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PubMed1992

Privatization in health and human services: a critique.

Privatization currently enjoys wide appeal as a solution to public problems. Supporters of privatization hope that shifting responsibility for the funding, administration, and delivery of services to private organizations and individuals will spur market competition and thus lower costs, improve service effectiveness, and enhance program quality. An increasingly common form of privatization in health and human services is contracting with nonprofit organizations. Such contracting, in practice, does not follow market principles but is, instead, fraught with politics and inadequate information and built on long-term relationships between government and contract agencies. The operations and practices of contracting have important implications for the ongoing debate on the desirability of vouchers for health care insurance and for reform in the contracting process.

Contract Services↗
PubMed1992

Financing long-term care: a practical mix of public and private.

Congress is considering proposals to improve its financing of long-term care. The key issue is whether it should support a social insurance program or a program targeted to a population group defined by income and assets. Social insurance is expensive, costing between $15 and $20 billion. For the most part, it provides benefits--primarily asset protection--to middle- and upper-income individuals. An improved Medicaid program, costing about $8 billion, benefits lower-income individuals but does not protect those with higher incomes. These two options cannot be viewed independently from trends in the private market. Sales of private long-term care policies have grown and between 30 percent and 40 percent of the elderly can be considered potential buyers. If private alternatives are available for those individuals who need asset protection, the case for a more targeted public approach--along with reliance on the private sector--becomes more compelling. Congress should consider a program that enhances Medicaid; improves consumer education; assists states in regulating long-term care policies, so as to enhance consumer protection and confidence; and clarifies taxes on long-term care insurance to encourage workers and the elderly to protect themselves against catastrophic expenses.

Aged↗
PubMedDate not supplied

The politics of managed competition: public abuse of the private interest.

The doctrine of managed competition in health care sought to achieve the social goals of access and efficiency using market incentives and consumer choice rather than governmental regulation and public administration. In retrospect, it demanded too much from both the public and the private sectors. Rather than develop choice-supporting rules and institutions, the public sector has promoted process regulation and benefit mandates. The private health insurance sector has pursued short-term profitability rather than cooperate in the development of fair competition and informed consumer choice. Purchasers have subsidized inefficient insurance designs in order to exploit tax and regulatory loopholes and to retain an image of corporate paternalism. America's health care system suffers from the public abuse of private interests and the private abuse of the public interest.

Consumer Behavior↗
PubMed2001

Private dentistry: why we need the facts.

Rumor and speculation abound within the dental profession about practitioners withdrawing from the NHS to deliver more private dentistry. Due to an absence of effective monitoring or research into this issue the real situation is unclear. We decided to find out what proportions of the gross incomes of general dental practitioners in the East Riding Health Authority were generated by private dentistry. We also sought to establish if they perceived any differences between the quality of their private and NHS work. Our findings and the issues raised are considered for general dental practitioners, for people residing in the authority, and for managers and policy makers. We conclude that the effective management of the supply of NHS dentistry should include a method of systematic monitoring of trends in the delivery of private dental services and the impact on the availability of NHS care. Effective measures are also needed to influence the number and location of dentists in health authorities in England and Wales to ensure adequate and equitable access to NHS dentistry.

Dental Care↗
PubMedDate not supplied

Private health purchasing practices in the public sector: a comparison of state employers and the Fortune 500.

State governments are influential purchasers of health benefits but have not been studied extensively. In a recent survey of senior benefit managers, we examine the extent to which states have followed the private-sector approach to purchasing health care. We found that states have adopted "industrial purchasing" practices similar to those of large private employers but offer greater choice of carriers and pay a higher percentage of premiums. Unions continue to influence health care purchasing in both the public and private sectors. Double-digit increases in health costs and the current budget crisis may force states to align their purchasing practices with the private sector to cut costs.

Budgets↗
PubMed1999

Assessing immunization performance of private practitioners in Maine: impact of the assessment, feedback, incentives, and exchange strategy.

INTRODUCTION: A provider-based vaccination strategy that has strong supportive evidence of efficacy at raising immunization coverage level is known as Assessment, Feedback, Incentives, and Exchange. The Maine Immunization Program, and the Maine Chapter of the American Academy of Pediatrics collaborated on the implementation and evaluation of this strategy among private providers. METHODS: Between November 1994 and June 1996, the Maine Immunization Program conducted baseline immunization assessments of all private practices administering childhood vaccines to children 24 to 35 months of age. Coverage level assessments were conducted using the Clinic Assessment Software Application. Follow-up assessments were among the largest practices, delivering 80% of all vaccines. RESULTS: Of the 231 practices, 58 were pediatric and 149 were family practices. The median up-to-date vaccination coverages among all providers for 3 doses of diphtheria-tetanus-pertussis vaccine and 2 doses of oral polio vaccine, and 4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of oral polio vaccine, and 1 dose of measles-mumps-rubella vaccine at age 12 and 24 months were 90% and 78%, respectively, and did not vary by number of providers in a practice or by specialty. Urban practices had higher coverage than rural practices at 12 months (92% vs 88%). The median up-to-date coverage for 4 doses of diphtheria-tetanus-pertussis vaccine, 3 doses of oral polio vaccine, and 1 dose of measles-mumps-rubella vaccine at 24 months of age improved significantly among those practices assessed 1 year later (from 78% at baseline to 87% at the second assessment). On average, the assessments required 21/2 person-days of effort. CONCLUSIONS: We document the feasibility and impact of a public/private partnership to improve immunization delivery on a statewide basis. IMPLICATIONS: Other states should consider using public/private partnerships to conduct private practice assessments. More cost-effective methods of assessing immunization coverage levels in private practices are needed.

Child↗
PubMed2001

Risk factors for improper vaccine storage and handling in private provider offices.

CONTEXT: Preventing loss of vaccine potency during storage and handling is increasingly important as new, more expensive vaccines are introduced, in at least 1 case requiring a different approach to storage. Little information is available about the extent to which staff in private physicians' offices meet quality assurance needs for vaccines or have the necessary equipment. Although the National Immunization Program at the Centers for Disease Control and Prevention (CDC) in 1997 developed a draft manual to promote reliable vaccine storage and to supplement published information already available from the CDC and the American Academy of Pediatrics, the best ways to improve vaccine storage and handling have not been defined. OBJECTIVES: To estimate the statewide prevalence of offices with suboptimal storage and handling, to identify the risk factors for suboptimal situations in the offices of private physicians, and to evaluate whether the distribution of a new National Immunization Program draft manual improved storage and handling practices. DESIGN: Population-based survey, including site visits to a stratified, random sample of consenting private physicians' offices. At least 2 months before the site visits, nearly half (intervention group) of the offices were randomly selected to receive a draft CDC manual entitled, "Guideline for Vaccine Storage and Handling." The remainder was considered the control group. Trained graduate students conducted site visits, all being blinded to whether offices were in the intervention or control groups. Each site visit included measurements of refrigerator and freezer temperatures with digital thermometers (Digi-thermo, Model 15-077-8B, Control Company, Friendswood, TX; specified accuracy +/- 1 degrees C). Their metal-tipped probes were left in the center shelf of cold storage compartments for at least 20 minutes to allow them to stabilize. The type of refrigerator/freezer unit, temperature-monitoring equipment, and records were noted, as were the locations of vaccines in refrigerator and freezer, and the presence of expired vaccines. Other information collected included the following: staff training, use of written guidelines, receipt of vaccine deliveries, management of problems, number of patients, type of office, type of medical specialty, and the professional educational level of the individual designated as vaccine coordinator. PARTICIPANTS: Two hundred twenty-one private physicians' offices known by the Georgia Immunization Program in 1997 to immunize children routinely with government-provided vaccines. OUTCOME MEASURES: Estimates (prevalence, 95% confidence interval [CI]) of immunization sites found to have a suboptimally stored vaccine at a single point in time, defined as: vaccine past expiration date, at a temperature of </=1 degrees C or >/=9 degrees C in a refrigerator or >/=-14 degrees C (recommended for varicella vaccine) in freezer, and odds ratios (ORs) for risk factors associated with outcomes. We performed chi(2) analysis and Student's t tests to compare the administrative characteristics and quality assurance practices of offices with optimal vaccine storage with those with suboptimal storage, and to compare the proportion of offices with suboptimal storage practices in the groups that did and did not receive the CDC manual. RESULTS: Statewide estimates of offices with at least 1 type of suboptimal vaccine storage included: freezer temperatures measuring >/=-14 degrees C = 17% (95% CI: 10.98, 23.06); offices with refrigerator temperatures >/=9 degrees C = 4.5% (95% CI: 1.08, 7.86); offices with expired vaccines = 9% (95% CI: 4.51, 13.37); and offices with at least 1 documented storage problem, 44% (95% CI: 35.79, 51.23). Major risk factors associated with vaccine storage outside recommended temperature ranges were: lack of thermometer in freezer (OR: 7.15; 95% CI: 3.46, 14.60); use of freezer compartment in small cold storage units (OR: 5.46; 95% CI = 2.70, 10.99); lack of thermometer in refrigerator (OR: 3.07; 95% CI: 1.15,8.20); and failure to maintain temperature log of freezer (OR: 2.70; 95% CI: 1.40, 5.23). Offices that adhered to daily temperature monitoring for all vaccine cold storage compartments, compared with those that did not, were 2 to 3 times more likely to assign this task to staff with higher levels of training, have received a recent visit from the state immunization program, and be affiliated with a hospital or have Federally Qualified Health Center status. In addition, sites using >1 refrigerator/freezer for vaccine storage were more likely to have at least 1 cold storage compartment outside recommended temperature ranges. We found no significant differences in the data reported above between the intervention group (received copy of the draft manual) and the control group (did not receive copy of draft manual), even when controlling for the annual number of immunizations given or the type of office. (ABSTRACT TRUNCATED)

Child↗
PubMed2001

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infection in pediatric private practice.

BACKGROUND: Universal screening of sexually active adolescents for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) has been recommended in settings in which prevalence is 2% or greater. Although believed to be above 2%, the prevalence of CT and GC infection in private practice settings has not been clearly established and may affect screening practices. OBJECTIVES: To determine CT and GC infection prevalence in 2 pediatric private practices. DESIGN: Cross-sectional study. SETTING: Two pediatric private practices in suburban North Carolina. PATIENTS: Convenience sample of patients aged 15 to 24 years who were seen from August 1998 through June 1999. MAIN OUTCOME MEASURES: Prevalence of CT and GC infection. RESULTS: Of 1114 eligible patients, 803 (72%) completed questionnaires and provided urine specimens tested for CT and GC infection using ligase chain reaction assays. Mean age was 17.1 years (standard deviation: 1.8). Most participants were female (63%), white (87%), and from highly educated families (64% of their mothers graduated from college). Sexual activity was reported by 41%. Prevalence of CT infection in all participants was 0.9% (confidence interval [CI]: 0.4%-1.8%); in sexually active participants, 2.1% (CI: 0.9%-4.3%); in sexually active females, 2.7% (CI: 1.0%-5.7%); and in sexually active males, 0.9% (CI: 0.0%-5.1%). One case of GC infection was found. CONCLUSIONS: The prevalence of CT and GC infection in this private practice population was much lower than reported in other settings. Screening recommendations may need to be reassessed if other low prevalence populations are found.

Adolescent↗
PubMed2004

[Cognitive disorders and dementias in the private practice of specialists: pilot study of a self-assessment survey].

OBJECTIVES: To know about the features of cognitive disorders and dementias in the private practice of specialists and these doctor's skills on that area. METHOD: In this pilot study, self-assessment questionnaires were delivered to neurologists of São Paulo State and 196 (22.8%) were respondents. RESULTS: Many neurologists are involved, besides the private practice, with teaching (61.5%) and/or research (59.5%) activities. Most of them assessed as not good the training on cognitive disorders and dementias they had had during both the graduate (77.3%) and residence (63.1%) courses; nevertheless 60.8% self rated their knowledge on that subject as satisfactory and 83.0% declared their interest on it as at least equal to other areas. The most frequent cognitive complaints occurring as primary reason for appointment are memory loss (73.0%) and attention/concentration deficits (48.0%). Dementia of Alzheimer type (54.9%) and vascular dementia (23.0%) are the most frequent ones in the neurologist private practice. CONCLUSION: Cognitive disorders and dementias represent a significant proportion in the neurological private practice. Although they had not had a good training on the area of cognitive disorders and dementias, the respondent neurologists demonstrated great interest on it.

Adult↗
PubMed2001

[Assessment of the promotion of breastfeeding in public and private maternities of São Paulo city, Brazil].

OBJECTIVE: The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) carried out a study to compare and evaluate the practices of protecting, promoting and supporting breastfeeding in public and private hospitals using the "ten steps" of the Hospital Initiative (BFHI) as a reference parameter. METHODS: Forty-five hospitals of the municipality of São Paulo participated in the study. Data on the practices of infant feeding were collected by interviewing nurseries' supervisors of all public hospitals (26), and from a random sample of private hospitals (19), corresponding to a third of the total, during the years 1996-1997. RESULTS: More than a quarter of the public hospitals and more than one third of the private hospitals did not comply with any of the BFHI steps. Seven of the "ten steps" were observed in only two public hospitals. In general, practices of protection, promotion, and support of breastfeeding were seen at a higher frequency in public hospitals. CONCLUSIONS: The present study shows that practices considered detrimental to the onset and progressing of breastfeeding - unnecessary separation of the mother and her newborn, restrictions regarding the length of time and frequency of breastfeeding, use of pre-lacteal foods and supplements - are still quite frequently observed in public and private hospitals within the city of São Paulo. Given the benefits of breastfeeding for both the mother's and their children's health, and the important role maternities play for an early and successful onset of breastfeeding, it is paramount that the BFHI patterns be adopted by hospitals within the municipality of São Paulo.

Brazil↗
PubMed2004

[Determinants of elders' choice between private and public health care providers].

OBJECTIVE: Elderly choose between utilizing private or public health care providers based on their socioeconomic, demographic, and epidemiological condition. The purposes of this study was to evaluate how these factors affect the choice of health care provider and to compare the impact of their choice on individual and family income. METHODS: Data from 7,920 elders interviewed in a study of the State Committee for the Elderly of the state of Rio Grande do Sul in 1995 was used to evaluate the impact of elders' gender, age, educational level, individual income, family income, family size, participation in the family total income, and health self-assessment when choosing private or public health care providers. The statistical analysis was carried out using logistic regression. RESULTS: To have access to private health care providers, family income had a much more significant impact than individual income. When family income increased in one minimum wage, the odds of using private providers increased by 20% while it was only 7% when there was a similar increase in individual income. Other variables had also a positive impact: female, age, schooling, and smaller family size. CONCLUSIONS: Elderly choices' on health care depend on the family's needs and resources and not on the individual's condition. Therefore, low-income elderly health is a lower priority in the family and it is disproportionately impaired by reduced family resources and deficiencies of public health care.

Aged↗
PubMed2004

A comparative study of congenital toxoplasmosis between public and private hospitals from Uberlândia, MG, Brazil.

The main purpose of the present study was to examine if there is difference in terms of incidence rates of congenital toxoplasmosis among populations assisted in public and private hospitals from Uberlândia, state of Minas Gerais, Brazil. A total of 805 serum samples from cord blood were collected, being 500 from public hospital and 305 from private hospital, and all patients answered a questionnaire about pregnancy and newborns. An indirect enzyme linked immunosorbent assay (ELISA) was performed to detect IgG antibodies to Toxoplasma gondii and the positive samples were retested to verify the presence of specific IgM and IgA antibodies in a capture ELISA. We found significant differences among data from both hospitals with respect to maternal age, origin city, gestational age, number of visits to physicians during pregnancy, type of delivery, and birth weight. Seroprevalence of IgG antibodies against T. gondii for patients from public and private hospitals was 57.6% and 41.9% respectively, and this difference was statistically significant (P < 0.0001). In addition, the frequency of congenital toxoplasmosis measured by the presence of IgM and/or IgA antibodies toward T. gondii was exclusively located in samples from public hospital (0.8%), and no positive sample was seen in private hospital (0%). Considering that almost all babies suffering from congenital toxoplasmosis, if undiagnosed and untreated, will develop visual or neurological impairments by adulthood, the results presented herein emphasized the importance to accomplish screening programs for toxoplasmosis during pregnancy, particularly in the public hospitals, due to the expressive rate of congenital disease showed in the patients attended at these centers.

Animals↗
PubMed2006

[Alzheimer's disease as viewed by relatives of patients at public and private clinics].

BACKGROUND: There are several ethical aspects related to the medical assistance of patients with Alzheimer's disease (AD) including diagnostic disclosure to the patient, performance of autopsy for diagnostic confirmation, and also topics pertaining to the caregivers constantly subjected by these patients to physical and mental stress. This work investigates some of these issues, by comparing family caregivers of patients with AD followed-up at both public and private health services. METHODS: Twenty family caregivers of AD patients followed up at a public university hospital and 20 family caregivers of AD patients followed up at a private clinic were interviewed using a specific questionnaire comprised of 36 questions about diagnosis, treatment and prognosis of the disease. RESULTS: The two groups presented similar age and gender distributions while the socioeconomic level was higher for the private clinic group. No differences were found between opinions of both groups regarding diagnostic disclosure to the patients, with 42.5% of the total in favor of disclosing the information only to the family. The number of caregivers who agreed with performance of autopsy was significantly higher in the public service (35% against 30% in the private clinic). Twenty caregivers (50% of the total sample) spontaneously manifested the wish to allow an autopsy for research purposes. CONCLUSION: Disclosure of AD diagnosis to patients was approved by more than half of all family caregivers and these rates were not correlated to the socioeconomic level. This variable, however, influenced the concordance rate related to the post-mortem neuropathological examination.

Alzheimer Disease↗
PubMed1989

Use of clinic versus private family planning care by low-income women: access, cost, and patient satisfaction.

Use of private physicians versus public family planning facilities by poverty level and near poverty level women was examined by means of a sample survey conducted in low-income areas of Los Angeles County. Utilization differed by race/ethnicity, with Hispanics more likely to go to federally subsidized family planning clinics (primarily county-run), Whites and Blacks to private physicians. Private family planning offers easier access, greater convenience, and higher satisfaction, albeit at almost double the cost. Clinic usage is influenced by lack of a regular source of medical care and lack of insurance coverage more than poverty level per se. Clinic patients report greater patient education regarding contraceptive methods, but less general medical care during clinic visits. They are more likely than private patients to express a desire for a different source of family planning care.

Adolescent↗
PubMed1999

The prevalence of low income among childbearing women in California: implications for the private and public sectors.

OBJECTIVES: This study examined the income distribution of childbearing women in California and sought to identify income groups at increased risk of untimely prenatal care. METHODS: A 1994/95 cross-sectional statewide survey of 10,132 postpartum women was used. RESULTS: Sixty-five percent of all childbearing women had low income (0%-200% of the federal poverty level), and 46% were poor (0%-100% of the federal poverty level). Thirty-five percent of women with private prenatal coverage had low income. Most low-income women with Medi-Cal (California's Medicaid) or private coverage received their prenatal care at private-sector sites. Compared with women with incomes over 400% of the poverty level, both poor and near-poor women were at significantly elevated risk of untimely care after adjustment for insurance, education, age, parity, marital status, and ethnicity (adjusted odds ratios = 5.32 and 3.09, respectively). CONCLUSIONS: This study's results indicate that low-income women are the mainstream maternity population, not a "special needs" subgroup; even among privately insured childbearing women, a substantial proportion have low income. Efforts to increase timely prenatal care initiation cannot focus solely on women with Medicaid, the uninsured, women in absolute poverty, or those who receive care at public-sector sites.

Adolescent↗
PubMed2005

Privatization and trade in health services: a review of the evidence.

Health care provision, like other areas of welfare, has increasingly been subject to processes of privatization and contracting out, leading in some cases to an increased involvement of for-profit corporations. Such processes are likely to interact with processes of liberalization at the international level in ways that we would expect to lead to a growth in the international trading of such services. However, health service provision is usually deeply embedded in state structures at the national level, and the form of such structures varies greatly. The degree and type of private involvement allowed for or facilitated by national-level systems defines the scope for the potential development of international trade in health services. The author reviews existing sources of data on the levels of private provision across advanced capitalist countries, countries in transition from Soviet-type systems, and developing countries, and highlights processes of change that are likely to increase such provision. Private provision is growing slowly but steadily in most countries. While levels of international trade in health services are difficult to ascertain, the interaction between national processes of reform and international processes of liberalization is likely to increase such trade.

Commerce↗
PubMed1991

Casemix based funding for private hospitals or there are still a number of options so can we please slow down.

Australian private hospitals should ask themselves and answer four questions in relation to case mix based payment before they reach a firm decision of the merits of such funding. Firstly, does Australia in general and the private sector in particular need case mix based funding? Secondly, if we are to have case mix based funding, does it have to be based on DRGs and, in particular, the system in use in the United States--the Medicare prospective payment system? Thirdly, will the U.S. system be forced upon us? Fourthly, will sufficient time be allowed for development and phasing in of a new system? This paper addresses all these questions and argues that the case mix based system currently in use and being further developed within the private hospital sector may be a better proposition for long term private sector funding because of its relative simplicity and low administrative costs. The paper also urges less haste in the development and implementation of any radical change.

Attitude to Health↗
PubMed1999

Constraints facing the female medical practitioner in private family practice in the Western Cape.

OBJECTIVES: To assess the existence and extent of employment-related problems facing female family practitioners in the context of a rapidly growing number of female doctors in South Africa. SUBJECTS AND METHODS: A descriptive survey was conducted using bilingual questionnaires. These were posted to all 280 female family practitioners in private practice in the Western Cape. RESULTS: Of the 280 questionnaires posted 169 were returned, but 45 of these were missampled. A response rate of 53% was obtained. The largest age category was 30-39 years. Of those not in solo practice, 68 (75%) were able to negotiate the terms of their working hours, 13 (19%) negotiated sick leave on commencing work, and only half had paid leave. Vacation leave was negotiated by 34 (50%), while only 6 (9%) discussed maternity leave with employers or colleagues. Of the 124 practices included in the survey, 6 (5%) had formal arrangements to cope with maternity leave. One hundred and seven respondents (86%) felt there was a need for maternity leave guidelines in the private sector in South Africa. Regarding practice-related problems, 33 female family practitioners (27%) reported some incidents of sexual harassment by patients. Despite these constraints, 88 respondents (71%) planned to continue working in this field. CONCLUSION: Definite obstacles exist in private family practice with regard to working conditions, in particular the lack of national regulations regarding maternity leave and the absence of legislation on pregnancy discrimination. This has important implications for the inclusion of female doctors in group practices and managed health care organisations--private primary health care of the present and future!

Adult↗