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PubMed2006

Is there a business case for quality in The Netherlands? A critical analysis of the recent reforms of the health care system.

Major reforms of the health insurance system and reimbursement systems for care providers are currently taking place in The Netherlands. These market-oriented health care reforms will transform the current central supply-driven system to a system of managed competition both among health care insurers and care providers. The reforms are not systematically linked to the discussions about quality of care and together with consumers who might be more interested in lower premiums; they offer almost no incentive for health care insurers and providers to steer on quality. Dutch policy makers should, therefore, be more explicit whether competition should take place on quality or price, and if the former is the case, additional incentives as part of the system reforms, are needed to create a business case for quality.

Health Care Reform↗

PubMed1997

New Zealand policy strategies concerning the funding of general practitioner care.

The evolution of New Zealand health policy concerning general practitioner care suggests six major goals: (1) providing GP services universally at zero or very low user charges, (2) increasing the proportion of GPs in rural and sparsely populated areas, (3) increasing the proportion of primary care going to low-income populations, (4) increasing the effectiveness of primary care in promoting health, (5) lowering the cost of primary care provision, and (6) giving patient-consumers (with particular emphasis on Maori) more control over the environments in which primary services are provided. Policy packages have lacked analytical coherence, however, with the consequence that only some of the goals have been effectively promoted at any point in time. The particular policies promoted have varied over time depending on the political party in power, and on the international climate of opinion concerning the prioritising of goals. The current view is that the most significant shift in New Zealand health policy orientation occurred during 1992-1994, with the emphasis on managed competition strategies and increased reliance on user charges. The 1992-1994 policy reforms also reflect a long-standing orientation in New Zealand of attempting to separate the care of the poor from that of everyone else, and of providing care for the poor by the state in a paternalistic context, and the care for the non-poor in market arrangements that reflect the preferences of patients.

Cost-Benefit Analysis↗

PubMed1998

Possible objectives and resulting entitlements of essential health care packages.

The notion of a defined 'core package of essential health care services' has appeared in many different health reform proposals in the 1990s. This paper attempts to explore the possible objectives of the 'core package' component of health care reform. Two board applications are apparent: the use of essential packages to ration scarce public funds and the incorporation of a minimum benefit package into 'managed competition' type reforms, where they constitute a mandated minimum level of private insurance cover. Eight possible objectives for an essential benefit package are described: To protect against catastrophic illness events; to ensure social risk pooling; to improve allocative efficiency in the health system; to eliminate 'high burden of disease' conditions; to improve equity of access to services; to combat cost-escalation; to encourage competition between insurers; and to facilitate public participation and transparency in decision making. Closer examination of objectives reveals that they often conflict, which suggests that a clear understanding of the purpose of reform is essential before it is worthwhile devoting energy to the development of essential benefit packages. It is argued that two main clusters of objectives emerge from the eight described, representing Rawlsian (risk avoidance) and utilitarian (efficiency improvement) social welfare philosophies, respectively. Practical experience suggests that priority setting exercises have been unsuccessful in meeting efficiency objectives, but that they may well be quite useful in fulfilling risk-pooling aims.

Cost-Benefit Analysis↗

PubMed2000

Long-term care restructuring in rural Ontario: retrieving community service user and provider narratives.

This paper examines the extensive restructuring of community-based long-term care that was initiated in Ontario, Canada in 1996, and does so with particular reference to longstanding problems of provision in rural communities. Specifically, it draws on a case study focussed on two small rural towns to develop a 'situated understanding' of service-user and service-provider perspectives on service coordination issues and on service cuts, particularly as they affect the ability of elderly people reliant on publicly-funded community services to stay in their homes, to continue to 'age in place'. The general and specific antecedents of long-term care reform are considered prior to the presentation of the case study. General antecedents include the rapid aging of Canada's population and aggressive strategies to reduce government deficits, while specific antecedents flow from a decade of failed attempts to address longstanding issues of service coordination and from the ideologically-driven, free market stance of the provincial government elected in 1995. The analysis of interviews conducted with 14 community-service users and 17 providers suggests that the managed competition system introduced as the centerpiece of long-term care reform has resulted in increasing diversity and uncertainty on both sides of the service provision equation. Despite continued attempts by rural elderly people and their families to 'cut and paste' support packages, it seems that the restructuring of publicly-funded community services, combined with a substantial re-investment in long-term care facilities, will make some elderly people more vulnerable to institutionalization.

Aged↗

PubMed2003

Expanding access to emergency contraception: the case of Brazil and Colombia.

Emergency contraception was proven effective nearly 30 years ago yet remains greatly under-utilised. In the Latin American and Caribbean region, it would serve the goals of reducing unwanted pregnancy, unsafe abortion and related morbidity, and as a back-up to condom use and a bridge to longer-term contraceptive methods if made more widely known and available. The International Planned Parenthood Federation Western Hemisphere Region has developed a model for the integration of emergency contraception into sexual and reproductive health care services. This model is being tested in a two-year project with national affiliates in Brazil, Chile, Colombia, the Dominican Republic and Venezuela, and will contribute to the work of the Latin American Consortium for Emergency Contraception. Case studies of Brazil and Colombia describe how health sector reforms, e.g. decentralisation and managed competition among health insurers and service providers, have influenced promotion strategies. The experience of Profamilia Colombia with registration of a dedicated product and providing emergency contraception within its national network of clinics, with a focus on staff training and work with young people, is described. In Brazil, BEMFAM's study of different modalities for offering emergency contraception, e.g. through contractual agreements with municipalities and its own clinics, is highlighted.

Brazil↗

PubMedDate not supplied

Gender impacts on health insurance coverage: findings for unmarried full-time employees.

Probit regression is applied to a sample of fully employed unmarried respondents from the 1996 Medical Expenditure Panel Survey to determine the likelihood of private health insurance vs. no insurance coverage. Gender-related employment segregation is a strong indicator for insurance coverage, since those in male-dominated industries are more likely to have coverage. The strong impact of unions and number of plans offered on insurance coverage suggests that insurance purchasing cooperatives and managed competition may increase availability of affordable coverage, thus alleviating some of the financial barriers to health care.

Adult↗

PubMed2001

Choice and solidarity: the health sector in Eastern Europe and proposals for reform.

The citizens of Eastern Europe have witnessed an unprecedented social and economic transformation during the past decade of transition from socialism to market-based economies. We describe the legacy of socialism and summarize the current state of the health sector in ten Eastern European countries, including financing, delivery, purchasing, physician incomes and the widespread phenomenon of under-the-table payments. The proposals for reform, derived from explicit guiding principles, are based on organized public financing for basic care, private financing for supplementary care, pluralistic delivery of services, and managed competition, with attention to incentives and regulation to impose a constraint on overall health spending.

Europe, Eastern↗

PubMed2005

On the origins of the task mixing cost in the cuing task-switching paradigm.

Poorer performance in conditions involving task repetition within blocks of mixed tasks relative to task repetition within blocks of single task is called mixing cost (MC). In 2 experiments exploring 2 hypotheses regarding the origins of MC, participants either switched between cued shape and color tasks, or they performed them as single tasks. Experiment 1 supported the hypothesis that mixed-tasks trials require the resolution of task ambiguity by showing that MC existed only with ambiguous stimuli that afforded both tasks and not with unambiguous stimuli affording only 1 task. Experiment 2 failed to support the hypothesis that holding multiple task sets in working memory (WM) generates MC by showing that systematic manipulation of the number of stimulus-response rules in WM did not affect MC. The results emphasize the role of competition management between task sets during task control.

Cues↗

PubMed2006

Made in the USA: the import of American Consumer Assessment of Health Plan Surveys (CAHPS) into the Dutch social insurance system.

BACKGROUND: In the Netherlands, managed competition between health plans has been introduced. For Dutch health plans this implies that they need to collect data about their own performance and that of the care providers they contract. To that end, Consumer Assessment of Health Plan Surveys (CAHPS) instruments have recently been adopted by a large Dutch health plan. OBJECTIVES: This paper presents the results of a validation study of the Dutch version of the CAHPS Adult Commercial questionnaire. The questions addressed are as follows: Can this questionnaire be adapted for use in the context of the Dutch insurance system? and Can it generate valid information about the quality of health care and the performance of Dutch health plans? METHODS: The translated questionnaire has been mailed to a sample of 977 enrollees. The psychometric properties of the translated instrument have been studied, and the results have been compared with those of other Dutch and American studies. RESULTS: The net response rate was 51% (n = 500). In general, the questionnaires were filled out completely and consistently. Principal component analyses revealed a factor that can be labelled as patient-centredness in the primary process. It contains the domains that in the CAHPS literature are described as 'courteous/helpful staff' and 'doctors communicating well'. CONCLUSIONS: The translated version of the CAHPS Adult Commercial questionnaire is a promising tool for Dutch health plans. More research is needed on the external and the content validity of these questionnaires in the Dutch context.

Adult↗

PubMed1998

Health policy reforms and their impact on the practice of tropical medicine.

This paper addresses the consequences of reforming health policies on the practice of tropical medicine. It briefly reviews the historical development of health systems in poor, tropical countries before summarising current trends in the reform of financing and management. Reforms considered include decentralising management, broadening choices in health financing, particularly introducing user fees, introducing 'managed competition' principles, and working with the private sector. Experiences in different countries are used to highlight some of the dangers inherent in current reform trends. It is suggested that while monopolistic and centralised systems of public provision are unlikely to come back into fashion, much can be done to build on the more positive aspects of current reforms and to minimise their undesirable side effects. Key issues are developing mechanisms that ensure that services are responsive to users, avoiding polarisation of services between rich and poor, and improving systems of regulation, supervision and monitoring.

Cost-Benefit Analysis↗

PubMed2002

A review of the 'welfare state' and alternative ways of delivering health care.

There was no such thing as a public policy for quality health care in the inception of what we now address as the 'welfare state'. The main objectives of those supporting the idea, epitomized by the 'freedom from want' that Beveridge postulated in his now famous November 1942 Report on Social Insurance and Allied Services, was to extend the benefits of social insurance, that is access to services such as health care, to every individual. In the same fashion, post World War II initiatives in Latin America somewhat disregarded the intrinsic quality of health care services, provided they were distributed equally, at least among the urban people. Therefore, it is licit to ascertain that the main, albeit implicit, quality feature of health care was access, that is the ability to reach the entire population with the available services. The health care reform movement following the welfare state crisis, from the Jackson Hole group and Einthoven's managed competition in the United States to the internal markets proposals in different European countries, started when universal coverage had been achieved where it had been pursued, and disregarded elsewhere. In other words, access as a measure of health care quality was not the point. Instead, the subject of both academic research and administrative initiatives was the quality of the health services effectively provided to the population. Furthermore, the World Health Organization in its World Health Report 2000 explicitly excluded access as an item to be assessed in the process of evaluating health systems, although many countries had not achieved, nor were even near, universal coverage. Therefore, notwithstanding the relevance of the continuous quality improvement of the health services actually delivered to the people, access should always be the first quality concern to those health systems lacking universal coverage of the population they are supposed to serve.

Congresses as Topic↗

PubMedDate not supplied

Upstream or downstream. Determinants of consumer willingness to recommend an HMO.

Understanding the attributes that explain an HMO members' willingness to recommend a health plan is considered by many to be critical in a competitive managed care market. The study reported in this article examines the relationship between provider panel composition on overall willingness to recommend a health plan. Our results indicate that a strong association exists between an HMO member's available choice of primary care physician and recommendation of their primary care physician with overall HMO members' recommendation of the health plan. Interestingly, a member's recommendations of hospitals and specialists did not influence HMO member's willingness to recommend a health plan.

Female↗

PubMed1995

Epidemiology and the Italian national health service.

The Italian national health services is under criticism. Although recent legislative changes are intended to introduce managed competition, there is no clear epidemiological view of the health care needs and priorities. Several inconsistencies and inequalities (particularly between the northern and the southern regions) are obvious, both in the health status of the population and in the provision of health care. Problems that should be addressed by future governments are: the uneven distribution of medical technology; the persistence of large inequalities, documented by outcomes such as rheumatic fever, between northern and southern regions; the large variability in clinical practices; the lack of an explicit policy as far as the diffusion of advanced technology is concerned; the ensuing "hidden" rationing; and the peculiar relationship between public and private health structures. Both the current ideological shift towards a market economy for health care and the traditional lack of epidemiological input in health care planning could threaten a rational approach to these problems.

Breast Neoplasms↗

PubMed2006

[Impact of palliative care and clinical features of patients with terminal diseases in areas of Internal Medicine].

INTRODUCTION: The medical assistance to patients with terminal diseases has been structured with Primary Care and Palliative Care Units as protagonists, and with other specialties as secondary roles. Nevertheless the impact of this group of patients in Internal Medicine areas is unknown. Our objective was to evaluate these parameters in the area of Internal Medicine of a tertiary teaching Hospital. MATERIAL AND METHODS: Prospective observational study of all patients attended in Internal Medicine areas during June 2003. Patients were stratified in three cohorts (palliative, pluripathologic, and general). Incidence of palliative patients, origin, clinical features, and burden of hospital care in the last 12 months were analyzed. Univariate analysis of the clinical differences between the palliative and the pluripathologic, and general cohorts was performed, using Chi-square, Fisher, ANOVA and post-hoc tests and Kruskal-Wallis test. RESULTS: 52 (53.8% women; mean age 66.5 +/- 15 years) were included from the global study cohort of 339 patients. Incidence of palliative patients was 15.4/100 admissions. The patients were admitted from other specialties (57.6%), Emergency department (27%), and Primary Care (10%). Mean hospital stay was 14.5 (1-150) days, and survival 63.5%. The 68.5% of deceases occurred at home. Patients of palliative cohort, with respect to general cohort had less functional ability at baseline (47.5 vs 95; p < 0.0001), admission (40 vs 75; p < 0.0001), and at discharge (20 vs 75; p < 0.0001), and more functional deterioration during hospital stay (mean fall in Barthel's values at baseline-discharge of 27.5 vs 20 points; p < 0.003). There were no differences in the burden of hospital care in the previous 12 months. With respect to the cohort of pluripathologic patients, palliative patients were younger (66.5 +/- 15 vs 75 +/- 11 years; p = 0.001) and had similar functional limitations at baseline (47.5 vs 45), admission (40 vs 20) and at discharge (20 vs 20). DISCUSSION: Patients with terminal diseases are prevalent in the clinical setting in areas of internal medicine. These data support the role of the internist in palliative care proceedings, and prompt internists to acquire enough specific abilities to manage competitively these population.

Aged↗

PubMed2002

Professional accountability in restructured contexts of occupational therapy practice.

Professional standards for accountability establish essential competencies for clinical practices and provide strategies for professional advancement. This study examines the perspectives of a sample of occupational therapists on their capacity to engage in continuing education, to provide evidence-based practices and to have confidence in the effectiveness of available quality assurance mechanisms within restructured contexts of occupational therapy practice. The analysis of in-depth interviews with participants from program management, managed competition and private practice suggested three urgent needs: the development of strategies to assist therapists' translation of research evidence into clinical practices, research to determine the effectiveness of models of professional leadership within the workplace that promote professional accountability and alliances to advance policies that eliminate workplace barriers to professional accountability.

Education, Continuing↗

PubMed1994

An American macromanaged health care system?

The implementation of President Clinton's proposed health reform plan that ensures universal access and relatively comprehensive health insurance benefits to over 250 million Americans would have a significant impact on their hospitals, physicians, and other health care providers. With this projected coverage, the 36.7 million Americans now uninsured would demand an additional volume of services. It is doubtful, because of this nation's trade and budget deficits, that any significant increases in expenditures for health will be made available from the public sector. Therefore, providers in the US will need to deliver significantly more care with a minimal increase in total reimbursement. These conclusions are further supported by the experiences of the Canadian and the German macromanaged health care systems that provide considerably more hospital and physician services per person per year than the US at a lesser cost per discharge and percentage of their respective nation's gross domestic product. America may be heading toward macromanaged global budget targets, but for political and other reasons President Clinton's health reform plan will be implemented with a multi-payer, managed competition approach.

Canada↗

PubMed1993

Is the time finally ripe? Health insurance reforms in the 1990s.

Reformers feel certain that the time is now ripe for progressive legislation to ensure universal citizen access to health insurance and to contain rising costs in the health care industry. But history shows us that reformers were equally confident in earlier periods of modern U.S. history, only to find themselves defeated by conservatives willing to deploy ideological, emotionally charged arguments against government-sponsored reforms. Today's advocates of inside-the-beltway bargains for hammering out compromise reforms may be vulnerable to similar conservative counterattacks. Reformers need to engage the U.S. citizenry as a whole in democratic discussion about the ideals of government-sponsored health care reforms. Advocates of single-payer plans can do this more readily than supporters of complex public-private schemes such as play or pay or managed competition, but all those who want inclusive and effective reforms during the 1990s must face the challenge of democratic dialogue.

Consumer Advocacy↗

PubMed2003

Has solidarity survived? A comparative analysis of the effect of social health insurance reform in four European countries.

Social health insurance reform has evolved as an important public policy issue in several European countries. Some of the most important reform programs have been the introduction of managed competition, a shift from full retrospective reimbursement of health insurers to prospective reimbursement, an increase of private payments, and a change in the health benefits of social health insurance. The article investigates the widespread assumption that reform programs have adverse effects on solidarity in social health insurance by looking at the concrete experience of four European countries (Belgium, Germany, The Netherlands, and Switzerland) over the past decade. A distinction is made between risk solidarity and income solidarity, and the scope of solidarity is shown to have two dimensions: entitlements and membership. The analysis consists of three parts: description of the structure of health insurance of each of the four countries in the early 1990s; discussion of health insurance reform; determination of the impact on each dimension of solidarity. The findings are mixed. There are indeed some examples of solidarity having declined as the result of health insurance reform. But, more important, many examples also were found of an increase in solidarity due to health insurance reform. In some cases, reform was explicitly intended to improve solidarity. If a reform program had a negative impact on solidarity (e.g., an increase in private payments), accompanying measures often were taken to keep solidarity intact as much as possible. Thus the assumption of a negative impact as a result of health insurance reform is not confirmed.

Belgium↗