Evaluation of recent changes in the financing of health services. Report of a WHO Study Group.
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Community Participation↗
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[Partnerships and distribution of Mectizan. Sector investment programs for an integrated approach to investment loans].
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Africa↗
Family-centered services: approaches and effectiveness.
Much of the emphasis in the nation's system of child protection focuses on investigations to determine whether child abuse or neglect has occurred, and procedures for arranging out-of-home care for children who are not safe at home. Less attention often goes to the capacity of public and private agencies to provide services that help stressed families prevent child maltreatment before it begins, or that enable families with serious child-rearing problems to stabilize the home and provide more appropriate care for their children. This article examines the current understanding of the most promising and effective means of serving families. It highlights the family-centered service approach, which encompasses family support services for families coping with normal parenting stresses, and family preservation services designed to help families facing serious problems and possible out-of-home placement. The article explains the characteristics of family support and family preservation services, and discusses how these services are accessed and financed. It reviews available evaluation findings regarding the effectiveness of the two types of family-centered services, and considers the challenges faced when evaluating such services. Finally, the article discusses issues related to planning and service delivery, such as coordination and system reform, financing, targeting, relationships between workers and families, and efforts to strengthen entire communities.
Child↗
Consumer health education in New Jersey community hospitals: a medical school initiative.
The Office of Consumer Health Education (OCHE) of the College of Medicine and Dentistry of New Jersey (CMDNJ) has developed a statewide network of hospital-based consumer health education programs. The rationale for a hospital-based program and the criteria for hospital selection emphasize the responsibility of health care institutions in providing patient and community health education. OCHE offers technical and consulting services to these and other hospitals in the areas of adult education, community programming, evaluation, and resource materials: it also participates in the teaching of medical students at CMDNJ. The need for each hospital to individualize its programs has been demonstrated, and eight problem areas have been revealed by OCHE'S experiences. Future financing will depend largely on third-party reimbursement for in-hospital patient education, while some community projects will be able to receive support from tuitions and grants.
Education, Continuing↗
[Ambulatory rehabilitation after myocardial infarct in Austria].
Cardiac rehabilitation after myocardial infarction has a positive effect on the patient's quality of life and on the prognosis of the disease as well. The cost-saving effect is of importance from the socioeconomical viewpoint. A measurable benefit of such rehabilitation programs can only be achieved by long-term comprehensive care, however. Therefore a hospital rehabilitation program should be followed by regular participation in a long-term community rehabilitation program. The network of cardiac rehabilitation centres in Austria is highly developed and consequently it is possible for every insured patient to be placed for inpatient follow-up therapy on recovering from myocardial infarction. On the other hand, the long-term community cardiac rehabilitation programs are organized only on a sketchy and small scale. A survey amongst patients after myocardial infarction carried out all over Austria showed that 700 patients are currently being treated in 56 community programs. The sponsorship varies a lot. A majority of these groups is organized and financed by the patients themselves. The medical and physiotherapeutic services are mainly organized by the patients as well. They are only partly trained for their task. The care programs take place on a regular basis and the provided services appear adequate, some groups excepted. Medical follow-up examinations to evaluate progress hardly exist. Therefore, quality control of the work in the community programs is not possible at the moment in Austria. A well-organized community care rehabilitation program covering the whole region exists only in Vorarlberg. This program mainly follows the "Feldkircher Modell". The results of this study indicate the urgent necessity to establish additional community care programs for outpatient cardiac rehabilitation in Austria. Furthermore, a common register of the groups, a common organisational model and sponsorship, as well as quality control based on regular medical examination of the patients are essential requirements. A constant exchange of experience with the inpatient rehabilitation centres is to be recommended as well.
Ambulatory Care↗
Entering the life care and retirement housing markets.
Life care communities and other forms of retirement housing can be compatible ministries for health care sponsors. Successfully financing such projects, however, may be difficult if sponsors do not carefully evaluate the market. Determining the need for a proposed project should include the following steps: Study the elderly population trends in the defined market area, particularly data for the over-70 group. Identify the minimum income level for potential residents; a general guideline is one and one-half to two times the annualized rental fee. Determine the penetration rate to obtain the optimal demand for housing. Determine whether the project is viable by subtracting the number of existing and other planned units from the optimal demand for units; the remainder should be large enough to support the proposed project. Further evaluation of the market should include research to discover potential residents' perceptions about retirement communities and their preferences for services and type of units. Because of increasing interest in providing services for the elderly, numerous financing alternatives are available. Sponsors need not rely on internal financing or debt financing to maintain control. By carefully structuring a limited partnership and working with a private developer, for example, the sponsor can ensure involvement in the project without having to assume responsibility for debt or invest scarce capital.
Age Factors↗
The resilience of the health care safety net, 1996-2001.
OBJECTIVE: To determine how the capacity and viability of local health care safety nets changed over the last six years and to draw lessons from these changes. DATA SOURCE: The first three rounds (May 1996 to March 2001) of Community Tracking Study site visits to 12 communities. STUDY DESIGN: Researchers visited the study communities every two years to interview leaders of local health care systems about changes in the organization, delivery, and financing of health care and the impact of these changes on people. For this analysis, we collected data on safety net capacity and viability through interviews with public and not-for-profit hospitals, community health centers, health departments, government officials, consumer advocates, academics, and others. We asked about the effects of market and policy changes on the safety net and how the safety net responded, as well as the impact of these changes on care for the low-income uninsured. PRINCIPAL FINDINGS: The safety net in three-quarters of the communities was stable or improved by the end of the study period, leading to improved access to primary and preventive care for the low-income uninsured. Policy responses to pressures such as the Balanced Budget Act and Medicaid managed care, along with effective safety net strategies and supportive conditions, helped reinforce the safety net. However, the safety net in three sites deteriorated and access to specialty services remained inadequate across the 12 sites. CONCLUSIONS: Despite pessimistic predictions and some notable exceptions, the health care safety net grew stronger over the past six years. Given considerable community variation, however, this analysis indicates that policymakers can apply a number of lessons from strong and improving safety nets to strengthen those that are weaker, particularly as the current economy poses new challenges.
Community Health Planning↗
Community perceptions about the tobacco industry and tobacco control funding.
OBJECTIVES: To determine community views about the believability and standards of honesty and ethics of tobacco companies, related policy options, and mechanisms for tobacco control funding. METHOD: A representative population survey of 808 South Australians aged 18 years and older, contacted by telephone, using an electronic white pages sampling frame, with a response rate of 72%. RESULTS: 80% of respondents and 74% of smokers thought tobacco companies mostly did not or never told the truth about smoking and health, children and smoking and addictiveness of tobacco. With regard to perceived standards of honesty and ethics, tobacco company executives were rated the lowest of all professional groups, with 74% of respondents judging them to have low or very low standards. 89% of smokers would support full product information on the pack about chemicals and additives in cigarettes. 77% thought shopkeepers should pay back the amount they gain from children smoking cigarettes and 80% thought tobacco companies should do so, or be fined or taxed accordingly. 53% agreed the government should spend an amount equal to the amount gained from children's smoking and 21% indicated a higher expenditure. CONCLUSION: Tobacco companies are held in low regard by the public and by smokers who are their customers. There is a high degree of support for tobacco control efforts to be financed by being indexed to the level of children's smoking in the community, through the amount made by shopkeepers, manufacturers and the government from children's cigarette consumption.
Adult↗
An osteopathic prescription for medical education reform: Part 1. Curriculum and infrastructure.
Medical education has not kept pace with the evolving healthcare system. Criticism from industry and policy observers focuses on four major areas requiring reform: the curriculum, the fragmented educational infrastructure, the specialist-to-generalist mix, and the alienation from community and public health. The dominance of managed care organizations in the delivery and financing of healthcare is forcing a new set of physician competencies to the fore and changing projections of physician manpower and specialty needs. The authors address the four major criticisms from a uniquely osteopathic point-of-view. In this first of two articles, the authors describe the evolving osteopathic medical education model, and then employ a medical analogy to diagnose the causes of and propose treatments for curricular issues and infrastructure fragmentation. In the second article of the pair, they explore the causes of and propose strategies to address the generalist-to-specialist imbalance and the alienation of medicine from community and public health; the article also explores the role of technology in support of reform. In each article, the authors propose treatments to correct the problems in the osteopathic medical education model, and conclude that the profession is well-positioned to lead medical education reform.
Curriculum↗
Spending-down to Medicaid in the nursing home and in the community. A longitudinal study from Monroe County, New York.
Medicaid spend-down continues to be of considerable interest in public policy discussions regarding long-term care financing reforms. Yet, "measuring" of spend-down has been difficult because of data limitations. This study focuses on patterns of spend-down affecting those who become Medicaid eligible both in nursing homes and in the community. The study uses a longitudinal, person-specific, merged Medicare and Medicaid claims and eligibility file constructed for Monroe County, New York. The analyses show that 27% of those who enter nursing homes as private pay can be expected to spend-down to Medicaid while in a nursing home. The spend-downers remain in nursing homes for a prolonged time, with 63% staying for more than 3 years. On admission, spend-downers appear somewhat more likely than those who remained private pay or Medicaid throughout to have been less disabled in terms of activities of daily living (ADL). The community-based spend-down group is larger, younger, and more heavily represented by those who are poor or marginally poor, than the nursing home-based spend-down population. Their spend-down to Medicaid appears to have been triggered principally by the cost of acute medical care not covered by Medicare or another third-party payer. It is this population of the elderly that would have been the principal beneficiary of the short-lived 1989 Medicare Catastrophic Coverage Act. The results of this study indicate that neither the existing private long-term care insurance policies nor the currently circulating public coverage proposals alone are sufficient to protect older persons, at risk of spend-down to Medicaid, from impoverishment. Effective long-term care financing reform will need to create partnerships between public and private insurance, rather than look at them as competing options.
Activities of Daily Living↗
Unmet long-term care needs of elderly people in the community: a review of the literature.
The extent of unmet need, or the extent to which needed assistance is unavailable for insufficient, is an important issue in public policy and financing of health and support services. This article reviews the research of literature to assess how unmet method is measured, and the extent of unmet needs among elderly people in the community. Measurement difficulties include variable definitions and measures of need across studies, the relative dearth of studies which undertake to measure unmet needs, and varying methodologies used to estimate need and unmet need. In addition, some measures of status and need, such as cognitive impairment and care giver burden are excluded from many estimates. Estimates of unmet need range from around 2 percent to about 35 percent of community dwelling elders, depending on what is included or excluded from the definition. Unmet need is associated with higher disability levels and living alone. The literature suggests that estimates of future unmet need will be mitigated by declining disability levels and increased use of assistive devices among the elder population.
Activities of Daily Living↗
Phoenix House: an interview with Mitchell S. Rosenthal.
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Adolescent↗
Can community hospitals survive without large scale health reform?
This nation's not-for-profit community hospitals, numbering over 4000 and providing the largest percentage of all hospital services to the US population, are threatened as never before by erratic reimbursement, reduced capital access and, more recently, by physicians who now compete both by virtue of outpatient/ambulatory services and by starting "specialty hospitals." This article examines some of these trends and their implications, raising the issue of whether it is time for major restructuring of our reimbursement systems and other significant health reforms.
Capital Financing↗
Hospitals differ on expectations of reform. Interview by Debra Mamorsky.
Health care reform will be played out in different ways at different institutions, predict two physicians who should know. One runs a large university hospital, the other heads up a small community institution, and their views are notable for their differences as well as for their agreements.
Connecticut↗
Sale of drugs and health care utilization in a health care district in Zaire.
Health centres of Idjwi district (Zaire) have been self-financed through the selling of drugs since 1985. Medical care is expensive and its use is low (24 visits per year per 100 inhabitants). In 1989 the medical team tried to reduce the cost of visits by changing the prices of drugs and prescriptions. A limited control was set up to assess this intervention. The study showed that although prescribed drug costs were stabilized compared to inflation, there was no increase in the use of medical care. Moreover, the reduction of drug profit margins for health centres seriously affected the health care institution by causing a drop in income. Six months after the intervention the monthly accounts showed a deficit in 6 centres out of 8. The need for health care centres to be self-financing is a major limiting factor in the use of health care in Idjwi district. There are no easy solutions for health centre managers that satisfy both low-cost access to care and health care self-financing. Some minimal financial participation from the state is required. Only then can the concept of financing health care through the selling of drugs be operational.
Community Health Centers↗
A baseline survey of the Primary Healthcare system in south eastern Nigeria.
A baseline survey to audit the PHC operations and determine community perception and expectations of PHC service delivery was conducted in 72 communities in Enugu state, southeastern Nigeria. The study was intended to facilitate the development of intermediate performance indicators for monitoring the progress of an ongoing health sector reform and to gather baseline data for planning and policy formulation. The tools used for the operations audit assessed indicators for evaluating: (a) Stewardship, (b) Service Provision and (c) Administrative and financial management; while the community survey was assessed by, (a) utilization of health services, (b) perception of service delivery and (c) health care financing. One hundred and sixteen respondents from each of the facilities in the sample frame were interviewed using a structured self-assessment questionnaire and a qualitative assessment was undertaken in 53 of the facilities using an audit guide. Focus group discussions (FGD) were conducted with the policy makers and planners in each of the 17 LGAs in the state. A total of 832 respondents were interviewed in the communities (using a structured questionnaire) and 42 community FGDs were conducted. The results indicate a lack of operational efficiency in the majority of the facilities audited. It was also observed that majority of the facilities do not provide all services required of it, are poorly maintained, do not have enough skilled health workers and operate without a budget. There appears to be no formal financial management system in place and no policy on financial resource generation. The community survey identified two major problems; low utilization of PHCs and poor service provision. The key indicator identified by the community for evaluating performance of the PHCs remains "access to essential drugs". The major prospect was the willingness of an appreciable number of respondents to invest in health financing through insurance schemes and payment of health tax among others. It was evident that poor funding, bad management practices and infrastructural decay is the bane of efficient PHC delivery. Consequently, we propose that cost determination studies, to establish the financial implication of the minimum package for provision of primary healthcare services, should be an essential prerequisite to the reform process. Some critical cross-cutting issues identified from the data obtained which could form the basis for major policy thrust include, development of strategies for sustainable promotion of public-private-partnership for enhanced community involvement in healthcare management, ensuring that interventional investment is proportional to the felt health needs of the populace and funding of healthcare through equitable integration of user fees/charges.
Attitude to Health↗
The United Kingdom: effective, efficient, equitable?
The British National Health Service (NHS) has, since its inception, aimed to make health care available to all regardless of income, and it has managed to achieve this goal while keeping costs lower as a proportion of the gross domestic product than many Western countries and at the same time assuring equitable distribution of resources regionally. Until the reforms introduced by the 1989 White Paper, the NHS was characterized by centralized financing and regulation; despite some problems in the delivery and management of care, the system was a popular one. The new reforms hope to enhance efficiency in the NHS by stimulating competition and further decentralizing the management of health care. However, it is not at all certain that in practice the reforms will have the desired effect. Initial costs will be high, people may not respond to incentives as predicted, and the quality of care and access to it could well deteriorate. Nations planning to use the U.K. system as a model are advised to use caution.
Community Health Services↗
The defined-contribution plan: the next generation of healthcare financing.
In response to rising health insurance premiums, many purchasers of coverage are evaluating the possibility of implementing defined-contribution health insurance plans. Under a defined-contribution plan, employers or the government pay a specified portion of the premium, and the consumer chooses a plan from a menu of options, paying the balance of the premium based on their plan selection. A shift to a defined-contribution model will have far-reaching implications for consumers, employer and government purchasers, payers, and providers. Providers will face changes in consumption patterns and the need to develop a brand image, market their strengths directly to consumers, educate consumers about their services and pricing, and reconfigure infrastructures to be able to respond efficiently to consumer demands.
Community Participation↗