Institutional apolysis. From horizontal to vertical financial reallocation in public hospitals

The process of reforming health care systems was initiated in several industrialized countries for more than two decades ago, but so far, we have limited knowledge of the outcome of the reforms. The present study was designed to research institutional changes as a result of changes in financial reallocation. The research question was: how does a change from horizontal to vertical financial reallocation contribute to apolysis, integration and technicalization of health care services? To study institutional changes a novel concept, apolysis, was created and defined for its content covering structural, operational, contentual and contextual changes. The target for the investigation was the public specialist-based hospital care in Finland, were the financial reallocation of hospitals had been changed from a horizontal and independent to a vertical and resource dependent form. This change in financial reallocation occurred in 1992. Forty-eight of 51 eligible public hospitals were included and the study period covered 15 years, from 1988 to 2002. The period from 1988 to 1992 served as control period and the interval from 1993 to 2002 as the period of intervention. Reallocation promoted institutional pressures and initiated a deinstitutionalization process. Structural, operational, contentual and contextual changes occurred on all levels of hospital care studied. Horizontal more than vertical integration was supported among providers of hospital care services. A previous social environment was transferred in a more technical oriented direction. The amount of ward as well as outpatient clinic services increased significantly for all disciplines of specialized care, in internal medicine and in surgery, less in gynecology. The onset of increase was closely related to the very early years after reallocation in 1992. Reallocation promoted further hospital productivity and cost-efficiency in surgery and internal medicine, but the effect was modest.