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PubMed1985

Hospital-sponsored medical groups: their impact on access to primary care in rural communities.

Rural communities have traditionally been underserved in terms of the availability of primary medical care services and providers. The Robert Wood Johnson Foundation launched a major program in the mid-1970s to improve the delivery of primary care to previously underserved rural, small town, inner city and other urban communities through their Community Hospital Program (CHP). This program provided grant funds to over 50 community hospitals throughout the country to develop primary care-oriented group practices. Twelve of the 53 programs eventually funded were sampled for a national evaluation of the impact of the CHP groups on access to care in the communities they served. The analyses reported here summarize the access impact of this innovation on the four rural and small town communities included in the larger evaluation. Baseline surveys in these four communities established that, in general, access was poorer in the rural areas, in particular, compared to the national average. The new groups tended to attract a cross-section of the communities they served. In general, they tended to do as well or better as other sources of care in the area in providing access to care. The most successful groups were those that most closely mirrored the traditional private practitioner--"family doctor"--model of care.

Community Health Services↗
PubMedDate not supplied

Design and implementation issues in Swedish individual pension accounts.

Sweden's new multipillar pension system includes a system of mandatory fully funded individual accounts. The Swedish system offers contributors more than 600 fund options from a variety of private-sector fund managers. However, in the most recent rounds of fund choice, more than 90 percent of new labor market entrants have not made an active choice of funds and thus have ended up in a government-sponsored default fund. The Swedish system offers a number of lessons about implementing a mandatory individual account tier. Centralized administration keeps administrative costs down but requires considerable lead time. A very large number of fund options are likely to be offered unless strong entry barriers are in place. Engaging new labor market entrants in fund choice is likely to be difficult. A significant percentage of those making an active fund choice may choose funds that are very specialized and risky. Finally, special care must be devoted to designing a default fund and continual consumer communication.

Choice Behavior↗
PubMed1994

The health insurance picture in 1993: some rare good news.

Based on a national survey conducted in spring 1993 of 1,953 private and public employers, this DataWatch examines the design of employer-sponsored health benefits and how they have changed during the past five years. We contrast cost of coverage, employee cost sharing, and premium increases among small, mid-size, and large firms. Premiums increased 8.5 percent from 1992 to 1993, the lowest rate of increase since 1986-1987. Future premium increases should be modest by historical standards. Small firms and conventional plans experienced larger premium increases last year. Managed care plans now constitute 51 percent of enrollment, up from 29 percent in 1988. If current trends continue, even without health care reform legislation, the health care system of the future will contrast strikingly with the system most Americans remember from past decades.

Cost-Benefit Analysis↗
PubMed2001

Sun protection practices in preadolescents and adolescents: a school-based survey of almost 25,000 Connecticut schoolchildren.

Sun protection practices in children and adolescents fall well below national recommendations. We present the results of a survey of sun protection use and other health-related behaviors in a sample of Connecticut Caucasian students aged 9 through 18 years (N = 24,645). Our objectives were to estimate the prevalence of sun protection use and to evaluate the relationship between sun protection use and health-risk behaviors and attitudes about appearance. We present data from 1988 through 1995 from the Connecticut Health Check, a health risk appraisal survey sponsored by the Connecticut Department of Public Health. Students enrolled in public and private elementary junior as well as senior high schools took the self-administered anonymous survey, which included multiple-choice questions about use of sun protection, cigarettes, and alcohol and about body image and self-esteem. We report prevalence proportions for use of sun protection by demographic features. We compared the proportion of students in 3 categories of outcome (always, sometimes, and never use sun protection) who reported various health-risk behaviors. Twenty percent of the sample reported always using sun protection; this is well below national goals set forth in the Healthy People 2000 recommendations. Sun protection use was inversely related to age and was higher among girls than boys at all ages. At all ages, students who did not use sun protection were more likely than those who did to report other health risk behaviors, such as use of cigarettes and alcohol. The data suggested that use of sun protection is associated with positive attitudes about appearance and self-image. Use of sun protection may be one component of an overall mode of health awareness and behavior. Programs promoting safe sun practices should target boys and be integrated into an overall campaign aimed at other risk-taking behaviors.

Adolescent↗
PubMedDate not supplied

Educational posters to reduce antibiotic use.

INTRODUCTION: Antibiotic overuse promotes resistant strains of bacteria and puts patients at risk for adverse reactions. Given the use of educational posters in government-sponsored public health campaigns, this study examined the effectiveness of a waiting room poster in reducing excessive antibiotic use in clinical practice. METHODS: Investigators conducted a 1-month trial of an educational poster with historical controls using three private pediatric group practices in Westchester County, New York. Children between the ages of 6 months and 10 years at the time of a visit to diagnose and treat symptoms of respiratory illness were enrolled as subjects. Antibiotic prescriptions for children with respiratory illnesses seen during the poster month were compared with prescriptions written during three 1-month historical control periods. The proportion of visits that resulted in a prescription for an antibiotic served as the outcome measure. RESULTS: Overall, 326 of the 720 patients (45.2%) enrolled in the study were treated with an antibiotic. Multiple logistic regression analysis revealed no statistically significant difference in the proportion of visits resulting in an antibiotic prescription among the 4 study months (P = .79), indicating that the educational poster had no effect on antibiotic use. DISCUSSION: Public education in the form of a waiting room poster was not sufficient to decrease antibiotic prescriptions. This finding has implications for current large-scale programs and for health care providers as they continue to attempt to educate patients on the appropriate use of antibiotics.

Anti-Bacterial Agents↗
PubMed1996

Physician-sponsored networks. Will physicians take back medicine?

Until about the late 1980s, American physicians and their allies, hospitals and the health care manufacturing industries, dominated all facets of the health system--the clinical, the economic, and the political. The bulk of these providers' revenue flowed to them from a highly fragmented insurance system whose governing principle was to provide each insured patient free choice of doctor and hospital. Two distinct, concurrent shifts threaten to erode the medical profession's traditional dominance. The first is a rapid, general shift of control from the supply side of the health sector to its demand side. The second is a shift away from government control, over which organized medicine held much sway in the past, toward private regulators--the executives of the managed care industry. Is the trend towards greater dependence of practicing physicians on non-physician executives inevitable, or can physicians retain--and, in part, regain--their hitherto autonomous position in the health system?

Community Networks↗
PubMedDate not supplied

The effects of federal funding cuts on family planning services, 1980-1983.

According to data from surveys conducted in the past two years, some changes occurred in the provision of family planning services between 1980, the year before the 1981 federal budget cuts, and 1983. Six percent of the family planning agencies that were operating in 1980 had closed or had stopped offering medical family planning services by 1983. The annual income of the family planning agencies that continued to operate, adjusted for inflation, was lower in 1983 than in 1980. While Title X remains the principal source of family planning funding, the proportion of clinics receiving income from Title X declined substantially during the period under study; this drop occurred among all types of providers. There was a slight decline in the proportion receiving funding from the Social Services block grant (formerly Title XX) in 1983, but there was no change in the contribution made by the Maternal and Child Health (MCH) block grant (formerly Title V). The proportion of total clinic income represented by Title XIX (Medicaid) funds rose slightly during this period. Decreases in federal funding appear to have been partly offset by an increase in the proportion of total income contributed by state and local governments and by private sources, particularly patient fees. Indeed, the number of agencies that collected patient fees, the proportion of clinic income derived from such fees and the proportion of patients who paid at least part of the cost of their family planning services all increased between 1980 and 1983. A separate survey of providers shows that fees varied widely, depending on a woman's income and on the type of agency.(ABSTRACT TRUNCATED AT 250 WORDS)

Family Planning Services↗
PubMed2004

A consensus action agenda for achieving the national health information infrastructure.

BACKGROUND: Improving the safety, quality, and efficiency of health care will require immediate and ubiquitous access to complete patient information and decision support provided through a National Health Information Infrastructure (NHII). METHODS: To help define the action steps needed to achieve an NHII, the U.S. Department of Health and Human Services sponsored a national consensus conference in July 2003. RESULTS: Attendees favored a public-private coordination group to guide NHII activities, provide education, share resources, and monitor relevant metrics to mark progress. They identified financial incentives, health information standards, and overcoming a few important legal obstacles as key NHII enablers. Community and regional implementation projects, including consumer access to a personal health record, were seen as necessary to demonstrate comprehensive functional systems that can serve as models for the entire nation. Finally, the participants identified the need for increased funding for research on the impact of health information technology on patient safety and quality of care. Individuals, organizations, and federal agencies are using these consensus recommendations to guide NHII efforts.

Health Policy↗
PubMed2003

Provider-sponsored virtual communities for chronic patients: improving health outcomes through organizational patient-centred knowledge management.

Patients with long-term chronic disease experience numerous illness patterns and disease trends over time, resulting in different sets of knowledge needs than patients who intermittently seek medical care for acute or short-term problems. Health-care organizations can promote knowledge creation and utilization by chronic patients through the introduction of a virtual, private, disease-specific patient community. This virtual socialization alters the role of chronic disease patients from external consumers of health-care services to a 'community of practice' of internal customers so that, with the tacit support of their health-care organization, they have a forum supporting the integration of knowledge gained from the experiences of living with chronic disease in their self-management. Patient-centred health-care organizations can employ the virtual community to direct and support the empowerment of chronic patients in their care.

Chronic Disease↗
PubMed2001

Abbreviated report of the WHO Western Pacific Region Workshop on National Plans of Action for Nutrition: key elements for success, constraints and future plans.

A workshop on National Plans of Action for Nutrition: Constraints, Key Elements for Success, and Future Plans was convened and organized by the WHO Regional Office for the Western Pacific in collaboration with the Institute for Medical Research Malaysia and co-sponsored with FAO and UNICEF from 25-29 October 1999. It was attended by representatives of 25 countries in the region and resource persons, representatives from WHO and other international agencies. The objectives of the workshop were to review the progress of countries in developing, implementing and monitoring national plans of action for nutrition (NPANs) in the Western Pacific Region and to identify constraints and key elements of success in these efforts. Most of the countries have NPANs, either approved and implemented or awaiting official endorsement. The Plan formulation is usually multisectotal, involving several government ministries, non-governmental organizations, and international agencies. Often official adoption or endorsement of the Plan comes from the head of state and cabinet or the minister of health, one to six years from the start of its formulation. The NPAN has stimulated support for the development and implementation of nutrition projects and activities, with comparatively greater involvement of and more support from government ministries, UN agencies and non-governmental agencies compared to local communities, bilateral and private sectors and research and academic institutions. Monitoring and evaluation are important components of NPANs. They are, however, not given high priority and often not built into the plan. The role of an intersectoral coordinating body is considered crucial to a country's nutrition program. Most countries have an intersectoral structure or coordinating body to ensure the proper implementation, monitoring and evaluation of their NPANs. The workshop identified the constraints and key elements of success in each of the four stages of the NPAN process: development, operationalization, implementation, and monitoring and evaluation. Constraints to the NPAN process relate to the political and socioeconomic environment, resource scarcity, control and management processes, and factors related to sustainability. The group's review of NPAN identified successful NPANs as those based on recent, adequate and good quality information on the nutritional situation of the country, and on the selection of strategies, priorities and interventions that are relevant to the country and backed up by adequate resources. Continued high level political commitment, a multisectoral approach, and adequate participation of local communities are other key elements for success. The participants agreed on future actions and support needed from various sources for the further development, implementation, monitoring and evaluation of their NPANs. The recommendations for future actions were categorized into actions pertaining to countries with working NPAN, actions for countries without working NPAN and actions relevant to all countries. There was also a set of suggested actions at the regional level, such as holding of regular regional NPAN evaluation meetings, inclusion of NPAN on the agenda of regional fora by the regional organizations, and strengthening of regional nutrition networks.

Guideline Adherence↗
PubMed1996

Community health clinics under managed competition: navigating uncharted waters.

In this article, we consider how major changes in the health care system, both real and proposed, may affect the future of community health clinics (CHCs) in the United States and their ability to continue to provide comprehensive care to underserved populations. We discuss the constraints and opportunities that CHCs face in a health care system that is rapidly moving away from fee-for-service medical care toward a model of managed competition. We describe the role that the National Association of Community Health Centers has played in advocating for CHCs in Congress and the role state primary care associations are playing in spear-heading the development of statewide CHC-sponsored health maintenance organizations. We also analyze CHC reactions to the changes in federal policies that were proposed in the major health care reform bills of the 103d Congress, as well as the prospects for CHCs under Medicaid managed care as it sweeps rapidly across the nation. As a case study, we examine California's policies that mandate that Medicaid recipients enroll in either a private managed care plan or a newly created public plan, which compete against each other within each county. CHCs are vulnerable during the transition to managed care and managed competition, and they have neither the resources nor the ability to integrate or compete successfully with private health maintenance organizations without safeguards, new sources of funding, technical assistance, improved infrastructure, and vigorous monitoring and oversight from federal and state governments, as well as the continued education, training, and policy advocacy provided by the National Association of Community Health Centers and state primary care associations.

California↗
PubMedDate not supplied

Healthcare pay: belts tighten--but who feels the squeeze?

A CEO of a renowned acute care facility echoes what many in the healthcare industry are experiencing: "At no time in my memory are we changing so much so fast ... with so little time in which to make changes." The once mighty fortress of the healthcare industry has been invaded by a Trojan horse: managed care. Consequently, managed care has become the primary impetus for industry change. Managed care penetration has increased dramatically over the past few years, and all indications point to its continued growth throughout the US. In 1995, 71% of employees covered under an employer-sponsored health plan received their care through a managed care arrangement (health maintenance organization, preferred provider organization, point of service plan) and only 29% were covered under a traditional indemnity plan. In contrast, 52% of employees had indemnity plans in 1992. Managed care is growing in the public sector as well. Government-sponsored programs such as Medicare and Medicaid increasingly rely on managed care to help control costs and utilization. Though Medicare managed care enrollment today represents only about 10% of the Medicare population, enrollment has more than doubled between 1990 and 1995. Almost every state has some form of Medicaid managed care program in place. Fifteen states have received waivers to mandate that recipients receive care through managed care arrangements, and an additional ten states await federal approval to do the same. Between the years 1993-95, the number of Medicaid beneficiaries enrolled in managed care plans increased 140% to a national enrollment of close to 12 million. In addition to factors in the healthcare field such as uncompensated care, increased outpatient services, excess bed capacity, and restrictions in government reimbursement, the shift to managed care has forced hospitals to find new ways to operate within the healthcare delivery system. In particular, because hospitals' human resource costs are a substantial portion of their budgets, compensation policies are an important component of managing the cost of day-to-day operations. The 1996 Coopers & Lybrand Compensation in the Healthcare Industry Survey summarizes the responses from 207 healthcare organizations, primarily hospitals, in terms of their efforts to survive this constantly changing environment. Respondents included acute care and specialty hospitals, community-based hospitals, academic medical centers, public, and private organizations. The survey addresses operational issues, compensation incentives, special pay, and other compensation-related programs. This article analyzes the results of the Coopers & Lybrand survey.

Cost Control↗
PubMed1997

Should governments subsidize the use of insecticide-impregnated mosquito nets in Africa? Implications of a cost-effectiveness analysis.

Recent large-scale field trials show that mosquito nets impregnated with insecticide can substantially reduce all-cause mortality in children in malaria-endemic areas in Africa. This paper considers the cost-effectiveness of impregnated nets, initially from the perspective of a government programme which would distribute nets free of charge and organize and fund re-impregnation on an annual basis. The calculations show that with the reductions in all-cause mortality observed in the trials, complete government subsidy of nets through a vertical programme would represent an efficient use of scarce resources for most combinations of assumptions. However, alternative ways of financing and organizing the use of impregnated nets are also possible and may be more cost-effective than vertical delivery. Distribution of nets and insecticide might be less costly than required for a vertical programme by integrating delivery with other types of government health programmes, with private sector delivery systems for other types of products, or with government systems developed for other sectors such as agriculture. Further, not all the costs need to be met by governments, as costs could be shared with donors, NGOs and the beneficiaries. The major conclusion is that impregnated nets would save a large number of lives in malaria endemic areas, they are an efficient use of scare resources, and ways of encouraging their use need to be developed and tested.

Africa↗
PubMed2002

Orthodontic graduate education survey, 1983-2000.

Throughout academic year 1999/2000, the fourth in a series of national surveys sponsored by the American Association of Orthodontists Council on Education was conducted to determine the status of graduate education, to assemble information on the didactic and clinical material being taught, and to provide a basis for comparison with past and future studies. The results of the previous studies were published in 1984, 1989, and 1995. The specific purpose of the 2000 study was to identify trends and evaluate new developments in orthodontic education over the past 17 years. A 346-item survey questionnaire, covering 8 major areas of orthodontic graduate education, was sent to graduate program directors in the United States and Canada. The major areas analyzed were program organization, graduate students, faculty, facilities, clinical details, treatment techniques, research, and curriculum. Findings showed that curricular time devoted to clinical activities is increasing, but curricular time devoted to research is declining. The rate of student publications is down precipitously. The numbers of full-time and half-time faculty members are declining, and departments increasingly rely on part-time faculty to meet teaching needs. Overall experience levels of the faculty are declining. Fewer faculty members are American Board of Orthodontics diplomates. Faculty salaries, when adjusted for inflation, are down from 1994. Tuitions have increased dramatically over the last 5 years. Approximately 50% of all programs are now 3 years long. Clinic fees are now roughly two thirds those of local private-practice fees. Students are treating more mixed dentition and craniofacial cases and fewer nonsurgical adult cases. Fewer departments are relying on centralized radiographic facilities in their parent dental schools, preferring in-department radiography. Approximately 50% of the first-year students are female.

Adult↗
PubMedDate not supplied

Design and implementation of a national clinical trials registry.

The authors have developed a Web-based system that provides summary information about clinical trials being conducted throughout the United States. The first version of the system, publicly available in February 2000, contains more than 4,000 records representing primarily trials sponsored by the National Institutes of Health. The impetus for this system has come from the Food and Drug Administration (FDA) Modernization Act of 1997, which mandated a registry of both federally and privately funded clinical trials "of experimental treatments for serious or life-threatening diseases or conditions." The system design and implementation have been guided by several principles. First, all stages of system development were guided by the needs of the primary intended audience, patients and other members of the public. Second, broad agreement on a common set of data elements was obtained. Third, the system was designed in a modular and extensible way, and search methods that take extensive advantage of the National Library of Medicine's Unified Medical Language System (UMLS) were developed. Finally, since this will be a long-term effort involving many individuals and organizations, the project is being implemented in several phases.

Clinical Trials as Topic↗
PubMed1992

HMOs for Medicaid: the road to financial independence is often poorly paved.

During the 1980s both the federal government and the private sector articulated policies to encourage the development and participation of health maintenance organizations (HMOs) in the Medicaid program. However, the policies, intended to save costs, limited the ability of new HMOs to achieve financial independence. New plans that emphasize Medicaid participation have few, if any, options on benefit design or in setting capitation rates. Relative to fee-for-service Medicaid programs, their costs to provide services may be quite high, as they have neither the buying power not the ability to impose discounts. As a consequence, plans must focus their financial planning efforts on targeting and attaining a stable enrollment base and on controlling the amount of services provided, tasks that are difficult for all HMOs. Achieving a stable enrollment base is particularly hard because Medicaid eligibles have few incentives to enroll and once enrolled often lose their Medicaid eligibility. Traditional HMOs control the amount of services provided through physician selection, financial incentives on physicians, and monitoring and utilization review. Lack of information and the difficulty inherent in attracting sufficient provider participation limit the first two strategies, so new plans often adopt organization structures that rely heavily on monitoring activities. Unfortunately, management information systems for HMOs are often the weakest link. We discuss the tasks and present data on financial planning, on putting financial plans into operation, and on monitoring progress toward financial independence for a set of ten demonstration projects sponsored by the Robert Wood Johnson Foundation.

Cost Control↗
PubMed1993

Managing the health care system under a global expenditure limit: a workshop summary.

There is ongoing debate as to whether global budgets, or expenditure limits, are compatible with a strategy for managed competition. The Robert Wood Johnson Foundation sponsored an invitational conference for public and private policymakers to discuss the issue. The meeting's purpose was to explore how global expenditure limits might work and what their implications would be for costs, access, and quality of health care. This article summarizes the ideas presented at the conference, looking in particular at global expenditure limit models in Germany and Canada. Overall, the papers and presentations at this meeting demonstrated that global expenditure limits have the potential to provide the necessary fiscal discipline to manage the health care system and provide a greater degree of certainty and accountability for payers, providers, and patients. However, it is also clear that without a common set of principles about the role health care should play in our society and an agreed upon framework of governance for the system, it will be difficult for the United States to resolve the detailed and complex implementation and administration issues of a reformed health care system.

Budgets↗
PubMed2001

Determinants of public and private insurance enrollment among Medicaid-eligible children.

BACKGROUND: Many Medicaid-eligible children are not enrolled in Medicaid and are not covered by private insurance. Reducing persistent lack of insurance for children requires a better understanding of why Medicaid-eligible children do not participate. RESEARCH QUESTIONS: Does the availability of free or low-cost medical services substitute for Medicaid or private insurance enrollment among Medicaid-eligible children? Does the availability and affordability of insurance coverage, particularly the offer of employer-sponsored insurance (ESI) and the presence of managed care, affect child insurance coverage? RESEARCH DESIGN: We use data from the National Health Interview Survey for 1994 and 1995, supplemented with county level measures of insurance and provider supply, to estimate a multinomial choice model of insurance coverage among children identified as Medicaid-eligible. We focus on county supply of public hospitals and community/migrant health centers (C/MHC); and the availability and cost of ESI. We control for child and parent characteristics. RESULTS: A positive effect of C/MHC supply is found on Medicaid enrollment, but no evidence is found of substitution between low-cost providers and Medicaid or private coverage. Local availability of ESI and private HMO penetration increased private insurance enrollment. CONCLUSIONS: Local community providers can play an important role in outreach and enrollment for Medicaid. Availability and cost of ESI constrain private coverage for Medicaid-eligible children. Policies that encourage offers of insurance coverage by employers, decrease premiums, and encourage adoption of managed care could have important positive effects on coverage for this population.

Adolescent↗