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PubMed1998

Metropolitan governance, residential segregation, and mortality among African Americans.

OBJECTIVES: This study tested the hypothesis that the degree to which local government is metropolitanized is associated with mortality rates for African Americans and with residential segregation, which has itself previously been shown to be positively associated with mortality among African Americans. METHODS: One hundred fourteen US standard metropolitan statistical areas were examined. The primary dependent variable was the age-adjusted, race- and sex-specific all-cause mortality rate, averaged for 1990 and 1991. The 2 primary independent variables were residential segregation, as measured by the index of dissimilarity, and metropolitanization of government, as measured by the central city's elasticity score. RESULTS: Mortality rates for male and female African Americans were lower in metropolitan statistical areas with more metropolitanized local governments and lower levels of residential segregation. Mortality for male and female Whites was not associated in either direction with residential segregation. White male mortality showed no association with level of metropolitanization, but lower White female mortality rates were associated with less metropolitanization. CONCLUSIONS: This study suggests the need for further research into whether policy changes in areas not traditionally thought of as "health policy" areas can improve the health of urban minorities.

Black or African American↗
PubMed1998

Psychiatry in transition: outcomes of mental health policy shift in Italy.

OBJECTIVE: To assess the outcomes of changes in mental health policy introduced in Italy in 1978. METHODS: Data on psychiatric services, before and after the policy change, are presented. Effects of change are evaluated through indicators related to four issues: transfer of care, criminalisation of the mentally ill, suicides, and homelessness. RESULTS: Admissions of new patients to mental hospitals have been stopped and the size of the mental hospital population is now very low (26 per 100,000 population). Psychiatric care has been shifted to community services including general hospital psychiatric units. There has been an overall reduction of psychiatric hospitalisation. However, the provision of residential facilities is inadequate and community services are unevenly distributed across the country. Few negative effects of changing patterns of care have been reported, although the low quality of data limits the validity of such a conclusion. Outcome of care in areas where the full range of community services is available has been rated as satisfactory. CONCLUSIONS: Although care of the mentally ill has been shifted to community services, we lack hard data on the social and clinical outcome of community care at the nation-wide level. Long-term monitoring and evaluation of community services is a high priority in Italy.

Deinstitutionalization↗
PubMed2001

The effect of physical restraints on fall rates in older adults who are institutionalized.

Since the Omnibus Budget Reconciliation Act (OBRA) of 1987, there has been a significant reduction in the use of physical restraints to prevent falls in older adults who are institutionalized because of the developing awareness of the physical and psychological problems associated with them. The purpose of this ex post facto descriptive study was to determine if there is a difference in falls when physical restraints are allowed or prohibited in one older adult population. Data from incident reports from a purposive sample of 97 older adults in one long-term care facility were analyzed before and after the implementation of a restraint-free policy. The results indicated no significant difference in the number of falls before and after the policy change. However, there was a significantly lower number of falls with injuries and a significantly higher number of falls without injuries. These findings suggest older adults will continue to fall with or without the use of physical restraints because of changes associated with the aging process and risk factors. Removing physical barriers from older adults and allowing freedom of movement may decrease the severity of injury sustained in a fall.

Accidental Falls↗
PubMed1991

The Medicaidization of certified home health care in New York City.

In New York City, Medicaid has replaced Medicare as the primary payor of certified home health care agencies. This shift has made agencies vulnerable to policy changes and budget cutbacks, changed the client population, and put new demands on service delivery.

Certification↗
PubMed1985

Health care for the poor: shaping public policy.

An AHA committee and a presidential commission recently examined the effects of government cutbacks and rising costs on the "health care poor." they found increasing inequity in access to and quality of care and noted that reimbursement and demographic changes threaten some facilities' ability to care for the poor. Recognizing the need to take a more active role in the public policy arena, the Sisters of Mercy Health Corporation, Farmington Hills, MI, established a task force to study the delivery and financing of health care services for the poor and make recommendations for influencing public policy. The task force identified 12 general principles to guide the development of public policies that have an impact on health care for the poor. It also outlined four actions that should be taken to ensure that necessary changes in public policy occur: Establish a national health policy on the delivery and financing of health care for the poor. Base public policy development on principles of equity and justice. Establish an effective constituency or coalition that can serve as an advocate for the poor in the policy development process. Develop and test models or programs that recognize the needs of both care recipients and providers and that support recommended policy changes.

Federal Government↗
PubMedDate not supplied

Early retirement in the United States.

Despite improvements in health and longevity, many workers in the United States retire young. By age 62, only 44 percent of men and 24 percent of women are still working full-time. The combination of younger retirement and increasing longevity means that Americans are spending more years in retirement than at any time in history. The widespread availability of post-retirement benefits is an important aspect of this national trend. Eligibility for employer-provided retirement benefits can begin as young as age 50 and occurs quite frequently at age 55. Eligibility for Social Security benefits begins at age 62. Eligibility for Medicare begins at age 65. As the population ages, the implementation of cost-saving reforms in retirement programs has become an increasing policy concern. To sustain the major public entitlement programs, proposals have been made to raise the age of eligibility for Social Security and Medicare, or to reduce benefit levels, or to target benefits to those most in need. Other cost-saving changes have been considered, and in many cases implemented, in employer-provided retirement benefits. These policy changes will have implications for the retirement decisions of working Americans in the future. This report, drawing on research sponsored by the National Institute on Aging, reviews the trend in the United States toward earlier retirement as well as some recent research findings on how retirement decisions relate to public and private retirement policies. With the changing age demographics of the population, the implementation of cost-saving reforms to retirement policies and other changes in the economic circumstances of individuals as they age, the work and retirement decisions of older workers will continue to evolve over the coming decades.

Age Factors↗
PubMed2000

Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition.

This paper summarizes eight country studies of inequality in the health sector. The analyses use household data to examine the distribution of service use and health expenditures. Each study divides the population into "income" quintiles, estimated using consumption expenditures. The studies measure inequality in the use of and spending on health services. Richer groups are found to have a higher probability of obtaining care when sick, to be more likely to be seen by a doctor, and to have a higher probability of receiving medicines when they are ill, than the poorer groups. The richer also spend more in absolute terms on care. In several instances there are unexpected findings. There is no consistent pattern in the use of private providers. Richer households do not devote a consistently higher percentage of their consumption expenditures to health care. The analyses indicate that intuition concerning inequalities could result in misguided decisions. It would thus be worthwhile to measure inequality to inform policy-making. Additional research could be performed using a common methodology for the collection of data and applying more sophisticated analytical techniques. These analyses could be used to measure the impact of health policy changes on inequality.

Data Collection↗
PubMed2001

Income-based drug benefit policy: impact on receipt of inhaled corticosteroid prescriptions by Manitoba children with asthma.

BACKGROUND: Drug benefit policies are an important determinant of a population's use of prescription drugs. This study was undertaken to determine whether a change in a provincial drug benefit policy, from a fixed deductible and copayment system to an income-based deductible system, resulted in changes in receipt of prescriptions for inhaled corticosteroids by Manitoba children with asthma. METHODS: Using Manitoba's health care administrative databases, we identified a population-based cohort of 10,703 school-aged children who met our case definition for asthma treatment before and after the province's drug benefit policy was changed in April 1996. The effects of the program change on the probability of receiving a prescription for an inhaled corticosteroid and on the mean number of inhaled corticosteroid doses dispensed were compared between a group of children insured under other drug programs (the comparison group) and 2 groups of children insured under the deductible program: those living in low-income neighbourhoods and those living in higher-income neighbourhoods. All analyses were adjusted for a measure of asthma severity. RESULTS: For higher-income children with severe asthma who were covered by the deductible program, the probability of receiving an inhaled corticosteroid prescription and the mean annual number of inhaled corticosteroid doses declined after the change to the drug policy. A trend toward a decrease in receipt of prescriptions was also observed for low-income children, but receipt of prescriptions was unaltered in the comparison group. Before the policy change, among children with severe asthma, the mean annual number of inhaled corticosteroid doses was lowest for low-income children, and this pattern persisted after the change. Among children with mild to moderate asthma, those covered by the deductible program (both low income and higher income) were less likely to receive prescriptions for inhaled corticosteroids than those in the comparison group, and this difference was statistically significant for the higher-income children. INTERPRETATION: The change to an income-based drug benefit policy was associated with a decrease in the use of inhaled corticosteroids by higher-income children with severe asthma and did not improve use of these drugs by low-income children.

Administration, Inhalation↗
PubMed2001

Effect of prescription benefit changes on medical care utilization in a Medicare HMO population.

OBJECTIVE: To examine the impact of 2 cost-containment efforts in prescription benefits in successive years that included changes in copayment and coverage levels, expanded generic coverage, and brand name prescription drug limit-of-coverage in a Medicare health maintenance organization (HMO). The benefit changes included moving to a drug benefit with increased total coverage and higher copayments in the first year (1998) and to one with brand name limit-of-coverage and unlimited generic availability in the second year (1999). STUDY DESIGN: A repeated-measures analytical design with enrollee follow-up before and after introduction of the 2 policies. PATIENTS AND METHODS: A cohort of 2411 older adults continuously enrolled in a Medicare HMO since 1998 was followed up for 1 year pre-post for healthcare service utilization and costs; 259 patients enrolled since 1997 were available to test the effects of the first policy change. RESULTS: Bivariate and multivariate analyses found a significant decrease of 27% in prescription costs, a 4% decrease in physician visits, and a 6% decrease in total costs associated with the change in prescription benefit in the second year (1999). The policy change in the first year (1998) resulted in a 29% increase in prescription costs and 38% increased total costs for the HMO. CONCLUSIONS: Introduction of a prescription benefit that included substantial brand name limit-of-coverage and generic drug coverage expansion was associated with significantly reduced prescription costs. In addition, this change did not seem to increase nonprescription-related healthcare service use in the population.

Aged↗
PubMedDate not supplied

The impact of policy changes on the health of recent immigrants and refugees in the inner city. A qualitative study of service providers' perspectives.

BACKGROUND: Dramatic changes to health and social policy have taken place in Ontario over the last five years with few attempts to measure their impact on health outcomes. This study explored service providers' opinions about the impact of four major policy changes on the health of recent immigrant and refugee communities in Toronto's inner city. METHODS: Semi-structured key informant interviews. RESULTS: Reductions in funding for welfare, hospitals and community agencies were seen to have had major effects on the health of newcomers. Emergent themes included erosion of the social determinants of health, reduced access to health care, increased need for advocacy, deterioration in mental health, and an increase in wife abuse. CONCLUSIONS: Several areas were identified where policy changes were perceived to have had a negative impact on the health of recent immigrants and refugees. This study provides insights for policy-makers, inner-city planners and researchers conducting population-based studies of immigrant health.

Community Health Services↗
PubMedDate not supplied

Fertility intentions and subsequent behavior: a longitudinal study in rural India.

This report compares fertility and family planning intentions of rural Indian women in 1975 with actual outcomes in 1987. Ninety-four of 103 respondents who had fewer children than they wanted in 1975 and had stated definite intentions with respect to future fertility and contraceptive use were reinterviewed in 1987. Overall, women had fewer children than desired and stopped childbearing when they reached or closely approximated their ideal number of sons. Since sons were clearly the determinant of "reproductive success," it is argued that only a significant change in the status of rural women can bring about widespread compliance with the official family planning program's two-child norm.

Adolescent↗
PubMed1986

The assessment of health policy changes using the time-reversed crossover design.

The time-reversed crossover design is a quasi-experimental design which can be applied to evaluate the impact of a change in health policy on a large population. This design makes use of separate sampling and analysis strategies to improve the validity of conclusions drawn from such an evaluation. The properties of the time-reversed crossover design are presented including the use of stratification on outcome in the sampling stage, which is intended to improve external validity. It is demonstrated that, although this feature of the design introduces internal validity threats due to regression toward the mean in extreme-outcome strata, these effects can be measured and eliminated from the test of significance of treatment effects. Methods for within- and across-stratum estimation and hypothesis-testing are presented which are similar to those which have been developed for the traditional two-period crossover design widely used in clinical trials. The procedures are illustrated using data derived from a study conducted by the United Mine Workers of America Health and Retirement Funds to measure the impact of cost-sharing on health care utilization among members of its health plan.

Costs and Cost Analysis↗
PubMedDate not supplied

Changing health policy in the post-Mao era.

A shift away from Mao Zedong's concept of equality in the delivery of medical care is now taking place in The People's Republic of China. This change is evident in the emphasis now placed upon high technology, basic research, and hospital care. All of these changes are occurring against the backdrop of extremely scarce medical resources. Medicine seemingly is viewed as one of many material incentives to be provided high productivity and leadership groups; the "modernization" of medicine is seen as one visible manifestation of the success of the broader modernization effort itself. As well, population policy has become more stringent, with rewards being given to one-child families and sanctions being applied against couples having three or more children. Although these policy changes offer bright prospects for Sino-American cooperation in the biomedical field, foreigners must remain sensitive to the controversial nature of these alterations in the Chinese political setting.

China↗