Consumer participation in Health Maintenance Organizations

Recent health legislation, particularly the Health Maintenance Organization Act, appears to invite the participation of consumers in the governance of health care programs. This represents an opportunity for the community organizer to influence the role of the consumer in health care systems. This paper examines federal policy relating to consumer participation, discusses resulting issues and dilemmas, and offers suggestions for programs to strengthen consumer participation in HMOs.     

Guthrie house: a rural community organizing for wellness

This paper is interested in the issue of community participation and empowerment in health care provision and decision-making. In Canada, the present scope for public involvement in planning or managing the state's health and social services system is limited. This poses a particular problem for rural communities--places where the provision of health care services has historically been limited when compared to urban locations. These rural communities are now facing a double burden as public policy moves increasingly towards a retrenchment of the welfare state. This paper examines one rural community's response to this double burden. The village of Elgin in rural Ontario recently established Guthrie House, a community-based resource center for health and wellness services. Community participation in this case involved a level of control whereby local citizens together defined the health and social care services that they saw as best meeting the needs of their community. This form of community participation is considerably different from the forms of public involvement in the established medical system and represents a critical link to 'empowering' the local community as partners in health care. Through an examination of Guthrie House, the paper presents a review of some critical 'characteristics' which mark successful community self-help organizations and concludes with a discussion of the policy implications for greater community participation. It is argued that such community participation in health care is a policy option which government should be paying particular attention to in these times of fiscal constraint, increasing health care needs and increasing consumer dissatisfaction with government service provision mechanisms.     

Economic evaluation in primary health care: The case of Western Kenya community based health care project

This paper describes the methodology and presents preliminary results of an economic appraisal of a community based health care project in Kenya. Community health workers, trained for 12 weeks and deployed in two locations in Kenya's Western Province, act as first contact providers of basic health care and promoters of selected health, sanitation and nutrition practices. A Cost Benefit Analysis has been undertaken using the Willingness to Pay approach to compare the costs of the project and its benefits. The benefits are in the form of more easily accessible basic health care and are measured as consumer surplus accruing to the community. Gain in consumer surplus is consequent on the fall of average user costs and rise in utilisation of the project established points of first contact with primary health care.The argument for the economic viability of the project is validated by the large Net Present Value and Benefit Cost Ratio obtained for the whole of the project area and for the two locations separately. Although the evaluation technique used faces the problem of valuation of community time, aggregation of health care services at all points of first contact and the partial nature of cost benefit analysis evaluations, the results are strongly in favour of decentralisation of primary health care on similar lines in the rest of the country.     

Balancing hospital and community treatment: effectiveness of an extended-hours community mental health team in a semi-rural region of australia

Objective: To examine the effectiveness of the introduction of a community mental health team on consumer psychosocial outcomes. Design: Longitudinal panel design. Setting: District general hospital in a semi‐rural region of Australia. Numbers: Two matched groups (n = 37 in each group) Main outcome measure: These included: Brief Psychiatric Rating Scale (BPRS), Global Assessment Scale (GAS), Rosenberg Self‐Esteem, Life Skills Profile as well as self‐report. Results: The study found that the introduction of the new service resulted in few significant differences in consumer outcomes. Conclusions: The paper argues that because the state was the only specialist mental health service provider and it was unable to offer assertive community treatment, hospital care remained central. Evidence that a substantial proportion of consumers and carers preferred hospital to community care is placed against this background. The paper argues that in regions like these, where community‐based services are likely to remain underdeveloped, it may be best to maintain quality hospital services and to target community services more precisely on what is achievable rather than developing community services at the expense of hospital care. What is already known: Studies on the efficacy of assertive community treatment suggest that it can lead to improved consumer outcomes. However, these studies are usually in urban settings and involve experimental teams. In many rural and regional areas community treatment teams offer standard rather than assertive community care. It is therefore important to investigate the effectiveness of community treatment teams in rural and regional Australia. What this study adds: This study suggests that in rural and regional areas characterised by limited resources, it is too much to expect community treatment teams to have a measurable impact on consumer outcomes. In these settings hospital care remains at the heart of the service. This means that regions such as these need to focus their community services on what is achievable given the level of resources and social ecology. For example, they may need to consider offering either crisis intervention or rehabilitation services and to rely on innovations, such as telehealth or strategic alliances with other service providers to fill the gap.     

Rural women's perceptions of community prenatal care systems: an empowerment strategy

Rural U.S. women often experience many barriers to prenatal care involving health care provider shortages, distance to health care, and less health insurance coverage as compared to urban women. Fewer community planning and consumer resources as well as less transportation also often decrease opportunities for rural women to participate in community health planning and assessment. The purpose of this article is to describe social work strategies for empowering rural women in their assessment of community prenatal care systems. A case study of a rural demonstration project addressing prenatal care barriers is presented as well as implications for social work practice.     

Lack of national primary care organization partnerships with community groups to promote health care reform

Coalitions are necessary for successful political change. Few national primary care provider organizations partner with community, consumer, or labor organizations, and very few do so to promote policy on access to health care. Many of these provider organizations do work on health care access policy issues and do work in partnership with a variety of organizations, suggesting that community-provider partnerships may be a promising but overlooked strategy for promoting health care reform.     

Consumer-based boards of health centers: structural problems in achieving effective control

The fact that consumers have problems in utilizing their formal power as board members is usually attributed to individual deficiencies or cultural differences. The position argued here is that such views need to be questioned and amended. Thus, the ties between a health center and the larger health care system, the relations of consumers to their community environments, and the internal organization of health centers are examined as structural factors which limit the effectiveness of consumer board members.Despite the magnitude and durability of such factors, suggestions are made for increasing the effectiveness of consumer-based boards.     

Recovery Orientation in Hospital and Community Settings

There has been an increasing emphasis on community integration, consumer involvement, and recovery-focused treatment; but the extent to which these recovery-oriented principles have been adopted in state hospitals is unknown. This study surveyed 1,150 staff at three state hospitals and 230 staff at four community mental health centers on personal optimism, consumer optimism, and agency recovery orientation. Responses were obtained from 729 (63.4%) hospital staff and 181 (78.7%) community staff. Staff at state hospitals scored significantly lower on all three recovery measures even after controlling for background differences. Treatment setting may be an important factor in the dissemination of recovery-oriented care principles.     

Who speaks for the health consumer?

Although consumer-directed health care has become a fashionable concept in recent years, stories abound asking whether the so-called free market in health care can provide adequate access to quality health care at an affordable price. In spite of these concerns, consumer-directed health care continues as the face of legitimacy behind an industry-driven campaign to limit regulatory protections of the consumer in the market and encourage the growth of health insurance products that place spending options closer to the consumer, whether or not these options are available, affordable, or easily understood. Understanding whether this empowerment is real begins with first asking what it now means to be a health consumer. This commentary offers perspective on the dilemma faced by millions of Americans in navigating our health care system under the assumption that market-driven choices foster consumer empowerment in health care, and suggests approaches for expanding the true consumer voice.     

Planning community-oriented primary care in Israel

The concept of primary care in the Kupat Holim Health Insurance Institution encompasses all the stages of health: the promotion of health, personal preventive care, curative care, and rehabilitation in the community. Primary care is, thus, the foundation of this nationwide comprehensive health insurance and health care delivery system; Kupat Holim covers 3.2 million people, close to 80 percent of Israel's total population in 1983. Primary care clinics in the community are the main focus of care and have undergone changes in the types of health care providers and functions as population characteristics change. In this system, the planning process allows constant review of changing needs and demands and the introduction of new functions. The main approaches to planning primary care that are presented deal with team members and the division of work in the community clinic, manpower training at undergraduate and postgraduate levels, and the content of primary care. Current trends include the extension of services provided to the patient in his home as well as the clinic and greater emphasis on preventive care. The interrelationship between policy and planning for primary care is strengthened by the linkage between financer, provider, and consumer in Kupat Holim. The planning process must make optimal use of this linkage to guide those responsible for health policy in implementing effective change.     

Health care consumer reports: an evaluation of consumer perspectives

There has been a proliferation of health care consumer reports, also known as "consumer guides," "report cards," and "performance reports," which are designed to assist consumers in making more informed health care decisions. While there is evidence that providers use such reports to identify and make changes in practice, thus improving the quality of care, there is little empirical evidence on how consumer guides/report cards are used by consumers. This study fills that gap by surveying 925 patients as they wait for ambulatory care in several clinics in a midwestern city. Findings indicate that consumers are selective in their use of these reports and quickly identify those sections of the report of most interest to them. Report developers should take precautions to ensure such reports are viewed as credible sources of health care information.     

Health care consumer reports: an evaluation of employer perspectives

The proliferation of health care consumer reports (also known as "consumer guides," "report cards," and "performance reports") designed to assist consumers in making more informed health care decisions makes it vital to understand the perspective of employers who provide the vast majority of health insurance to the working population regarding the use of these reports. There is little empirical evidence on how consumer reports are used by employers to make health care purchasing decisions. This study fills that gap by surveying 154 businesses in Boone County, Missouri, regarding their evaluation of a consumer guide. The majority of employers surveyed indicate that the report will not have a direct effect on their health care purchasing decisions. However, they indicate that the reports are "positive and worthwhile" and their responses reflect a favorable view of the health care organization that developed and disseminated the report. Additionally, findings indicate that employers generally prefer consumer reports as a means to compare local health care institutions, rather than reviewing national averages to locate the same information. Report developers should take precautions to determine the intent of such reports, as they may not achieve the objective of changing employers' health care purchasing behavior.     

Holding health providers in developing countries accountable to consumers: a synthesis of relevant scholarship

Health care providers in low-income countries often treat consumers poorly. Many providers do not consider it their responsibility to listen carefully to consumer preferences, to facilitate access to care, to offer detailed information, or to treat patients with respect. A lack of provider accountability to health consumers may have adverse effects on the quality of health care they provide, and ultimately on health outcomes. This paper synthesizes relevant research on health provision in low-, middle- and high-income countries with the aim of identifying factors that shape health provider accountability to consumers, and discerning promising interventions to enhance responsiveness. Drawing on this scholarship, we develop a framework that classifies factors into two categories: those concerning the health system and those that pertain to social influences. Among the health systems factors that may shape provider accountability are oversight mechanisms, revenue sources, and the nature of competition in the health sector-all influences that may lead providers to be accountable to entities other than consumers, such as governments and donors. Among the social factors we explore are consumer power, especially information levels, and provider beliefs surrounding accountability. Evidence on factors and interventions shaping health provider accountability is thin. For this reason, it is not possible to draw firm conclusions on what works to enhance accountability. This being said, research does suggest four mechanisms that may improve provider responsiveness: 1. Creating official community participation mechanisms in the context of health service decentralization; 2. Enhancing the quality of health information that consumers receive; 3. Establishing community groups that empower consumers to take action; 4. Including non-governmental organizations in efforts to expand access to care. This synthesis reviews evidence on these and other interventions, and points to future research needs to build knowledge on how to enhance health provider accountability to consumers.     

Planning within multi-agency context

Current environmental conditions such as limited financial resources, cost containment, rising consumer expectation, and perhaps more stringent regulation of available public monies to support social services signal declining opportunities for survival of autonomous, freestanding community agencies and the development of newer collaborative forms of organization. In order to preserve maximum input of need information among their professional and community environments, community agencies will require improved procedures for processing multisource assesments. A methodology is presented for weighting and pooling of multisource need information geared for use by planners and decisionmakers of performance oriented multi-agency health care systems.     

Implementation of a Reverse Colocation Model: Lessons from Two Community Behavioral Health Agencies in Rural Pennsylvania

This qualitative study examined the implementation of a reverse colocation pilot program that sought to integrate medical care in two community behavioral health agencies. To accomplish this, each agency hired a registered nurse, provided training for its staff to function as wellness coaches, and implemented a web-based tool for tracking consumer outcomes. The findings from two rounds of stakeholder discussions and consumer focus groups suggested that agencies successfully trained their staffs in wellness coaching, integrated nurses into agency functions, developed integrated care planning processes, and increased awareness of wellness among staff and consumers. Similar to other complex interventions, the agencies experienced challenges including difficulty establishing new procedures and communication protocols, discomfort among staff in addressing physical health concerns, difficulty building collaborative relationships with primary care providers, and modest uptake of the web-based tool. The study offers insights into the practical aspects of integrating care and makes recommendations for future efforts.     

Consumer‐Oriented Health Care Reform Strategies: A Review of the Evidence on Managed Competition and Consumer‐Directed Health Insurance

Context: For many years, leading health care reform proposals have been based on market‐oriented strategies. In the 1990s, a number of reform proposals were built around the concept of “managed competition,” but more recently, “consumer‐directed health care” models have received attention. Although price‐conscious consumer demand plays a critical role in both the managed competition and consumer‐directed health care models, the two strategies are based on different visions of the health care marketplace and the best way to use market forces to achieve greater systemwide efficiencies. Methods: This article reviews the research literature that tests the main hypotheses concerning the two policy strategies. Findings: Numerous studies provide consistent evidence that consumers’ health plan choices are sensitive to out‐of‐pocket premiums. The elasticity of demand appears to vary with consumers’ health risk, with younger, healthier individuals being more price sensitive. This heterogeneity increases the potential for adverse selection. Biased risk selection also is a concern when the menu of health plan options includes consumer‐directed health plans. Several studies confirm that such plans tend to attract healthier enrollees. A smaller number of studies test the main hypothesis regarding consumer‐directed health plans, which is that they result in lower medical spending than do more generous plans. These studies find little support for this claim. Conclusions: The experiences of employers that have adopted key elements of managed competition are generally consistent with the key hypotheses underlying that strategy. Research in this area, however, has focused on only a narrow range of questions. Because consumer‐directed health care is such a recent phenomenon, research on this strategy is even more limited. Additional studies on both topics would be valuable.     

How to bring primary care back to patients

Reforming the health care system is too often thought of in the context of finding new financing methods to preserve the existing system. The nursing profession's agenda for health reform argues for a return to more basic values of consumer empowerment, access, primary care, prevention and self-care balanced with acute care. Family-care clinics based in schools, workplaces, and other community sites are an important element to this approach. The ever-worsening shortage of primary care providers can be solved by support of advanced practice nurses.     

The Role of Consumers in Health Care Decision Making

This paper focuses on the results of a survey of chief executive officers and consumer board members of Ontario hospitals and community health centres regarding the role of consumers in health care decision making. The opinions of both the chief executive officer and consumer board member respondents were elicited regarding the value of consumer input in decision making for the organizations studied. Results indicate that consumer board members feel that their input into organizational decision making is valued, chief executive officers value the input of consumers, and consumer involvement in decision making is increasing. More women are now involved on boards of the organizations studied, but visible minority representation remains low on hospital boards. Consumer board members feel that their decision making is influenced by providers on the board.