various sectors of thecommunity. These agencies are mandated to orga-nize health care services according to the particularneeds of the region. In addition, they are responsiblefor allocating resources to public institutions. Itshould be stressed, however, that these regulatoryagencies do not control budgets allocated for med-ical treatment, because to maintain its power, theQuebec medical profession opposes decentralizationof these budgets.

The current structure of the Quebec health caresystem has several shortcomings:

� On the one hand, most physicians who bill on a fee-for-services basis have little incentive to assume therole of health care managers or use resourcesefficiently.

� On the other hand, health care institutions fundedby independent fixed budgets are subject to dis-incentives, which lead to a fragmentation of health

Care Access in Rural Areas: What Leverage Mechanisms Do Regulatory Agencies Have in a Public System? 251

care services, inadequate utilization of resources, andincreased service costs.28

Other factors such as the nonexistence of sharedvalues, rigid collective agreements preventing inter-changeability of human resources within the system, andcompartmentalized areas of professional practice alsohelp maintain the current health care system as aproduction-oriented system.29 Therefore, the challengelies in developing a population-oriented system thatemphasizes health improvement, rather than services.Regional regulatory agencies are being called on to leadthis challenge. As we will see later, because of the var-ious leverage mechanisms at their disposal, these agen-cies can guide the health care system toward greaterintegration, especially by reinforcing interdependencebetween care providers.

A THEORETICAL APPROACH

Regulatory agencies can employ various leveragemechanisms to influence the way in which the healthcare system operates. There are four main types of me-chanisms linked to four exchange media in the actionsystems:30 Power, money, influence, and commitment.More specifically, in the Quebec context, these re-sources for action are as follows:

� Formal power of regional regulatory agencies, asso-ciated with their role in the health care system(public, political and regulatory authority—in par-ticular, formal supervision of institutional perform-ance). This formal power has significant limitations,in that regional regulatory agencies have no controlover physicians. In addition, the exercise of authorityis very much restricted by the fact that health careinstitutions are professional bureaucracies. We mustalso bear in mind that regional regulatory agencies

do not always possess the expertise required to makeinformed decisions. The ‘‘necessity’’ of ratifying reg-ulatory agency decisions through the democraticprocess at the local level adds to the difficulty ofexercising that authority, especially in rural areaswhere the population plays an active role in thehealth care system and can disagree with regulatoryagency decisions.

� Economic power (money): Regulatory agencies holdcore remunerative power, as they are responsible forallocating resources to institutions. As we will see,this would allow them, through judicious allocationof resources, to make the various levels of care awareof their interdependence and thus commit them-selves to the process of integration. It should benoted, however, that institutions are not entirelydependent on public funds; they are partially fundedthrough other sources (e.g., foundations), whichgives them some power of their own. In addition, aspreviously mentioned, regional regulatory agenciesdo not manage budgets earmarked for the remuner-ation of physicians.

� Influence: This leverage mechanism refers essentiallyto the persuasive role of regional regulatory agencies,in particular because of the knowledge they bring tothe collective dynamic. As a leverage mechanism,such knowledge must be analyzed separately and notmerely as a source of power. Only by analyzing thedynamic of knowledge will we understand why socialsystems survive power struggles.31 Regional regulato-ry agencies can take on the role of true educators,using information that they are able to provide onpast performances, proven clinical practices and or-ganizational models, and the population’s needs inthe area of health care services. At arm’s length fromoperations, and thus in a position to expand theirknowledge by viewing the system as a whole, region-al regulatory agencies can provide the educational

TABLE 1

Mission Statements of Institutions in the Public Health Care System

Institution Mission

Acute Care Hospital To provide diagnostic services as well as general and specialized medical carein the fields of physical and mental health (psychiatric care)

Residential Long-TermCare Hospital

To provide, on an ongoing or temporary basis, an alternative livingenvironment, housing services, assistance, support, supervision andrehabilitation, psychosocial, nursing, pharmaceutical and medical servicesto adults who, because of their loss of functional or psychosocialindependence, can no longer remain in their usual living environment despitethe support of their entourage

Local CommunityService Center (CLSC)

To provide ongoing preventive or curative frontline health, social, rehabilitation,and reinsertion services to the population of the territory served

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process with legitimate knowledge, in addition toinformation from professionals and managersof health care institutions.

� Lastly, by showcasing Canadian health care systemvalues and guiding principles32 (accessibility, com-prehensiveness, universality) within the context ofthe collective dynamic, that is, the standards sharedby society (in other words by encouraging theinvolvement of various actors), regional regulatoryagencies are acquiring other means of fostering asense of belonging and introducing more subjectivevalues for action into social relationships.

Leverage mechanisms used by regional regulatoryagencies combine with those of other actors, physicians,and institutions, resulting in interactive processes thatnumerous studies have interpreted in light of theories onpolicy networks.33–35 Thus, the process of implementingpublic policy is akin to a negotiating process betweenmultiple actors, each with different interests and powers.Although this theoretical framework is certainly inter-esting in a public context, where actors’ strategies arehighly politicized, it can, nonetheless, be improved byincorporating the dynamic specific to knowledge, andfocusing on the educational processes in question.Analyzing these processes, which are themselves inter-active,36 involves adopting a realistic point of viewwhen examining the transformation of systems, tounderstand what kind of knowledge would lead toimproved performance within the health care system.For this reason, we consider it important to view theactions of regional regulatory agencies as integral to aninteractive political and cognitive process.

We will illustrate this concept of the dynamic be-tween actors in the health care system through lessonslearned in an experiment that took place in a rural areaof Quebec. This experiment, which we evaluated, per-fectly illustrates the range of leverage mechanisms thatregional regulatory agencies have at their disposal.

STEPS TO IMPROVE INTEGRATIONOF HEALTH CARE SERVICES: ANEXPERIMENT IN RURAL QUEBEC

CONTEXT OF THE EXPERIMENT

The experiment took place recently from 1998 to 2001in a rural area with a population of 25,000, in which twocultural communities (Francophone and Anglophone)live side by side. The local health care system includesthree public institutions: an acute-care hospital withforty-nine beds, supported financially by the Anglo-phone community; a CLSC (local community clinic);and a long-term care hospital with sixty beds. The

Francophone community identifies more strongly withthe two latter institutions. Three private medical clinicsare located close to these institutions. The fifteen gen-eral practitioners in these clinics all complain of veryheavy workloads. More specifically, as far as organizingexisting services is concerned, all parties involved con-sider these resources to be insufficient to meet the needsof the population. The prevailing context of provincialgovernment budget cuts, which threaten the survival oflocal institutions and thus risk aggravating the problemof access to health care, motivated the various stake-holders to participate in an experiment subsidized bythe Health Transition Fund (HTF) (a fund establishedby the federal government to explore new ways of con-trolling health care costs). The regional regulatoryagency is in charge of this project.

PURPOSE OF THE EXPERIMENT

The purpose of the experiment was specifically to assesswhether integrating services would among other thingshelp improve access to care through greater efficiencyand effectiveness. To accomplish this, it was necessaryfor public institutions to collaborate more closely and forphysicians in private practice to be integrated moreeffectively into the public system. In fact, according toseveral parties involved, the established organizationsoperated in an uncoordinated fashion. Furthermore, de-spite that the local physicians, like physicians in ruralareas generally, are better at taking responsibility formanaging health care than their urban counterparts37

and have a more comprehensive approach to healthcare, the fact remains that there was still room forimprovement.

EVALUATION METHOD

We evaluated the experiment using a qualitativemethod of analysis,38 using several sources of data: (i)participatory and nonparticipatory observation of work-groups formed to implement the experiment, (ii)analysis of the results of changes (agreements betweeninstitutions, minutes of meetings), and (iii) twenty-seven interviews held with representatives of theregional regulatory agency, managers of institutions,participating physicians, and other professionals (nurses,social workers) involved in the experiment.

RESULTS

WHERE AUTHORITY ALONE FALLS SHORT

As indicated previously, the challenge for regionalregulatory agencies lies in reinforcing interdependence

Care Access in Rural Areas: What Leverage Mechanisms Do Regulatory Agencies Have in a Public System? 253

between stakeholders in the health care system, inparticular, by making them financially dependent.Legally speaking, the only way to accomplish this is tomerge institutions. Therefore, the regional regulatoryagency first attempted to use its authority to persuadethe established institutions to merge. Unfortunately,this restructuring was unsuccessful because of dissensionbetween the boards of directors of the two institutionsconcerned, over the terms and conditions of the merge.This failure can be attributed to power struggles betweenmembers of the two cultural communities, who werefighting to retain their seats on these boards of directors.The regional regulatory agency, unable to impose anagreement regarding the structure of the board (it hadno interest in exercising its authority by violating therules of democracy, especially since it still could notprovide convincing data ‘‘proving’’ that there were validreasons to proceed with the merger), resigned itself toexploring other options for carrying out functionalintegration. Structural integration was abandoned infavor of virtual integration.39

GRADUAL INTRODUCTION OF CHANGEMAY BE A WINNING STRATEGY WHENBASED ON EARNING POWER, INFLUENCE,AND COMMON VALUES

The regional regulatory agency took advantage of itseconomic power to implement a strategy for attaining aminimum level of functional integration. More specif-ically, a steering committee, made up of representativesfrom the various institutions, the regional regulatoryagency, the evaluation team, and physicians, was formedto manage the budget awarded by the HTF. The role ofthis committee was to select a group of projects proposedby different clinical committees (consisting of repre-sentatives from the various institutions and local phy-sicians). The clinical projects were chosen according totheir potential ability to integrate health care services.Each of these projects would be funded partly from theHTF budget managed by the regional regulatory agencyand partly from the budgets of the institutions them-selves. Thus, these projects constituted the nucleus ofinterorganizational collaboration processes and weremeant to act as the leverage mechanism for resourceallocation procedures.

Among the projects selected was one with greatpotential to promote integration of health care services.It involved experimenting with a multidisciplinary teamin a private clinic. The adoption of this project resultedfrom a review process fueled mainly by representativesof the regional regulatory agency, who considered itimportant to guarantee everyone quality medical care.The agency played its role, exerting its influence andpromoting values such as fairness of access to care, and

stakeholders in the health care system agreed to have anurse from the public system join the medical team inprivate practice. The local physicians expected this neworganization of primary care services to result in greaterintegration of services and, therefore, improved access tohealth care. Although a certain amount of overlapbetween the role of the physician and that of the nurse40

was allowed, these physicians initially favored acomplementary role where the specificity of the nurse’srole (i.e., ‘‘care’’ as opposed to ‘‘treatment’’) would bemaintained.41 Thus, for example, the nurse would haveto ensure systematic follow-up of chronic care patientsand refer them to the various educational programsavailable in the area (with the aim of improving thepatient’s control over his or her medical problem). Thiswould result in less frequent visits to the physician, andmedical resources would, thus, be used more efficiently.

It should be noted that until very recently in Quebec,there has been little exploration of the possible roleof nurse practitioners. In spite of intervention by thegovernment through the Office des Professions (which itcreated), urging that nurses be delegated medical tasks,the medical profession has maintained its dominanceover the other professions. On the one hand, local phy-sicians accepted this development, because they ac-knowledged its potential to promote efficient use ofresources, increase access to care (a principle theystrongly support), and lighten their burdensome work-load; therefore, they found this project quite appealing.On the other hand, however, they were very careful toensure that this new sharing of roles would not affecteither their income (patients evaluated by a nurse weresubsequently examined by the doctor; fee-for-servicesbilling was maintained) or their professional responsi-bilities (insurance rates did not increase). However, thephysicians did contribute to the project by agreeing todevote some of their time to supervising nurses.

The evaluation of this experiment clearly indicatesthat it would have been difficult to implement this kind ofchange without the intervention of the regional regula-tory agency and more specifically without the following:

� its remunerative power (the HTF budget),� its authority (to impose rules regarding the use of

this budget, in this instance the funding of projectsthat led to improving integration of care and requirefinancial contributions from health care institutionsin order to formalize interdependence),

� its influence in the adoption of a credible organi-zational model,

� its role as a promoter of common values.

As we observed, the context in which the regulatoryagency operates, in particular, the relations betweenopposing actors (e.g., power struggles between cultural

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communities that are fighting for seats on the boardof directors and the power of physicians who wish topreserve their benefits with regard to remuneration)greatly influences the use and impact of the leveragemechanisms at its disposal. We were also able to notethe importance of knowledge as a determinant forinteraction between stakeholders, that is, in the absenceof any proof demonstrating the advantages of mergers, itwas difficult for the regulatory agency to impose itsauthority on the institutions to enforce this type ofrestructuring. All in all, we have taken political andcognitive considerations into account when interpretingthe actions of the regional regulatory agencies.

WHAT PROGRESS HAS BEEN MADE? TOWHAT EXTENT HAS ACCESS IMPROVED?

Despite the project’s shortcomings, in particular, themaintaining of fee-for-services billing, which limitedgains in efficiency, we can conclude that in the opinionof the actors within the system, the experimental projectinvolving a multidisciplinary team in a private clinic ledto greater integration of services, in particular, careproviders coordinated services more efficiently. Physi-cians themselves acknowledged that they had workedmore efficiently, in that, because of the role played bynurses, they spent less time on the less serious cases.

The question we must ask is whether this progress inintegrating health care services has affected access tocare. It would seem so. In fact, according to a pre–postintervention survey among a sample of the population,within the space of a year, the percentage of thepopulation who have a family doctor has increased from75 to 82 percent. Because no new physicians were re-cruited to serve in the region, this development isprobably attributable to improved efficiency and effec-tiveness in the local health care system. However, tovalidate this hypothesis properly, the development ob-served in this region should be compared to that in othersample regions.

CONCLUSION: WHAT CAN THEQUEBEC EXPERIENCE TEACH HEALTHCARE SYSTEMS WANTING TOIMPROVE ACCESS TO CAREIN RURAL AREAS?

This Quebec case study is a good illustration of the rolethat regulatory agencies can play in the public systemby promoting integrated health care services, and notmerely exercising authority. Other leverage mechanismsused by the government such as incentives, influence,and commitment to values are essential to promotinggreater integration of health care services. The experi-

ment involving integration of care in a rural area throughthe establishment of a multidisciplinary team in a pri-vate clinic, as described in this article, clearly illustratesthat the government can use its various leveragemechanisms to successfully encourage physicians inprivate practice to participate in the integration process,by offering them professional and personal incentives. Ofcourse, the changes introduced in Quebec may appearlimited and fragile with regard to the economic incen-tives to which the actors are subjected, and whichessentially remain nonaligned. To further encourageefforts toward integration, regional regulatory agenciesmust explore new avenues, based on the concept of‘‘managed care,’’ in this case, by introducing capitation asa method for funding primary, secondary and tertiarycare, managed by a body that is clinically and financiallyresponsible. The potential for improved coordination,and thus efficiency, would be a priori more evident, giventhe broader range of services (primary, secondary, andtertiary) covered in a public system such as the Quebecsystem, as compared to HMOs, which, for reasons ofprofitability, often offer only partial coverage for services.Additionally, implementing managed care models in apublic system that cannot rely on the exclusion clausesused by HMOs (e.g., ineligibility following a change ofjob, loss of employment, and interruption of premiumpayment because of illness) should involve greateremphasis on preventive services. For the moment, thebenefits of implementing health care service organiza-tional models based on managed care have not beenassessed to any great extent. Introducing such modelsinto Quebec is no easy task. Some of the reasons for thisinclude the following: It would be difficult to combine allthe budgets for services, in particular, because themedical services budget is independent of other budgets;the introduction of some sort of restriction on patients’choice of institution would be questioned, given theimportance that consumers place on freedom of choicewithin the Quebec health care system; and determining astrong per capita cost would be complex. A priori, suchobstacles are not insurmountable.

Finally, we conclude that there is real potential forpublic health care systems to remedy the problem ofaccess to care in rural areas without resorting to pricecompetition (in any case, this is less relevant in ruralareas, where competition is nonexistent42).

Private health care systems recognize the importanceof government intervention to remedy the persistentproblems of access to health care services in rural areas.In fact, there seems to be no strong evidence to showthat managed care improves access to care in rural areas,at least in the United States.43

We may question whether the three leverage mech-anisms that governments use in the private sectorto regulate health care systems (authority [legislation],

Care Access in Rural Areas: What Leverage Mechanisms Do Regulatory Agencies Have in a Public System? 255

expertise, and commitment to moral values) cangenerate any major impact if they are not accompaniedby that essential power—financial control.

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