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Ethics and equity in Canadian health care: policy alternatives.

Four interrelated phenomena are at work in Canadian health care. First, in Canada as all over the world, there is growing momentum toward greater cost containment and imposition of tighter ceilings on health expenditures. Second is the demography of a falling birth rate and a greater number of elderly. Third, the failure of ratification by the provinces of the Canadian Meech Lake accord has created a constitutional structure that strongly favors provincial and not federal powers, and further guarantees widened regional and local disparities. Fourth, the economic union implicit in the United States-Canada free trade agreement of late 1988 will serve to weaken east-west ties within Canada in favor of north-south ties, and is likely to lead to taxation policy in Canada to favor the rich, with pressures toward privatization and restrictions on universal entitlement programs.

Canada↗

Children's utilization of medical care.

Children's utilization of medical care remains unequal even after the implementation of policies such as Medicaid and Neighborhood Health Centers. Children in lower-income areas or from larger families are less likely to see a provider over a 1-year period. Sharper differences are found when one analyzes the type of providers used. Here income, race, marital status, family type, type of insurance coverage and community characteristics are all associated with type of provider used. Children to whom more resources are available (in terms of income, parents' time, community income and insurance) appear more likely than other children to use what is traditionally termed higher-quality care. The fact that the data used are from a community with generous Medicaid benefits and a university-sponsored pediatric project suggests that inequalities in utilization continue to exist even after substantial government intervention.

Adolescent↗

The effect of health insurance on medical care utilization and implications for insurance expansion: a review of the literature.

Both the costs and benefits associated with extending health insurance coverage depend on the extent and exact ways in which health insurance affects the utilization of medical care. We review the literature relating to such effects with the goal of informing researchers interested in simulating the impact of policy initiatives aimed at achieving universal coverage. Overall, this literature is quite consistent in finding significant effects of insurance on all types of utilization. Insurance coverage increases outpatient utilization by roughly 1 visit per year for children and between 1 and 2 visits for adults. For both children and adults, these visits are associated with an increased receipt of preventive care. Insurance coverage also increases inpatient utilization for children and adults; for children, there is some evidence that insurance coverage reduces ambulatory care sensitive hospital admissions.

Adolescent↗

Child health benefits packages: lessons from Minnesota for State Children's Health Insurance Programs.

The State Children's Health Insurance Program (SCHIP) provides state maternal and child health (MCH) programs an opportunity to assure comprehensive health services are available to children through the selection of an appropriate benefits package. Minnesota had this chance in 1994 when the state was considering development of a universal standard benefits set. While the Minnesota MCH program was not at the policy table, they worked through a process that increased their influence on decisions by responding to a legislative call for a definition of "appropriate and necessary" care. This definition was ultimately adopted by policymakers in creating the recommended Universal Standard Benefits Set. This experience may provide an important incentive to other state MCH programs seeking opportunities to participate in the development of state SCHIP plans.

Child↗

John E. Ware Jr. on health status and quality of life assessment and the next generation of outcomes measurement. Interview by Marcia Stevic and Katie Berry.

John E. Ware Jr. PhD, is a founder of QualityMetric. Inc., as well as its president and chief scientific officer. He also is executive director of the Health Assessment Lab at the Health Institute, New England Medical Center, and holds professorships at Harward University and at Tufts University School of Medicine. For 14 years, he was senior research psychologist at RAND, where he developed health status and patient satisfaction measures used in the Health Insurance Experiment. He also was principal investigator for the Medical Outcomes Study (MOS), which developed the SF-36 Health Survey and other tools widely used in monitoring patient outcomes. A coauthor of papers from the MOS that received the Association for Health Services Research (AHSR) Article of the Year Award in 1993, Dr. Ware has received numerous awards for work in the field of outcomes research. He now is principal investigator of the International Quality of Life Assessment Project, which is translating and validating the SF-36 Health Survey for use in 45 countries. Dr. Ware also is developing the next generation of patient-based assessments that use advances in computer technology to provide very brief measures, yet meet the standard of precision necessary for use on an individual patient basis.

Centers for Medicare and Medicaid Services, U.S.↗

Thomas A. Scully and the Centers for Medicare and Medicaid Services. Interview by Kevin C. Park and Wanda Bishop.

Thomas A. Scully became the administrator of the Centers for Medicare and Medicaid Services (CMS; previously the Health Care Financing Administration) in 2001. Before that, he was the president and chief executive officer of the Federation of American Hospitals, the trade association representing the nation's 1,700 privately owned and managed community hospitals and health systems. Before joining the federation, Mr. Scully was a partner in the Washington, DC, law firm of Patton Boggs, LLP, where his practice focused on regulatory and legislative work in healthcare. Before joining the law firm, Mr. Scully worked at the White House as deputy assistant to the President and counselor to the director of the Office of Management and Budget (OMB) and as associate director of OMB for Human Resources, Veterans and Labor. In these positions, he oversaw the fiscal policy and regulatory review of the Departments of Health and Human Services, Education, Labor, and Veterans Affairs. He also advised former President Bush on healthcare policy and Medicare and Medicaid payment reform. Mr. Scully has served on the board of directors of Oxford Health Plans and of DaVita Corporation, two of the nation's largest healthcare service providers. Mr. Scully holds a Juris Doctor from Catholic University of America and a bachelor's degree from the University of Virginia.

Centers for Medicare and Medicaid Services, U.S.↗

Population trends in BMD testing, treatment, and hip and wrist fracture rates: are the hip fracture projections wrong?

UNLABELLED: A worldwide epidemic of hip fractures has been predicted. Time trends in BMD testing, bone-sparing medications and hip and wrist fractures in the province of Ontario, Canada, were examined. From 1996 to 2001, BMD testing and use of bone-sparing medications increased each year, whereas despite the aging of the population, wrist and hip fracture rates decreased. INTRODUCTION: If patients with osteoporosis are being diagnosed and effective treatments used with increasing frequency in the population, rates of hip and wrist fractures will remain stable or possibly decrease. We report here time trends in BMD testing, prescriptions for bone-sparing medications, hip and wrist fracture rates, and population projections of fracture rates to 2005 in the province of Ontario, Canada. MATERIALS AND METHODS: Ontario residents have universal access to Medicare. To examine time trends in BMD testing, all physician claims for DXA from 1992 to 2001 were selected from the Ontario Health Insurance Plan (OHIP) database. Trends in prescribing were examined from 1996 to 2003 using data from the Ontario Drug Benefit plan, which provides coverage to persons > or = 65 years of age. Actual numbers of hip and wrist fractures were determined for 1992-2000 and population projections for 2001-2005 using time-series analysis. Wrist fractures were identified in the OHIP database and hip fractures through hospital discharge abstracts. RESULTS: From 1992 to 2001, the number of BMD tests increased 10-fold. There has been a steady increase in the number of persons filling prescriptions for antiresorptives (12,298 in 1996 to 225,580 in 2003) and the majority were for etidronate. For women, the rate of decline for wrist fractures is greater than that for hip fractures. The rate of hip fracture was fairly constant around 41 per 10,000 women > or = 50 years between 1992 and 1996. In 1997, the hip fracture rate began to decrease, and the population projections suggest that this downward trend will continue to a rate of 33.1 per 10,000 in 2005. CONCLUSIONS: Our findings suggest that fracture rates may be on the decline, despite the aging of the population, because of increased patterns of diagnosis and treatment for osteoporosis.

Aged↗

Social security: a program and policy history.

Many of the federal and state programs that provide income security to U.S. families have their roots in the Social Security Act (the Act) of 1935. This Act provided for unemployment insurance, old-age insurance, and means-tested welfare programs. The Great Depression was clearly a catalyst for the Social Security Act of 1935, and some of its provisions--notably the means-tested programs--were intended to offer immediate relief to families. However, the old-age insurance program-the precursor to today's Old-Age, Survivors, and Disability Insurance, or Social Security, program-was not designed specifically to deal with the economic crisis of that era. Indeed, monthly benefit payments, under the original Act, were not scheduled to begin until 1942. In addition, from the beginning, the Social Security program has embodied social insurance principles that were widely discussed even before the onset of the Great Depression. The first four decades of the Social Security program were, in general, ones of expansion. In fact, the program was expanded even before it became truly operational. In 1939, amendments added child, spouse, and survivor benefits to the retirement benefits authorized by the 1935 Act. Those amendments also allowed for monthly benefits to begin in 1940. Although the program was not changed substantially during the war years and the initial postwar period, the 1950s were a transformational decade in the program's history: benefit amounts were increased substantially, coverage under the program became close to universal, and a new disability insurance benefit was offered. The 1960s witnessed additional growth in Social Security, but the most important development in social insurance occurred in health insurance, with the creation of the Medicare program in 1965. Legislative actions in the 1970s had profound effects on the Social Security program and, indeed, set the stage for many of today's reform debates. Large benefit increases, a new benefit formula that was erroneously generous, and other changes in the early 1970s created a situation in which annual program costs, as a share of gross domestic product, increased during a 12-year period from about 3 percent to 5 percent. In 1977, amendments to the Act corrected the flawed benefit formula and made other changes in the financing of the system to shore up the program. Thus, the 1970s represent a watershed in the program's history-program growth gave way to increasing concerns about the program's finances. Those concerns were reflected in the amendments to the Act in 1983, which were the last major changes to the program. These amendments, based largely on recommendations from a commission chaired by Alan Greenspan, adjusted benefits and taxes to address pressing near-term financing problems faced by the system. Although the Greenspan Commission focused to a large extent on short-range issues, the resulting reforms have generated large surpluses in the program and the buildup of a substantial trust fund. However, the looming retirement of the baby boomers and several other demographic factors will, according to projections, result in the exhaustion of the trust fund by 2042.

Adult↗

Why it's time for a national health program in the United States.

The United States lacks a coherent national health program. Current programs leave major gaps in coverage and recently have become more restrictive. Influential policies that have failed to correct crucial problems of the health-care system include competitive strategies, corporate intervention, and public-sector cutbacks with bureaucratic expansion. A national health program that combines elements of national health insurance and a national health service is a policy that would help solve current health-care problems. Previous proposals for national health insurance contained weaknesses that would need correction under a national program. Based on the experiences of other economically advanced countries, a national health program could provide universal entitlement to health care while controlling costs and improving the health-care system through structural reorganization. Current proposals for a national health program contain several basic principles dealing with the scope of services, copayments, financing, cost controls, physician and professional associations, personnel and distribution, prevention, and participation in policy making. Support for a national health program is growing rapidly. Such a program would help protect all people who live in this country from unnecessary illness, suffering, and early death.

National Health Programs↗

Frame disturbances in no-fee psychotherapy.

The frame of psychotherapy shows both universality and social relativity. Since the intrapsychic world is permeable to social reality, the meaning of insurance in psychotherapy depends on context. Experience with Canadian National Health Insurance suggests that when no-fee psychotherapy in normative, it is absorbed in the frame. There are still trouble spots in the Canadian system, particularly the management of missed sessions. Depending on the needs of the patient, charging for missed sessions can disrupt therapy entirely or be constructive for the treatment.

Adult↗

Let the patients speak.

The 1997 Texas Legislature directed the Office of Public Insurance Counsel (OPIC) to issue annual report cards comparing Texas health maintenance organizations (HMOs). OPIC released its first statewide consumer survey in August, conducted by The University of Texas Office of Survey Research.

Data Collection↗

Financing reforms for the Thai health card scheme.

The Thai health card scheme originated from a pilot study on community financing and primary health care in maternal and child health in 1983. The scheme later changed to one of voluntary health insurance and finally received a matching subsidy from the government. The coverage of the scheme is described by a U-curve, i.e. it started with 5% of the total population in 1987, declined to 3% in 1992, with an upturn to 14% in 1997. The upturn has been the result of concerns about universal coverage policy, together with reforms of fund management. The provincial fund is responsible for basic health, basic medical, referral, and accident and emergency services. The central fund takes 2.5% of the total fund to manage cross-boundary services and high cost care (a reinsurance policy). On average, the utilization rate of the voluntary health card was higher than that of the compulsory (social security) scheme. And amongst three variants of health cards, the voluntary health card holders used health services twice to three times more than the community and health volunteer card holders. Cost recovery was low, especially in the provinces with low coverage. In the province with highest coverage, cost recovery was as high as 90% of the non-labour recurrent cost. Only 10% of the budgeted fund for reinsurance was disbursed, implying considerable management inefficiency. The management information system as well as the management capacity of the Health Insurance Office should be strengthened. After comparing the health card with other insurance schemes in terms of coverage, cost recovery, utilization and management cost, it is recommended that this voluntary health insurance should be modified to be a compulsory insurance, with some other means of premium collection and minimal co-payment at the point of delivery.

Community Health Services↗

Inappropriate use of hospital beds: a case study of university hospitals in Turkey.

The purpose of this study is to estimate the degree of Inappropriate Patient Days (IPDs) in a teaching hospital in Turkey using the Appropriateness Evaluation Protocol (AEP) criteria. One day was randomly chosen in 1995 for review and a second day was chosen close to the randomly selected day to indicate possible differences between a weekday and a weekend. Total hospital days reviewed were 221 with 114 days on Sunday and the remaining 107 days on a Tuesday. The evaluation indicates that more than 22 percent of patient days were inappropriate in the university hospital in Turkey. Multiple logistic regression equations were estimated to identify the determinants of IPDs. The results imply that age and sex of patient, clinical diagnosis at admission and type of health insurance coverage affect IPDs significantly. However, most of the IPDs occurred during the initial few days of hospital stay. Therefore, to improve the productivity of hospital resources, the gap between the admission date and the date of medical or surgical interventions should be reduced.

Adolescent↗

Paying the bill.

Businesses are in revolt over President Clinton's proposal to require employers to underwrite their workers' health coverage. But it won't be easy to find another way to provide universal coverage without higher taxes.

Health Benefit Plans, Employee↗

Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care.

BACKGROUND: Chronically ill patients often experience difficulty paying for their medications and, as a result, use less than prescribed. OBJECTIVES: The objectives of this study were to determine the relationship between patients with diabetes' health insurance coverage and cost-related medication underuse, the association between cost-related underuse and health outcomes, and the role of comorbidity in this process. RESEARCH DESIGN: We used a patient survey with linkage to insurance information and hemoglobin A1C (A1C) test results. PATIENTS: We studied 766 adults with diabetes recruited from 3 Veterans Affairs (VA), 1 county, and 1 university healthcare system. MAIN OUTCOMES: Main outcomes consisted of self-reported medication underuse as a result of cost, A1C levels, symptom burden, and Medical Outcomes Study 12-Item Short-Form physical and mental functioning scores. RESULTS: Fewer VA patients reported cost-related medication underuse (9%) than patients with private insurance (18%), Medicare (25%), Medicaid (31%), or no health insurance (40%; P <0.0001). Underuse was substantially more common among patients with multiple comorbid chronic illnesses, except those who used VA care. The risk of cost-related underuse for patients with 3+ comorbidities was 2.8 times as high among privately insured patients as VA patients (95% confidence interval, 1.2-6.5), and 4.3 to 8.3 times as high among patients with Medicare, Medicaid, or no insurance. Individuals reporting cost-related medication underuse had A1C levels that were substantially higher than other patients (P <0.0001), more symptoms, and poorer physical and mental functioning (all P <0.05). CONCLUSIONS: Many patients with diabetes use less of their medication than prescribed because of the cost, and those reporting cost-related adherence problems have poorer health. Cost-related adherence problems are especially common among patients with diabetes with comorbid diseases, although the VA's drug coverage may protect patients from this increased risk.

Aged↗