Reexamining the delivery system as part of Medicare reform

Medicare is more than a payment system. As the nation's largest public payer of health care, Medicare dictates the way health care is delivered to elderly and disabled persons. Health care and health outcomes cannot make substantial improvements until the delivery system is changed. Medicare reform must support a coordinated health care delivery system (in place of hospital-centered, fragmented care) and proactive chronic disease management (in place of episodic, reactive care). Consumers, government, community-based agencies, employers, health plans, and others need to develop a shared understanding of what outcomes we want to obtain, what delivery system reforms are required, and how financing can support those reforms.     

Use of maternity services by pregnant women in a small Nigerian community

Pregnancy is a time when women's health is placed at risk by a host of factors; however, professionals providing antenatal care can reduce that risk by monitoring women's health regularly and offering preventive services. Hygienic delivery services by a qualified attendant also help to reduce risks associated with childbearing. We explored these considerations in a rural Nigerian town by following 60 Yoruba women through pregnancy to childbirth. Although a functioning government maternity center in the community offered a full range of antenatal and delivery services, most of the women did not register for antenatal care until their sixth month of pregnancy or later, and 65% delivered at home. This behavior is explained in terms of (a) fees for delivery services, (b) level of income, (c) cultural beliefs, and (d) education. We conclude that provision of relatively accessible services does not guarantee their use and that other social and cultural considerations must be taken into account.     

Home birth and short-stay delivery. Lessons in health care financing for providers of health care for women

The current restructuring of the U.S. health care delivery system is driven primarily by economic forces. Although primary care providers may understand the roles of technology and advocacy in fostering fundamental change, they may not be familiar with the issues related to financing of health care and, thus, may not fully appreciate the extent to which economic factors influence the character of their professional lives and the services they provide. Analysis of the loss of the home birth option in the 1950s provides a method for understanding and influencing the factors driving health care restructuring today. In examining short-stay delivery in the 1990s, this article also addresses ways in which managed health care systems may improve or restrict women's access to a variety of primary care services.     

Dynein inner arm heavy chain identification in cAMP-activated flagella using class-specific polyclonal antibodies

In 1993, the Medical College of Pennsylvania (MCP), mindful of the rapidly changing environments of health care delivery, created three surveys to gather information from outside the school that would help the faculty plan how the curriculum and advising system could better prepare students and residents for the demands of twenty-first-century medicine. The first survey focused on the MCP seniors graduating that year and asked about their perceptions of their medical education and their specialty and residency choices. The second survey, directed to 40 medical residency program directors in family medicine, internal medicine, pediatrics, and surgery, sought to identify the characteristics of applicants that these directors valued when selecting entrants to their programs. The third survey, of 30 employers of physicians representing four practice environments (private practice, hospitals/other health systems, academic medical centers, and health maintenance organizations), sought information on hiring and recruitment practices and the skills, competencies, and attitudes these employers valued most when hiring recently graduated physicians. The responses showed several differences and/or misperceptions among the views held by the three groups surveyed and suggest that medical educators have not adapted as rapidly as have employers to changes in the health care environment. Academic health centers must broaden their missions and make changes in their own institutional cultures, both to maintain their own viability and to train physicians who have the balance between scientific and technical competency and essential personal characteristics (such as empathy) that the next century's practice will probably demand.     

Adolescent pregnancy prevention in managed care

Efforts by the US government, employers, and insurance industry to address women's health issues have neglected the problem of adolescent pregnancy. 30 million of the 37.4 million US adolescents have health insurance coverage and 20-40% of them are enrolled in managed care plans, either through private insurance or Medicaid. Each year, managed care insurance plans pay for 150,000-300,000 adolescent pregnancies, half of which end in a live birth. There are many gaps in current approaches to adolescent health care that can be filled by physicians and managed care organizations. Prevention of adolescent pregnancy would have immediate, cost-effective results. Managed care insurance, with its organizational structure, has the potential to address the traditional obstacles to adolescent reproductive health of lack of confidentiality and difficulties with access. An adolescent health care coordinator could be hired to track teen care within the insurance plan, educate staff, and arrange and enforce protocols. It would be instructive to see whether such case management could achieve reductions in repeat adolescent pregnancies by targeting follow-up activities to this risk group. Finally, managed care organizations should analyze teen pregnancy prevention programs in their own setting and select the most effective interventions on the basis of cost and medical outcome rather than political expediency.     

Restructuring health services delivery research: a community-based model

As management of acute illness shifts to the community from tertiary care centres, there is a need for community-based research into the delivery of health services. One author is the coordinator of a health services delivery research unit located in a community health centre as well as the director of research in the Department of Family Medicine at McMaster University. The other author is a member of the administration of the sponsoring institution. The research unit, created in 1994, has close links with the sponsoring hospital, a research centre and the faculty of health sciences at a nearby university. Its staff has grown from 2 to 12 members, mainly as a result of grant support. Its aim is to improve the delivery of community-based health services, and to this end it conducts research in collaboration with programs at the health centre, stakeholder groups, communities and institutions. Research projects have been undertaken in clinical guidelines, women's health, mature adults' health, medication use and new technologies for screening. As an example, concern about chlamydial infections in women in the community led to research into burden of illness, diagnosis, screening methods, test technologies, validation of guidelines and provider behaviors. In the future, funding will be a major concern. The authors contend that more funding from such agencies as the Medical Research Council of Canada should flow to community-based research.     

Women's oral health issues: an exploration of the literature

As interest in women's health issues grows, there is increasing concern that today's practice of medicine may not meet the health needs of women. A primary reason is the gender bias that has been inherent in medical education, research and clinical practice. The prevailing medical viewpoint has often been that the male body is considered to be the norm and that the female body exactly the same except for the reproductive function. This attitude has led to a lack of interest in researching gender differences and a consequent lack of knowledge of women's health issues. Fortunately, there is a movement for change. The Women's Health Interschool Curriculum Committee was formed in January 1992 to develop curricula concerning women's health and examine bias that may exist in existing curricula. The Canadian Women's Health Network has been growing across the country and there have been calls to create a new specialty in women's health. According to Angell, this proposal for a new specialty was provocatively debated in the Journal of Women's Health, which started publication in 1992. There is also a growing concern on how to conduct better research to address women's health needs. As more attention is paid to women's health issues, what will happen in the area of oral health? In health care, it would seem that the mouth has become completely separated from the rest of the body. Health conferences rarely have any oral health content at all. To correct this problem, there must be an increase in general awareness of the importance of oral health as it relates to the overall health of both women and men. Good oral health is more than just decay-free teeth. Oral health encompasses the teeth, the supporting periodontal structures, soft tissues of the mouth and oral pharynx area, temporomandibular joints and muscles of mastication. The mouth is a gateway to the body and will also reflect many systemic health problems, such as diabetes, leukemia and lupus. The second step would be the recognition that women may have different oral health needs and issues than men. The common view may be that teeth are gender free, but how can this be when teeth exist in a body, and that body is male or female? For many years, the primary acknowledged difference between men and women's oral health was pregnancy gingivitis. Like medicine, dentistry must re-examine the viewpoint that women's oral health differs from men's only as it is influenced by reproductive processes. There are many areas where women's oral health may differ from that of men. This paper will explore the literature for potential women's oral health issues in the areas of oral hygiene behaviours, esthetics, eating disorders, temporomandibular disorders, and hormonal influences on periodontal health.     

Employer-based innovations in behavioral health benefits.

Since the early 1980s, employers have been developing processes to more effectively manage their behavioral health care expenditures. Initially, employers focused their cost-containment efforts on inpatient admissions or substance abuse rehabilitations. Over time, employers realized that finding a solution with the greatest impact entailed a more comprehensive approach to the problem. They developed cost-containment strategies to the employer carve-out, an all-encompassing managed care approach focused on psychiatric and substance abuse conditions. The results of employer-initiated carve-outs have been dramatic. If passed, President Clinton's health care bill would have discouraged employer incentives for similar innovations, and would have ended this chapter in health care when the programs developed on behalf of employers achieved marked improvement in controlling health care costs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ensuring health care quality: a purchaser's perspective--a health care coalition

This paper explores how one health care purchasing coalition in Minnesota, the Buyers Health Care Action Group (BHCAG), has taken an active role in restructuring its local health care market. BHCAG started with the belief that the consumer should be the motivating force in health care delivery. Unfortunately, providing consumers with the information and incentives they need to make informed, effective health care decisions has triggered numerous problems. This paper examines groups of providers who network to form care systems, and explores the roles of consumers, employers, and health plans in the current market. It identifies specific methods for gathering data and distributing information to the consumer, and discusses the problems associated with attempting to implement quality improvement, as well as the questions that arise when the market does not support those improvements.     

Results of three courses of adriamycin, bleomycin, vindesine, and dacarbazine with subtotal nodal irradiation in 189 patients with nodal Hodgkin''s disease (stage I, II and IIIA)

This paper will explore the delivery of mental health nursing care within a neo-liberal model of mental health care delivery in New Zealand. Mental health nursing as a socially constructed activity occurs within a particular political context, which determines its role and function. This environment determines the nature of the nurse-patient relationship which is integral to the role of mental health nurses. Critical analysis of the New Zealand Government's neo-liberal health policies will be conducted to explore their effect on mental health care delivery and the nurse-patient relationship. Some of the ideologies and values maintained by current dominant discourses within nursing and the State are discussed. To establish therapeutic partnerships with service-users, mental health nurses are urged to critically analyse their practice and the context in which it occurs.     

What does postnatal care do for women's health?

In developed countries, postpartum care begins in the hospitals where most women give birth. In the UK, midwives continue postpartum care with home visits up to the 10th day, which can be extended to the 28th day if necessary. Then care is transferred to the health visitor who performs child health surveillance to age 5 years. Family physicians usually perform the 6-week postpartum maternal check-up. This routine, which was more appropriate in days when serious postpartum maternal infection was prevalent, seeks to promote and monitor maternal and infant health but its ability to meet these goals is questionable (this includes the value of a 6-week vaginal exam). Common and persistent maternal problems such as backache, perineal pain, urinary or bowel incontinence, sexual problems, hemorrhoids, depression, or exhaustion are not addressed by this routine. Research in Australia suggests that the timing as well as the content of maternal care should be reexamined. In this case/control study, no differences were found in health outcomes at 3- and 6-month follow-up among women who received their postpartum exam at 1 week from those who were examined at 6 weeks. It may be beneficial to base postpartum care on women's individual needs rather than on routine, but this must be investigated in order to devise proper guidelines and distinguish the roles of various health professionals. Reorganization of the delivery of postpartum care to improve its impact on women's health is a priority in the UK, and several research trials are in progress.     

Planning flexible learning to match the needs of consumers: a national survey

The injection of market forces into the National Health Service (NHS) has led to nurse education being viewed as a commodity which educational institutions supply and NHS employers purchase. Conscious of the costs of paying for courses within this new consumer culture, NHS trusts and other health service employers are increasingly looking for cost-effective flexible training to educate their workforce quickly and efficiently. Parallel to this is the accelerated demand for continuing professional development (CPD) brought about by the inception of the UKCC's Post-Registration Education and Practice Project (PREPP). Both registered and enrolled nurses are finding they need professional updating and skills and thus increased access to courses. The increased demand for education and training brought about by these changes cannot be met through traditional methods alone, requiring educational institutions to re-appraise their methods of delivery and introduce more flexible approaches to learning. There is every evidence that this is now the case with open learning, distance learning and flexible approaches to learning ever growing in popularity as providers of nurse education recognize the benefits such approaches offer. The emphasis is on meeting the diverse needs of the health care employers and individuals by providing education that is flexible, learner-centred and customer focused. This paper presents the findings of a national survey to ascertain how providers of flexible education plan educational programmes to meet the needs of their customers. Based on data collected from 120 educational institutions within the higher education, health and social care and private sectors, it highlights: the ways in which flexible learning programmes and courses are delivered; what aspects of flexibility are considered important when designing programmes to meet the needs of prospective customers; and what approaches are used to assess demand for flexible education. The study stresses the need for providers of flexible education to take into account the dual perspectives of those who have a stake in the flexibility of nurse education; NHS employers as funders of students and individual healthcare professionals themselves.     

Expression of carboxymethylcellulase on the surface of Escherichia coli using Pseudomonas syringae ice nucleation protein

Geriatric assessment is a means to collect health and functional data of an individual older person in a standard way. It has been developed on the secondary care level in the specialties of geriatric and rehabilitative medicine. Transferring geriatric assessment into primary care may improve health outcomes of older people, especially as it facilitates preventive diagnostic and therapeutic intervention. Yet, it is not possible to use geriatric assessment, as it is carried out in secondary care, under primary care conditions. Several adaptations will be necessary. An assessment instrument will have to be developed which takes epidemiological features of the older population into account. It will have to be tailored to the specific conditions of health delivery in primary care. Moreover, to achieve effectiveness and acceptance by health care providers and users, we see the necessity of creating an algorithmic assessment instrument which allows the use in different health situations with different levels of diagnostic detail. A primary care assessment for older people then would need to be evaluated according to its effectiveness of improving health outcomes. Potential negative effects on health beliefs may be worth considering. The final task lies in the implementation of a primary care assessment instrument into our existing health delivery format.     

Women and the 1993-1994 health reform debate: issues and questions

Provides a review of the major issues raised during the 1993-1994 national health reform debate, with emphasis on the implications of these issues for women's health. I begin with an overview of the current health care system and the access to care by women in it, based in part on their health characteristics. The need to reform the current system is noted, along with a discussion of the major issues and proposals debated during 1993-1994, the years of the 103d US Congress. Questions are raised that could enable women's health advocates and activist women health care consumers to assess the implications for women of various future health reform proposals.     

Women's use of complementary and alternative therapies in reproductive health care

Numerous studies have documented that health care consumers all over the world are spending money out of pocket for alternative therapies and that billions of dollars are spent in the United States alone. In this article, the use of complementary and alternative therapies by women health care consumers is discussed, particularly as this phenomenon relates to women's reproductive health in the United States. Women use conventional health care services more frequently than men; thus, it is not surprising that women account for approximately two thirds of health care appointments for complementary and alternative therapies. The traditional conceptual frameworks of herbal medicine, homeopathy, acupuncture, and acupressure are presented, and common clinical applications to women's reproductive care are discussed.     

Individuals with COBRA coverage, 1994-1995. Consolidated Omnibus Budget Reconciliation Act

COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) coverage can be considered advantageous for most workers. Although an employee can be required to pay 102 percent of the premium for COBRA coverage, workers can usually realize significant savings compared to purchasing the equivalent health insurance policy in the private market. Many employers consider COBRA to be a costly mandate for three reasons. First, premiums collected from COBRA beneficiaries typically do not cover the costs of the health care services rendered. Second, COBRA imposes an additional administrative cost on employers. Third, many employers view the penalties for noncompliance as excessively large. We examined data from the 1993 panel of the Survey of Income and Program Participation (SIPP) to gain a better understanding of the COBRA population. The COBRA population was found to be much older than the population of individuals with employment-based coverage through their current employer. COBRA beneficiaries were also more likely than individuals with coverage through a current employer to be male, married, white and to have a graduate school education. They were also less likely to be working and were more likely to have retirement income. Any attempt to expand COBRA coverage, either through subsidies or by allowing workers to choose from plans with lower premiums, will likely result in increased employer health care costs. Survey data indicate that the primary issue concerning COBRA is its impact on claims experience and administrative costs on active employees, employers and COBRA beneficiaries. If the cost issues are not addressed with future COBRA expansions, employers may consider various alternatives to reduce, shift or eliminate the impact of this increased cost.     

Delivering health and mental health care services to children in family foster care after welfare and health care reform

As the 20th century draws to a close, fundamental changes in the organization, financing, and delivery of health care and welfare services, principally directed at poor families, are likely to result in an increased number of children entering out-of-home care. These children typically have significant physical, mental health, and developmental problems. Whether the quality of health care services they receive will improve as a result of health care reform efforts and new approaches to service delivery remains to be seen. This article addresses some of the major changes wrought by welfare and health care reform and describes the essential features of a health care system that can meet the special needs of children in care.     

Appropriateness in health care delivery: definitions, measurement and policy implications

A major focus of the current health care debate is the notion that a substantial proportion of the health care delivered in Canada is inappropriate. There are two types of appropriateness: appropriateness of a service and appropriateness of the setting in which care is provided (i.e., inpatient v. outpatient or home care). Measuring both types objectively requires the comparison of observed patterns of care with explicit criteria for appropriate care. The few studies of appropriateness conducted in Canada have shown that inappropriate services are provided and inappropriate settings are used. Reducing inappropriate health care delivery could involve active strategies for the implementation of guidelines and better cooperation and coordination within the health care system. However, lower rates of health care delivery or even inappropriate health care will not necessarily translate into higher quality care or lower costs overall.     

Assessing quality of care via HEDIS 3.0. Is there a better way?

Patients, employers, and third-party payers are all calling for improved measures of health care quality. This has led to the development of "report cards," assessments that are many times applied not just to health plans but also to providers. One attempt at creating a standardized set of quality and effectiveness measures is the Health Plan Employer Data and Information Set (HEDIS). The HEDIS measures are based primarily on analyses of administrative data sets. Problems with HEDIS measures, including the probability that plans will use different data collection methods and a lack of risk adjustment, may result in incorrect conclusions about the quality of care delivered by various providers. An alternative method of standardized surveys is proposed that will overcome many of the limitations of the current HEDIS measures, provide outcome rather than process data, and provide data for developing interventions to improve quality.     

Benefits of comprehensive health care for improving health outcomes in women.

The American Psychological Association Health Care for the Whole Person Task Force was formulated to provide a rationale for integrating behavioral health services in primary care. Collectively, the task force called for a transformation of the biomedical system into one based on the biopsychosocial model. This article is a summary of the Women's Health Committee position paper that reviewed contextual factors in women's health, provided recommendations for clinical service action, and recommended an integrated primary health care system to address women's health needs. This article provides a vision of integrated care and a practical guide for psychology practitioners as they collaborate with other health care providers and health policy groups to improve health outcomes for women over the life course. (PsycINFO Database Record (c) 2010 APA, all rights reserved)