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PubMedDate not supplied

The impact of financial constraints and incentives on professional autonomy.

General practice has been the subject of extensive reforms over the 1990s in Australia as elsewhere. Reforms have attempted to improve quality and contain the overall cost of health care, and have often been seen as reducing the autonomy of medical professionals. This paper examines the impact of financial constraints and incentives introduced during the 1990s on Australian GPs' perceptions of autonomy. An existing seven component definition of autonomy and six themes that emerged from reviewing publications were used to construct focus group questions. A total of 25 GPs participated in four focus groups. Those who participated believe that their financial autonomy has been diminished by policy changes and consumer expectations. They also perceive that their ability to control clinical decisions, which they regard as the most important aspect of professional autonomy, has been reduced along with financial autonomy. Organized medicine in Australia sees financial accountability and clinical decision making as polar opposites, and has continued to argue that fee-for-service payment is the only appropriate method of remuneration, despite increasing evidence that this does not guarantee clinical autonomy. Major changes to the financing of general practice in Australia are required to address the concerns of GPs, governments and patients.

Attitude of Health Personnel↗

PubMed2006

Development of a Money Mismanagement Measure and cross-validation due to suspected range restriction.

A measure of the tendency to mismanage money was developed in an evaluation of a representative payee program for individuals with serious mental illnesses. A conceptual model was composed to guide item development, and items were tested, revised, added, and rejected in three waves of data collection. Rasch analyses were used to examine measurement properties. The resulting Money Mismanagement Measure (M3) consisted of 28 items with a Rasch person reliability at .72. Restriction of range was likely responsible for the low Rasch reliability. Validity analyses supported the construct validity of the M3. Subsequently, a cross-validation study was conducted on an untreated sample not as susceptible to range restriction. The M3 produced a Rasch person reliability = .85 with good validity. The M3 fills a gap that can facilitate research in the understudied area of money mismanagement.

Cross-Sectional Studies↗

PubMed1971

The Medical Library Assistance Act: an analysis of the NLM extramural programs, 1965-1970.

The imbalance between medical library resources and information needs of the health professional led to a reexamination of the mandate for the National Library of Medicine. Legislation known as the Medical Library Assistance Act (MLAA) was passed in 1965 which enabled the NLM to (1) initiate programs to assist the nation's medical libraries and (2) develop a medical library network with the establishment of regional medical libraries to link the NLM with local institutions. The National Library of Medicine, through the MLAA, has made available $40.8 million to the medical library community under a competitive grant and contract mechanism for the period July 1965-June 1970. A total of 604 projects has been executed in resources, research and development, training, construction, regional medical libraries, publications, and special scientific projects. An assessment is given of each of these programs and their impact on both the National Library of Medicine and individual medical libraries. In the aggregate, these programs have significantly improved library and information services to the professional health user. The principal limitation has been inadequate funding to accomplish the level of originally stated objectives.

Financing, Government↗

PubMed1982

Expanded phase out provisions of intermediate care facilities for the mentally retarded (ICFs/MR) correction plans--Health Care Financing Administration. Final rule.

This regulation authorizes Intermediate Care Facilities For the Mentally Retarded (ICFs/MR) to negotiate revisions to their 1977 correction plans for Life Safety Code, living, dining, and therapy area deficiencies under certain circumstances. Under this regulation, HCFA is authorized to approve revised correction plans when facilities have completed at least 25 percent of their original plans and agree to phase out an increased number of beds in previously certified units not already scheduled for phase out under existing correction plans. The timetable for the phase out and the actual number of beds to be phased out will be negotiated with target figures established for each six-month period of the plan. The total time for the plan cannot exceed five years from the effective date of this rule. Facilities are still required to meet the July 18, 1982 deadline for those items in existing plans which include construction or renovation of units that will remain in use after the phase out is completed. The intent of this regulation is to stimulate an overall reduction in the number of certified beds in large residential facilities. We hope that it will forestall further expenditures of capital funds for renovation of existing facilities or construction of new units where an expanded phase out of units is feasible.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed1985

Medical facility construction and modernization; requirements for provision of services to persons unable to pay--PHS. Proposed rules.

This notice proposes revisions to the rules currently governing how health care facilities assisted under Titles VI and XVI of the Public Health Service Act fulfill the assurance, given in their application for assistance, that they would provide a reasonable volume of services to persons unable to pay. Comment on the current rules and operational experience with them have indicated the need to revise the current requirements as they pertain to publicly owned facilities.

Financing, Government↗

PubMed2000

Comparison of nurse practitioner and family physician relative work values.

PURPOSE: With the enactment of the Balanced Budget Act of 1997, American nurse practitioners were granted direct Medicare reimbursement for Part B services. Payment structures in fee-for-service and managed care systems are physician-based, leading to difficulties in constructing payments for other health care professionals. The purpose of this pilot study was to examine the feasibility of using nurse practitioner data for specifying relative work values in the Medicare Fee Schedule for three office-visit codes. DESIGN: An exploratory survey was designed to establish relative work values using magnitude-estimation scaling. Nurse practitioners (N = 43) responded to a structured questionnaire in a national mail survey. Physician data (N = 46) were obtained from a computerized database from the American Academy of Family Physicians. METHODS: The methods used in this study were the same as the process used by the American Medical Association and the Health Care Financing Administration to establish relative work values in the Medicare Fee Schedule. Respondents established relative work values for three Current Procedural Terminology (CPT) codes for office visits (99203, 99213, 99215) commonly billed in primary care practice. Each CPT code descriptor and associated vignette were compared with reference services germane to the practice of nurse practitioners and family physicians, using magnitude-estimation scaling. To establish relative work values for each code, respondents were asked to consider the time to provide the service and intensity of the work involved for each CPT code. FINDINGS: No significant differences between nurse practitioners and family physicians were found in the three CPT codes for relative work values and intensity. Nurse practitioners estimated significantly (p < .01) higher intraservice (face to face) time with patients than did family physicians, and family physicians estimated significantly (p < .05) higher pre-service time for two codes and significantly (p < .05) higher postservice times for three codes. CONCLUSIONS: Nurse practitioner relative work values did not differ significantly from family physician relative work values. Although the sample sizes were small, the significance of the findings support the need for further research with large data sets and additional CPT codes. Such studies could then be used as a basis for decisions about Medicare payment and public policy.

Humans↗

PubMed1991

Good neighbors. A collaborative effort develops housing for the low-income elderly on Chicago's southeast side.

On Chicago's southeast side, the Claretian missionaries--in collaboration with the Oblates of Mary Immaculate, members of the local community, and local business interests--will soon open Villa Guadalupe, a housing project for low-income seniors. Recent developments have combined to make the creation of low-income housing for the elderly more compelling than ever from a mission perspective and more feasible from a structuring and financing perspective. Since 1925, the Claretians have served a predominantly Hispanic population in south Chicago. The neighborhood suffered economic devastation in the 1960s with the collapse of the local steel industry. A 1985 needs assessment determined that nearly one in five elderly residents in the area lives at or near the poverty level. As a result of the assessment, the Claretians decided to develop the Villa Guadalupe project. For assistance in managing and financing the project, the Claretians drew on the resources and expertise of the Oblates of Mary Immaculate, who have a history of ministering to the elderly. The project also had to overcome legal obstacles to securing property tax exemption from the state of Illinois. The project cleared another hurdle when it secured financing by issuing tax-exempt bonds secured by a letter of credit issued by a commercial bank. In addition, interest in monies from an endowment fund will make up the difference between funds Villa Guadalupe will receive through rents and the income that is required to support the project.

Aged↗

PubMed1997

The next generation of vascular surgeons: how should they be trained and credentialed? Who should pay for it?

Vascular surgery has matured as a subspecialty of general surgery during the past 25 years. The discipline currently faces a number of challenges including duration and scope of training, financing of graduate medical education, specialty and subspecialty certification, hospital privileging or credentialing, and practice opportunities. This article reviews these issues in terms of present realities and future opportunities. Emphasis is placed on curricular redesign to tailor length and breadth of training to future career goals, be they private practice as a general surgeon with vascular surgery interests, a vascular surgical subspecialist, a rural versus an urban practice, or a subspecialist in an academic setting. A plea is made for regulatory bodies, including the Residency Review Committee for Surgery and the American Board of Surgery, as well as specialty societies, particularly the American College of Surgeons, to maintain a flexible and constructive posture in dealing with proposed educational innovations. With cooperative efforts of both the Association of Program Directors in Surgery and the Association of Program Directors in Vascular Surgery, vascular surgery education and training of both general surgeons and vascular surgeons should be enhanced to fulfill the workforce needs as we enter the next millennium.

Costs and Cost Analysis↗

PubMed1995

Cross-cultural correlates of life satisfaction and self-esteem.

College students in 31 nations (N = 13,118) completed measures of self-esteem, life satisfaction, and satisfaction with specific domains (friends, family, and finances). The authors assessed whether cross-cultural variations in the strength of associations were related to societal dimensions including income and individualism. At the national level, individualism correlated -.24 (ns) with heterogeneity and .71 (p < .001) with wealth. At the individual level, self-esteem and life satisfaction were correlated .47 for the entire sample. This relation, however, was moderated by the individualism of the society. The associations of financial, friend, and family satisfactions with life satisfaction and with self-esteem also varied across nations. Financial satisfaction was a stronger correlate of life satisfaction in poorer countries. It was found that life satisfaction and self-esteem were clearly discriminable constructs. Satisfaction ratings, except for financial satisfaction, varied between slightly positive and fairly positive.

Adolescent↗

PubMed1996

How will medical savings accounts affect medical spending?

This paper estimates that if a cross-section of nonelderly adults switched from comprehensive insurance to a combination of catastrophic insurance and a medical savings account (MSA), they would reduce their medical spending by between 2% and 8%. The author constructs measures of the prices individuals pay for medical care under a typical comprehensive insurance policy and a particular combination of catastrophic insurance and MSA. The difference in prices paid in the two health plans is combined with price elasticity estimates from the Health Insurance Experiment to predict changes in spending. Several qualifications to the estimate are considered.

Adult↗

PubMed1992

Regular pattern of preventive dental services--a measure of access.

Having a regular pattern of care should be an indicator of access to and periodic use of preventive and health maintenance services. The analyses reported in this study are intended to provide a better understanding of the factors related to having a regular pattern of preventive dental care. The data were collected in 1981 as part of a U.S. household survey, 'A Study of Dental Health Related and Process Outcomes Associated with Prepaid Dental Care', the most comprehensive cross-sectional data base available in dentistry. Descriptive analyses of a constructed variable, representing perceived and realized access and a preventive orientation, indicate that 53% of the population had a regular pattern of preventive care. Those with a regular pattern of care were more likely to be white, younger, have dental insurance, have no cost barriers, have more than 12 years of education, be dentate, have no perceived symptoms, and no fear of pain. Logistic regressions indicated that there was an increased probability of having a regular pattern of preventive care if individuals had no economic access problems, had positive attitudes, had higher income, reported few oral symptoms, and were non-Black. Overall, the descriptive models used suggested that individuals with resources in the form of finances and education, and a sense of self-efficacy as expressed in attitudes toward oral health, had the greatest probability of having a regular pattern of preventive care.

Attitude to Health↗

PubMed1976

Implementing formative health planning under PL 93-641.

The National Health Planning and Resources Development Act of 1974 (PL 93-641) melds the Hill-Burton program, Regional Medical Program and Comprehensive Health Planning into a new network for health planning and resources development. Health-systems agencies will possess broader powers than predecessor agencies, particularly in the areas of regulation, control of federal funds, resources development and implementation. PL 93-641 thus offers the possibility of transforming the basic concept of health planning from reactive to "proactive." Successful legislative implementaion will require each health-systems agency to build local legitimacy, ensure constructive consumer/provider dialogue, and respond to state and national managerial requirements. Many questions about planning implementation, the role of subarea councils, agency co-ordination and local governance remain unresolved. The new health-planning network has the potential to assume the function of active system transformation, but will be critically dependent on adequate program budgeting to fulfill this promise. (N Engl J Med 295:698-703, 1976).

Delivery of Health Care↗

PubMedDate not supplied

Review: feedback about practice patterns for measurable improvements in quality of care--a challenge for PROs under the Health Care Quality Improvement Program.

The Health Care Quality Improvement Program (HCQIP), administered by the Health Care Financing Administration and implemented through Utilization and Quality Control Peer Review Organizations (PROs), is a new approach to monitoring the health care received by Medicare beneficiaries. The HCQIP shifts the focus of the PRO program from regulatory quality management to quality improvement principles. Through a series of cooperative projects, each focusing on a specific medical condition or procedure, PROs will conduct pattern analysis and share information about these analyses with health care organizations for the purpose of stimulating internal quality improvement efforts. As a fundamental shift in the way PROs have conducted quality-related activities, the HCQIP presents PROs with numerous challenges. This paper provides insight into one of their most significant challenges, the development of a model for constructive, nonevaluative feedback. Successful HCQIP feedback efforts may serve as models for quality management programs that will accompany national health care reform.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed2001

Measuring competition in health care markets.

OBJECTIVE: Measuring competition is increasingly important for analysis of health care markets and policies. Measurement of competition in health care is made complex by the breadth of potential issues under study, by the lack of necessary data, and by rapid changes in health care financing and delivery. This study reviews key issues in the measurement of competition and is designed to familiarize researchers and policymakers interested in competition measurement, but not steeped in its practice, with key concepts, data sources, and ways of adapting measures to fit ongoing changes in health care markets. PRINCIPAL FINDINGS: Attention to several key issues will strengthen measurement. Important components of successful measurement are: careful identification of the products and market areas for study; selection of Herfindahl-Hirschman or other indices to fit the issues being considered; consideration of econometric problems, like endogeneity, with common measures; and attention to the ways that current marketplace changes, like growth in managed care, affect the performance of classic measures. Data needed for constructing measures are also frequently scarce, insufficient, or both. Measurement could be improved with access to better data.

Catchment Area, Health↗

PubMedDate not supplied

Federal health information policy: a case of arrested development.

Computerized patient records (CPRs) have reached a state of technical maturity that makes them an essential component of modern patient care. However, because uniform technical standards do not exist, CPRs constructed by different vendors do not convey clinical information easily from provider to provider. Moreover, unequal access to capital may mean a two-tier clinical information environment in the future. HIPAA, while important, did not anticipate the CPR revolution. New federal activism is required to assure not only interoperability of clinical data systems, but also that providers who lack capital and technical resources can make the needed digital conversion.

Ambulatory Care Information Systems↗

PubMed1988

Edentulous ridge augmentation. Part II.

Edentulous ridge augmentation has evolved from an attempt to control progressive atrophy of both denture-bearing bone and soft tissue. Preprosthetic surgery to reverse these undesirable conditions should only be attempted after other methods, such as proper denture construction, proper patient compliance, and patient management have been unsuccessful. Also a thorough evaluation by both a prosthodontist and an oral surgeon is required. Prosthodontically, the surgical procedure should produce the following features: (1) enlargement of the area of bony support, (2) improved contour of the ridge for denture stability, and (3) elimination of the displacing action of muscle attachments on the complete denture. Ideally we would like to combine all of these distinct features to arrive at the goal of optimum denture retention. The oral surgeon must also be aware of these principles, and in essence, determines the immediate post-surgical results. However, the oral surgeon is also limited by specific patient factors such as systemic conditions, oral health maintanence, and finances. He must recognize these and determine which surgical methods would give the best denture retention and patient service. It is in this context that the prosthodontist and oral surgeon must work together to facilitate total patient care.

Alveolar Ridge Augmentation↗

PubMed2000

Mental health services for American Indians and Alaska Natives: need, use, and barriers to effective care.

This special review summarizes and illustrates the state of our knowledge regarding the mental health needs of American Indians and Alaska Natives. These needs are considerable and pervasive. The discussion begins by reflecting on the limits of psychiatric nomenclature and conceptual frameworks for revealing Native constructions of mental health and mental illness. The experience and manifestation of psychopathology can be both different and the same across cultures, hinging upon the extent to which such basic assumptions as the relationship of mind to body--and spirit in the case of Native people--or the primacy of the individual or social collective are shared. Having set the stage, this paper moves to recent empirical evidence regarding the mental health needs of American Indians and Alaska Natives: we review that evidence and consider it within the broader context of available services. The report closes with a brief overview of the most pressing issues and forces for change afoot in Indian country in the US. Most have to do with the structure and financing of care as tribes and other Native community-based organizations seek to balance self-determination and resource management to arrive at effective, fiscally responsible, culturally informed prevention, treatment, and aftercare options for their members. These changes may herald similar trends among First Nations people to the immediate north.

Adult↗

PubMed2003

Respiratory illness in the Dominican Republic: what are the predictors for health services utilization of young children?

Respiratory illness and diarrhoea continue to be the leading causes of paediatric morbidity and mortality in the Dominican Republic. An important first step in alleviating this disease burden is to understand patterns and predictors of health services utilization for these conditions. This study examines the predictors of (a) health services utilization, and (b) public versus private sector use, for respiratory illness in the under-five population in the Dominican Republic. The DHS-2 dataset (1991) was utilized for analysis. Logistic regression models for predicting use and non-use, and for predicting private versus public sector use, were constructed using the Andersen Behavioural Model as the conceptual framework. Our findings indicate that sex, location and possession index quartile are factors that influence the decision to seek care or not for respiratory illness in under-fives. In contrast, the choice between the public and private sector is determined by location and insurance status. From the policy perspective, if the Dominican Republic were to undertake steps to increase private insurance coverage, our results indicate that this would lead to increased utilization of private sector providers for respiratory illness by children having private insurance, but would not have an impact on overall utilization (i.e. use vs. non-use). On the other hand, one of the ways to deliver cost-effective interventions by the publicly financed system would be to improve facilities in the rural areas.

Child Health Services↗