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PubMed2001

[Tuberculosis control strategy in the 21st century in Japan--for elimination of tuberculosis in Japan].

Modern tuberculosis control programme has been launched in 1951 by the major revision of the previous Tb. Control Law in Japan. Main control measures were BCG vaccination programme for tuberculin negatives, annual screening of Tb. by miniature radiophotography (MMR), charge free diagnosis and treatment of Tb. patients, registration and case-holding at Health Centres throughout the country and so on. Thanks to the efforts of the Government and people concerned, Tb. incidence has decreased with the annual reduction rate of 11% during 1961 and 1977. However, Tb. decrease has stagnated after that, and it is increasing slowly in these 3 years since 1998. Moreover, regional variations of Tb. incidence are considerable, and Tb. is concentrated in specific risk groups such as elderly persons, homeless, foreign born individuals and so on. However, the present Tb. Control measures were introduced prior to the discovery of most major anti-Tb. drugs and all modern internationally accepted Tb. Control strategies, so that it is strongly desired to improve the present control programme from rather classical present Tb. control measures to global standard one to overcome the resurgence of Tb. in Japan. At first, the author stressed that the priority of Tb. Control Programme should be changed according to the development of science and the change of epidemiological situations. BCG vaccination and Tb. screening by MMR might be very important when the annual risk of Tb. infection was very high--about 4% in 1950. Now it is around 0.05% and the incidence of Tb. among 0-14 years of age is 1.1 per 100,000 so that the priority should be given on treatment of the detected cases instead of BCG vaccination or MMR. The doctors in the public health field should give more strong concern on clinical aspects of Tb. Control Programme at present. It was considered that the main urgent problems to be improved in the present Tb. control measures are as follows. 1. It is strongly recommended to spread the global standard regimen with 2HRZE/4HR (E) more widely and rapidly. Because the standard regimen is used in only 50% of new smear positive cases at present although 15.3% of Tb. patients are 80 years or more, or 56.3% of them are 60 years or more, and the side effects by PZA are higher among elderly patients. 2. Shortening of the hospitalization duration is required because 76.7% of newly detected bacilli positive cases are hospitalized at first, and the median of the period of hospitalization is 4 months, and 18.4% of them are hospitalized 6 months or more at present. 3. DOT treatment has been introduced for special groups in the big cities in 2000 for the first time in Japan, but it is needed to spread DOT treatment more widely, for example, by increasing health insurance payment for the institutions where DOT treatment is being implemented. 4. It is recommended to build special rooms to accept Tb. patient at general hospitals and/or university hospitals to avoid the neglect of Tb. by general medical doctors. 5. Follow-up of Tb. patients after treatment completion at Health Centres is not needed now, because the relapse rate is so low. 6. Indiscriminative screening programme for all the people aged 19 years old or more should be stopped, at least up to 39 years of age, because Tb. detection rate has become so low as 0.0069% at present. As Tb. decrease is so slow, or is increasing in some areas, that the contact surveys among the young aged 20 to 39 should be strengthened in the future. 7. As Japan Anti-Tb. Association is being carrying out mass screening programme extensively at present, so that the Association has started to discuss the future health check system. Because of the rapid and constant increase of the lung cancer, the Association is discussing the method to detect the lung cancer, too. In any way, it is needed to focus the screening programme for special high risk groups instead of indiscriminative screening. 8. BCG vaccination for infants should be continued a little more, because BCG vaccination can protect the development of 7 miliary Tb. and/or meningitis cases during 15 years if BCG is given 70% of the infants in 2000. However, it was strongly recommended to stop re-vaccination of BCG, because it is not so effective, and disturb the diagnosis of Tb. infection by tuberculin testing. 9. Treatment of latent Tb. infection will become more and more important, so that it's indication should be expanded to the adults in the future instead of the present indication up to 29 years of age. It is needed to revise Tuberculosis Control Low to improve control programme in Japan. The author hoped that the members of Japan Tuberculosis Society will promote the improvement and to support the Government to improve the Law.

Age Factors↗
PubMed1993

Health care reform: clarifying the concepts.

Despite agreement about problems with the health care system, there is disagreement about the remedy. Like most health care reform debates, this article focuses on financing methods rather than service delivery. Reform strategies are intentionally oversimplified into four categories: employer-based or "play or pay"; single-payer and modifications, such as expanding Medicaid or Medicare; market competition; and managed competition, which appears to be favored by the Clinton administration. Cost-control mechanisms and insurance reforms are applicable to all four financing methods. Reform is inevitable. The challenge for nurses is to understand reform issues and then influence policymakers to initiate reforms that make essential medical and preventive services universally available.

Competitive Medical Plans↗
PubMedDate not supplied

Veteran's health care: time for a change?

The Department of Veterans Affairs' mission is "to care for him who are shall have borne the battle for his widow and orphan." The Veterans Health Administration comprises 172 hospitals that are the hub of the health care delivery system. It is the largest provider of graduate medical education, and one of the major research organizations in the United States. The medical care budget exceeds $17 billion annually. Most of the persons cared for are not legally entitled to this health care based on service connected disability. The utilization of acute care hospital beds appears excessive when compared to that obtainable with managed care for Medicare or commercial insurance beneficiaries--the cost per member per month is three times higher. There may also be exploitation of the Veterans Administration hospitals by university medical schools. The Veterans Health Administration is a very expensive way to deliver care to entitled service connected veterans. Therefore, it is suggested that privatization be considered as an alternative vehicle for delivering health care.

Consumer Organizations↗
PubMed1989

Why the conservatives gave us universal health care: a parable.

The provider and financing segments of health care are now in a "destabilization" phase, using Eli Ginsberg's perfectly descriptive term. Even with the lowest unemployment levels in years, the numbers of people who have no health insurance, most of them employed, keep going up. The health sector has been on a competitive binge that was supposed to contain cost increases, but aggregate expenditures for health care are rising on about the same curve as before. As Americans continue to spend more for health services, more health care providers, insurers, and "managed care" enterprises are in deep financial trouble. These providers include many HMOs that were supposed to apply the incentives that save money and the investor-owned hospital chains that were supposed to give health care big business efficiencies. These and other anomalies have created a situation where politicians are likely to take desperate and impulsive measures, especially on the issues of access and cost. This means that anything can happen, and nobody knows what. The many futurists in our midst are predicting intensification of "marketplace" behavior, but they don't know, either. This is a parable of one of the things that could happen. The conservatives could decide that having a universal health care entitlement is the conservative thing to do. Even though some of the events in this parable seem on the edge of absurdity, all of them are merely extensions in time of things that have already happened in our country in a pattern that is now rapidly unfolding.

Forecasting↗
PubMed1991

New Mexicare.

An inexpensive plan is offered that provides access to basic, outpatient, primary, and preventive health care for all uninsured citizens of the State of New Mexico. New Mexicare rewards hospitals and hospital-affiliated specialists for inpatient care that is now unreimbursed. The establishment of a Health Care Trust Fund would create a mechanism that could influence the allocation of scarce and expensive resources to areas of need. New Mexicare would be set up within the State Medicaid Division and would be predicated on a mandate that all employers must provide health insurance with reasonable cost sharing by higher paid employees. It would not have great fiscal impact on small businesses, require complicated new tax rules, or impact current state revenues. New Mexicare solves the problem of the uninsured in incremental fashion and does not create an enormous administrative or budgetary burden to the state. It may be a suitable model for other states that share New Mexico's demography. New Mexicare could easily and rapidly be dissolved in the event that the federal government finally acts and provides universal access with some type of national plan.

Cost Allocation↗
PubMed2004

Too close for comfort? Appointment of Blues exec as head of board overseeing Iowa system resurrects questions about corporate conflicts of interest.

What happens when a top insurance executive also serves on a hospital-related board? In Iowa, where Wellmark Chairman John Forsyth is leading the board overseeing the University of Iowa Hospitals and Clinics, observers say it's sometimes difficult to avoid potential conflicts. Concerns also crop up for Joel Allison, left, head of Baylor Health Care System, who serves on the board of an Abbott spinoff.

Administrative Personnel↗
PubMed2001

Sarcoidosis severity and socioeconomic status.

Several chronic diseases are more severe in persons who are Black, of low socioeconomic status (SES), and underinsured. The authors ask if this is true for sarcoidosis. Associations among sarcoidosis disease severity, SES, insurance coverage, and functional limitations were analysed. Back and White sarcoidosis patients (n=110) of a municipal and university hospital sarcoidosis registry were interviewed by telephone. Data on disease severity were abstracted from patient charts. Most patients reported good or excellent health by demographic characteristics. Low SES and no or public insurance were associated with worse health status and more severe dyspnoea. More advanced radiographic stage was associated with lower income, and forced vital capacity impairment with less education. Physical and social activity limitations due to physical and emotional disability were related to no or public insurance and lower income, but not education. Sarcoidosis severity is associated with socioeconomic status and insurance indicators; no or public insurance and low income are associated with functional limitations. Sarcoidosis-associated limitations are substantial, emphasizing the social significance of sarcoidosis. Lack of private insurance may inhibit the use of medical care, contributing to disease severity and impairment.

Black or African American↗
PubMedDate not supplied

Rationing medical care.

Recent proposals to reform the health care financing system have sparked discussions concerning the need to ration health care. Relative to other western industrialized democracies, the US rations primary and preventive care more, tertiary care less, and makes greater use of price rationing and bureaucratic controls. Because insurance coverage is not universal and the extent of coverage varies across services, the poor and those patients needing long-term care are most heavily affected by price rationing. The current system also works to the advantage of procedure-oriented specialists and to the disadvantage of primary care physicians. Major reform of health care financing could change what is rationed, how it is rationed, and who is most affected. However, some rationing will remain necessary under any conceivable financing system.

Canada↗
PubMed1980

Consumer-centered vs. job-centered health insurance.

Today's dominant health care financing system blocks economic competition and rewards doctors and hospitals for cost-increasing behavior. The author believes that the most effective and acceptable way to get health care costs under control, and at the same time achieve universal coverage, would be through a system of fair economic competition. He discusses his Consumer Choice Health Plan proposal and describes how one of the main barriers to competition is today's system of job-linked health insurance.

Community Participation↗