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PubMed1993

Practitioners speak out.

Most of our colleagues report that the recession has caused them to alter the way they have been providing services on a day-to-day basis. Even though changes, cutbacks, and concessions have been made, our professions have, for the most part, been resilient and have been spared the massive layoffs and salary cuts seen in other sectors of the workforce. In fact, given our colleagues' comments, our professions seem to have fared well in what have been gloomy times for many other industries and careers. The number of vacant positions far exceeded the number of people seeking positions at the 1992 ASHA convention (many report position vacancies that have gone unfilled for some time); salaries appear to be keeping up with or in some cases even exceeding inflation; and the number of clients who need us keeps growing. No one knows what lies ahead. We do know that our professions survived the recession. In the years ahead we will be preparing the groundwork for the practice of the professions in the next century. It will be a time of change in the delivery of care. We will be required to be as creative or even more creative than we have been.

Ambulatory Care Facilities↗
PubMed2005

Renal replacement therapy among disadvantaged populations in Mexico: a report from the Jalisco Dialysis and Transplant Registry (REDTJAL).

BACKGROUND: End-stage renal disease represents a serious public health problem in Jalisco, Mexico. It is reported among the 10 leading causes of death, with an annual mortality rate of 12 deaths per 100,000 population. The state population is 6.3 million, and more than half do not have medical insurance. In this study, we report the population's access to renal replacement therapy (RRT). METHODS: Patients > or =15 years of age, who started RRT between January 1998 and December 2000 at social security or health secretariat medical facilities, were included. Nine facilities participated in the study. At the start of treatment, the patient's facility, age, gender, cause of renal failure, and initial treatment modality were registered. RESULTS: Within the study period, 2456 started RRT, 1767 (72%) at social security facilities and 687 (28%) at health secretariat facilities, for an annual incidence rate of 195 per million population (pmp). The main cause of renal failure was diabetes mellitus (51% of patients). There were significant differences between the 2 populations. Patients with social security were older (53.1 +/- 17 vs. 45.1 +/- 20 years, P= 0.001) and had more diabetes (54% vs. 42%, P= 0.001) than those without social security. They had higher acceptance (327 pmp vs. 99 pmp, P= 0.001) and prevalence rates (939 pmp vs. 166 pmp, P= 0.001) than patients without medical insurance. Dialysis use was similar in both populations. Eighty-five percent of patients were on continuous ambulatory peritoneal dialysis and 15% on hemodialysis. Kidney transplant rate was higher among insured patients (72 pmp vs. 7.5 pmp, P= 0.001). The number of dialysis programs and nephrologists that offered renal care also differed. There were 10 dialysis programs in social security and 3 in health secretariat facilities. Fourteen nephrologists looked after the insured population, whereas 5 cared for the uninsured (7.7 pmp vs. 2.1 pmp, P= 0.001). The latter had access to 8 hemodialysis stations compared with 34 for the insured population (3.4 pmp vs. 18.8 pmp, P= 0.001). CONCLUSIONS: Access to RRT is unequal in our state. Although it is universal for the insured population, it is severely restricted for the poor. Social and economical factors, as well as the limited number of understaffed, centralized dialysis facilities, could explain these differences.

Female↗
PubMed2001

[The Basel Medical University Polyclinic on the brink of the 21st century: retrospective and prospective view].

At the occasion of its 125th anniversary the outpatient department of internal medicine is being analysed with regard to its history, development and future. Originally it was founded to improve practical patient-oriented teaching of students and to serve the poor population of Basel. While today the Swiss Health Insurance system warrants proper care for every citizen and thus renders the latter purpose unnecessary, new marginal patient groups have evolved that need proper attention such as HIV patients, asylum-seekers, geriatric patients and others. Teaching obligations have even increased, especially with regard to primary care and family medicine. Thus the reasons for running a medical outpatient department have changed considerably, but still include teaching, research and provision of care to special patient groups. Outpatient departments have to be flexible and to adapt to modern trends in health care.

Forecasting↗
PubMed2004

Employee choice of consumer-driven health insurance in a multiplan, multiproduct setting.

OBJECTIVE: To determine who chooses a Consumer-Driven Health Plan (CDHP) in a multiplan, multiproduct setting, and, specifically, whether the CDHP attracts the sicker employees in a company's risk pool. STUDY DESIGN: We estimated a health plan choice equation for employees of the University of Minnesota, who had a choice in 2002 of a CDHP and three other health plans--a traditional health maintenance organization (HMO), a preferred provider organization (PPO), and a tiered network product based on care systems. Data from an employee survey were matched to information from the university's payroll system. PRINCIPAL FINDINGS: Chronic illness of the employee or family members had no effect on choice of the CDHP, but such employees tended to choose the PPO. The employee's age was not related to CDHP choice. Higher-income employees chose the CDHP, as well as those who preferred health plans with a national provider panel that includes their physician in the panel. Employees tended to choose plans with lower out-of-pocket premiums, and surprisingly, employees with a chronic health condition themselves or in their family were more price-sensitive. CONCLUSIONS: This study provides the first evidence on who chooses a CDHP in a multiplan, multiproduct setting. The CDHP was not chosen disproportionately by the young and healthy, but it did attract the wealthy and those who found the availability of providers more appealing. Low out-of-pocket premiums are important features of health plans and in this setting, low premiums appeal to those who are less healthy.

Choice Behavior↗
PubMedDate not supplied

Toward improving the oral health of Americans: an overview of oral health status, resources, and care delivery. Oral Health Coordinating Committee, Public Health Service.

Dental and oral diseases may well be the most prevalent and preventable conditions affecting Americans. More than 50 percent of U.S. children, 96 percent of employed U.S. adults, and 99.5 percent of Americans 65 years and older have experienced dental caries (also called cavities). Millions of Americans suffer from periodontal diseases and other oral conditions, and more than 17 million Americans, including 10 million Americans 65 years or older, have lost all of their teeth. Preventive dental services are known to be effective in preventing and controlling dental diseases. Unfortunately, groups at highest risk for disease--the poor and minorities--have lower rates of using dental care than the U.S. average. Cost is the principal barrier to dental care for many Americans. Of the $38.7 billion spent for dental services in 1992, public programs, including Medicaid, paid for less than 4 percent of dental expenditures. More than 90 percent of care was paid for either out-of-pocket by dental consumers or through private dental insurance. Americans are at risk for other oral health problems as well. Oropharyngeal cancer strikes approximately 30,000 Americans each year and results in an estimated 8,000 deaths annually. Underlying medical or handicapping conditions, ranging from rare genetic diseases to more common chronic diseases, affect millions of Americans and can lead to oral health problems. Among persons with compromised immune systems, oral diseases and conditions can have a significant impact on health. Oral diseases and conditions, though nearly universal, can be prevented easily and controlled at reasonable cost. Prevention and early, regular primary dental care are the best strategies to improve the oral health and quality of life of all Americans.

Adolescent↗
PubMed1993

Providing universal access is not easy.

In whatever reform system legislators develop, states may be given leeway in what they do to provide for their residents. Vermont is one of those states that will strive for universal access. What have been the pitfalls so far as the state develops its own system?

Health Policy↗
PubMed1994

Choosing among health plans.

The health care reform system that is ultimately adopted, suggest the authors of this analysis, should rely on market forces, rather than government regulation, to reduce cost and improve quality in our health care delivery. A major portion of this paper compares the Health Security act (the Clinton proposal), the American Health Security Act (the McDermott bill), the Health Equity and Access Reform Today, HEART (the Chafee proposal), and the Managed Competition Act (the Cooper bill). The article focuses on the major areas of difference between these alternative proposals in the extent to which they would achieve true market-based reform, small group reform, universal coverage, and financing mechanisms.

Evaluation Studies as Topic↗
PubMed2004

Safe teleradiology: information assurance as project planning methodology.

The Georgetown University Medical Center Department of Radiology used a tailored version of OCTAVE, a self-directed information security risk assessment method, to design a teleradiology system that complied with the regulation implementing the security provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The system addressed threats to and vulnerabilities in the privacy and security of protected health information. By using OCTAVE, Georgetown identified the teleradiology program's critical assets, described threats to the assurance of those assets, developed and ran vulnerability scans of a system pilot, evaluated the consequences of security breaches, and developed a risk management plan to mitigate threats to program assets, thereby implementing good information assurance practices. This case study illustrates the basic point that prospective, comprehensive planning to protect the privacy and security of an information system strategically benefits program management as well as system security.

Academic Medical Centers↗
PubMed1989

The Jackson National Health Program.

In this position paper we outline the major problems that exist in the U.S. health care system and present a proposal for addressing them. This paper contains the major health proposal put forward by the Jesse Jackson 1988 Campaign, calling for the establishment in the United States of a universal and comprehensive National Health Program (NHP) that will be federally funded and administered and be equitably financed. We also discuss how the NHP will affect patients, unions, corporations and employers, practitioners and other health workers, hospitals, and the insurance industry. Specific proposals are made for the transition from the current system to the proposed NHP, with a discussion of the major differences between national health proposals put forward by the two major Democratic contenders for the U.S. Presidency. This position paper also includes a brief appendix sketching some of the major differences between the U.S. and the Canadian medical care systems.

Cost-Benefit Analysis↗
PubMed2003

Cost of acute stroke care at a tertiary care hospital in Karachi, Pakistan.

OBJECTIVE: To evaluate cost of acute stroke care and its determinants at a tertiary care hospital in Karachi and to find out predictors of high cost care. Acute stroke is a leading cause of morbidity and mortality. Cost of care is the single most important determinant in availability of acute stroke care at a tertiary care hospital in Pakistan. It is also an important factor in development of public health policies and medical insurance plans. Average annual income in Pakistan is 4881 rupees (85 U dollars). METHODS: Medical and billing records of 443 patients with acute stroke were retrospectively reviewed from 1998-2001 at The Aga Khan University Hospital (AKUH), Karachi. Acute stroke care at AKUH usually includes routine laboratory investigation including Lipid profile, Magnetic resonance imaging/angiography (MRI/MRA), Echocardiogram, Carotid Doppler's ultrasound and medical management in the Stroke care unit. RESULTS: 443 patients were included in study. Age range was 25-98 years (Mean 58 years). 269 (61%) were male. Length of hospital stay was 1 day; 67 patients, 2 days; 83 patients, 3 days; 70 patients, 4-5 days; 87 patients, 6-10 days; 75 patients, 11-30 days; 49 patients and more than 30 days; 12 patients. Average length of stay was five days and median length was three days. Average total cost was 70,714 rupees (1179 U dollars) which included average radiology cost; 12,507 rupees (208 U dollars), average laboratory cost; 8365 rupees (139 U dollars), average pharmacy cost; 13,320 rupees (222 U dollars) and average bed/room charges; 27,552 rupees (459 U dollars). Length of hospital stay is the most important determinant of cost. Average total cost for patients who stayed for 1 day was 19,597 rupees (326 U dollars), 2-3 days; 25,568 rupees (426 U dollars), 4-7 days; 49,705 rupees (828 U dollars), 8-30 days; 153,586 rupees (2559 U dollars), more than 30 days; 588,239 rupees (9804 U dollars). Average cost for general ward was 60,574 rupees (1010 U dollars), private ward was 74,880 rupees (1248 U dollars) and intensive care unit was 155,010 rupees (2583 U dollars). CONCLUSION: Cost of acute stroke care is extremely high as compared to average national income at our hospital. Most important determinant of cost is length of hospital stay. Cost cutting measures and increased funding from state are necessary to increase the availability of acute stroke care.

Acute Disease↗
PubMed1992

[The importance of the Czech Medical Society yesterday and today].

Fourteen physicians headed by Jan Evangelista Purkynĕ signed the proposed by-laws of the Czech medical society in october 1861. Emperor's approval was received 26th june 1862 and in july Purkynĕ was elected the first president. The same illuminated personalities were the founders of the Casopis lékarů ceských--the Czech medical Journal which has remained the most important Czech periodical until the present time. The aims of the Society were to cultivate medical science and promote Czech language in medicine. Weekly scientific sessions, medical periodical and publication of monographs related to medicine were the means how to achieve the aims. The Czech Medical Society became soon the centre of medical science in Bohemia. Its members were among the foremost fighters for the use of Czech language in Charles university and their relentless effort helped much to the establishment of the Czech Univerzity in 1882 and Czech medical faculty a year later. In subsequent years the Society was also involved in professional problems related to social health insurance, medical fees, ethical problems and other relevant questions such as the establishment of medical chambers. The activity of the Czech medical Society was never interrupted during its 130 years of existence, although there were several difficult periods in its life, mainly during the first and second world war and also in the past 40 years. In spite of the atomization of medicine the Czech medical Society has been continuing its eminent mission to create communication and establish close links between the medical science and practical medicine by systematically bringing new knowledge in medicine and biology to general physicians and by putting together physicians, surgeons and basic scientists. The task for the future is seen in optimal transfer of new knowledge and ideas from scientists to practicians and vice versa; and to take care of the highest possible moral and ethical standard required for humane medicine. Tradition and achievements of our teachers is binding and we are looking forward to better future in united Europe.

Czechoslovakia↗
PubMed2000

Cervical cancer--the impact of clinical presentation, health and race on survival.

This study evaluated the association of race, comorbid illness, insurance status, and other prognostic factors on treatment and survival of patients with invasive carcinoma of the cervix, using as its methodology a retrospective study of patients with invasive carcinoma of the cervix treated from 1991 to 1998 at the University of Maryland. Of 161 such patients, 153 met the study criteria. Of these 153 women, 83 (54%) were African Americans and 70 (46%) were white. The mean (+/- SE) age of African American women was 52 +/- 1.8 years and that of white women was 50 +/- 1.8 years. African American women were more likely to present with stages II-IV disease (P = 0.01) and, as a consequence, underwent radiation therapy rather than surgery (P = 0.04). The survival of African American women with stage I-II disease was significantly lower than for white women. In the final regression model, stage III-IV disease (hazard ratio 3.2, 95% (CI 1.7, 6.1) African American race, (hazard ratio 1.9; 95% CI 1.0, 3.3) and comorbid illnesses (hazard ratio 2.3; 95% CI 1.3-4.0) were associated with poor survival. Adverse outcomes of African American women with cervical cancer persist after adjustment for stage of disease and other factors and are particularly apparent in stage I-II disease. The role of comorbid illness is deserving of further study.

Black or African American↗
PubMed1999

Inequalities in health--future threats to equity.

In discussions about equity there is a tendency to focus on the inequalities in health status that appear to be the result of the material and immaterial consequences of a lower income, professional or social status in society. If we look at publications such as the Black Report in the UK or Ongelijke gezondheid in The Netherlands, we have to accept that despite our universal access to healthcare and the existence in many Western countries of social security measures that preclude 'real' poverty, considerable differences in health continue to exist between socioeconomic groups. This is corroborated for many other European countries in the research carried out by a concerted action led by Mackenbach. These inequalities in health have been referred to in many countries as inequities, meaning that society finds them unjust and expects them to be 'avoidable' or amenable to policy interventions. However, the research on the causal networks underlying the occurrence and the avoidability of inequalities in health remains sparse and intervention studies seem to focus on policy measures that can be evaluated, but which will most likely have a limited impact on the inequalities measured at the population level. Thus the research community leaves policymakers with very little evidence on which to build policy initiatives that are nevertheless requested by many governments. The third element, which needs to be addressed in this context, is the ominous inequality in access to healthcare. Since the debate on equity in health has rightly been initiated in the context of a broader, more intersectoral approach to health policy, very little attention has been paid, so far, to the issue of universal access to quality healthcare services. This is because in the second half of this century most Western (European) countries have created a healthcare system with universal access, financed either through taxation or through social insurance schemes. It is these financing systems that will be threatened in the years to come by the considerable demographic shift occasioned by the ageing of the post-war baby boom and the incentives for risk selection that have been introduced in many systems as part of the 'market' mechanisms. The benefits of these incentives have clearly been a greater efficiency at the patient or service level, but there is still the question of whether it will be a more efficient system also at a population level if equity considerations continue to require a system of universal access to all the healthcare technology that will become available in the coming years. The other side of the coin of risk solidarity is the delimitation of the collective responsibility, thus of a basic benefit package. It is important to realize that equity has been a fundamental underlying value that has led to the creation of the healthcare systems as we know them but which may have become so accepted that it is no longer carefully considered when looking at issues of rationing or health reforms.

Forecasting↗
PubMed2004

Ethnic politics, policy fragmentation, and dependent health care access in California.

One out of every six nonelderly Americans without health insurance lives in California. The problem of access to competent and dependable health care is especially problematic among the state's minority, and especially Hispanic, population. Because one-third of the country's Hispanics live in California, how this state deals with health access issues will affect the practice and progress toward universal care in the nation as a whole. Expanding health care access to California's dependent population will involve overcoming a number of well-known administrative and fiscal obstacles, including an underfunded, highly fragmented public health care system that has developed incrementally and incoherently over decades. However, a key to understanding the problem of access to health care in California involves a story of how ethnic conflict and partisan politics often conspire to deny or discourage access for eligible women and children.

Age Factors↗
PubMed1987

The determinants of hospital utilization under a universal public insurance program in Canada.

This study employs the individual as the unit of analysis to examine the relative importance of medical need, sociodemographic and economic factors in determining the use or non-use of hospital care and the volume of service consumed by those who experienced an episode of hospitalization during the study period. The data were derived from the Canada Health Survey which is a stratified, multistaged sample of the entire population. The results of the discriminant and weighted regression analyses indicate that the use or non-use of hospital care and the volume of service consumed are largely determined by medical need and not by income. The findings are supportive of the view that the national health insurance scheme in Canada has resulted in a more equitable distribution of hospital care.

Adolescent↗
PubMed1995

Interruptions in rheumatology subspecialty care among patients with rheumatoid arthritis.

OBJECTIVE: To identify factors associated with interruptions in care from rheumatologists among patients with rheumatoid arthritis (RA). METHODS: A person-time analysis was used to examine the association of medical insurance status, income, health status, treatment by a primary care physician, and presence of comorbid conditions with interruptions in rheumatology subspecialty care in a cohort of 161 patients with RA followed prospectively for up to 10 years. An interruption was defined as a 6-month period during which a patient was not treated by a rheumatologist. Each patient had at least one interruption. RESULTS: Interruptions in rheumatology care occurred more commonly during periods when patients reported no medical insurance coverage than when they had medical insurance coverage (relative risk, RR = 1.49; 95% confidence interval, CI = 1.05, 2.11). Interruptions in care were more common during intervals in which patients reported at least a 40% improvement in functional disability (RR = 1.30; 95% CI = 1.03, 1.63), but interruptions were not associated with either absolute or relative changes in pain or global arthritis status. Interruptions in rheumatology care also occurred more commonly during periods when patients reported seeing a primary care physician (RR = 2.07; 95% CI = 1.71, 2.50), and when they reported having a comorbid condition (RR = 1.37; 95% CI = 1.06, 1.77). Income was not associated with interruptions in care. CONCLUSION: Lack of medical insurance and short term improvements in functional disability are associated with interruptions in rheumatology care among patients with RA. Patients also appear to substitute primary care for care from rheumatologists. These associations suggest that potential strategies for enhancing continuity in rheumatology care might include the promotion of universal insurance coverage and the development of informational programs for patients.

Adult↗
PubMed1994

Student healthcare delivery and financing programs: adapting to healthcare reform.

College health professionals want to assure the unique healthcare and health education needs of college students will continue to be met under national and state healthcare reform. This may be an "all or nothing" proposition. Either colleges and universities will have exclusive control of healthcare delivery for the college student population or else college health will not be a major force in healthcare reform. If college health is to play a meaningful role in future government-controlled health insurance programs, it must first demonstrate that current health services and insurance financing programs meet minimum quality standards. This proposal calls for expanding existing federal laws to create qualified student health plans and integrating the college health model into a reform package based on employer-sponsored health insurance. The concept of qualified student health plans allows for a high degree of flexibility that can be integrated into the majority of state and federal healthcare reform proposals, including the plan proposed by President Clinton, that are not based on a single-payer system. Ultimately, the authors suggest, their proposed plan would eliminate the current situation, in which large numbers of college students are uninsured or underinsured.

Adolescent↗