Hospital ownership and cost and quality of care: is there a dime's worth of difference?

Nonprofit organizations may predominate when output quality is difficult to monitor. Hospital care has this characteristic. This study compared program cost and quality of care for Medicare patients hospitalized following onset of four common conditions by hospital ownership. Payments on behalf of Medicare patients admitted to for-profit hospitals during the first 6 months following a health shock were higher than for those admitted to other hospitals. With quality measured in terms of survival, changes in functional and cognitive status, and living arrangements, we found no differences in outcomes by hospital ownership.     

Information and access to health care: is there a role for trust?

In many countries health policy has been guided by a focus on the supply side factors of access to health care, a lot of attention being directed at the availability of services. This paper concentrates on the demand side of access and investigates relational factors that may limit people's subjective choice sets or their freedom to utilise health services, emphasising that relations between service providers and individuals are based on an interchange of information. It develops an argument for health communication strategies based on an interactive exchange of information as a means of improving access and is intended as a conceptual basis for further debate. Trust assumes a key position within this transactional process of information exchange or communicative interaction. Information may enlarge individual choice sets and increase the freedom to use health care; it serves as a stimulus for access. The paper argues that trust plays a role in the utilisation of provided information. Trust emerges as a prerequisite of the effectiveness of information with regard to access. A discussion of the origins of trust shows that, while trust enhances communicative interaction, it is the process of communicative interaction that generates trust in the first place. Culturally diverse societies are often low-trust environments. The paper analyses the driving forces of trust and distrust in health care within these societies and delineates barriers for the individual and the community to the transfer of information. Specific characteristics of health communication turn out to be key determinants of access. In conclusion, principles for health policy on equity and information are derived which are rooted in a distinctive notion of democratic societal structure.     

‘Every single minute and hour is scrutinised’: neoliberalism and Australian private mental health care

There is little understanding of how recovery-oriented approaches fit within contemporary mental healthcare systems, which emphasise biomedical approaches to care, increased efficiency and cost-cutting. This article examines the established models of service delivery in a private, youth, mental health service and the impacts of the current system on staff. It explores whether the service is prepared or capable of adopting recovery-oriented approaches to care. Qualitative interviews were undertaken with staff and thematically analysed to understand the everyday practices on the unit. Data suggest that economic efficiencies and biomedical dominance largely shaped how health care was organised and delivered, which was perceived by staff as inflexible to change. Additionally, findings suggest that market-oriented principles associated with neoliberalism restricted the capacity of individuals to transform services in line with alternative models of care and lowered staff morale. These finding suggest that, while neoliberal ideologies and biomedical approaches remain dominant in organisations, there will be challenges to adopting alternative recovery-oriented models of care and promoting healthcare systems that understand mental health issues in broader socio-political contexts and can flexibly respond to the needs of service users.     

Delegation versus empowerment: what, how, and is there a difference?

Delegation--or empowerment--represents the essence of the supervisory task: getting things done through people. The terms are no different from each other; empowerment is simply delegation done properly. The process still fails for the same old reasons, and failure still causes the same kinds of problems. Delegation or empowerment involves authority; it is authority that is delegated, not responsibility, as commonly claimed. Under either name it is an imperfect process requiring subjective judgments and chronic risk. Although either label is acceptable--the few differences between delegation and empowerment are semantic only--the significant constant that must be present is a sense of task ownership on the part of the empowered employee.     

Social support and self-rated health revisited: is there a gender difference in later life?

This study examines the physical, behavioral, emotional and social determinants of self-rated health among Chinese older persons, and investigates if the effect of social support varies by gender. A representative sample of 1589 elderly community dwellers in Hong Kong were interviewed using a structured questionnaire. Gender difference in the effect of social support was tested by an interaction term, 'gender x social support', in a hierarchical regression analysis. The frequency of falling ill, the number of chronic illnesses, sleep quality, mobility and positive emotions were most important determinants of self-rated health. The effect of social support was completely redundant when these factors were taken into account. The interaction term 'gender x social support' was significant and indicated a stronger effect for women, but the effect size was negligible (adding only 0.3% to the explained variance). This suggests that the effect of social support by and large is gender free. These findings suggest a high degree of similarity in the determinants of self-rated health between Western and Chinese older populations.     

What drove private health insurance spending on mental health and substance abuse care, 1992-1999?

Trends in MH/SA treatment spending from 1992 to 1999 were examined using employer claims data from approximately 1.7 million covered lives in each year. The analysis finds that employer-based private insurance spending on MH/SA treatment did not keep pace with total employer-based private insurance spending or general price inflation. MH/SA spending dropped from 7.2 percent of total private insurance spending in 1992 to 5.1 percent in 1999. The decline was attributable to a dramatic decrease in inpatient MH/SA treatment--specifically, the probability of admissions and average length-of-stay.     

Entitlements to health care: Why is there a preference for private facilities among poorer residents of Chennai,India?

This paper examines access to health care by poorer residents in Chennai, India. It reveals constraining and enabling conditions for impoverished users seeking treatment. We explore patterns of health-seeking behaviour through the reasoning of residents themselves as well as stakeholders involved in providing care for these users. Particular attention is paid to the needy residents' preference for private health care providers despite the costs involved and that free public facilities are available. We address this issue by combining Sen's entitlement approach with Penchansky and Thomas' work on access to health care. Based on data gathered in a qualitative field-based research design including interviews with 14 residents and 58 stakeholders involved in caring for poor people, we argue that the availability of health care facilities within walking distance is a necessary but not sufficient precondition for satisfactory access. Rather, we demonstrate the influence of 'entitlements to health care' which allow poor households that are endowed with resources such as income, knowledge and social networks to realise access. The narratives we present reveal not only experiences of health care, but also feelings about its utilisation. The latter, we contend, are crucial in determining choice of health care facilities. This finding suggests that analyses of affordability and physical access to health care in less developed countries should include a focus on emotional dimensions of utilisation. In other words, there is a need to consider not only effective access to health care, but also affective dimensions of treatment for poorer citizens.     

Maternal health: does prenatal care make a difference?

This research attempts to close an important gap in health economics regarding the efficacy of prenatal care and policies designed to improve access to that care, such as Medicaid. We argue that a key beneficiary-- the mother-- has been left completely out of the analysis. If prenatal care significantly improves the health of the mother, then concluding that prenatal care is 'ineffective' or that the Medicaid expansions are a 'failure' is premature. This paper seeks to rectify the oversight by estimating the impact of prenatal care on maternal health and the associated cost savings. We first set up a joint maternal-infant health production framework that informs our empirical analysis. Using data from the National Maternal and Infant Health Survey, we estimate the effects of prenatal care on several different measures of maternal health such as body weight status and excessive hospitalizations. Our results suggest that receiving timely and adequate prenatal care may increase the probability of maintaining a healthy weight after the birth and, perhaps for blacks, of avoiding a lengthy hospitalization after the delivery. Given the costs to society of obesity and hospitalization, these are benefits worth exploring before making conclusions about the effectiveness of prenatal care-- and Medicaid.     

Public trust in health care: a performance indicator?

PURPOSE: If public trust in health care is to be used as a performance indicator for health care systems, its measurement has to be sensitive to changes in the health care system. For this purpose, this study has monitored public trust in health care in The Netherlands over an eight-year period, from 1997 to 2004. The study expected to find a decrease in public trust, with a low point in 2002. DESIGN/METHODOLOGY/APPROACH: Since 1997, public trust in health care was measured through postal questionnaires to the "health care consumer panel". This panel consists of approximately 1500 households and forms a representative sample of the Dutch population. FINDINGS: Trust in health care and trust in hospitals did not show any significant trend. Trust in medical specialists displayed an upward trend. Trust in future health care, trust in five out of six dimensions of health care and trust in general practitioners actually did show a decrease. However, only for trust in macro level policies and trust in professional expertise this trend continued. For the remaining trust objects, after 1999 or 2000, an upward trend set in. RESEARCH IMPLICATIONS/LIMITATIONS: No support was found for our overall assumption. Explanations for the fact that trust did increase after 1999 or 2000 are difficult to find. On the basis of these findings the study questions whether the measure of public trust is sensitive enough to provide information on the performance of the health care system. ORIGINALITY/VALUE: The aim of this research is to study public trust in health care on its abilities to be used as a performance indicator for health care systems.     

Economic evaluation in health care: is there a role for cost-benefit analysis?

This paper is devoted to the contingent valuation (CV) method and its possible area of application in health economics. With the CV method willingness to pay or willingness to accept is measured with survey methods. The CV method has been developed in environmental economics and is now the most commonly used method of measuring environmental benefits. The method has, however, seldom been used in economic evaluations of health care. The development of economic evaluation in the health care area is reviewed, and the existing methods (the human capital approach, cost-effectiveness analysis and cost-utility analysis) are compared with cost-benefit analysis using the CV method. It is shown that existing methods have several weak points, this makes the CV method an appealing alternative and/or complement to existing methods. From the empirical applications of the CV method in economic evaluations of health care it is evident that it is possible to achieve acceptable response rates. The methodological problems encountered when measuring willingness to pay with survey methods are shown to be similar to the problems encountered when measuring utility and quality of life in cost-utility analysis. Further studies with the CV method are necessary to further explore questions concerning the reliability and validity of the method.     

Behavior therapy and cognitive-behavioral therapy of obesity: is there a difference?

Current practice guidelines for management of overweight and obesity recommend a program of diet, exercise, and behavior therapy for all persons with a body mass index (calculated as kg/m(2)) of at least 30 (and those with body mass index > or =25 plus two weight-related comorbidities). In this tripartite treatment--often referred to as lifestyle modification--behavior therapy provides a structure that facilitates meeting goals for energy intake and expenditure. Although standard behavior therapy reliably induces mean weight losses of approximately 10% of initial weight, these reductions are difficult to maintain. Some authors argue that a shift in focus from behavior change to cognitive change will improve long-term results of lifestyle modification programs. This review describes, in detail, the standard behavioral treatment of obesity and compares it with an alternative treatment model that is based in a cognitive conceptualization of weight control. A review of the literature suggests that the differences between standard behavior therapy and cognitive-behavioral therapy of obesity lie more in their underlying theories than in their implementation. Empirical comparisons of the long-term effects of these approaches are needed.     

Partnerships with health and private voluntary organizations: what are the issues for health authorities and boards?

BACKGROUND: The number of voluntary organizations active in health care is considerable. There have been recent calls for a new closer working relationship between voluntary bodies and the National Health Service. The relationship between the two healthcare sectors needs to be efficient and harmonious in the interests of patient care; however, little is known about the nature and problems in the current relationship. The present study was undertaken to examine aspects of this relationship from the point of view of health board personnel. OBJECTIVE: To identify the practices and views of Scottish health board staff concerning the funding, role and responsibility of voluntary organizations in the health sector. METHODS: A qualitative study based on in-depth interviews with health board officials in all 15 Scottish health boards. RESULTS: Policies for financial and other relationships with the voluntary sector were often not explicit. The levels and method of funding voluntary health organizations varied across boards, as did the tenure of awards (from 1 to 3 years). Demand for funding far exceeded monies available. Some health boards ensured accountability through audited accounts, annual reports and site visits; however, others thought this inappropriate for small organizations. Health boards recognized the problems of the precariousness of funding and the administrative burden of the monitoring process and the ritual of applying for funding. CONCLUSION: The uncertainties of long-term funding may impede the contribution of voluntary organizations. There is a tension between the requirements of clinical governance and the ability of small voluntary organizations to provide the necessary documentation. One proposed solution, to reduce the number of organizations, might not appeal to the voluntary sector. Future initiatives could address the problem of tailoring funding and accounting to the resources of voluntary organizations.     

Unmet needs for specialty, dental, mental, and allied health care among children with special health care needs: are there racial/ethnic disparities?

We examined racial/ethnic disparities in unmet specialty, dental, mental, and allied health care needs among children with special health care needs (CSHCN) using data on 38,866 children in the National Survey of CSHCN. Compared with White CSHCN, Black CSHCN had significantly greater unmet specialty (9.6% vs. 6.7%), dental (16% vs. 8.7%), and mental (27% vs. 17%) health care needs. Hispanic CSHCN had greater unmet dental care needs (15.8% vs. 8.7%). Black females had greater unmet mental health care needs than other groups (41% vs. 13-20%). Most disparities disappeared after multivariate adjustment. Significant risk factors for unmet health care needs included uninsurance, having no personal doctor/nurse, poverty, and condition stability and severity. Eliminating unmet specialty, dental, and mental health care needs for all CSHCN, and especially minority CSHCN, may require greater efforts to reduce poverty and increase insurance coverage among CSHCN, better mental health care assessment of Black female CSHCN, and ensuring all CSHCN have a medical home.