The policy debate on patient care financing for victims of end-stage renal disease.
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Attitude↗
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Results for “Community Financing”
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The National Plan for the Chronically Mentally Ill: a review of financing proposals.
In this, a companion piece to the preceding article, the author summarizes and examines the financing issues and recommendations set forth in the National Plan for the Chronically Mentally Ill. The major federal programs that provide assistance to chronic patients are described briefly. Sixteen proposed incremental reforms designed to fill gaps in the existing service system are listed and discussed; nine involve changes in the Medicaid program. The author also considers the options to go beyond incremental changes toward the establishment of a comprehensive program focused specifically on the needs of the chronically mentally ill. He discusses the advantages and drawbacks of three methods of organizing financing of mental health services that are described in the National Plan--a structured services program, a benefit-voucher program, and a cash transfer program.
Chronic Disease↗
Elderly care policy, formal and informal care. The Swedish case.
This paper discusses the consequences of a 'greying' Sweden with respect to the present Swedish policy for the care of the elderly and the role of the family as care provider for the elderly. The present system of elderly welfare is questioned, based on demographic facts, a review of the service systems and research findings. The tentative conclusions are two-fold. Firstly, present trends point to a shift in the Swedish welfare model, from a publicly financed and run elderly care system to a mixed model based on public, private and voluntary resources. Secondly, the fact that the informal care system functions as the main provider of services for the elderly, means that the development and implementation of support programmes for the family caregivers is of crucial importance for the future. The challenge for the 1990s, then, is to improve conditions for informal carers in order to enlarge the caring capacity of the community.
Aged↗
Is it ACT yet? Real-world examples of evaluating the degree of implementation for assertive community treatment.
Despite growing interest in assessment of program implementation, little is known about the best way to evaluate whether a particular program has implemented the intended service to a level that is minimally acceptable to a funding source, such as a state mental health authority. Such is the case for assertive community treatment (ACT), an evidence-based practice being widely disseminated. Using an exploratory, actuarial approach to defining program standards, this study applies different statistical criteria for determining whether or not a program meets ACT standards using the 28-item Dartmouth Assertive Community Treatment Scale. The sample consists of 51 ACT programs, 25 intensive case management programs, and 11 brokered case management programs which were compared to identify levels of fidelity that discriminated between programs, but were still attainable by the majority of ACT programs. A grading system based on mean total score for a reduced set of 21 items appeared to be most attainable, but still discriminated ACT programs from other forms of case management. Implications for setting and evaluating ACT program standards are discussed.
Case Management↗
Wanted!! a wizard to finance adequate programs for the mentally disabled.
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Community Mental Health Services↗
[The influence of community support services on the costs of treatment of chronically mentally ill patients].
AIM: To determine changes in costs of treatment for chronically mentally ill patients after their admittance to new social help units; Vocational Rehabilitation Center, Community Center of Mutual Help and Specialised Social Help Services at Client's Home. METHOD: In the group of 73 chronically mentally ill persons, for two years before and after their admission to social help units, the global amount of care (months x persons) and all the costs (PLN) in both social help and mental health systems were compared. RESULTS: For two years after the admission to the mentioned services all the costs in mental health system were significantly decreasing (71.9%), but new costs in social welfare system emerged. The overall costs of care were higher than before, but the elevation (35.4%) of all the costs was not so high as the increase (99,3%) of the care. The structure of care was improved (more day-, and less stationary care). The "out of the pocket" expenses for patients increased. CONCLUSIONS: The implementation of social help services for chronic mentally ill patients is reducing the amount of stationary and day treatment, but increasing active community treatment. Money in the health system is saved, but all the expenses on community care are increased. Coordination of care and finances between the mental health and social welfare is needed. Common financing for both systems is questionable because of impending over medicalisation. The allocation of money saved to early rehabilitation in schizophrenia would be profitable in the future.
Adult↗
The use of Health Care Financing Administration data for the development of a quality improvement project on the treatment of anemia.
The Health Care Financing Administration maintains a wide array of data systems that are essential to the functioning of the Medicare program. These data, collected and maintained for the purposes of ensuring entitlements and payment for services, also can be used to monitor programmatic changes and to define potential problem areas. The end-stage renal disease (ESRD) Program Management and Medical Information System (PMMIS) is a subset of the larger Medicare statistical system. It is a historic record of all Medicare ESRD beneficiaries dating back to 1978. Basic Medicare enrollment information on ESRD beneficiaries is enhanced with the addition of information on the cause of renal failure, type of dialysis therapy, transplantation history, and cause of death. The ESRD PMMIS has been put to a number of uses in the past decade or so, ranging from basic descriptive epidemiology to analyses of mortality rates to assessments of programmatic issues such as the composite rate and dialyzer reuse. Because of the limited clinical detail in the PMMIS, there are many specific questions that cannot be adequately addressed. With approval of the Food and Drug Administration and Medicare coverage of erythropoietin, a erythropoietin monitoring system was developed to assess utilization trends of this anemia control drug. Within a few months it became evident that dosing levels for erythropoietin were much lower than expected from the clinical trials. Following a change in the payment method from a fixed amount to one based on dose level, dosing has increased markedly. However, hematocrit levels still remain below optimal levels. This lack of hematocrit response has led the Health Care Financing Administration, in concert with the renal community, to target anemia control as a potential health care quality improvement project. This paper presents an example of the type of data presentation that can be derived from the current PMMIS. The Health Standards and Quality Bureau has made a commitment to a program of continuous quality improvement. Part of this process is the provision of descriptive data that can be the starting point for an iterative approach to quality improvement.
Anemia↗
Quantifying components of drug expenditure inflation: the British Columbia seniors' drug benefit plan.
OBJECTIVE: To quantify the relative and absolute importance of different factors contributing to increases in per capita prescription drug costs for a population of Canadian seniors. DATA SOURCES/STUDY SETTING: Data consist of every prescription claim from 1985 to 1999 for the British Columbia Pharmacare Plan A, a tax-financed public drug plan covering all community-dwelling British Columbians aged 65 and older. STUDY DESIGN: Changes in per capita prescription drug expenditures are attributed to changes to four components of expenditure inflation: (1) the pattern of exposure to drugs across therapeutic categories; (2) the mix of drugs used within therapeutic categories; (3) the rate of generic drug product selection; and (4) the prices of unchanged products. DATA COLLECTION/EXTRACTION METHODS: Data were extracted from administrative claims files housed at the UBC Centre for Health Services and Policy Research. PRINCIPAL FINDINGS: Changes in drug prices, the pattern of exposure to drugs across therapeutic categories, and the mix of drugs used within therapeutic categories all caused spending per capita to increase. Incentives for generic substitution and therapeutic reference pricing policies temporarily slowed the cost-increasing influence of changes in product selection by encouraging the use of generic drug products and/or cost-effective brand-name products within therapeutic categories. CONCLUSIONS: The results suggest that drug plans (and patients) would benefit from more concerted efforts to evaluate the relative cost-effectiveness of competing products within therapeutic categories of drugs.
Aged↗
Living conditions of adults with intellectual disabilities from a gender perspective.
BACKGROUND: The role of gender has been a neglected issue in research on intellectual disability (ID). People with ID are generally treated as a homogenous group that are largely categorized by their level of ID. This study compared living conditions of women and men with ID and related the results to similarities and differences among the general population in corresponding age groups. METHODS: Persons with ID born in Uppsala County between 1959 and 1974 constituted the study sample. Information on the living conditions of 110 persons with ID was collected using questionnaires completed by relatives and staff. Information on living conditions of the general population was obtained through national welfare statistics conducted by Statistics Sweden (SCB). RESULTS: In both samples corresponding diversities were revealed for type of employment/daily activities, where women worked in traditional female job sectors and men were occupied with traditional male jobs. Women and men with ID participated to about the same extent in recreational and cultural activities and on only four of the 19 activities listed in the questionnaire (visits to the cinema and library, reading books and practising hobbies alone) significant differences were observed. Among women and men in the general population, we found gender-related differences in 13 of the activities listed. However, with the exception of women more frequently visiting the library and reading books, the two samples demonstrated no corresponding gender-related differences. For the remaining six domains (finances, family and social relations, housing, transport, community participation and personal safety), no differences were noted between women and men with ID. This finding contrasted sharply with the differences found between women and men in the general population. CONCLUSIONS: Surprisingly, the comparison yielded few differences in living conditions between women and men with ID compared with those found in women and men of the general population. This finding suggests that people with ID were treated as gender-neutral persons rather than as women and men with individual preferences and needs. Thus, it appears that having ID is a more important determinant than gender regarding living conditions for women and men with ID.
Activities of Daily Living↗
Principles for developing interdisciplinary school-based primary care centers.
A 50% increase has occurred in the number of school-based primary care centers (SBPCCs) in the United States since 1993-94. Public schools offer a well-established and respected community-based infrastructure within which health centers may feasibly be developed. SBPCCs have documented improved access to care for underserved children and some initial success in addressing the complex morbidities and associated behavioral risk factors of children and adolescents. This paper presents five working principles to help communities establish SBPCCs that link community health and social services with their educational system. The principles encompass community participation, early assessment of community needs, integration of health and human services with educational services through an interdisciplinary and interagency team approach, development of a business plan, and program evaluation. These principles reflect the experiences of 22 Texas communities which operate 76 SBPCCs. They should prove helpful to many other communities and states that propose to develop, finance, and evaluate school-based, interdisciplinary health care and prevention services.
Adolescent↗
Measuring the incremental cost of clinical cancer research.
PURPOSE: To summarize evidence on the costs of treating patients in clinical trials and to describe the Cost of Cancer Treatment Study, an ongoing effort to produce generalizable estimates of the incremental costs of government-sponsored cancer trials. METHODS: A retrospective study of costs will be conducted with 1,500 cancer patients recruited from a randomly selected sample of institutions in the United States. Patients accrued to either phase II or phase III National Cancer Institute-sponsored clinical trials during a 15-month period will be asked to participate in a study of their health care utilization (n = 750). Costs will be measured approximately 1 year after their trial enrollment from a combination of billing records, medical records, and an in-person survey questionnaire. Similar data will be collected for a comparable group of cancer patients not in trials (n = 750) to provide an estimate of the incremental cost. RESULTS: Evidence suggests insurers limit access to trials because of cost concerns. Public and private efforts are underway to change these policies, but their permanent status is unclear. Previous studies found that treatment costs in clinical trials are similar to costs of standard therapy. However, it is difficult to generalize from these studies because of the unique practice settings, insufficient sample sizes, and the exclusion of potentially important costs. CONCLUSION: Denials of coverage for treatment in a clinical trial limit patient access to trials and could impede clinical research. Preliminary estimates suggest changes to these policies would not be expensive, but these results are not generalizable. The Cost of Cancer Treatment Study is an ongoing effort to provide generalizable estimates of the incremental treatment cost of phase II and phase III cancer trials. The results should be of great interest to insurers and the research community as they consider permanent ways to finance cancer trials.
Clinical Trials as Topic↗
Life care: new options for financing and delivering long-term care.
Continuing care retirement communities provide full insurance protection for and access to long-term care services. A new model, which retains risk pooling for long-term care and provides benefits and protections similar to continuing care retirement communities, is called life care at home. Life care at home combines the financial and health security of a continuing care retirement community with the freedom and independence of living at home and is affordable to a greater proportion of elderly people. The feasibility of this model is, in part, supported by the fact that nursing home use in the fully insured access-guaranteed continuing care retirement community is not that different from use among the elderly living in the general community.
Age Factors↗
Measurement: the key to success for providers, payors, and patients in long-term care.
The complex financing structure that supports home and community-based long-term care services has resulted in the application of different quality assurance requirements to similar services. Goals for home and community-based care are viewed differently by providers, payors, and customers. This raises the issue of how goals can be harmonized and what should be used to measure goals. Current quality assurance strategies are judge insufficient to assure the delivery of high-quality services; in part due to the state of health programs and lack of unified outcome measurement. The need for multidimensional assessment to adopt a baseline measure of health status to support allocation of services and enhance successful client outcomes has become the aim for health care providers.
Aged↗
[The brain drain, internal migration, and management of human resources in China].
"A major impediment to Third World development, the brain drain in the People's Republic of China originates from a variety of factors which, to a notable extent, differ from more traditional causes identified in most other developing countries. In addition to political management of human resources, the organization itself of the educational system and the regularisation of internal migration are basic causes of China's massive brain emigration. Through various relations maintained by the Chinese Government with its expatriate communities, and in order to promote (and finance) the economic and technological process engaged in the early 1980s, a number of measures and incentives to integrate more rationally the resident professionals and to promote the return of expatriate brains have been adopted.... Uncertainties today impede any clear assessment of the...viability of China's official policy of recognition and integration of national professionals." (SUMMARY IN ENG)
Asia↗
The changing health care environment: implications for residency training.
Throughout the United States, the growth of managed care is forcing pediatric providers (physicians and hospitals) to reconstruct and integrate the health care delivery system with a focus away from the academic center and toward the community. Managed care also is forcing new financing approaches geared toward the assumption of economic risk for patient management and utilization of services. Radical changes in pediatric training programs will be necessary to accommodate the strategic and operational changes being pursued in response to these evolving market forces. These changes, while disruptive, will strengthen the breadth and diversity of graduate medical education and will better prepare trainees for the new delivery system in which they will practice. In this article, we examine how the evolution of managed care is redefining the basic financial and organizational framework for pediatric care and the implications of this redefinition for children's hospitals and academic medical center-based pediatric programs. We draw on our experience in the greater Philadelphia market to illustrate the impact of these changes and discuss one pediatric system's response. Finally, we review the educational opportunities provided by these changes.
Delivery of Health Care↗
Training persons with schizophrenia in illness self-management: a randomized controlled trial in Japan.
Despite the worldwide shift from inpatient to community-based treatment for individuals with severe mental illness, Japanese psychiatric services remain hospital based. In 1998, Japan had 29 psychiatric beds per 10,000 persons, twice as many as in most European countries and five times as many as in the United States (1). The reasons for Japan's slow transition to a community-based mental health system are both economic and cultural. For instance, 90 percent of psychiatric beds are in private for-profit hospitals. There is little incentive for inpatient facilities to discharge patients promptly, because the Japanese health care system provides universal coverage with virtually unlimited reimbursement for inpatient services, and the government does not have a mechanism for financing the relocation of resources from hospitals to communities (2). In addition, the stigma associated with mental illness in Japanese families is high (3). Thus a patient's primary residence is the psychiatric hospital, and opportunities are provided for periodic visits from the family.However, psychiatric rehabilitation principles and practices are beginning to take root in Japan. Anzai and his colleagues at the Matsuzawa Psychiatric Hospital in Tokyo have adapted an empirically validated skills training program to prepare patients with schizophrenia for life in the community after discharge from the hospital. In this column, they report the results of a randomized controlled trial of this approach in an inpatient facility serving a large urban center.
Community Mental Health Services↗
The Robert Wood Johnson Foundation Program on Chronic Mental Illness: an overview.
In 1985 the Robert Wood Johnson Foundation implemented the Program on Chronic Mental Illness, which provides grants and assistance to nine cities across the country in their efforts to improve services to persons with chronic mental illness. A basic premise of the program is that a central mental health authority is the cornerstone of improved systems of care. To be eligible for participation in the program, each city had to develop a service system incorporating a central authority and four other features: continuity of care, a full range of services, a housing plan, and new sources of financing. The authors describe how the cities were selected and how the program operates. They also provide a case example of the problems one city faced in establishing a central authority.
Chronic Disease↗
Toward a rational community health care system: the Hunterdon model.
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Ambulatory Care↗