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PubMed2004

Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients.

OBJECTIVE: This study tested the hypothesis that weight-reduction (bariatric) surgery reduces long-term mortality in morbidly obese patients. BACKGROUND: Obesity is a significant cause of morbidity and mortality. The impact of surgically induced, long-term weight loss on this mortality is unknown. METHODS: We used an observational 2-cohort study. The treatment cohort (n = 1035) included patients having undergone bariatric surgery at the McGill University Health Centre between 1986 and 2002. The control group (n = 5746) included age- and gender-matched severely obese patients who had not undergone weight-reduction surgery identified from the Quebec provincial health insurance database. Subjects with medical conditions (other then morbid obesity) at cohort-inception into the study were excluded. The cohorts were followed for a maximum of 5 years from inception. RESULTS: The cohorts were well matched for age, gender, and duration of follow-up. Bariatric surgery resulted in significant reduction in mean percent excess weight loss (67.1%, P < 0.001). Bariatric surgery patients had significant risk reductions for developing cardiovascular, cancer, endocrine, infectious, psychiatric, and mental disorders compared with controls, with the exception of hematologic (no difference) and digestive diseases (increased rates in the bariatric cohort). The mortality rate in the bariatric surgery cohort was 0.68% compared with 6.17% in controls (relative risk 0.11, 95% confidence interval 0.04-0.27), which translates to a reduction in the relative risk of death by 89%. CONCLUSIONS: This study shows that weight-loss surgery significantly decreases overall mortality as well as the development of new health-related conditions in morbidly obese patients.

Adult↗
PubMed1997

Economy, politics, and health status in Cuba.

An economic contraction occurred in Cuba at the beginning of the 1990s, of a magnitude greater than in any developed country in the last half century. This resulted primarily from the disappearance of the European socialist bloc and simultaneous tightening of the U.S. government's blockade at a time when Cuba was engaged in correcting its main economic problems. The economic crisis affected a number of areas of Cuban society. The state adopted a series of measures to cope with the socioeconomic situation, which have yielded positive results in the social and economic fields, as well as some undesirable results. In the health sector, the economic crisis has mainly reduced the availability of resources and has adversely affected some health determinants and some aspects of the population's health status. Despite the prevailing economic difficulties, the government is determined to preserve the country's achievements in health, and to develop them still further. The solution is not privatization or the introduction of health insurance systems or similar measures. Rather, Cuba will seek greater rationality and economic efficiency in the health sector. It has ratified the principles that the state should continue to finance the health system and maintain universal coverage and accessibility through free services.

Cost-Benefit Analysis↗
PubMed1994

Health care paper chase, 1993: the cost to the nation, the states, and the District of Columbia.

The U.S. health care payment system is an elaborate and increasingly wasteful paper chase. This article presents new state-by-state estimates of health care administrative costs in the United States, and savings that could be realized with single-payer reform. In 1993, health care bureaucracy will consume 24.7 cents of every health care dollar, a total of $232.3 billion. Administration's share of health spending is up from 23.9 percent in 1987, and from 21.9 percent in 1983. Reducing the cost of administration to Canadian levels by adopting a single-payer health care system would cut U.S. health care bureaucracy by more than half (50.7 percent), saving at least $117.7 billion in 1993. The savings achievable with a single-payer system could fund universal access for the uninsured and improve benefits for the tens of millions of Americans who currently have only partial coverage, without any increase in overall health spending. Reform measures such as electronic billing, insurance industry consolidation, and increased competition (including "managed competition") would save little or nothing on administration. Only a single-payer reform that incorporates the "macro-management" approach to cost control, as in Canada, can achieve significant administrative savings.

Cost Savings↗
PubMed2005

Disparities and discrimination in health care: an introduction.

Racial disparities in health care and health outcomes are a disturbing feature of the American health care system. Efforts to reduce or ameliorate these disparities must be informed by an understanding of the factors that underlie and contribute to them. The papers in this issue are based on a recent conference that was held at the University of Chicago to address this problem. Socioeconomic status is an important determinant of health, and socioeconomic disparities are major determinants of the racial disparities in health. These socioeconomic disparities are complicated by access to health insurance, geographic factors, and unhealthy behaviors. Geographic disparities, both regional and local, also contribute to racial disparities in health. Moreover, current disparities in the health of adult populations may reflect socioeconomic disparities that prevailed during their intrauterine or early infant development. There seems little evidence that either overt or unconscious discrimination on the part of physicians is an important cause of racial disparities in health; blaming physicians for this problem is counterproductive. Improving the quality of medical care holds the promise not only of improving health for all Americans, but of decreasing the racial disparities in health care that are so troubling today.

Health Behavior↗
PubMed1999

The missing millions: organized labor, business, and the defeat of Clinton's Health Security Act.

During the battle over comprehensive health care reform in the early 1990s, organized labor was not only unable to put together a winning coalition but also found itself divided and on the defensive as it struggled to prevent any further erosion of the private-sector safety net of the U.S. welfare state. Labor's relative ineffectiveness has deep institutional and political roots and was not merely a consequence of its dwindling membership base. Several key institutions of the private welfare state, notably the Taft-Hartley health and welfare funds and the Employment Retirement Income Security Act (ERISA) preemption, brought the interests of organized labor more closely in line with those of large employers and commercial insurers and aggravated divisions within organized labor and between unions and public interest groups. In addition, several political factors conspired to reinforce labor's tendency to stick to a policy path on health care issues that was predicated on an employer-mandate solution and that had been charted primarily by business and leading Democrats. As a result, organized labor did not emerge from the 1993-1994 struggle with its political base fortified nor with a viable long-term political strategy to achieve universal health care and to shift the political debate over health policy in a more desirable direction.

Attitude to Health↗
PubMed2006

Realigning economic incentives for depression care at UCSF.

Behavioral health carve-out arrangements create financial disincentives for primary care providers (PCPs) to treat depression. A novel collaboration between a primary care practice, a health insurer, and a managed behavioral health organization (MBHO) allows PCPs to receive reimbursement and schedule longer appointments to care for depressed patients. This article describes the details of the arrangement, and early results of this collaboration. Early results find that financial incentives are critical for implementation, but that time incentives do not appear to motivate PCPs. Sustainability of this model will require participation of multiple primary care practices, health insurers, and MBHOs.

California↗
PubMed2003

Policy without politics: the limits of social engineering.

The extent of coverage provided by a country's health services is directly related to the level of development of that country's democratic process (and its power relations). The United States is the only developed country whose government does not guarantee access to health care for its citizens. It is also the developed country with the least representative and most insufficient democratic institutions, owing to the constitutional framework of the political system, the privatization of the electoral process, and the enormous power of corporate interests in both the media and the political process. As international experience shows, without a strong labor-based movement willing to be radical in its protests, a universal health care program will never be accepted by the US establishment.

Capitalism↗
PubMed2001

Is German long-term care insurance a model for the United States?

German long-term care insurance, implemented in 1995, significantly extends the coverage of care-related risks. Given the similarities of German and U.S. institutional features, the German social insurance approach has been put forward as a possible model for long-term care in the United States. Using a political economy framework, the authors conducted a policy analysis that compares the main shortfalls of long-term care (LTC) provision in the United States and Germany, examines the responses provided by LTC insurance in Germany, and relates them to broader trends and proposals for change in welfare policy in both countries. German LTC insurance includes a high degree of consumer direction and compensation and protection for informal caregivers; it supports the extension of community-based services. Its shortfalls include the continued split between health and LTC insurance. In both countries, decentralization and institutional and financial fragmentation are some of the characteristics responsible for the failure to promote egalitarian social policy and substantially expand social protection to family- and care-related risks. The German LTC program is a good model for the United States. With a social insurance approach to LTC, costs are spread across the largest possible risk pool. Major goals that can be reached with such a program include establishment of universal entitlements to LTC benefits, consumer choice, and equitability and uniformity.

Activities of Daily Living↗
PubMed1991

An American approach to health system reform.

In terms of the major objectives one would have for health system reform, this plan makes the following choices: 1. It would cover everyone, through Medicare (the elderly), employer-based coverage (some workers and dependents) or a state-level public program that would replace Medicaid (the poor, unemployed, and other workers and dependents). 2. There would be a standard minimum package of required benefits for employer-based and public programs, with legislative requirements on maximum cost-sharing. Choice of provider might be restricted in some states. 3. Administration of the private programs would be the responsibility, as now, of the employers and/or insurance companies. Administration of the public program would be the responsibility of the states, with the objective of maximizing responsiveness to local needs and conditions. 4. It would control costs through giving the states a substantial financial stake in ensuring that the public program costs did not grow faster than nominal GNP. State control would also allow the testing of different mechanisms for cost control, with the ultimate objective of identifying the most effective cost-containment strategies. 5. The cost would be borne by employers, employees, and taxpayers. Employers would be protected from exorbitant costs by being allowed the option of paying into a public plan rather than providing health insurance themselves. The poor and unemployed would be protected by having their coverage under the public program subsidized on a sliding scale. 6. The political feasibility test would be met by retaining a major role for insurance companies and by retaining the role of employer-based coverage--thus reducing the tax increase needed to ensure universal coverage. By allowing flexibility in design of cost-containment strategy, some of the controversy over this issue would also be deflected. Our proposal is also not without problems. First, our approach would still have adverse effects on the profitability of small businesses and on the employment prospects for low-wage workers--although these effects would be less than under conventional mandates and less than under proposals with higher tax rates. Second, some states may not want the responsibility we envision or have the capacity to carry it out. But several Canadian provinces are relatively small and are able to perform the same administrative functions within the Canadian national health system. In addition, since the federal government would continue to administer the Medicare program, states would have the option of tying their policies for hospital and physician payment and utilization control to those of Medicare.(ABSTRACT TRUNCATED AT 400 WORDS)

Canada↗
PubMed1994

The $147,000 misunderstanding: repercussions of overestimating the cost of AIDS.

The increasing incidence of AIDS in the 1980s prompted inquiry into the resources required to meet projected needs. In the first economic study to appear on the illness, the Centers for Disease Control (CDC) estimated that the costs of inpatient care were $147,000 per AIDS patient, heightening concern that the health care system would be overwhelmed by the epidemic. However, every study published subsequently has produced much lower cost estimates. As a result, many have concluded that treatment costs declined due to improved delivery of AIDS care. We offer an alternative interpretation, based on evidence demonstrating that the CDC's methods and assumptions yielded a figure about three times too high. The CDC's erroneous estimate had significant policy repercussions. Using the $147,000 figure, the health insurance industry lobbied successfully for the right to screen applicants for HIV. Next, when a study of San Francisco AIDS patients found local hospital costs per case to be $27,571, many concluded that billions of dollars could be saved if the "San Francisco model" of care (emphasizing home and community-based services and case management) were universalized. Since then, most programs for AIDS services have provided funds for community care. While such programs improve access to vital services, they are unlikely to guarantee "better care for less money." A more informed understanding of the cost of AIDS should lead to programs that also strengthen inpatient care.

AIDS Serodiagnosis↗
PubMedDate not supplied

Role of gender, insurance status and culture in attitudes and health behavior in a US Chinese student population.

INTRODUCTION: Asians are an understudied population in health research. Often their lower utilization of health care services and low participation in clinical trials has been attributed to socioeconomic factors and cultural beliefs. However, the role of gender and perceptions of health beliefs across generations in determining access have not been studied in this population. OBJECTIVE: This study seeks to examine the relationship of gender to the health beliefs and health utilization patterns of a group of undergraduate Chinese students in regard to their own use and what they perceived as their parents' use. DESIGN: Seventy-eight Chinese students responded to a health belief and utilization survey. They were asked to provide information on their perceptions and attitudes of health as well as what they perceived to be their parents' health attitudes and behavior. RESULTS: Findings indicated that female students were more proactive in their health beliefs towards preventive care and getting regular check-ups than male students. This difference between genders remained true in the students' perceptions of their mothers being more likely to seek preventive care and to get regular check-ups than their fathers. Cultural factors including privacy and modesty were important factors in determining use of health care by Chinese women. Insurance status played an important role in determining health behavior among Chinese men. Uninsured fathers were perceived as more likely to use complementary and alternative therapies (CAM) than mothers. Male students and fathers who had private insurance were perceived to access and utilize health services equally as the women. Gender differences are seemingly less apparent among parents who are using CAM. Language difficulty was identified most frequently as the major barrier to accessing care among this population. CONCLUSIONS: Considerations of socioeconomic factors, cultural and language barriers need to be made with particular focus on gender differences in attitudes and health behavior when making policy decisions for the Asian American population. Further studies are also needed on intergenerational attitudes and health behavior of older Asian Americans.

Adolescent↗
PubMed1994

The Health Security Act and academic medicine.

The speaker emphasizes the importance of academic medical centers in providing the foundation upon which the excellence of the American health care system is built. The challenge of health care reform is to preserve what is best about that system and to fix what needs to be changed. The most important aspect of the president's health care reform initiative (the Health Security Act)--and one that the president insists upon--is universal coverage with comprehensive benefits. But many areas of the reform package are negotiable. The speaker then discusses health care reform issues that are of concern to academic medicine: the proposed new source and magnitude of future federal funding for academic medical centers; the need to resist efforts to cap the rate of growth of Medicare and Medicaid rather than to reduce the rate in the context of overall health care reform; and the dangers of the balanced budget amendment to health care reform and academic medical centers. Next, the principles of the president's plan are explained: security (i.e., universal coverage with comprehensive benefits); savings (i.e., a more efficient health care system); simplicity (i.e., moving toward a single claim system and other ways to eliminate unnecessary paperwork); choice (for patients and for physicians regarding insurance plans); quality of care; and responsibility (of individuals for their own health care, of professionals for various decisions about health care; and for the financing of health care, a proposed employer-employee system). The speaker closes by reviewing the history of past administrations' efforts to reform U.S. health care: all these failed because of the efforts of the defenders of the status quo.(ABSTRACT TRUNCATED AT 250 WORDS)

Academic Medical Centers↗
PubMed2006

Drawing from Freirian empowerment methods to develop and use innovative learning maps: increasing enrollment of uninsured children on Detroit's eastside.

In 2001, virtually every child on Detroit's eastside was eligible for health coverage, yet approximately 3,000 children remained uninsured. The primary aim of the Eastside Access Partnership (EAP), a community-based participatory research collaboration, was to increase enrollment of uninsured children in state programs. To achieve this aim, one of the approaches that EAP is using is the innovative Learning Map titled Choosing the Healthy Path, which was developed in collaboration with Root Learning, Inc. Although Learning Maps were originally developed to assist corporations in implementing strategic change, their integration of visualization and interactive dialogue incorporates Freirian principles of empowerment education, making them a viable option for providing meaningful learning opportunities for community residents. This article presents the collaborative process involving the University of Michigan, local community-based organizations, community members, and Root Learning consultants to develop a visual map that enables community residents to understand and overcome the barriers that prevent them from obtaining health insurance for their children.

Adolescent↗
PubMed1996

Health care reforms and managed care for substance abuse services: findings from eleven case studies.

In 1992, the United States spent $820 billion on health care. For the same year, an estimated 15 percent of the U.S. population, approximately 43 million people, were uninsured. As health care costs continue to rise, the number of people able to afford coverage continues to decline. Given these statistics, it is not surprising that concern over health care reform is at the forefront of government policy. Over the past few years, policymakers have faced the challenge of creating a more cost-efficient, universal health care system. Many of the proposed reforms rely heavily on managed care practices and treatment limits to help control costs. The impact of managed care is already apparent in primary health care where private insurers have been using it for years (e.g., HMOs, PPOs). However, its full impact on substance abuse treatment services remains unknown. In this paper, we present the perceptions, opinions, and experiences of eleven drug treatment programs regarding the actual or anticipated effects of managed care and health care reforms on the delivery, financing, and costs of substance abuse treatment. We also present an analysis of these programs' current costs and financing. We believe that the information presented in this paper provides timely insights into the substance abuse treatment system; these insights should assist policymakers in developing optimal health care reform policies.

Cost-Benefit Analysis↗
PubMed2002

The general public's perceptions and use of antimicrobials in Trinidad and Tobago.

OBJECTIVE: To determine the general public's perceptions and use of antibiotics in Trinidad and Tobago, a two-island republic in the Caribbean. METHODS: This prospective study surveyed 824 randomly selected households listed in the telephone directory, from November 1998 to January 1999. Through telephone interviews we determined knowledge about antibiotics and beliefs concerning their safety and efficacy. We studied the influence of age, gender, education, and having private health insurance on knowledge, self-medication, storing medication at home for emergency use ("hoarding"), and asking a private doctor to prescribe antibiotics ("demand prescribing"). RESULTS: For the 824 telephone calls that the interviewers completed, 753 of the households agreed to participate (91.4% response rate). Of those 753 participants, 699 of them (93%) knew the term "antibiotic," 29% (206/699) said it was a drug for bacterial infections, and 25% (170/690) had asked a doctor for an antibiotic prescription. Penicillin was correctly identified as an antibiotic across age, gender, and education categories, but 36% of respondents incorrectly said Benadryl (diphenhydramine), a common over-the-counter cough and cold formulation, was an antibiotic. Gender was not significantly associated with knowledge of antibiotic safety, with self-medication, or with hoarding antibiotics. On the other hand, completion of tertiary (university) education was significantly associated with correct knowledge of the safety of antibiotics and whether or not they could cure all infections. Of the various antimicrobials, beta-lactams were the ones that survey respondents had used most frequently in the preceding year, and 20% of antibiotics users had used multiple antibiotics in that period. In comparison to persons with private health insurance, more individuals without private health insurance said that antibiotics are safe and do not have side effects, and more of them also incorrectly called aspirin and Benadryl antibiotics. CONCLUSIONS: In Trinidad and Tobago, inappropriate use of antimicrobials results from self-medication, over-the-counter availability at the community pharmacy, prescribing on demand, and lack of regulatory control. In order to contain antibiotic abuse, both the Drug Inspectorate of the Ministry of Health and the Pharmacy Board should exert stricter control on the dispensing of antibiotics at private pharmacies. Further, education of the general public and of health care professionals on antibiotic misuse and appropriate use must be instituted, along with community-based surveillance of antimicrobial resistance trends.

Adolescent↗
PubMed2002

Advancing the role of nonprofit health care.

This article comes out of a series of discussions among a diverse group of chief executive officers (CEOs) and other leaders of nonprofit hospitals, long-term care facilities, health maintenance organizations, and other insurance providers, including several nonprofit Blue Cross Blue Shield (BCBS) plans. The group was convened as part of Howard Berman's Walter J. McNerney Fellowship project. (Berman is CEO of Excellus, Inc., a nonprofit Blue Cross Blue Shield affiliate that insures the health of more than 2.15 million people in upstate New York. He was awarded the McNerney Fellowship in April 2001 by the Health Research and Educational Trust, an American Hospital Association affiliate. The Fellowship goes annually to at least one fellow to highlight or pursue work that will provide new insights into how different sectors of the health care system can better work together for improved outcomes.) The group has met several times over the past year around a shared concern: the current challenges to nonprofit health care organizations and the future role for nonprofits in the re-visioning and creation of an American health care system that is characterized by universal access, patient-centered quality, and national affordability. Members have supported the public relations campaign of the "Alliance for Advancing Nonprofit Health Care," an effort initiated by the Caucus, an independent group of nonprofit BCBS plans. The group continues to explore the need for a broad-based coalition of providers, insurers, and other organizations to effectively protect and enhance the role of nonprofit health care.

Community Health Planning↗
PubMed1997

Factors influencing effect of mammography screening in a university workplace.

The purpose of this study was to examine the relationship between theoretically identified variables and participation in mammography screening in a university workplace. A sample of 1093 women 50 and over returned a questionnaire following the offer of a free workplace breast cancer screening. Anderson's Behavioral Model of Health Services Use identified factors predisposing and enabling women to have mammograms. Predisposing variables included attitudes and experience related to mammography. Enabling variables included income, willingness to pay for mammography, health insurance coverage, and regular source of health care. Comparisons were made among: (i) those who were screened in the workplace, (ii) those who were screened elsewhere, and (iii) those who were not screened. Differences in perceived barriers, perceived benefits, practice of breast self-examination (BSE), and education surfaced. Results indicated, among other things, that women who were older, had no more than 12 years of education, had a family member with breast cancer, and were proficient with breast self-examination were more likely to have participated in the university work-site screening.

Breast Neoplasms↗