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PubMed2005

Universalism without the targeting: privatizing the old-age welfare state.

Decades of conservative attempts to scale back Social Security and Medicare, by limiting the program's universality through means testing and drastic benefit cuts, have failed. Thus, after numerous unsuccessful attempts at dismantling the U.S.'s universal old-age welfare state, or even meaningfully restraining its growth, conservative critics have developed a new approach. They are wrapping promarket "privatization" policy proposals in the popular universal framework of Social Security and Medicare. What is fundamentally different about privatization is that it embraces (or at least acquiesces to) key aspects of universalism, including broad-based eligibility and benefits that "maintain accustomed standards of living," which leave universal programs with rock-hard public support. Proponents argue privatization will "save" these programs. What distinguishes this approach from past retrenchment efforts is that promarket privatization policies, while supporting key universal tenets, will retrench Social Security's and Medicare's redistributive facets. Instead of limiting the most popular features of universalism, privatization proposals limit the redistributive elements of our large social insurance programs.

Medicaid↗
PubMed1995

Efficiency and quality in the public and private sectors in Senegal.

It is often argued that the private sector is more efficient than the public sector in the production of health services, and that government reliance on private provision would help improve the efficiency and equity of public spending in health. A review of the literature, however, shows that there is little evidence to support these statements. A study of government and non-governmental facilities was undertaken in Senegal, taking into account case mix, input prices, and quality of care, to examine relative efficiency in the delivery of health services. The study revealed that private providers are highly heterogeneous, although they tend to offer better quality services. A specific and important group of providers--Catholic health posts--were shown to be significantly more efficient than public and other private facilities in the provision of curative and preventive ambulatory services at high levels of output. Policies to expand the role of the private sector need to take into account variations in types of providers, as well as evidence of both high and low quality among them. In terms of public sector efficiency, findings from the study affirm others that indicate drug policy reform to be one of the most important policy interventions that can simultaneously improve efficiency, quality and effectiveness of care. Relationships that this study identified between quality and efficiency suggest that strategies to improve quality can increase efficiency, raise demand for services, and thereby expand access.

Efficiency, Organizational↗
PubMed2002

Linking private and public sectors in tuberculosis treatment in Kathmandu Valley, Nepal.

Tuberculosis (TB) is a major public health problem and the world's foremost cause of death from a single infectious agent. Despite the increasing number of TB patients who seek help in the private sector, there are few practical examples of how to create a public/private linkage of TB services. The paper presents a pilot service-linkage project between the public and private sector in TB control in Kathmandu Valley, Nepal. The study documents and examines the process of the service-linkage project through the undertaking of a longitudinal analytical case study. A detailed description of the project from formulation to a short-term evaluation is given. The analysis relates the activities and early outcomes of the service-linkage project to the context, characteristics and interactions of the organizations involved. The study reveals that although the involved organizations initially agreed on the objective of the service-linkage project, differences in capacity, motivation, environment and needs had implications for the implementation and short-term success of the project. The public sector, despite the will, did not have the structure or resources to engage with the private sector. The private sector lacked interest in public health aspects of TB treatment and trust in the public sector. The study points to two different organizations that have the potential capacities to act as mediators between the public and private sectors: international research institutions and non-governmental organizations.

Antitubercular Agents↗
PubMed2005

A descriptive study of private practice in music therapy.

Of professional music therapists in the American Music Therapy Association, 9% report being self-employed or in private practice. The purpose of this paper was to provide initial data concerning music therapists who are in private practice. The researchers successfully sent out 353 surveys and 118 were completed and returned via electronic mail for a response rate of 33.4%. Although general, results indicate that music therapists in private practice are active within the profession, doing presentations and inservices, conducting research, supervising practica students and interns, and keeping current with forthcoming research. Data indicate that most music therapists chose private practice due to a more flexible schedule, increased salary, and the lack of previously established job opportunities. Additionally, 65.8% of respondents reported having a bachelor's degree in music therapy, 29.2% reported having a master's degree, and 5.1 % reported having a doctoral degree. Quantitative results, rationale, and suggestions are included in an attempt to assist music therapists who are interested in starting private practices.

Attitude of Health Personnel↗
PubMed1991

A comparison of hospital-based and private outpatient physical therapy practices.

A paucity of data exists about the delivery of contemporary adult outpatient physical therapy services in the United States. Although many debates about this issue have taken place within the physical therapy profession, assumptions about practice patterns have generally not been studied. This article reports some of the first-year findings from a 3-year survey research effort begun in September 1988 by Mathematica Policy Research Inc for the American Physical Therapy Association. Analyses are based on survey data from national probability samples of physical therapy facilities and discharged patients from 155 hospital-based and 166 private outpatient practices. The primary goal was to compare outpatient physical therapy practice patterns in the hospital-based and private practice settings. Findings reveal considerable homogeneity in private and hospital-based outpatient physical therapy practices. Hospital-based and private practices serve predominantly young, white adults who have private health insurance and a prevalence of orthopedic impairments. In both settings, direct access to outpatient physical therapy services was the exception and not the rule. Even in states in which direct access without a physician's referral was permitted by law, the majority of outpatient physical therapy was provided with a physician's referral. Most respondents in direct-access states indicated that reimbursement requirements were the major reason for needing a physician's referral to provide outpatient physical therapy.

Adult↗
PubMed1999

Private or NHS General Dental Service care in the United Kingdom? A study of public perceptions and experiences.

BACKGROUND: Recent changes in the NHS General Dental Service have led to a reduction in the availability of NHS dental care and increased charges. This study explores public and user views and experiences of NHS and private dental care in the light of these changes. METHODS: The study employed a combination of quantitative and qualitative methods. The first phase involved a postal survey of a random sample of adults on the electoral registers in a county in Southern England, which yielded a response rate of 55 per cent (n = 1506). Follow-up face-to-face interviews were carried out with sub-samples (n = 50) selected from survey respondents. RESULTS: The evidence shows greater satisfaction with certain aspects of private care than with NHS dental care and suggests that the decline in perceived quality of NHS care is less to do with the quality of dental technical skills and more to do with perceived access and availability. However, there was general support for the egalitarian principles associated with NHS dentistry, although payment for dental care by users was acceptable even though dentistry on the NHS was preferred. CONCLUSION: The shift in the balance of NHS and private dental care reflects the interests and preferences of dentists rather than of the public. It suggests, however, that a continued shift towards private practice is a trend that the public will not find acceptable, which might limit the extent of expansion of private practice.

Adult↗
PubMedDate not supplied

Sociodemographics, general health, and psychologic health in uninvestigated dyspepsia: a comparison of public and private patients.

GOALS: To compare the dyspepsia severity, general health, and psychologic health of patients with uninvestigated dyspepsia presenting in private and public settings. STUDY: Patients in this cross-sectional study were recruited from the Houston Veterans Administration (VA) General Medicine Outpatient Clinic and from the nearby private practice of a family physician. To be included, patients had to be at least 18 years of age and had to report a history of dyspepsia (epigastric discomfort) without alarm of at least 1 week's duration. Clinical information was obtained. Dyspepsia severity was measured using dyspepsia-related health scales, general health was measured using the Short Form 36, and psychologic health was measured using six scales. RESULTS: The authors enrolled 159 patients (59 VA). There were no differences in VA and private patients in most of the clinical characteristics related to dyspepsia. Compared with the private patients, the VA patients had worse scores on all Short Form 36 subscales, had lower expectations for treatment outcome, were more depressed, and had less optimism about life. CONCLUSIONS: Burden of illness and psychologic factors such as patient expectations are known to have important effects on patient outcomes. Striking differences in these factors exist in patients with uninvestigated dyspepsia seen in private and public settings. In the future, these factors must be taken into account both in conducting studies in dyspepsia and in interpreting the results for different practice settings.

Adult↗
PubMed1980

Real costs of dental care in private and public practices.

The Chattanooga Project was a publicly funded program providing dental care to indigent children by private practice and public fixed and mobile clinics. Previous studies of the project have shown that the cost of providing dental care in public practices was lower than in private practices, and that this difference was not attributable either to the social characteristics of the children nor to the type of care provided. This article analyzes potential economic causes of the cost differences arising from the input-output relationships in each mode. Because the number and frequency of service types and productivity rates differed among the modes, a standard service package was developed. Productivity and costs were recalculated on the basis of this standard set of services. The results were that with services and productivity held constant the differences between private and public costs increased. The implications are that resources in the private practices were earning significantly higher returns than those in the public practices, and that public practices can offer viable economic alternatives to private practices in the provision of dental care.

Adolescent↗
PubMed1991

Contracting between public agencies and private psychiatric inpatient facilities.

Purchasing human services through contracts with private providers has become an increasingly common practice over the past 20 years. Using data from a national survey of psychiatric inpatient facilities, this paper examines the extent to which psychiatric units in privately controlled general hospitals and private psychiatric specialty hospitals (N = 611) participate in contractual arrangements to provide services to governmental bodies. It also examines how the likelihood of such a practice is affected by hospital characteristics (general or specialty, for profit or nonprofit) and features of hospitals' environments, including the competitiveness of the market for psychiatric inpatient care and the population's need for services in the hospital's county. The findings indicate that nonprofit psychiatric specialty hospitals were more likely than other types of hospitals to enter into such contracts, and that forces such as local competition and need for services were not predictors of such involvement. Contracting was shown to have a significant impact on the level of referrals a hospital accepted, but these levels were also affected by competition and need. Among hospitals with public contracts, referral acceptance from public agencies was unaffected by these factors, but they did have a significant effect on referral acceptance by hospitals without public contracts. These data suggest that public agencies contracting for services with private hospitals may represent a means by which "public sector" patients may gain access to private providers. Further, this mechanism may impose sufficient structure and regulation on the acceptance of such patients that many concerns of hospital administrators regarding patients who are costly and difficult to treat and discharge can be allayed.

Contract Services↗
PubMed2004

Variation in care for nonmelanoma skin cancer in a private practice and a veterans affairs clinic.

BACKGROUND: Nonmelanoma skin cancer is the most common malignancy. Multiple therapies prevent recurrence but vary widely in cost. The most common therapies are local destruction, excision, and Mohs surgery (histologically guided tumor removal). Clinical variables that may affect treatment choices can be identified, but little is known about how clinicians choose among therapies. OBJECTIVE: The objective of this study was to learn if variations exist in the treatment of nonmelanoma skin cancer in different practice settings. RESEARCH DESIGN: Prospective cohort study. SUBJECTS: Subjects consisted of consecutive patients with nonmelanoma skin cancer at a university-affiliated private dermatology practice and the dermatology clinic at the nearby affiliated Veterans Affairs (VA) medical center. DATA: We studied data from medical records and patient surveys. RESULTS: Overall, 1777 nonrecurrent nonmelanoma skin cancers were diagnosed in 1375 patients. Compared with the VA site, patients at the private site were younger, more likely to be female, and less likely to be poor, and their tumors were smaller and less likely to be on visible areas of the body. Treatments varied between the 2 sites (P <0.001). The proportions of tumors treated at the private and VA sites, respectively, were 23% and 19% for destruction, 25% and 48% for excision, and 37% and 25% for Mohs surgery. In multiple clinical subgroups, Mohs surgery was more likely to be performed at the private site than at the VA. Moreover, in multivariable models controlling for clinical features that may have affected treatment choice, tumors at the private site were more likely than tumors at the VA to be treated with Mohs surgery (odds ratio, 2.39; 95% confidence interval, 1.54-3.70). CONCLUSIONS: Care for nonmelanoma skin cancer varied at 2 academic practice sites that are near each other and that share some clinician staff. These findings raise questions not only about overuse or underuse of procedures at the 2 sites, but also about systematic differences in patient preferences and/or physician incentives in prepaid and fee-for-service settings.

Age Factors↗
PubMed1989

Elderly patients' satisfaction with care under HMO versus private systems.

In one community, 100 elderly persons (25 HMO and 75 private patients) completed a 20-item scale that measured satisfaction with medical care. Data on demographics, health care utilization, and self-assessed health status also were collected to determine whether these variables would relate to HMO membership. Satisfaction scores were compared between HMO and private care groups by multivariate analysis of variance. Satisfaction with the doctor-patient relationship and convenience of care was higher in the private care group, whereas satisfaction with cost was higher in the HMO group. Interestingly, the HMO group evaluated private care and HMO care similarly. The private group rated HMO care less favorably. Additional comments reveal specific areas of satisfaction/dissatisfaction.

Aged↗
PubMedDate not supplied

Public and private sector contributions to the discovery and development of "impact" drugs.

Recently, well-publicized reports by Public Citizen and the Joint Economic Committee (JEC) of the US Congress questioned the role of the drug industry in the discovery and development of therapeutically important drugs. To gain a better understanding of the relative roles of the public and private sectors in pharmaceutic innovation, the Tufts Center for the Study of Drug Development evaluated the underlying National Institutes of Health (NIH) and academic research cited in the Public Citizen and JEC reports and performed its own assessment of the relationship between the private and public sectors in drug discovery and development of 21 "impact" drugs. We found that, ultimately, any attempt to measure the relative contribution of the public and private sectors to the research and development (R&D) of therapeutically important drugs by output alone, such as counting publications or even product approvals, is flawed. Several key factors (eg, degree of uncertainty, expected market value, potential social benefit) affect investment decisions and determine whether public or private sector funds, or both, are most appropriate. Because of the competitiveness and complexity of today's R&D environment, both sectors are increasingly challenged to show returns on their investment and the traditional boundaries separating the roles of the private and public research spheres have become increasingly blurred. What remains clear, however, is that the process still starts with good science and ends with good medicine.

Drug Industry↗
PubMed2003

In-hospital mortality following coronary artery bypass graft surgery in Veterans Health Administration and private sector hospitals.

OBJECTIVES: Compare severity-adjusted in-hospital mortality in patients undergoing coronary artery bypass graft surgery (CABG) in VA and private sector hospitals in two geographic regions. RESEARCH DESIGN: Retrospective Cohort Study. SUBJECTS: Consecutive male patients undergoing CABG from October 1993 to December 1996 in: 43 VA hospitals with cardiac surgery programs (n = 19,266); 32 hospitals in New York (NY) State (n = 44,247); and 10 hospitals in Northeast (NE) Ohio (n = 9696). METHODS: Demographic and clinical data were abstracted from medical records. Logistic regression analysis identified 10 independent patient-level predictors (P <0.01) of in-hospital mortality: age, prior CABG, angioplasty before CABG, ejection fraction, diabetes, peripheral vascular disease, congestive heart failure (CHF), cerebrovascular disease, renal insufficiency, and chronic obstructive pulmonary disease (COPD). RESULTS: Unadjusted mortality was higher in VA patients than in NY or NE Ohio patients (3.5% vs. 2.0%, and 2.2%, respectively). Mortality decreased (P <0.001) with increasing volume (3.6% in low [<500 cases], 3.0% in moderate [500-1000 cases], and 2.0% in high [>1000 cases] volume hospitals). Median volume was lower in VA than private sector hospitals (410 vs. 1520), and no VA hospitals were classified as high volume. Adjusting for patient-level predictors and volume, the odds of death was higher in VA patients, relative to private sector patients (OR, 1.34; 95% CI, 1.11-1.63; P <0.001). In stratified analyses, the odds of death in VA patients was similar in low volume hospitals (OR, 0.86; P = 0.39), but higher in moderate volume hospitals (OR, 1.50; P = 0.01). CONCLUSIONS: VA hospitals had lower CABG volume than private sector hospitals in NY and NE Ohio, and higher in-hospital mortality. However, the difference in mortality was limited to moderate-volume hospitals. These findings suggest that hospital volume is an important modifier in comparisons of CABG mortality in VA and private sector hospitals. The higher mortality in VA hospitals may, in part, be caused by differences in surgical capacity and patient demand that lead to lower volume cardiac surgery programs.

Age Distribution↗
PubMed2003

Methods for estimating private sector payments for VA acute inpatient stays.

OBJECTIVES: To describe methods for estimating hypothetical private sector payments for Veterans Health Administration (VA) acute inpatient stays. METHODS: We assumed all VA hospitalizations would have occurred under a hypothetical VA system that paid private sector providers but had the current benefit package for VA patients. We compared aggregate budgets for VA inpatient care (less physician salaries) at six VA hospitals over federal fiscal year 1999 to aggregated hypothetical private sector payments developed using VA diagnosis-related groups matched to metropolitan-based average Medicare payments. Counts of care came from the VA's statistical analysis system (SAS) inpatient files. Inpatient stays with both medical or surgical and psychiatric or rehabilitation care were counted as two stays. An external auditor conducted three reviews of VA coding practices during the study year, and the appropriateness of admissions was examined using a commercial utilization review tool. RESULTS: For 30,518 inpatient discharges, hypothetical payments were $188 million, compared with the VA budget of $171 million. Fifteen of the 25 most frequent diagnosis-related groups in the VA were also in the top 25 for Medicare in 1998 and 1999. Audits established that the overall financial impact of VA coding problems was similar to that in the private sector. DISCUSSION: Differences in organization, practice, and incentives limit estimates of the financial impact of shifting VA acute inpatient care to the private sector.

Budgets↗
PubMed2001

Perceived outcomes of public health privatization: a national survey of local health department directors.

Almost three quarters of the nation's local health departments (LHDs) have privatized some services. About half of LHD directors who privatized services reported cost savings and half reported that privatization had facilitated their performance of the core public health functions. Expanded access to services was the most commonly reported positive outcome. Of those privatizing, over two-fifths of LHDs reported a resulting increase in time devoted to management. Yet, one-third of directors reported difficulty monitoring and controlling services that have been contracted out. Communicable disease services was cited most often as a service that should not be privatized. There is a pervasive concern that by contracting out services, health departments can lose the capacity to respond to disease outbreaks and other crises.

Administrative Personnel↗
PubMed2006

Sharing the burden of TB/HIV? Costs and financing of public-private partnerships for tuberculosis treatment in South Africa.

OBJECTIVE: To explore the economic costs and sources of financing for different public-private partnership (PPP) arrangements to tuberculosis (TB) provision involving both workplace and non-profit private providers in South Africa. The financing required for the different models from the perspective of the provincial TB programme, provider, and the patient are considered. METHOD: Two models of TB provider partnerships were evaluated, relative to sole public provision: public-private workplace (PWP) and public-private non-government (PNP). The cost analysis was undertaken from a societal perspective. Costs were collected retrospectively to consider both the financial and economic costs. Patient costs were estimated using a retrospective structured patient interview. RESULTS: Expansion of PPPs could potentially lead to reduced government sector financing requirements for new patients: government financing would require $609-690 per new patient treated in the purely public model, in contrast to PNP sites which would only need to $130-139 per patient and $36-46 with the PWP model. Moreover, there are no patient costs associated with the treatment in the employer-based facilities and the cost to the patient supervised in the community is, on average, three times lower than in public sector facilities. CONCLUSIONS: The results suggest that there is a strong economic case for expanding PPP involvement in TB treatment in the process of scaling up. The cost to the government per new patient treated could be reduced by enhanced partnership between the private and public sectors.

Antitubercular Agents↗
PubMed2000

Epidemic of cesarean section at the general, private and university hospitals in Thailand.

OBJECTIVE: To undertake a survey of cesarean section in the general, private and university hospitals in Thailand. METHODS: Postal questionnaires were sent to all the general, private and university hospitals with 200 beds or more. The questionnaires were prepared to find out the percentage, the indications and the trend of cesarean delivery, the measures taken to decrease cesarean section rate, and the practice of external cephalic version (ECV) and vaginal birth after cesarean section (VBAC) in the hospitals. RESULTS: The overall response rate was 88%. Mean cesarean section rates were 24, 48, and 22% in the general, private and university hospitals, respectively. Cesarean section rates in most of the hospitals were increased in the past 5 years namely 78% in the general hospitals, 50% in the private hospitals, 66% in the university hospitals. However, only 38% of the hospitals had measures to regulate this operation. Repeated cesarean section was the most common indication in the private (63%) and the university hospitals (88%) while failure to progress was the most common indication in the general hospitals (55%). ECV and VBAC were performed in 26 and 12% of the hospitals. They were, however, not the standard practices. CONCLUSION: Rising of cesarean section rate without any measure to regulate it is the problem in the developing countries. Standardised labor management and reduction of unnecessary primary cesarean section will automatically reduce repeated operation and overall cesarean section.

Cesarean Section↗
PubMed1990

Private hospital and phase I.

Since December 1988. French law has authorized phase I studies and the creation of phase I units within public or private hospitals. The scientific standards regarding private hospitals are not different from those in public hospitals. Practitioners who conduct clinical trials in private hospitals are well aware of good clinical practices and methodological constraints. Phase I units can be structured in private as well as within public hospitals. Finally, the question to be addressed is whether clinical pharmacology and scientific investigations in healthy volunteers should be integrated in the policy of private hospitals.

Drug Evaluation↗