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The American nursing community has not wholeheartedly endorsed comprehensive health care system reform because of fear that nursing salaries, wage compression, direct reimbursement, and political power will be negatively affected in a single-payer system. These issues are evaluated under the Canadian health care system (a single-payer system). The source of payment does not appreciably affect these issues.
The problems of inequitable access to care, health care inflation, and reduced physician autonomy confront physicians and health care reformers with a dilemma. Piecemeal measures attempting to alleviate one problem in isolation simply exacerbate the others. A logical approach to addressing these problems together is a national health program based on a single payer of health services. By reducing administrative waste and emphasizing global budgetary strategies, the single-payer system could promote more efficient health care spending. While single-payer systems create more explicit political conflict over resource allocation, they also have demonstrated an ability to maintain quality of care and reduce bureaucratic intrusions into clinical practice.
Part 1 of this roundtable discussion [Geriatrics 1992; 47(Sept):34-48] examined the flaws in our current healthcare system and factors that are interfering with our nation's ability to achieve reforms. This month, the panelists discuss the benefits and drawbacks of the major healthcare reform proposals, including managed care, single-payer systems, and so-called "play or pay." The practical aspects of any redistribution of healthcare resources are considered as each panelist outlines a favored approach. The influence of special interests, such as the insurance industry, is also discussed.
Long-term care has been described as the "missing piece" in many healthcare reform proposals. Yet the cost of nursing home care often exceeds that of acute care, especially for the elderly with Alzheimer's disease. In this final installment of a three-part roundtable discussion, panelists discuss the options for providing long-term care, such as social insurance, a single-payer system, play or pay, or private insurance models. Alternatives to nursing home care, such as community service centers and home care, are discussed. The panelists conclude with an examination of how these proposed reforms might affect the practices of physicians and the U.S. economy.
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This article describes the software developed in the process of creating the Population Health Information System. The software can be applied to a range of administrative data and provides standardized data on the health status and health care use of populations by generating population-based rates of discrete events. The standardized approach permits construction of a comprehensive, comparative picture for residents of defined geographic regions. The addition of a user friendly graphic interface will permit regional planners to do their own data analyses and allow out-of-province researchers to adopt the system for their own uses.
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The authors introduce the Population Health Information System, its conceptual framework, and the data elements required to implement such a system in other jurisdictions. Among other innovations, the Population Health Information System distinguishes between indicators of health status (outcomes measures) and indicators of need for health care (socioeconomic measures of risk for poor health). The system also can be used to perform needs-based planning and challenge delivery patterns.
This article discusses the lessons learned from the experience of designing and using a population health information system and the policy implications of information generated. A useful system must include measures of the population's health status and socioeconomic risk when analyzing health care use. The strong gradient that can be demonstrated in service use across income groups where these indicators are included challenges policymakers and health care managers to rethink fundamental beliefs about the role of medical care. Given the size of health care expenditures in western economies, the author argues for redirecting some of these resources toward other means of improving the health of populations. Outcomes research should be expanded to assess the efficacy of non-medical and medical interventions. A population-based health information system can help identify opportunities for shifting expenditures toward meliorating the determinants of health, while monitoring the health care system to ensure that adverse effects do not occur.
The total use and cost of nursing homes in Manitoba, for the fiscal year 1991/1992 were analyzed using a population-based health information system. The use of hospital beds by elderly patients for stays of 60 days or more was also analyzed to see if long hospital stays were substituting for nursing home beds. More than one in ten Manitobans 75 years of age and older and one in three who were 85 years and older resided in a nursing home for some time during the study period. The nursing home sector is characterized by none of the marked differences previously found in hospital use across the southern regions of the province, whose residents are similar in health and need characteristics. A single entry system, combined with a population-based planning approach, appears to provide equitable access to care across the province.
A set of 102 population-based indicators was developed from multiple administrative data sources; these indicators were used to compare the health status of 1 million Manitoba residents across eight administrative regions for 1 year. Marked variations in health status were shown. Despite theoretically equal access to care in a universally insured system and high rates of utilization of hospital and physician services, residents of Manitoba's two northern, more remote regions scored most poorly--consistently and with statistical significance--across a variety of health status indicators. The strength of the various indicators was evaluated, and premature mortality emerged as the most useful "flagship" indicator for future analyses. Indicators that purport to be sensitive to how well a health care system is performing showed patterns similar to those derived from more classic measures (eg, mortality, low birth weight). Furthermore, the "system sensitive indicators" did not appear to be sufficiently independent of utilization biases.
Because the health status of a population does not usually respond immediately to interventions, whether social or medical, the ability to analyze change over time is important. Therefore, patterns of change and stability in health status and health care use of Manitoba residents during a 3-year period from 1990 to 1992 were analyzed using the Population-based Health Information System. This article presents summary findings and discusses methodological and policy issues arising from the analyses. A small but significant decrease in premature mortality (the primary health status indicator) was observed in most regions of the province, but two remote, northern regions, those whose residents scored at high socioeconomic risk, remained distinguished for their poor health status. These "poor health" regions also had the highest contact rates with primary caregivers, raising questions about the role of the health care system in improving the health of the population. A persistent increase in surgery was observed in several regions, led by increases in outpatient surgery over and above increases in the elderly population and beyond substitution for inpatient procedures. This trend (not obvious before these analyses) is important as hospitals move to expand their outpatient facilities in response to restraints on inpatient care.
A population-based approach was used to monitor impact of hospital bed closures in Winnipeg, Manitoba. Four years of administrative data were analyzed. Access to hospital services was not adversely affected: The reduction in beds resulted in increases in outpatient surgery and earlier discharges. In addition, access favored the admission of persons with more health care needs. Quality of care, as measured by mortality within 3 months of admission, readmission rates within 30 days of discharge, and increased contact with physicians within 30 days of discharge, did not change. The health status of the Winnipeg population, measured by premature mortality, did not change. However, health status and hospital use was found to be strongly related to socioeconomic status. In light of this gradient, the authors conclude that well designed and evaluated experiments that focus on the determinants of health, rather than on providing more health care services, could help identify ways of reducing hospital use.
To examine the relationship of a population's socioeconomic characteristics to its health status and use of health care services, a composite socioeconomic risk index was developed for the Population Health Information System. From a set of 23 socioeconomic indicators derived from public use census data, a summary index was formed from six indicators to generate profiles for the eight health regions of the province. Regional scores were plotted against an index of health status measures and against measures of health care utilization. Strong regional variations were found in all of these measures, and the socioeconomic risk index explained 87% to 92% of the differences in health status and acute hospitalizations. Moreover, regions with the worst health status on our indicators were found to be among the highest consumers of health services. The socioeconomic risk index appears to be a powerful tool in clarifying which benefits in improved health status might accrue from changing the underlying inequities in amenable socioeconomic risk factors, rather than simply increasing services to regions of low health status.
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The medical profession is going through a traumatic period characterized by loss of autonomy and subversion of doctor-patient relationships. To prepare for the future, physicians need a shared vision and cohesive strategies and goals. Physicians need to be informed and proactive.
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Several leading health policy staff of the AFL-CIO and major unions met with the Board of Physicians for a National Health Program (PNHP) in May 1990. They described the active discussions currently ongoing within the AFL-CIO Health Care Committee, which is composed of 14 international union presidents and sets AFL-CIO policy on health care issues. Some union presidents reportedly favored a single-payer, Canadian-style approach, while others apparently preferred a proposal modeled after the West German system, which preserves a major role for insurance companies. The PNHP Board was emphatic in its preference for the single-payer approach. Board member Dr. Vicente Navarro wrote the following letter to the union presidents on the AFL-CIO Health Care Committee detailing his critique of the West German approach.