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The government-sponsored health system, once looked on as a political asset and certain "vote getter," has now become a financial and political liability as governments struggle to slow down the spiral of increasing costs.
In recent years leaders at Presentation Health System (PHS), Sioux Falls, SD, have expanded their mission to help strengthen local communities economically and socially. PHS now offers support to rural leaders in business, politics, and healthcare through its Center for Rural Health and Economic Development. In addition, educational outreach coordinators have created programs that address the needs of the entire rural community. To establish an effective network of services in the region, two of the system's tertiary care hospitals are collaborating to provide emergency helicopter service. These larger facilities also extend outreach services to rural hospitals and clinics. PHS assists rural hospitals in grant writing and in adapting to changing government reimbursement rules. In addition, the healthcare system coordinates a group purchasing program and a debt collection agency. An important voice for its region's healthcare needs, PHS has worked with the state of South Dakota to address problems and concerns about emergency medical services. The system also publishes Report, a quarterly newsletter that keeps rural residents abreast of healthcare issues affecting them. Two years ago, PHS's Center for Rural Health and Economic Development sponsored its first Invitational Rural Health Leadership Conference. These annual conferences bring together leaders to examine ways to improve rural healthcare delivery by strengthening the social and economic fabric of rural communities.
HIV incidence is rising more rapidly in some areas of Central and Eastern Europe than anywhere else in the world. Carrying out effective HIV prevention programs requires the presence of "bridges" that can reach community populations most vulnerable to the disease. Nongovernmental organizations (NGOs) are in a natural role to conduct HIV prevention programs. The Directors of 29 HIV prevention NGOs representing almost all countries in Central and Eastern Europe participated in in-depth interviews by telephone. The broad topics of these interviews included descriptions of the three largest programs conducted by each NGO during the past six months, at-risk target populations served, major barriers faced, and funding sources that sponsored HIV prevention activities. NGO programs most often targeted injection drug users (IDUs); other stigmatized groups were less frequently served by NGOs in the sample. The most common types of prevention activities were needle exchange, HIV prevention peer education, and delivering AIDS presentations and distributing educational materials. Among the major barriers that hampered effective conduct of HIV prevention programs were a shortage of available financial resources, governmental indifference or opposition, and AIDS-related stigma. National governments rarely provided substantial funds for NGO programs, and most funding came from United Nations agencies or private foundations. The information sources reported to be most helpful in assisting NGOs in program development were sharing ideas with other NGOs, participating in conferences, and accessing information from the Internet. A number of programs reported by the NGO Directors were innovative, outstanding, and comprehensive. Five such exemplary programs are described in this article. HIV epidemics in the region are still potentially controllable. NGOs need immediate support so that they can carry out their community-based activities on a larger scale.
The Conrad "State 20" Program places international medical graduates (IMGs) on J-1 visas in health professional shortage areas (HPSAs). The authors surveyed program administrators from health departments in forty-two participating states. Problems reported include unfair working conditions and compensation for physicians. Federal immigration agencies were reported to be unresponsive and difficult. Employers seem to be more satisfied than physicians with the program. After the exit of the U.S. Department of Agriculture as a sponsor for physician J-1 visa waivers, Congress expanded the Conrad Program, signaling a continued reliance on IMGs to serve in shortage areas.
The analyses upon which this publication is based were performed under Contract No. 500-99-NC03, entitled "Utilization and Quality Control Peer Review Organization for the State of North Carolina," sponsored by the Health Care Financing Administration, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Health Care Financing Administration, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.
The basic objective of the programme of monitoring the dietary exposure in the Czech Republic is to describe the character of the health risk based on the exposure of the Czech population to chemical substances in food. The conception of the monitoring programme is based on the methods of the Total Diet Study, established on the principle of defining the consumption of the most important foodstuffs, their purchase in the network of stores in selected shops on fixed dates, their transport to the central laboratory, cooking and consequent chemical analyses in the central laboratories. In the Czech Republic monitoring has been conducted since 1991/1992 and routine activities have been ongoing since 1994. The programme is fully sponsored by the government. Monitoring carried out in 1994-2001 provided a considerable amount of information, which was applied when drawing programmes of health protection and promotion, in regulatory work and when solving problems of the international food trade.
Health officials often wish to sponsor nutrition and other health promotion programs but are hampered by lack of funding. One source of funding is suggested by the fact that 18 states and 1 major city levy special taxes on soft drinks, candy, chewing gum, or snack foods. The tax rates may be too small to affect sales, but in some jurisdictions, the revenues generated are substantial. Nationally, about $1 billion is raised annually from these taxes. The authors propose that state and local governments levy taxes on foods of low nutritional value and use the revenues to fund health promotion programs.
Tunisia, the smallest North African country in size, has recently published the results of its part of the World Fertility Survey (WFS) taken in 1978. About 1/2 of this Missouri-sized country consists of arid and semiarid desert, with well-irrigated fertile areas in the north. The country, which has a population of about 7 million, must import large quantities of food each year and also suffers from widespread unemployment. In 1964, the government was among the earliest to announce a policy to reduce the rate of population growth and Tunisia now has 1 of the lowest birth rates of the African continent (33 births/1000 population) although it is still moderately high. Part of the reason for the birth rate decline has been a risking age at marriage; the legal minimum was fixed at 17 years for women and 20 for men by a 1964 law. The Tunisia WFS indicates that, of women 20-24 in 1978, 56% had not yet married, a large increase from the 27% of 1966. The mean age at 1st marriage for females was 24 in 1978, very high by less developed country standards. It may be that the fertility-lowering impetus from rising age at marriage has been spent (this measure cannot rise indefinitely): Tunisia's total fertility rate (TFR), the average number of children/woman, dropped from 7.1 children in 1966 to 5.7 in 1976, but the decrease has tapered off somewhat since. The TFR appears to have dropped to 5.2 as of 1981. When asked how many children they would like to have, the women surveyed gave 4.2 children, on average, as their "ideal" number. This number is, of course, considerably above that needed to ultimately stop population growth (about 2.1-2.5 children/woman). Contraceptive use in Tunisia is quite high by developing country standards; much of this is due to the efficient network of government-sponsored clinics. About 44% of the women exposed to pregnancy were practicing an efficient form of family planning with the pill or sterilization accounting for most of that number (22 and 20% respectively). Nonetheless, traditions which still favor 3-5 children and some possible loss of momentum from a rising age at marriage may cause future fertility declines to be slower than in the recent past. Tunisia does present an interesting case of a country maintaining a government program to reduce population growth as an overall part of the country's development efforts.
As fiscal resources for mental health programs dwindle, it is becoming increasingly important to preserve non-direct-service priorities such as staff development. The West Virginia Training Resources Center, a collaborative program operated by the West Virginia Department of Health and the West Virginia University department of behavioral medicine and psychiatry, addresses problems of staff training in the state mental health service system. The authors discuss the development of the center and its functions as provider of training programs, sponsor of statewide training conferences, and clearinghouse of information and expertise. They also discuss problems stemming from the increased need for continuing education for paraprofessionals, the use of outside consultants, and the relationship between academia and the health service sector.
A study of 227 elderly participants attending Title III-C nutrition programs was conducted to determine food supplement use and its relationship to nutrition knowledge and quality of the diet. Although nutrition knowledge was found to be positively related to the quality of the diet for all subjects, no significant differences were found between supplement and nonsupplement users for these two variables. Although the mean knowledge score was low, positive relationships were found between nutrition knowledge and both education and income for all subjects. Amount of participation in the government-sponsored nutrition centers was negatively correlated with nutrition knowledge.
The authors report the highlights of a one-day symposium, "Academic Medicine and Managed Care: Seeking Common Ground," sponsored in early 1997 by Tulane University Medical Center. The meeting was held to foster better understanding of the gap between managed care organizations (MCOs) and academic health centers (AHCs) and to define their common ground. There were 62 participants, mainly executives froin AHCs and MCOs, plus government officials and policy researchers interested in the interface of academic medicine and managed care. The participants agreed that there are indeed some common areas in which the two types of organizations can develop programs and interests that serve the missions of both. These include (1) a commitment to high-quality health care, objectively measured by outcomes; (2) issues of "customer service"; (3) certain areas of research (e.g., examining outcomes of medical interventions; measuring cost and cost-effectiveness; measuring quality of care); and (4) preventive medicine, an area in which both AHCs and MCOs are still relatively weak. On the other hand, large elements of AHCs' basic missions of education and research are not seen by MCOs as areas for developing a common agenda. Participants agreed that AHCs must do their best to improve and demonstrate the quality of their care, address the challenges of the market (i.e., take "customer service" seriously), address the issue of how many specialists and how many generalists should be trained, and define the cost of each of their missions. On the other hand, managed care must acknowledge that the missions of AHCs greatly benefit patients and society. Participants agreed that all approaches to AHC-MCO interfaces must be flexible and local, that common ground does exist, and that understanding can grow between these two kinds of organizations if acrimonious exchanges are avoided and serious efforts are made to work together for solutions.
The new Medicare+Choice managed care program authorized by the Balanced Budget Act of 1997 affords hospitals and physicians an opportunity to contract directly with HCFA to provide services to Medicare beneficiaries through a provider-sponsored organization (PSO). Developing and operating a Medicare PSO is a complex process, however, and organizations that lack certain strategic and operational "readiness" characteristics may encounter significant barriers to success. To ascertain their readiness to form a Medicare PSO, providers should assess their capabilities in six key strategic areas: culture and governance, organizational and legal structure, market position and strategy, provider network, risk-contracting experience and supporting infrastructure, and capital resources and fiscal soundness.
This notice is to advise interested parties of an expansion of a demonstration project in which the DoD provides CHAMPUS reimbursement for eligible beneficiaries who receive cancer treatment under approved National Cancer Institute (NCI) clinical trials to include NCI sponsored cancer prevention clinical trials. Participation in these clinical trials will improve TRICARE/CHAMPUS eligible beneficiary access to emerging new therapies that have significant promise for the prevention and successful treatment of cancers. DoD financing of these procedures will assist in meeting clinical trial goals and arrival at conclusions regarding the safety and efficacy of emerging therapies in the prevention and treatment of cancer. At this time, there is insufficient demonstration data for a full evaluation of costs associated with enrollment in clinical trials. Expanding the current demonstration to provide reimbursement for costs associated with NCI sponsored clinical trials for cancer prevention will augment current patient accruals to clinical trials and allow for data collection in order to perform a comprehensive economic analysis. This demonstration also affects TRICARE, the managed health care program that includes CHAMPUS. This demonstration project, which is under the authority of 10 U.S.C., section 1092, will expire December 31, 1999.
Understanding the state-level processes that can shape the operations of health and welfare programs is of particular importance today. This article describes the process by which the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program was implemented in the Commonwealth of Pennsylvania. The case study highlights the factors that facilitated and hindered the transformation of this federal policy into a local program. Implications for children's health programming are identified.
The economic crisis of the 1980s led to cuts in both government and household expenditure on health in the Third World. In order to address these issues it is necessary to adopt a macroeconomic approach to the analysis of the health sector; this allows its relationship to the whole economy to be understood. The efficient and equitable utilization of resources is particularly important in times of severe financial constraint.
The European Clinical Trials Directive came into force on April 4th, 2001. This regulation will be implemented into the German Drug Law (AMG) through the 12th amendment to the AMG. It will impose major changes on the preparation and conduct of clinical studies with medicaments. In particular, the procedure to gain an ethical committee's approval and permission for multicentric studies from the German Federal Authority (BfArM) will increase bureaucracy and complexity for the sponsor. The new German procedures, which by far exceed the European regulation, will lead to increased costs and will require more time for the preparation of clinical studies.
In January 2000, the Agency for Healthcare Research and Quality (AHRQ) and the National Library of Medicine (NLM) cosponsored an invitational workshop entitled "Medical Informatics and Health Services Research: Bridging the Gap." Planned by a small committee of representatives from NLM and AHRQ institutional training centers, the workshop was designed to address the need for education of researchers interested in working at the intersection of the fields of medical informatics and health services research. More than 100 educators and researchers from AHRQ- and NLM-sponsored training programs in medical informatics and health services research participated in the workshop. Through a series of plenary presentations and breakout sessions, the workshop addressed ways of increasing the pool of persons interested, trained, and experienced in addressing specific areas of synergy between the two fields. This paper reports on the results of the workshop.
A Cabinet-level recommendation is expected soon on whether employers will be allowed to seek exemption from federal mental health parity-of-coverage requirements based on prospective or retrospective calculations of their compliance costs. The law provides exemption for plan sponsors whose parity costs exceed 1 percent of their total health spending. Meanwhile, though, many states are forging ahead with parity laws of their own, while advocates see the federal law as only a modest prelude.