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PubMed2006

Job satisfaction among obstetrician-gynecologists: a comparison between private practice physicians and academic physicians.

OBJECTIVE: Physician job satisfaction has been the subject of much research. However, no studies have been conducted comparing academic and private practice physician satisfaction in obstetrics and gynecology. This study was undertaken to measure satisfaction levels for academic and private practice obstetrician-gynecologists and compare different aspects of their practice that contributed to their satisfaction. STUDY DESIGN: A survey was mailed to randomly selected obstetrician-gynecologists in Memphis, TN; Birmingham, AL; Little Rock, AR; and Jackson, MS. Physicians were asked to respond to questions concerning demographics and career satisfaction. They were also asked to assess the contribution of 13 different aspects of their practice in contributing to their job selection and satisfaction using a Likert scale. A score of 1 meant the physician completely disagreed with a statement regarding a factor's contribution or was completely dissatisfied; a score of 5 meant the physician completely agreed with a factor's contribution or was completely satisfied. Simple descriptive statistics, as well as the 2-sample t test, were used. Likert scale values were assumed to be interval measurements. RESULTS: Of the 297 questionnaires mailed, 129 (43%) physicians responded. Ninety-five (74%) respondents rated their overall satisfaction as 4 or 5. No significant difference was found between academic and private physicians when comparing overall job satisfaction (P = .25). When compared to private practice physicians, the aspects most likely contributing to overall job satisfaction for academic physicians were the ability to teach, conduct research, and practice variety (P = .0001, P = .0001, and P = .007, respectively). When compared with academic physicians, the aspects most likely contributing to job satisfaction for private practice physicians were autonomy, physician-patient relationship, and insurance reimbursement (P = .0058, P = .0001, and P = .0098, respectively). When choosing a practice setting, academic physicians found variety, teaching, and research to be more important (P = .0027, P = .0001, and P = .0001, respectively). In contrast, private practice physicians found autonomy, physician-patient relationship, coworkers, and geographic location to be more important (P = .0005, P = .0001, P = .0035, and P = .0016, respectively). CONCLUSION: Academic and private practice physicians are equally satisfied with their careers. However, teaching, research and variety contribute more to academic satisfaction, whereas autonomy, physician-patient relationship, and coworkers contribute more to satisfaction for the physician in private practice. This study may be used when counseling residents concerning their career options.

Adult↗
PubMed2006

Does federal health care policy influence switching between the public and private sectors in individuals?

OBJECTIVE: The aim of this study was to determine if changes in Australian Federal health policy have influenced individual behaviour regarding utilisation of private health insurance in Western Australia. METHOD: The WA Data Linkage System was used to extract all hospital morbidity records in Western Australia from 1980 to 2001. For each individual, episodes were grouped into hospital couplets classified according to the mix of public and privately insured events. Logistic regression was used to estimate the likelihood of switching towards or away from the private sector, according to the time between episodes in each of five health care policy eras. RESULTS: The odds of a switch away from the private sector increased by 29% with each additional year between episodes, while the odds of a switch towards the private sector increased by 15% per intra-couplet year. In those with a private first episode the odds of switching decreased approximately exponentially across the five eras whereas the odds of switching in those with a public first episode stabilised after 1985. In the last era (1999-2001) the odds of switching away from the private sector reduced substantially. CONCLUSION: Our analysis suggests that the recent policies supporting PHI (30% rebate and Lifetime Health Cover) appear to have been effective at modifying individual behaviour to reduce the drift away from the private sector. However, the reported increases in utilisation of PHI were only partially explained by switching of existing demand in patients who had been previously hospitalised as public patients, suggesting that the policy reforms had generated, rather than merely shifted, demand for health care. This finding has significant policy implications for Australia.

Adolescent↗
PubMedDate not supplied

[The role of private insurance in public health care systems: conceptual framework and policies].

The structure of the health care system ans specifically the type and amount of the public and private mix is not a closed issue. This article provides and update of the arguments that justify public intervention in health, and emphasizes the failures of the private insurance market that call for mandatory universal health insurance, although that does not necessarily mean that state has to be the insurer. The relationship between both sectors and the variables determining the relative level of expenditure in both are also analyzed. Following the literature on the public provision of private goods, the level of expenditure in a democracy is seen to depend on the preferences of the median voter, where private insurance usually tops up public insurance. The key variable determining the decision to buy additional private insurance is the difference in quality, defined broadly, between both sectors. Concerning policies, the appropriateness of fiscal incentives to promote the uptake of private insurance is discussed and it is concluded that there is no clear evidence of its suitability. Also, it is argued that models in which the public and private sectors appear totally segregated or totally integrated are preferable to intermediate models, in which both sectors appear combined. Medical coverage bought by an informed agent in exchange for a capitation payment seems a better way to integrate the private sector than through a system of vouchers.

Delivery of Health Care↗
PubMed2000

Private health care.

During the last decade there has been considerable international mobilisation around shrinking the role of States in health care. The World Bank reports that, in many low and middle-income countries, private sources of finance comprise the largest share of total national health expenditures. Private sector health care is ubiquitous, reaches throughout the population, preferred by the people and is significant from both economic as well as health perspective. Resources are limited, governments are weak, and a new approach is needed. This paper provides a broad overview and raises key issues with regard to private health care. The focus is on provision of health care by private medical providers. On the background of the world's common health problems and interventions available to tackle them, the place of private health care in the overall context is first discussed. The concept of privatisation within the various forms of health care systems is then explained. The paper then describes the genesis and key elements of rapidly enhancing role of the private sector in health care and points to the paucity of literature from low and middle-income countries. Common concerns about private health care are outlined. Two illustrative examples--tuberculosis, the top infectious killer among the poor and coronary heart disease, the top non-infectious killer among the rich--are presented to understand the current and possible role of private sector in provision of health care. Highlighting the need to distinguish between health care as a public good or a market commodity, the paper leaves it to the reader to draw conclusions.

Cardiovascular Diseases↗
PubMed2003

Public and private sector responses to essential drugs policies: a multilevel analysis of drug prescription and selling practices in Mali.

Many African countries have introduced cost recovery mechanisms based on the sale of drugs and measures aimed at improving drug supply. This study compares prescribing and selling practices in Mali, in 3 cities where the public sector contributes differentially to the supply of drugs on the market. Multilevel models are used to analyse the content and cost of 700 medication transactions observed in 14 private and public legal points of sale. Results show that the objective of improving access to drugs seems to have been achieved in the sites studied. Costs of prescriptions were lower where public health services had been revitalized. Affordable generic drugs were accessible and widely used, even in the private sector. However, measures intended to rationalize the prescription and delivery of drugs did not always have the desired effect. While agents in the public sector tended to prescribe fewer antibiotics, injectables, or brand-name drugs, the data confirm the virtual absence of advice concerning the use or the side effects of the drugs in both public and private sectors. In addition, data supported the notion that the public and private sectors are closely intertwined. Notably, availability of drugs in the public sector contributed to diminishing the prices charged in the private sector. Similarly, the use that agents in the public sector made of the opportunities afforded by the presence of the private pharmaceutical sector provided another illustration of interrelatedness. Finally, the data showed that the presence of a private sector, which has not been affected by measures aimed at rationalizing prescription and sales practices, limits the effects of measures implemented in the public sector. More assertive policies, based on strategies encompassing actors in the private sector, are needed to increase the safety and effectiveness of prescription and sales practices.

Community Health Centers↗
PubMed2003

The role of the private sector in monitoring health care quality and patient safety.

BACKGROUND: As payers, purchasers, and providers, both the public and private sectors have a stake in developing sound methods of measuring health care quality and patient safety. However, the role of the private sector in a national quality monitoring system remains largely underdeveloped. PRIVATE SECTOR ROLE IN HEALTH CARE QUALITY MONITORING: There have been some attempts to pool private-sector data through health care industry efforts to measure and monitor the quality of health care services. Yet despite a number of public/private partnerships, no standard method exists for measuring and monitoring health care quality and safety across public and private payers. THE AHRQ WORKSHOP ON PRIVATE-SECTOR QUALITY MONITORING: The Agency for Healthcare Research and Quality (AHRQ) sponsored a workshop in fall 2000 to address the private sector's role in monitoring quality in the health care system. National experts developed a conceptual framework and recommendations on the design and scope of a private-sector data monitoring system. Ten key attributes of the monitoring system, such as timeliness of reports, flexibility, efficiency, and linkability, were identified. Barriers and gaps to the development of such a system include the cost of data collection, the diversity of the units of data collection, data privacy, and limitations of administrative data elements. SUMMARY: A comprehensive, public/private data collection system would address the multidimensional nature of quality and use data to effectively represent this complexity to the extent possible.

Consensus Statements as Topic↗
PubMedDate not supplied

Privatization and emergency medical services.

Osborne and Gaebler's Reinventing Government has sparked discussion amongst elected officials, civil servants, the media, and the general public regarding advantages of privatizing government services. Its support stems from an effort to provide services to municipalities while reducing taxpayer expenditure. Many echo the sentiment of former New York Governor Mario Cuomo, who said, "It is not government's obligation to provide services, but to see that they're provided." Even in the area of public safety, privatization has found a "market." In many localities, privatizing Emergency Medical Services (EMS) is a popular and successful method for providing ambulance services. Privately owned ambulance services staff and respond to medical emergencies in a given community as part of the 9-1-1 emergency response system. Regulations for acceptable response times, equipment, and other essential components of EMS systems are specified by contract. This allows the municipality oversight of the service provided, but it does not provide the service directly. As will be discussed, this "contracting-out" model has many benefits. Privatizing EMS services is a decision based not only on cost-savings, but on accountability. A thorough evaluation must be utilized in the selection process. Issues of efficiency, effectiveness, quality, customer service, responsiveness, and equity must be considered by the government, in addition to cost of service. The uncertain future of health care in the United States has led those in EMS to look beyond the field's internal market to explore additional opportunities for expanding and redefining its roles beyond emergency care. It is important, however, to consider how emergency medical care, the original role of EMS, can be best delivered. Responding to emergencies is not just one of the functions involved in this field, it is the principal function from which public perception of EMS is formed, and from which support for entering other markets can be fostered. The purpose of this paper is to present several important concepts and considerations that public officials, medical directors, and the public must be aware of when contemplating the possibility of privatizing their Emergency Medical Services. A review of the general concepts of privatization and issues of accountability will be presented, referencing policy experts, followed by an examination of how advocates of privatization might see these issues as they relate to providing EMS. The conclusion will present prescriptions for both municipal and commercial ambulance providers.

Contract Services↗
PubMed2002

Private dental visits per dentist in Spain from 1987 to 1997. An analysis from the Spanish national Health Interview Surveys.

OBJECTIVES: In view of the sharp increase in the number of dentists in Spain, the aim of the present study was to analyse changes in the private dentist workload in Spain over the period 1987-97. METHODS: Data were taken from censuses of the population and of dental practitioners, and from the Spanish National Health Interview Surveys. The percentage of people that had visited the dentist in the 3 months prior to the survey was calculated, and of these, the percentage whose last visit was private. The total number of visits made by those people was taken as the estimate of total private visits in Spain during 3 months. Total private activity in 1 year was derived by multiplying this estimate by four. Annual private activity was then divided by the number of dentists. RESULTS: From 1987 to 1997, the Spanish population grew 2.5% (from 38.7 to 39.7 million) and the number of dentists increased by 136.1% (from 6373 to 15,044). The total annual number of private dental visits (+/-SE) was 35.7 +/- 1.0 million in 1987, and 48.9 +/- 2.0 million in 1997 - a 36.8% increase. Thus, the mean number of private dental visits per dentist decreased 42.0% (from 5610 +/- 152 to 3251 +/- 133). CONCLUSION: A significant reduction in private dental visits per dentist is taking place in Spain.

Data Interpretation, Statistical↗
PubMed2002

Policy change and private health insurance: did the cheapest policy do the trick?

From the introduction of Australia's national health insurance scheme (Medicare) in 1984 until recently, the proportion of the population covered by private health insurance declined steadily. Following an Industry Commission inquiry into the private health insurance industry in 1997, a number of policy changes were effected in an attempt to reverse this trend. The main policy changes were of two types: "carrots and sticks" financial incentives that provided subsidies for purchasing, or tax penalties for not purchasing, private health insurance; and lifetime community rating, which aimed to revise the community rating regulations governing private health insurance in Australia. This paper argues that the membership uptake that has occurred recently is largely attributable to the introduction of lifetime community rating which goes some way towards addressing the adverse selection associated with the previous community rating regulations. This policy change had virtually no cost to government. However, it was introduced after subsidies for private health insurance were already in place. The chronological sequencing of these policies has resulted in substantial increases in government expenditure on private health insurance subsidies, with such increases not being a cause but rather an effect of increased demand for private health insurance. The paper also considers whether the decline in membership that has occurred since the implementation of lifetime community rating presages the re-emergence of an adverse selection problem in private health insurance. Much of the decline to date may be attributable to failure on the part of some members to honour premium payments when they first fell due. However, the changing age composition of the insured pool since September 2000, resulting in an increasing average age of those insured, suggests the possible reappearance of an adverse selection dynamic. Thus the 'trick' delivered by lifetime community ratings may not be maintained in the longer term.

Australia↗
PubMed1996

The utilisation of public and private hospitals in Victoria: an issue of access?

Consumers regard access to hospital services as one of the key components of quality in health care delivery. A mixed public/private system operates in Victoria, but a morbidity collection from private hospitals was commenced only relatively recently. In 1993-94 the collection covered 82 per cent of private hospital separations, and it was considered timely to examine the utilisation patterns in the private system and compare them with those in the public system. Medical and surgical emergencies and other complex conditions and procedures are serviced largely in the public sector, whereas private hospitals are utilised for elective and less complex surgery and non-urgent conditions. Occupancy rates are around 79 per cent in public hospitals and 67 per cent in private hospitals. Elective surgery waiting list data suggest that while urgent cases are treated within a month, significant proportions wait six months or more for non-urgent surgery. Private health insurance is the main factor in determining access to and the utilisation private hospitals. The current Medicare Agreement and the move to separate the role of purchaser and provider may allow the maximal utilisation of private hospitals and diminish the burden of chronic illness.

Adolescent↗
PubMed1990

The impact of private residential and nursing care on statutory residential and hospital care of elderly people in south Belfast.

Dependency levels were compared in residents of private, voluntary and statutory residential homes, private nursing homes and patients in geriatric continuing-care wards in South Belfast. Dependency levels were least in private and voluntary residential homes, were similar in residential and private nursing homes, but were very much greater in the geriatric wards. Evidence of dementia was found in 23% of residents of voluntary homes, 35% of residents of private residential homes, 61% of residents of statutory residential homes, 54% of those in private nursing homes and 80% of patients in geriatric wards. Severe degrees of immobility and incontinence were commoner in nursing than in residential homes, but much commoner in geriatric wards. The number of private residential and nursing home places in the area studied has increased three- to five-fold since a previous survey in 1985. In this time, dependency levels, and frequencies of dementia, immobility and incontinence have increased in both statutory residential homes and geriatric continuing-care wards. It appears, therefore, that private residential and nursing homes take rather less dependent old people and that highly dependent old people are being concentrated in hospital.

Activities of Daily Living↗
PubMed2003

Privatization in the health care system of Croatia: effects on general practice accessibility.

This paper analyzes some effects of the privatization process in primary health care in Croatia, and in particular evaluates actions taken by providers to improve their accessibility for patients. The sample was stratified by regional density of practices and the status of practices in relation to privatization. Three groups of general practices were included in the study and were assessed twice (in 1997/1998 and 1999/2000): (1) 106 privatized before the beginning of the study; (2) 96 privatized during the study period and (3) 65 that were not yet privatized. The research was performed by structured interview with general practitioners as informants. The indicators analyzed were: possibilities of obtaining first and follow-up visit appointments, honouring scheduled appointments, scheduling visits by telephone, visiting the practitioner after hours and obtaining telephone advice after working hours. Number of registered patients in the practice and perception of patients' waiting times were also assessed. Privatized practices performed better in improving the accessibility of their services for patients: they increasingly offered the possibility for first and follow-up appointments at precise times, scheduled visits by telephone and provided telephone advice outside working hours. They showed greater intention to honour made appointments in order to lower their patients' waiting times. The study indicates that, in the initial stage of privatization, practitioners tend to extend accessibility by structural improvements that are not time consuming. It seems that providers adjust the level of offered accessibility benefits according to the intensity of market competitiveness. Further research is needed to precisely delineate the range of structural adjustments that could be expected by privatization and to verify the effect of observed changes on the quality of care and health outcomes.

After-Hours Care↗
PubMed1999

Private patients in NHS hospitals: comparison of two sources of information.

BACKGROUND: The use of National Health Service (NHS) hospitals to treat private patients is debatable on the grounds of equity of access. Hospital Episodes Statistics (HES) annual reports are the only routine source of information on the scale of this activity. The accuracy of the information is doubted. This enquiry tested the completeness of HES data against information obtained directly from private patient unit managers. METHOD: Managers of the 71 pay bed units in NHS hospitals in England were asked to supply from local registers and accounts the numbers of in-patients and day cases admitted in 1995-1996. Their reports were matched with the numbers of first consultant episodes for private in-patients and day cases shown for those hospitals in the HES data file for that year. RESULTS: Of the 71 units 62 responded; 53 of these gave usable data. The 53 included, and 18 excluded from the comparison, matched on median and range of bed numbers. Managers identified 16 per cent more total admissions than did HES, 62,572 against 54,131; 13 per cent more in-patient admissions, 39,776 against 35,319; and 21 per cent more day cases, 22,796 against 18,812. More total admissions were reported by managers of 38 pay bed units than were recorded in HES, fewer by 12, and equal numbers by three. Similar sized discrepancies were noted for in-patient admissions and day cases. Reasons for the under-reporting of private patients in HES included the use of separate patient administration systems for private patients with a failure to feed data to HES, and the omission of some provider units altogether by a minority of trusts from the returns made to the Department of Health. CONCLUSION: Overall, HES underestimates the amount of private patient activity reported directly by NHS hospitals. No method of validating private patient data is currently available. An amendment to an existing statistical return would provide a check on numbers. Central guidance on the inclusion of private patient activity in data transmitted by providers to the HES processing agency should be reinforced.

England↗
PubMed2001

Unwanted caesarean sections among public and private patients in Brazil: prospective study.

OBJECTIVE: To assess and compare the preferences of pregnant women in the public and private sector regarding delivery in Brazil. DESIGN: Face to face structured interviews with women who were interviewed early in pregnancy, about one month before the due date, and about one month post partum. SETTING: Four cities in Brazil. PARTICIPANTS: 1612 pregnant women: 1093 public patients and 519 private patients. MAIN OUTCOME MEASURES: Rates of delivery by caesarean section in public and private institutions; women's preferences for delivery; timing of decision to perform caesarean section. RESULTS: 1136 women completed all three interviews; 476 women were lost to follow up (376 public patients and 100 private patients). Despite large differences in the rates of caesarean section in the two sectors (222/717 (31%) among public patients and 302/419 (72%) among private patients) there were no significant differences in preferences between the two groups. In both antenatal interviews, 70-80% in both sectors said they would prefer to deliver vaginally. In a large proportion of cases (237/502) caesarean delivery was decided on before admission: 48/207 (23%) in women in the public sector and 189/295 (64%) in women in the private sector. CONCLUSIONS: The large difference in the rates of caesarean sections in women in the public and private sectors is due to more unwanted caesarean sections among private patients rather than to a difference in preferences for delivery. High or rising rates of caesarean sections do not necessarily reflect demand for surgical delivery.

Adult↗
PubMed1995

Factors associated with admission to public and private hospitals from a psychiatric emergency screening site.

OBJECTIVE: The study examined factors associated with admission to public and private hospitals from a mental health care emergency screening system operating under a longstanding mandate to maximize use of private inpatient treatment. METHODS: For 206 patients evaluated at the mental health emergency screening site over a two-and-a-half-month period, data were collected on demographic and clinical characteristics, admission history, services received during the emergency encounter, system variables such as time the patient spent at the emergency screening site, number of admission sites asked to accept the patient, and all reasons cited by providers for refusing to admit the patient. Logistic regression was used to develop a model of factors most likely and least likely to be associated with private hospitalization. RESULTS: Overall, 60 percent of the sample was refused admission by one or more providers, and 55 percent, who were not accepted by and private hospital, became public patients. Private hospital admission was associated with patient or family involvement in referral and disposition, private or Medicaid insurance, a presenting problem of depression or suicidality, and longer time spent at the emergency screening site. Public admission was associated with no insurance, a past history of major public hospitalization, current or past history of assaultiveness, a presenting problem of aggression, and lack of any discharge site. CONCLUSIONS: Private providers are reluctant to admit patients who have characteristics associated with public hospitalization. In the restructuring of health care, a more fully privatized system will likely be called on to absorb such patients. Their care, treatment, and impact on the system should be carefully monitored and evaluated.

Adult↗
PubMed2001

Comparison of continuity in a resident versus private practice.

BACKGROUND: There is widespread agreement among pediatric educators that continuity (following a panel of patients on a first contact basis for all their health care) is an important part of the education of pediatricians. OBJECTIVE: To measure continuity in a pediatric residency practice and to compare this continuity with 2 nearby private general pediatric group practices. We also examined measures of continuity suggested in the literature. DESIGN: Visit data were obtained from the practice billing system for a resident continuity practice and 2 nearby private practices for the 3-year period from July 1, 1992, to June 30, 1995. Visit data used were restricted to patients seen in the office of the practices during regular office hours. Continuity was measured using 5 different indices: 1) the usual provider of care index, visits by the usual clinician/total visits, 2) continuity for patient, the average proportion of visits that an individual patient was seen by his or her own physician, 3) continuity for physician (PHY), the average proportion of visits that an individual physician saw his or her own patients, 4) Continuity of Care Index (COC), and 5) the Modified, Modified Continuity Index. During the period examined, pediatric residents were present in the continuity practice for 1 half-day each week. The resident continuity practice (RCP) had 57 residents and saw 3386 patients for 18 955 visits. Private practice 1 (PP1) had 4 pediatricians who saw 4968 patients for 33 537 visits. Private practice 2 (PP2) had 5 pediatricians who saw 11 953 patients for 75 778 visits. RESULTS: For all visit types, continuity in the RCP was not as high as in the private practices, PHY-RCP versus PP1, PP2; 53% versus 70%, 77%. However, continuity in RCP was greater than 50% for all measures except the COC index, which precipitously decreases as the number of clinicians seen increases. Examining continuity for health maintenance visits (PHY-RCP, PP2 vs PP1; 96%, 96% vs 82%) RCP was equal to the best of the private practices. The percentage of patients not seen for a health maintenance visit during the study period was lowest in the resident practice (RCP/PP1/PP2, 15/22/30). CONCLUSIONS: Although continuity for all visits in this RCP was less than in private practice, it was surprisingly high, considering the limited time residents spend in clinic. In a particularly important area for continuity, health maintenance visits, continuity was identical to one and superior to the other private practice.

Continuity of Patient Care↗
PubMed2001

Privatization and the scope of public health: a national survey of local health department directors.

OBJECTIVES: This study sought to obtain and analyze nationally representative data on (1) privatization of local health department services, (2) local health department directors' beliefs and perspectives on the desirable role and focus of health departments, and (3) the influence of these views on privatization practices. METHODS: A stratified representative national sample of 380 local health department directors was drawn, and 347 directors were interviewed by telephone. Logistic regression established the independent effects of various factors on decisions to privatize. RESULTS: Almost three quarters (73%) of the local health departments privatized public health services of some type. The 12% of the directors who believed that local health departments should be restricted to the core public health functions and move entirely out of direct provision of personal health care were more likely to privatize services. The 77% of the directors who believed that local health departments should be involved in an increasing array of social problems were more likely to privatize. CONCLUSIONS: Privatization has quietly and quickly become commonplace in public health, and privatization practices are intimately related to divergent conceptions of public health and the role of local health departments.

Administrative Personnel↗
PubMed2004

Privatization of Medicare: toward disentitlement and betrayal of a social contract.

An intense political battle is being waged over the future of U.S. Medicare. The 40-year social contract established with the nation's elderly and disabled is seriously threatened. The basic issue is whether Medicare will remain a universal entitlement program or be privatized and dismantled as an obligation of government. Faced with the growing costs of the Medicare program, changing demographics of an aging population, and long-term federal deficits, conservative interests are promoting further privatization of the program under the guise of increasing beneficiaries' choice and the claimed efficiency of the private marketplace. Following a historical overview of past efforts to privatize Medicare, this article reviews the track record of private Medicare plans over the last 20 years with regard to choice, reliability, cost containment, benefits, quality of care, efficiency, public satisfaction, and fraud. In all of these areas, privatized Medicare has performed less well than original Medicare. Based on the evidence, one has to conclude that privatization of Medicare is detrimental to the elderly and disabled, the most vulnerable groups in our society, and that the only winners in that transformation are private market interests.

Aged↗