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PubMed1980

Cost containment through risk-sharing by primary care physicians: a history of the development of United Healthcare.

A new type of independent practice association has been organized to encourage primary care physicians in private practice to become coordinators and financial managers for their patients' medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all specialized care. The primary care physician authorizes payment from his/her own account for hospital and referral care provided to patients. He or she shares any deficit or surplus remaining at the end of the year. This is a background paper detailing the history of development and specific features contained in this new concept of putting the physician in charge and "at risk" for the costs of medical care to his/her patients. The plan has been operating in northern California, Washington, and Utah and has 40,000 members and 750 participating physicians. This historical background paper is part of a large project--State Employees' Insurance Benefits Utilization Study (SEIBUS) being done by the University of Washington School of Public Health to evaluate use and costs of medical care under this innovative plan.

California↗
PubMed2000

Brief history of the tissue bank, charles university hospital, hradec králové, czech republic.

A brief history of the Tissue Bank (TB) of the University Hospital Hradec Králové, Czech Republic, established by Dr. R. Klen in 1952 is presented. In Dr. Klen's original concept the TB was defined as a department specialised in the harvesting, processing, preservation, storage and distribution of various kinds of tissue for clinical and experimental practice. The first kinds of tissue collected in cadaveric donors were corneas, bone and skin. Xenogeneic cartilage and bone grafts were prepared at the same time. Later, preparation of soft connective tissues and chorion-amnion was introduced. During the first 15 years of activity a total of 11,443 grafts preserved by hypothermy at +4 degrees C or freezing in absence of cryoprotectants (-20 degrees C) were prepared. In the 60's freeze-drying of tissue grafts was introduced and the bank of cryopreserved cell lines was established. In the 80's cryopreservation of haematopoietic progenitor cells for clinical transplantations was started and the spectrum of tissue grafts was enlarged (xenogeneic pericardium and allogeneic specially treated dura mater for neurosurgical operations, pigskin for burn treatment, demineralised bone for parodontology and implantology). In the 90's human keratinocyte culture for treatment of burns and chronic skin defects was started. The human milk bank and organ bank co-operating with the Regional Transplantation Centre are component parts of the TB as well. The TB is an institutional member of the European Association of Tissue Banks and annually delivers approximately 1000 grafts that are used in University and county hospitals as well as in surgeons' private practices. Health insurance companies reimburse all grafts on a non-profit and tax-free basis.

Journal Article↗
PubMed1990

Functional status and financial barriers to medical care among the poor.

We compared the functional status of 94 poor patients with financial barriers to recommended medical care with that of 94 poor control patients without such barriers in a university-affiliated community clinic. Financial barriers existed when an insured patient's health insurance failed to cover recommended care or when an uninsured patient could not afford recommended care. Patients with financial barriers scored significantly lower than control subjects on the psychologic function/mental health component of the functional status questionnaire and tended to score lower on all other functional status measures. The results suggest that poor patients with financial barriers to recommended medical care may be sicker than other poor patients.

Adult↗
PubMed1997

Managed care and dental education and research: should academicians be concerned?

This paper examines the restructuring of the delivery system resulting from managed care. As HMOs consolidate to a few large companies in urban areas, they put great pressure on medical providers to reduce their costs and excess delivery capacity. In this environment, academic health centers face serious problems, because HMOs are reluctant to pay their higher charges, and public educational subsidies are declining. Managed care is unlikely to have the same impact on dentistry. Although managed dental care is growing, most Americans will not be enrolled, since they do not have dental insurance. Also, the supply of dentists is starting to decline, increasing the relative demand for dental services. Managed care will have only a limited direct impact on most dental schools, but a significant indirect effect. As academic health center budgets are reduced, all health professional schools can expect to contribute to solving the financial problems of University hospitals and medical schools. The response of dental academicians to these challenges will determine the future of dental education and research for the next decade. Bold new initiatives are needed to find new sources of revenue to support educational and research programs.

Academic Medical Centers↗
PubMed2003

Trusted online sources of health information: differences in demographics, health beliefs, and health-information orientation.

BACKGROUND: The recent surge in online health information and consumer use of such information has led to expert speculations and prescriptions about the credibility of health information on the World Wide Web. In spite of the growing concern over online health information sources, existing research reveals a lacuna in the realm of consumer evaluations of trustworthiness of different health information sources on the Internet. OBJECTIVE: This study examines consumer evaluation of sources of health information on the World Wide Web, comparing the demographic, attitudinal, and cognitive differences between individuals that most trust a particular source of information and individuals that do not trust the specific source of health information. Comparisons are made across a variety of sources. METHODS: The Porter Novelli HealthStyles database, collected annually since 1995, is based on the results of nationally-representative postal-mail surveys. In 1999, 2636 respondents provided usable data for the HealthStyles database. Independent sample t tests were conducted to compare the respondents in the realm of demographic, attitudinal, and cognitive variables. RESULTS: The most trusted sources of online health information included the personal doctor, medical university, and federal government. The results demonstrated significant differences in demographic and health-oriented variables when respondents who trusted a particular online source were compared with respondents that did not trust the source, suggesting the need for a segmented approach to research and application. Individuals trusting the local doctor were younger (t2634 = 4.02, P <.001) and held stronger health beliefs (F1 = 5.65, P =.018); individuals trusting the local hospital were less educated (t2634 = 3.83, P <.001), low health information oriented (F1 = 6.41, P =.011), and held weaker health beliefs (F1 = 5.56, P =.018). Respondents with greater trust in health insurance companies as online health information sources were less educated (t2634 = 1.90, P =.05) and less health information oriented (F1 = 4.30, P =.04). Trust in medical universities was positively associated with education (t2634 = 11.83, P <.001), income (t2634 = 10.19, P <.001), and health information orientation (F1 = 10.32, P <.001). Similar results were observed in the realm of federal information credibility, with individuals with greater trust in federal sources being more educated (t2634 = 7.45, P <.001) and health information oriented (F1 = 4.45, P =.04) than their counterparts. CONCLUSIONS: The results suggest systematic differences in the consumer segment based on the different sources of health information trusted by the consumer. While certain sources such as the local hospital and the health insurance company might serve as credible sources of health information for the lower socioeconomic and less health-oriented consumer segment, sources such as medical universities and federal Web sites might serve as trustworthy sources for the higher socioeconomic and more health-oriented groups.

Academic Medical Centers↗
PubMed1993

Potential impact of managed care on national health spending.

Illustrative estimates suggest that if all acute health care services were delivered through staff- or group-model health maintenance organizations (HMOs), national health spending might be almost 10 percent lower. If the delivery of all such services (except those now provided by staff- or group-model HMOs) were subject to utilization review arrangements incorporating precertification and concurrent review of inpatient care, spending might be 1 percent lower. The estimates assume no changes in the health care system apart from expansion of these two forms of managed care to cover all insured persons. They also assume that moving to universal managed care would produce a one-time drop in the level of national health spending with no subsequent effect on spending growth.

Health Expenditures↗
PubMed1992

The uninsured and the debate over the repeal of the Massachusetts universal health care law.

OBJECTIVES: The debate in Massachusetts over the repeal of the first state-based "pay or play" universal health plan is discussed using data from a survey of 1066 Massachusetts households. The survey attempted to measure the problems of the uninsured, to estimate the likelihood that they would buy insurance if offered, and to calculate the proportion of the uninsured who would be covered under an employer mandate. DESIGN: A survey conducted in person and by telephone in 1066 households, with an oversample of uninsured households, using stratification, clustering, disproportionate sampling, and poststatistical weighting. PARTICIPANTS: Adults aged 18 years and older who were knowledgeable about the insurance status of persons in their household. MAIN OUTCOME MEASURES: Insurance status, employment status, access to and use of health services, and willingness to purchase health insurance. RESULTS: First, the present system of hospital-based uncompensated care in Massachusetts is inadequate by itself to meet the needs of uninsured residents. Uninsured persons are less likely than insured ones to seek medical care for chronic health problems and serious symptoms requiring evaluation. Second, 83% of uninsured families and 24% of uninsured individual respondents would purchase one of several insurance options with 30% of the cost subsidized. Last, the employer mandate provisions of the legislation would cover 43% of the uninsured in Massachusetts. CONCLUSION: In the current economic climate, the political viability of the universal health care plan and similar national initiatives is uncertain given the intractable conflict between perceptions of the financial stability of small businesses that do not offer insurance and the health care needs of uninsured individuals.

Cluster Analysis↗
PubMed1994

Paying for long-term care.

Everyone agrees that insurance for long-term care is inadequate in the United States. Disagreement exists, however, on whether such insurance should be provided through the private or public sector. Private insurance generally uses the experience-rating principle that persons with higher risk of illness are charged higher premiums. For private insurance for long-term care, this principle creates a dilemma. Most policies will be purchased by the elderly; yet, because the elderly have a high risk of needing long-term care, only about 20% of them can afford the cost of premiums. A public-private partnership by which the government partially subsidizes private long-term-care insurance is unlikely to resolve this dilemma. Only a social insurance program for long-term care can provide universal, affordable, and equitable coverage.

Health Care Reform↗
PubMed1990

Pepper Commission recommends universal health care coverage.

Many Americans are without adequate health care as costs continue to rise. Health care insurance is unaffordable or unavailable to over half the working poor, but hospitals can no longer bear the expense of uncompensated care. The United States Bipartisan Commission on Comprehensive Health Care has issued recommendations to Congress entitled "Health Care and Long Term Care for All Americans." The Commission plan proposes a system that would be phased in over several years. This article discusses phases of the system from the first through the fifth year.

Health Services Accessibility↗
PubMedDate not supplied

Evaluation of a worksite mammography program.

We implemented a one-year program to promote mammography for employees at one campus of a state university system; a second campus served as a comparison site. Measurement cohorts, who were surveyed immediately before and after the intervention, had been randomly selected at each site; all of the subjects had insurance coverage that included mammographic screening. The intervention consisted of print media, on-site workshops, and incentive drawings. Results indicated that mammography rates increased significantly at both sites, for both those 40-49 years of age and for those > or = 50 years of age. The rate increases for the 40- to 49-year-old age group at the intervention and control sites were 17.6% and 13.6%, respectively, and, for the > or = 50-year-old age group, 11.9% and 6.3%. However, the differential changes in rates between the sites were not significant for either age category. The intervention was perceived positively by the intervention site cohort, and participation in the various components was encouraging. We present suggestions for future research on this topic.

Adult↗
PubMed2002

The prospects for reform of the Japanese healthcare system.

It is widely recognised that the Japanese healthcare system has been ranked as one of the best in the world because of its excellent efficiency and equity. The longevity and low infant mortality of the Japanese population have been achieved with a relatively low ratio of health expenditure to gross domestic product. All Japanese are covered by universal medical care insurance and all are provided with completely free access to the same medical care. Nevertheless, it should be pointed out that the medical care service is not as good as it looks. Owing to lack of competition between both hospitals and powerless insurers - the outcome of too many regulations - there is only a small incentive to improve the efficiency and quality of medical service. Furthermore, because of Japan's rapidly aging society and low birth rate, together with the long depression the economy has experienced, it is very difficult to maintain the 'pay-as-you-go' health system. For health system reform, our proposals are as follows: deregulating health markets, including pharmaceutical markets; strengthening the role of insurers; introducing information technology; and restructuring the healthcare of the elderly. We are expecting the new cabinet, which enjoys much popularity, to have the courage to initiate health reform along these lines, in spite of opposition from powerful interest groups, bureaucrats, and even members of ruling parties.

Aged↗
PubMed1997

[Establishment of a laboratory information office in response to the expanding need for consultation--actual situation of the laboratory information room, Clinical Laboratory Department, Kitasato University Hospital].

Due to the advancement, segmentation and specialization of the medical care, laboratory examinations covered by the National Health Insurance (NHI) tariff have exceeded several hundred, and it is not possible for medical staff to be familiar with all of these and to utilize them appropriately. There is an urgent need for laboratory information for physicians, nurses, and other health professionals. Accordingly, our Clinical Laboratory Department, Kitasato University Hospital, established a "Laboratory Information (Consultation) Office" in July 1995 to provide consultations on clinical laboratory tests to those engaged in daily clinical practice and in medical research. The office is situated on the second floor of the Laboratory Building of the Kitasato University Hospital. One laboratory technician and one laboratory physician (clinical pathologist) are stationed there. They are available for telephone consultations from 9:00 to 17:00 on weekdays, except for holidays, and from 9:00 to 13:00 on the first, third and fifth Saturdays. In addition, since January 1997, this office also has been open to members of medical associations in various cities in our area. To cope with requests for laboratory information, including whether an examination is covered the NHI tariff, selection of appropriate screening examinations and availability of new laboratory tests, consultations by fax are accepted at any time, even after regular working hours. As a post-graduate education program, the clinical laboratory physicians study specimen handling analytical methods and interpretation of results. At medical staff meeting, personnel from the Laboratory Information Office provide clarification on the types of consultations offered, address complex questions and find resolutions for rarely encountered and difficult laboratory issues. At these meetings, a summary of new laboratory examinations also is presented. This system of an information office where full-time laboratory physicians and laboratory technicians are stationed is the first such attempt in Japan. It may be considered a pilot project to determine if such a system may be applied to other laboratory departments in the future.

Clinical Laboratory Information Systems↗
PubMed2002

How comprehensive are the basic packages of health services? An international comparison of six health insurance systems.

OBJECTIVES: Interest in the composition of the health care menu has grown. Its outwardly comprehensive nature is as rhetorical as the slogans of universal access and affordability. This paper summarizes the international part of a report to the Swiss government, in which we explored the basic package of services covered by social health insurance in France, Germany, Israel, Luxembourg, The Netherlands and Switzerland. The aim of the initial report was to check the appropriateness of the Swiss catalogue, with special attention to the risk of unequal access to health care by rationing of effective services. In this paper, we highlight the major differences in service coverage between the countries and address the possible factors explaining those differences. METHODS: The contents of the basic packages of the six countries were compared using data from government ministries and sickness funds. RESULTS: Coverage is most comprehensive in Germany and Switzerland; these are also the countries with the greatest total health expenditure. Three countries separated nursing care from other types of health care by creating an independent insurance scheme. Some health care benefits are also covered under the heading of social care. High out-of-pocket payments are increasingly used as hidden rationing instruments. CONCLUSIONS: The present comparison highlights the multi-factorial character of the choices made in six countries in order to keep their health care menu within the possibilities offered by available resources.

Comprehensive Health Care↗
PubMed1999

Educational level, voluntary private health insurance and opportunistic cancer screening among women in Catalonia (Spain).

Health care services in Catalonia (Spain) are organized in a national health service with universal population coverage and include preventive services such as mammography and Pap tests. In addition to a national health service (NHS) coverage, 22% of the population is enrolled in a voluntary private health insurance (VPHI), leading to a double coverage. This situation offers an opportunity to study the impact of this organizational aspect of health care with regard to cancer screening access. The source of data was the Catalan Health Survey (CHS), a cross-sectional survey conducted in a random sample of non-institutionalized population carried out in 1994. Variables analysed were age, educational level and voluntary private health insurance (VPHI). Women were asked if they had ever had a mammography and Pap test for preventive purposes. Logistic regression was used to study the relationship between these variables and the mammography or Pap test participation. The study sample was 5865 women aged 20 years and older. A Pap test and mammography were carried out on 42% and 25% of women, respectively. Participation had a peak between the ages of 30 and 39 years in Pap test and between 40 and 49 years in mammography; it decreased in older women. The percentage of Pap test practice increases according to a higher educational level than it does in mammography. Women who had a VPHI showed a higher percentage of screening tests than the rest of the population. There is also an increase in the mammography practice related to the educational level in older groups, but this fact is not observed in women younger than 40 years . Multivariate logistic regression analysis showed an increase in the likelihood of ever had a mammography and a Pap test according to age and to educational level, although this situation is less pronounced in older age groups. Both variables (educational level and age) remained significant after introducing the VPHI into the model (women who reported having a VPHI were more likely to have had a Pap test and a mammography than the rest of the women). In conclusion the opportunistic screening is associated with age, educational level and VPHI. Educational level is also associated with participation in both screening tests after adjusting by age. Furthermore, screening for cervical cancer shows a higher educational gradient than for breast cancer screening. The influence of VPHI after adjusting by age and by educational level poses the question about the role of private health insurances with regard to preventive practices in the context of a national health service aimed at promoting equity of health care access.

Adult↗
PubMed1991

How satisfying is the practice of internal medicine? A national survey.

OBJECTIVE: To survey members of the American College of Physicians about their level of satisfaction and sources of dissatisfaction with practice, the extent to which their satisfaction is reflected in their counseling of students about careers in internal medicine, the prevalence of their concerns about patients' access to care, and their attitudes toward changes in the health care system. DESIGN: A questionnaire survey of a random sample of members of the College. PARTICIPANTS: Members (2254) of the College were surveyed; 1446 (64%) responded and 1290 (57%) of the responses were usable. MEASUREMENTS AND MAIN RESULTS: More than 80% of respondents were satisfied with their relationships with patients, professional challenges, and opportunities to interact with colleagues. Only about half were satisfied with their potential income, and most were dissatisfied with their autonomy or loss of control over clinical decision making. Major sources of concern were administrative burdens, the threat of malpractice litigation, loss of income, and loss of clinical autonomy. Forty percent of internists say that they discourage students from careers in internal medicine, and only 39% would once again pursue such a career. "Pain in the practice" seems generalized among internists: logistic regression analysis failed to show any specific groups who were most dissatisfied or concerned. With regard to access, 18% of internists had many patients without health care insurance; 69% had some patients without coverage; and the majority (61%) had some patients who lost their insurance because of changing jobs or location. Assuring universal access to care received the highest priority rating of a set of criteria for health care reform. CONCLUSIONS: There is growing dissatisfaction with the practice of internal medicine, primarily related to concerns over loss of clinical autonomy, the increase in administrative burdens, the potential loss of income, and the threat of malpractice litigation. Although physicians are concerned about patients' access to care, proposals to improve access should be examined for their effects on the major sources of physicians' dissatisfaction with practice.

Attitude of Health Personnel↗