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PubMed1997

Antigovernment sentiment and support for universal access to care: are they incompatible?

OBJECTIVES: Attitudes toward universal access to medical care were examined to determine whether support for it among people opposed to government involvement in health care was modified by three proxy measures of self-interest: being uninsured, in poor health, or a high user of medical care. METHODS: Data on support for universal access, attitudes toward government involvement in health care, and the indicators of self-interest were obtained from a representative sample of adult Oklahomans (n = 1547) surveyed between October 1992 and December 1994. Forced-order multiple regression with interaction terms was the data analysis technique. RESULTS: People opposed to government involvement in health care were found to be less likely to favor universal access to medical care, but poor health, lack of insurance, and high usage of medical care moderated this effect. CONCLUSIONS: The findings support the view that antigovernment sentiment need not foreclose the public option for health policymakers. Other considerations such as self-interest may modify the effect of unfavorable attitudes toward government.

Adult↗
PubMed1995

[Positive experiences in Scandinavian patient insurance].

Voluntary insurance for the compensation of patients for damage sustained in health care was introduced in Sweden 20 years ago and similar systems exist in Finland, Denmark and Norway. This type of insurance is, or is in the process of becoming, statutory. The basic principle is that the apportioning of blame to any individual(s) is not a prerequisite for compensation to be paid out for injury sustained by a patient. Owing to hospital proprietors and care givers having taken out patient insurance policies with approved insurance companies, it has been possible for damages to be compensated in accordance with current insurance norms and the frequency of lawsuits arising from injury sustained in health care has been minimised. This type of insurance is universally accepted, and has often enabled unfortunate confrontations between doctors and patients to be avoided.

Clinical Competence↗
PubMed1993

[Cost-effectiveness analysis of long-term liver transplantation; the liver transplantation program of Groningen 1979-1991].

A medical technology assessment of the liver transplantation programme of Groningen University Hospital, which was commissioned by the Dutch National Health Insurance Board, is discussed. The results of all 152 liver transplantations performed between 1979 and November 1990 were analysed. The main objective of the study was to evaluate the long-term effects of liver transplantation. Five years after transplantation 59% of the adult patients were still alive. The survival probability depended greatly on the primary liver disease. Mortality and morbidity occurred mainly within the first year after transplantation. Thereafter the prospects for the patients were excellent, with regard to both the probability of survival and the quality of life. The costs of liver transplantation could be calculated only for patients with primary biliary cirrhosis and other forms of biliary cirrhosis, not caused by hepatitis B infection or alcohol abuse. For these patients the costs of a liver transplantation were estimated at HFl. 263,000--(with a 10% margin), 10 years of follow-up included and corrected for the costs that would have been made for the treatment of the liver disease. For this population of patients a liver transplantation costs between Hfl. 64,000--and Hfl. 79,000--per life year gained, 10 years of follow-up included. Costs of cyclosporin still take up a major part of the costs. The need for liver transplantation in the Netherlands was estimated at between 35 and 126 transplantations per year, depending on indications, contraindications, referral policy and the percentage of retransplantations.

Adolescent↗
PubMed1996

Treatment differences between blacks and whites with colorectal cancer.

OBJECTIVES: The authors examine interracial variations in treatment for over 20,000 patients hospitalized with colorectal cancer in a national sample of hospitals. METHODS: To reduce clinical heterogeneity that could explain differences in treatment, hospitalizations were classified into relatively homogeneous subgroups based on diagnoses indicating primary colorectal tumor, oncologic sequelae, and metastasis. Procedures were classified into clinically relevant treatment types. Multivariate techniques controlled for differences in patient demographics, insurance status, other clinical factors, and provider characteristics. RESULTS: Blacks were more likely than whites to be hospitalized with oncologic sequelae, diagnoses indicating advanced disease, which may capture the effects of unmanaged or poorly managed cancer. Inpatient mortality was equivalent only for the most severely ill. Otherwise, the odds of inpatient mortality were 59% to 98% higher for blacks than whites. Treatment, in terms of procedure type, was equivalent only for the sickest patients. Among the less severely ill, blacks were less likely than whites to receive major therapeutic procedures. CONCLUSIONS: Multiple findings suggest that blacks with colorectal cancer were hospitalized with more severe conditions and treated less aggressively than whites. In an era of health-care reform, such differences, which are net of insurance effects, may require more than universal insurance coverage to be overcome.

Adolescent↗
PubMed1995

A longitudinal evaluation of fissure sealants applied in dental practices.

Sealants are highly effective in preventing dental caries in the pits and fissures of teeth when applied by trained operators in clinical trials and public health programs. The effectiveness of fissure sealants when applied in dental practices is still not known. The purpose of this longitudinal study was to evaluate the effectiveness of fissure sealants applied in dental practices in preventing dental caries on occlusal surfaces of first permanent molars. In 1990, on the Island of Montréal, 911 randomly selected children, from 6 to 9 years of age, were examined; out of those, 816 and 733 were re-examined in 1991 and 1992, respectively. Only the 733 children with complete examination records were included in this evaluation. Sealant applications were either personally paid for or were paid for by private dental insurers. All children were covered for diagnosis and restorative care by a publicly financed and universal insurance program. Dental treatment records were provided by Quebec's health insurance board. In the epidemiological examination, the occlusal surfaces of first permanent molars, which are the only surfaces included in this analysis, were classified into: sound, non-cavitated and cavitated status, restored, and sealed. Sealants were evaluated for full or partial coverage of the occlusal surface and presence of dental caries. During the first and second years, 11.6% and 17.5% of the students had new sealants. The number of new sealants placed during the two years was 507. Children with caries-free status and whose parents had high school education or higher were significantly more likely to receive sealants during the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Binomial Distribution↗
PubMed1986

Psychiatry across borders.

To gain an understanding of the challenges and opportunities confronting mental health professionals throughout the world, the author sent a brief questionnaire to psychiatric leaders in a diverse group of countries. Questions focused on patient care issues, education, and delivery systems. Responses from 13 countries indicated universal concern about the cost of psychiatric care and how it is delivered. Most countries consider health care a national responsibility and provide some form of universal insurance coverage. There is a lack of uniformity in resource distribution and use as well as in standards of care for acute and chronic patients. ICD-9 is the diagnostic classification system used in almost all responding countries, but use of DSM-III is increasing. The author emphasizes the importance of considering national differences and similarities in the delivery of psychiatric services so that professionals around the world can learn from each other's experiences.

Africa↗
PubMedDate not supplied

[Private health expenditures and income distribution in Brazil].

BACKGROUND: This paper analyses the share of the family private health expenditures in the Brazilian GDP and in personal income; and the distribution of the family private health expenditures among social groups. METHODS: The research utilized the 1998 Brazilian Home Sample Survey (Pesquisa Nacional por Amostra de Domicilios) with the division of the population into four social groups according to the family income per capita; and the distribution of the family private health expenditures among health insurance, physicians, other health professionals, medical tests, drugs, orthopedic and other medical durables, vision products, dental services, hospital care, nursing home care and other health spending. RESULTS: In 1998, only 7.2% of the population with family income per capita up to 1 minimum wage had health insurance and the health expenditures of this group, that represented 52.5% of the population, was US$ 4.62 per capita. For the people with 9 and more minimum wages per capita the health insurance coverage was 83.2% and the health expenditures was US$ 114.66 per capita. CONCLUSIONS: The implementation of the Brazilian public universal health care system in 1988 denominated "Sistema Unico de Saude" was followed by an expressive expansion of private insurance coverage in the 1990's. Even if all public health expenditures had been exclusively directed to the population without any private insurance, these people's health expenditures would only reach 43% of the health expenditures of those with private insurance.

Brazil↗
PubMed1995

Values and value--a vision for the Australian health care system.

The Australian health care system is at a crossroads. Status quo is not a sustainable option for the future. Rising consumption, spiralling costs, the decline of private health insurance and a public sector 'bursting at the seams' threaten our traditional values of a universal, affordable, accessible, equitable, high-quality system. As a result, we believe that major reform of the health care system is both necessary and inevitable in order to ensure that the values of the system are maintained and to extract maximum value from limited health resources. In this article we lay out our vision for the Australian health care system. It is a vision characterised by transformational change--shifting of risk from patients and taxpayers to providers, downsizing of acute care capacity, integration of services across the system, rationalisation of State and Federal responsibilities and a 'shakeout' of providers and insurers resulting from intensified, but bounded, competition. We believe that the direction for health care players needs to be clarified so that, as a country, we can continue to have a best practice model of health care delivery. We present this vision as a 'stake in the ground' to set parameters around which this debate can emerge. It may be provocative and challenging, but it is our vision into the future.

Australia↗
PubMed2005

[Introduction of quality management with the EFQM Self-Assessment method. Implementation and experience in a university department of dermatology].

In the near future, the German legislative and health insurance agencies will increasingly demand proof of quality in hospital health care. The role of quality management in hospitals is emphasized by the introduction of per-case payment (DRG) in Germany. The implementation of internal quality management at an early stage sets the course of a systematic and continuous quality improvement process, with the goal to increase performance and results by efficient utilization of resources. The decision for or against one or another quality management model appears to be difficult, since the possible impacts of the quality management system can hardly be foreseen. As this article shows, the Self-Assessment method of the European Foundation for Quality Management (EFQM) provides a valuable and efficient tool to introduce quality management in a hospital environment. The Self-Assessment method enables a systematic survey of levels of performance and outcome of the hospital. Furthermore, it provides an appropriate basis to identify areas of strengths and weaknesses. A high degree of motivation of the personnel is fostered by the creation of a local guidance circle, a coordinating group, and several Self-Assessment teams. However, formulation and deployment of improvement actions are necessary for the long-term implementation of quality management. The application of Self-Assessment in quality management appears a suitable tool to promote excellence.

Dermatology↗
PubMed1987

Privatisation of South African health services--are the underlying assumptions correct?

Six key assumptions made by proponents of privatisation are critically appraised in the light of Canadian, US and UK studies. 'Counter' assumptions, equally credible, are: (i) the economic behaviour of the health-care market does not correspond to the idealized rules of the free market nor, given the nature of health care as a 'public good', should it do so; (ii) national health-care systems with a heavy emphasis on private insurance are as or more costly than universal public systems; (iii) private for-profit hospitals do not usually enjoy any cost-efficiency advantages over public hospitals; (iv) subsidizing individuals to purchase private care carries a risk of adding administrative costs, fueling the inflationary spiral in health care, and reducing public accountability of tax money; (v) user-fees and co-insurance will not deter over-utilisation without penalising and reducing legitimate use of health services; and (vi) savings from privatisation are unlikely except for the more affluent citizens of the RSA who will carry a slightly reduced tax burden--all others will pay more and may be deterred from seeking necessary care.

Canada↗
PubMed1985

Evaluating corporate wellness and promotion programs: the cases of Johnson & Johnson Corporation and Metropolitan Life Insurance Company.

In 1983 the Health Systems Management Center of Case Western Reserve University (CWRU) contracted with the Business Roundtable Health Initiatives Task Force to use their survey of members as a guide to the top firms who had taken action regarding health care costs but, more importantly, who had also evaluated that action in terms of its cost implications. The mandate was to draw together representative case studies on seven firms who met those criteria for use in Business Roundtable (BRT) educational seminars and elsewhere. These cases may provide important insight for other companies who are contemplating action regarding their health care costs. They should also lead to further research on alternative actions available and the means of evaluation that should be considered. Most importantly they may provide some methodologies for top management to choose among proposals for attacking this burgeoning corporate cost. Two of the case studies presented here, Johnson & Johnson and Metropolitan Life, examine the area of wellness promotion and sickness prevention. Both of these companies believe that the employer can have a positive impact on employee health and thus corporate costs and productivity. Both also attempted to measure the benefit although Johnson & Johnson has made a significantly larger investment in this effort. The ongoing Johnson & Johnson evaluation does hold the greatest promise for measuring economic benefits. The limited results available are positive. Although financial ramifications are difficult to demonstrate, gains in employee morale are significant.

Cost-Benefit Analysis↗
PubMed1996

Individual choice in spending accounts. Can we rely on employees to choose well?

Flexible spending accounts (FSA) represent a current health care financing tool that may become an important component of incremental health care reform. Because FSAs require employees to make financial contributions based on anticipated health care needs, contribution decisions are likely to be subject to many of the errors made in other insurance decisions. The authors analyzed the benefits selections, benefits forms completion, and FSA contribution levels of approximately 9,500 employees of the University of Pennsylvania from 1987 to 1992. Default and repeat choice trends characterize the completion of benefits forms and the reselection of health insurance options by employees. Despite the economic benefits of contributing to an FSA, only 14% of employees contributed in any one year and 73% never made a contribution. Multivariate models of these contributions fail to demonstrate the importance of what ought to be relevant influences in contribution decisions (for example, age, income, family status, or underlying health insurance). Whereas most FSA decisions are characterized by default contributions of $0, employees who contribute in one year are most likely to contribute exactly the same amount the next year, even when other circumstances change. The pervasiveness of these patterns raises concerns that health care reform plans that rely on financial incentives at the consumer level--for example, proposed medical saving accounts--will be inefficient.

Choice Behavior↗
PubMed1994

Health systems planning at a state level: New Jersey.

In 1991, New Jersey undertook a planning effort to eliminate the proliferation of high cost, redundant services, downsize or eliminate underutilized services, develop primary and preventive services, and consolidate regional services. The recommendation to reduce the number of accredited hospitals created serious opposition from a variety of interests and the legislature subsequently enacted legislation prohibiting enactment of rules to implement the plan. More recently, New Jersey undertook new legislation to reform health insurance to require community rating, availability of individual and small group policies, eliminate restriction on pre-existing conditions, and promote competition. Legislation also provided for hospital care of indigents to be funded by a change in the unemployment insurance system. The latter was to replace a funding mechanism which was initially invalidated by a Federal Court. In future years, some of these funds will be shifted to a subsidized insurance program. There is already evidence that these reforms have resulted in increased competition among insurance companies, hospitals, and providers. Hopefully, this will contain costs without a decrement to quality. It should also increase the number of people with health coverage, although this does not provide for universal coverage.

Health Care Reform↗
PubMed2006

Health care for older persons in Switzerland: a country profile.

Switzerland has the second-most-expensive healthcare system worldwide, with 11.5% of gross domestic product spent on health care in 2003. Switzerland has a healthcare system with universal insurance coverage and a social insurance system, ensuring an adequate financial situation for 96% of the 1.1 million older inhabitants. Key concerns related to the care of older persons are topics such as increasing healthcare costs, growing public awareness of patient autonomy, and challenges related to assisted suicide. In 2004, the Swiss Academy of Medical Sciences issued guidelines for the care of disabled older persons. Since 2000, geriatrics has been a board-certified discipline with a 3-year training program in addition to 5 years of training in internal or family medicine. There are approximately 125 certified geriatricians in Switzerland, working primarily in geriatric centers in urban areas. Switzerland has an excellent research environment, ranking second of all countries worldwide in life sciences research-but only 13th in aging research. This is in part due to a lack of specific training programs promoting research on aging and inadequate funding. In addition, there is a shortage of academic geriatricians in Switzerland, in part due to the fact that two of five Swiss universities had no academic geriatric departments in 2005. With more-adequate financial resources for academic geriatrics, Switzerland would have the opportunity to contribute more to aging research internationally and to improved care for older patients.

Aged↗