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PubMed2000

["Managed care"--perspectives in Germany].

There is a public discussion in Politics and Health services whether managed care should be realized in Germany. The German Medical Services of the Statutory Health Insurance (MDK) are also involved and have great interest and an opinion about this topic because the introduction of managed care or elements of managed care will influence the cooperation between the MDK and the German Statutory Health Insurance. The following article informs on certain elements of managed care already practised in Germany and discusses which of these elements can be used more intensively in the future according to Social Laws and developed structures.

Case Management↗
PubMed1980

Structural conflicts in the neighborhood health center program: the national and local perspectives.

The paper reports the findings of a study of the neighborhood health center (NHC) program which was initiated by the Office of Economic Opportunity (OEO) in 1965. The study focuses on the structure of the NHC system (funding agency, operating agency, and community board), analyzes the goals of the different sets of actors, and argues that the conflicts which evolved within the system were the natural outcome of the divergence in the goals of the different actors. Based on a series of 88 in-depth interviews with key health officials in OEO as well as project officers in NHCs throughout the country, the study suggests a framework for a more comprehensive analysis of the outcome of the NHC program and notes the implications of these findings for some current health legislation.

Community Health Centers↗
PubMed2003

Is Ministry of Health fully prepared to implement an effective DOTS program in Pakistan? An operations research on TB control program in the public health sector in Sindh.

PURPOSE OF THE STUDY: Pakistan is among the high-burden countries for tuberculosis. One of the fundamental problems in TB control is a high defaulter rate among the registered TB cases in the public sector. In 1999, a cross-sectional study was designed to identify the determinants of low compliance for the TB treatment in two rural districts in Sindh. METHODS: Before the actual data collection, a pilot testing was planned in a secondary level care hospital. Fourteen defaulters for TB treatment were identified but none could be contacted due to incomplete addresses. Other alternatives were explored with the health facility team to reach them including a field-based search through Lady Health Workers of the National Health Program but all endeavors went into vain. The pilot testing propelled us to postpone the cross-sectional study but we continued scrutinizing the follow up problem for TB patients in other health facilities. Not surprisingly, more or less a similar picture was found in those health facilities. PRINCIPAL CONCLUSIONS: The study concludes that the public health care system in Pakistan lacks even the basic requirements for an effective TB control program, that is, a viable information system and the functional integration of program with rest of the health care delivery system. A DOTS strategy to control TB was initiated in the public sector in Pakistan just one year prior to this study. The Ministry of Health requires re-visiting the program to ensure that the lacunae identified in this study are being taken care of in the current DOTS strategy.

Communicable Disease Control↗
PubMed2000

[Personal responsibility and prevention in the tension field of health care systems].

Thesis 1. The health care system determines the framework in each case. Thesis 2. Traditional health care systems impede self-responsibility and prevention. Thesis 3. New system elements are essential and possible. Thesis 4. In a given overall frame new systems have to set up with the responsibility of the individual promulgator. Thesis 5. These are the "clever" systems in the sense of European Managed Care.

Europe↗
PubMed1991

National health insurance and the problems of American medicine.

The problems of inequitable access to care, health care inflation, and reduced physician autonomy confront physicians and health care reformers with a dilemma. Piecemeal measures attempting to alleviate one problem in isolation simply exacerbate the others. A logical approach to addressing these problems together is a national health program based on a single payer of health services. By reducing administrative waste and emphasizing global budgetary strategies, the single-payer system could promote more efficient health care spending. While single-payer systems create more explicit political conflict over resource allocation, they also have demonstrated an ability to maintain quality of care and reduce bureaucratic intrusions into clinical practice.

Canada↗
PubMed1990

Local advocacy for the medically indigent. Strategies and accomplishments in one county.

Access to health care for the medically indigent has emerged as a major policy issue throughout the United States. Because no national health program ensures entitlement to basic services, practitioners and patients must cope with barriers to access on the local level. We report several separate but integrated strategies that a community-based coalition has used to achieve improvements in indigent care within a single county. Research strategies have involved short-term investigations of barriers to needed services so that local awareness of the problem would increase rapidly. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor, to modify the practices of local health care institutions, and to influence state and national policies that affect local conditions. Legal strategies have involved the participation of attorneys who represent clients unable to receive care and who could initiate litigation as appropriate. Each of these strategies contains weaknesses as well as strengths. Although such advocacy efforts do not achieve a coherent system that guarantees access, they can substantially improve the availability of local services.

California↗
PubMed1995

Takeover of Ontario Blue Cross may be sign MDs will soon face US-style managed care.

The privatization of health care is becoming a major issue on the Canadian health care agenda, with even the prime minister musing that the Canada's medicare system may no longer be able to cover all medical needs. This would appear to indicate that there will soon be a growing market for private health care in Canada, and the recent takeover of Ontario Blue Cross by an American company, the Liberty Mutual Group, is a sign this market is being recognized. Milan Korcok says the privatization trend holds major implications for Canadian physicians, who soon may witness firsthand US-style managed care.

Blue Cross Blue Shield Insurance Plans↗
PubMed1992

Local advocacy for the medically indigent: strategies and accomplishments in one county.

Access to health care for the medically indigent has emerged as a major policy issue throughout the United States. Because no national health program assures entitlement to basic services, practitioners and patients must cope with barriers to access on the local level. The authors report several separate but integrated strategies that a community-based coalition has used to achieve improvements in indigent care within a single county. Research strategies have involved short-term investigations of barriers to needed services, so that local awareness of the problem would increase rapidly. Political strategies have attempted to improve the county government's administrative procedures and financial support of services for the poor, to modify the practices of local health care institutions, and to influence statewide and national policies affecting local conditions. Legal strategies have involved the participation of attorneys who represent clients unable to receive care and who could initiate litigation as appropriate. Each of these strategies contains weaknesses as well as strengths. Although such advocacy efforts do not achieve a coherent system guaranteeing access, they can substantially improve the availability of local services.

California↗
PubMed2002

Hepatitis B vaccination: how to reach risk groups.

Current hepatitis B vaccination programmes targeting risk groups have met with little success in controlling HBV infection in the general population. Despite the long-standing existence of unambiguous recommendations for risk-group vaccination, hepatitis B vaccination coverage remains low in most risk groups in most high-income countries. This low coverage may be attributed to a lack of perceived risk of hepatitis B and the absence of appropriate health care programmes targeting hepatitis B monitoring and vaccination for certain risk groups, particularly sex workers, injecting drug users, and prisoners. The Viral Hepatitis Prevention Board (VHPB) recognises the importance of raising the awareness of health care providers, policymakers, and the general public, about hepatitis B as a risk to both the community in general and to specific groups considered at increased risk. The VHPB also recognises that new strategies will have to be developed and implemented.

Awareness↗
PubMed1990

Public health's promise for the future: 1989 presidential address.

Public health's promise for the future is inextricably related to efforts which maximize human potential and which realize the world's interdependence. Public health challenges are not only constant and complex but frequently surrounded by political activities. In this environment, the public health enterprise has been enhanced by the Institute of Medicine, National Academy of Sciences' report on The Future of Public Health and the assessment framework it provides. Risk reduction through preventive and health promotion activities is the primary focus of public health, but facilitation is often dependent upon society's understanding and willingness-to-pay for such services. The effectiveness of public health is related to an ability to coordinate public and private efforts at national, state, and local levels. Also in this environment, public health is empowered through its multidisciplinary approach. However, epidemiology provides a unifying framework for the collective public health effort. Based on the use of epidemiology, public health is empowered to make the argument for a national health program and to support the concept of health as a determinant of life options. Public health's promise for the future can be fulfilled by continuing to increase its scientific base for decision-making, by self-examination and correction, by advocating and promoting self-examination and correction, by advocating and promoting social justice and by promoting firm partnerships with the public.

Forecasting↗
PubMed2000

[Physician's anxiety and physician's elegance. Problems in dealing with cost reduction, education of general practitioners and optimal size of practice networks in a cross-national comparison].

The key reason for physicians networking in managed care is to get a better coping with uncertainty on action (treatment) decisions. The second reason for networking in managed care are financial benefits grounds. But this reason is very ambivalent. Three different action problems (role conflicts) in managed care network are to solved, which was also in single practices. In the lecture the decision strategies and decision resources has been compared. Observations are done using expert interviews, patient interviews and analysis of documents in USA, Germany and Switzerland. The first problem is the choosing of a cost reduction strategy which is not reducing the effectiveness. Such "ugly" solution strategies like exclusion of "expensive" patients and a rationing of necessary medical services in a kind of McDonalds network of physicians will fail the target. The optimost way is a saving of all unnecessary medical even injourious performances. The chosen cost reduction strategy is not real visible from outside but in fact limited cognizable and controllable. Evidence based health care can be a resource of treatment decisions and could train such decisions but it will not substitute these decisions. The second problem is the making of real family practitioners as gatekeepers. Knowledge about the care system is still not making a real family practitioner, even if this is the minimum condition of their work. Also contractual relationships between insurance and doctor as a gatekeeper or financial incentives for patients are still making not a real family practitioner as a gatekpeeper. Only throughout the trust of patients supported by second opinions is making the real family practitioner as a gatekeeper. "Doctor hopping" could be the reaction by scarcity of trustworthy family practitioners as gatekeepers. The third problem is the choosing of the optimal scale of a network due to the very different optimal size of networks regarding the requirement of risk spreeds, of the motivated engagement, of competition, incentives of inclusion of insurantes, they always need other net sizes. But it is possible, for each requirement there could function different networks. A practice (doctor's office) can be a member in different networks in several levels. The social transition from a small office to a network of offices is in all business lines a cultural shock involving not only benefits also psychical and social distress. In this there is no difference between health or agriculture or each other business of trade and industry. The destiny of the joint doctor's offices in Germany suggest due to a very serious power to scatter this networks. The comparative analysis of conflicts, strains, resources and strategies of associations and networks could yield from a developed methodical repository in sociology and social psychology what exists since 40 years (see also Meyer--in this journal). But therefore must be included also the action problems, which are only mentioned in passing of the according profession horizon.

Cost Control↗
PubMed2006

The National Eye Health Education Program: increasing awareness of diabetic eye disease among American Indians and Alaska Natives.

With the highest prevalence of diabetes in the United States, American Indians and Alaska Natives are at greatest risk for diabetic eye disease (DED), a leading cause of blindness. The National Eye institute (NEI) conducted formative research to understand DED-related knowledge, identify approaches to managing this disease, and design a communication plan to increase awareness and reduce DED among these populations. The NEI conducted qualitative research at five locations in indian country with representatives from national organizations, tribal members, and healthcare providers. While diabetes ranked high on their list of primary community health issues in need of attention, study participants had only a basic level of diabetes-related knowledge, acknowledged the need for DED education, and underscored the importance of the use of interpersonal and culturally appropriate communication strategies. This is the first exploratory qualitative research study to examine the status of diabetic eye disease among American indians and Alaska Natives whose primary purpose was to inform the design of a national DED communication campaign.

Adult↗
PubMed1997

Umbanda healers as effective AIDS educators: case-control study in Brazilian urban slums (favelas).

During a 12-month period (November 1994-October 1995), Afro-Brazilian Umbanda healers (Pais-de-Santo) taught 126 fellow healers from 51 Umbanda centres (terreiros) located in seven overcrowded slums (favelas) (population 104-343) in Brazil's northeast, the biomedical prevention of AIDS, including safe sex practices, avoidance of ritual blood behaviours and sterilization of cutting instruments. A face-to-face educational intervention by healers, marginalized in society yet respected by devotees, which blended traditional healing-its language, codes, symbols and images- and scientific medicine and addressed social injustices and discrimination was utilized in this project supported by the Brazilian Ministry of Health, National Program in STDs/AIDS. Significant increases (P < 0.001) in AIDS awareness, knowledge about risky HIV behaviour, information about correct condom use, and acceptance of lower-risk, alternative ritual blood practices and decreases (P < 0.001) in prejudicial attitudes related to HIV transmission were found among mobilized healers as compared to 100 untrained controls. Respected Afro-Brazilian Pais-de-Santo can be creative and effective partners in national HIV prevention programmes when they are equipped with biomedical information about AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1996

[Managed health care--second opinion from the viewpoint of Swiss orthopedists].

Health Care reform rapidly changes the US health system and enters our "free system" with various aspects. The understanding of the buzzwords in managed care and the so-called managed competition are the context for making informed decisions about our future. We must develop at least a rudimentary understanding of the ways many types of collaborative efforts and managed care organisations evolve. We must know to ask the right questions and hopefully find the correct answers for the benefit of our patient.

Cost Control↗
PubMed1991

National health care and the public's oral health.

This article presents an outline of a proposal for a national health program, together with a discussion of the necessity of inclusion of dentistry for optimum benefit to the public. A thorough restructuring of current principles of coverage, benefits, methods of payment, administration, and methods of protection of the public is proposed. Disease prevention and the role and responsibility of public health dentistry would be enhanced in such a scheme. Current total dental care expenditures should be sufficient to cover most of the costs. It is the author's belief that further tinkering with the existing health care system and the application of more bandaids can only exacerbate existing problems.

Dental Health Services↗
PubMed1998

[Disease management. Current trend or potential solution?].

Main deficit in the present health care system is the inadequate integration of service providers into therapy procedures. Disease Management opposes (objects) this. It is a method to systematically improve quality- and economic-standards. Disease management programs include the following five elements: 1. Information standardisation and information technology, 2. improvement of therapy guidelines, 3. motivational programs for service providers and patients and 4. the patient in the centre of all activities. These four elements directly influence patient therapy. With the fifth element, Outcomes Research, treatment results can be evaluated and, if necessary, additional measures taken. With this, a line of rules is established. Looking at the results of Disease Management it becomes evident that it is an interesting starting-point which offers solutions to help eradicate deficits in the present healthcare system.

Cost-Benefit Analysis↗
PubMedDate not supplied

John P. Peters and the committee of 430 physicians.

John Peters and his committee had a few basic goals. One was that local, state, and federal governments needed to provide money to construct facilities, support medical research and education, and care for the poor. And they wanted experts to call the shots. Over time, Peters and the committee got what they wanted for the most part: Hill-Burton money for building the hospitals, the rise of the National Institutes of Health, Medicare, Medicaid, a Veterans Administration system, and new and expanded medical schools. The experts calling the shots included David Kessler at the Food and Drug Administration and Surgeon General C. Everett Koop. In the halcyon days of American health system reform, back in 1993, Yale's Paul Beeson wrote about the Committee of 430 Physicians and its goals in the Pharos of Alpha Omega Alpha. Beeson was optimistic and he quoted from my 1991 JAMA health system reform editorial as a sharp contrast to what Fishbein had written - although coincidentally, we both quote Lincoln. My editorial began, "'with malice toward none, with charity for all...' so spoke Abraham Lincoln in his second inaugural address recognizing that he had no political consensus regarding either the constitutionality of states seceding or the morality of slavery being abolished. Nonetheless, he knew what was right and was able, through persuasive, often inspiring rhetoric, to conclude a bloody and decisive Civil War and constitute the foundation for this great republic.... Yet access to basic medical care for all of our inhabitants is still not a reality in this country. There are many reasons for this, not the least of which is a long-standing, systematic, institutionalized racial discrimination.... An aura of inevitablitiy is upon us. It is not acceptable morally, ethically, or economically for so many of our people to be medically uninsured or seriously underinsured. We can solve this problem. We have the knowledge and the resources, the skills, the time, and the moral prescience. We need only clear-cut objectives and proper organization of existing resources. Have we now the national will and leadership?" Beeson's answer to that question in 1993 was, "Yes, but not by one comprehensive act." He quoted Peters from his 1938 Annals of Internal Medicine article: "a sweeping program suddenly imposed in this country as a whole out of the head of any Jove would undoubtedly create confusion if not chaos. Thoughtful investigation and experiment promises more than grandiose projects born of emotional preconceptions. The programs must be built of an evolutionary manner, step by step." Very wise, very valid. But how long must our people wait?

History, 20th Century↗