Change in the U.S. health care system: effects on physician retirement and implications for health care managers

Several authors have postulated that managed care and other related changes in the U.S. health care system, perceived negatively by mature physicians, may contribute to their early retirement. This, in turn, may produce adverse effects on the availability of medical care. The authors investigate this and other related issues through analysis of a unique data set obtained from a survey of nearly four thousand physicians that elicited responses to numerous factors potentially relevant to their retirement decisions. The empirical analysis reveals that, while managed care is an important factor in the retirement decision of physicians, it does not necessarily lead to earlier retirement. Physicians rank other factors, related to financial and personal issues, as more important in their retirement decisions and the authors find that several of these factors significantly impact their expected retirement age. The results have several implications for health care managers relating to the retention or retirement of practicing physicians, successful planning, and seamless generation of income.     

Health care and secondary access to care inequalities

The role of health care inequalities in social inequalities in health should be reconsidered since the quality of health care varies according to the social status. Some of the health care inequalities are constructed by not taking account of health inequalities in the development of programs or recommendations of medical practice and thus ending up with management procedures that do not reduce inequalities to a minimum but even contribute to increasing them. Other health care inequalities are due to omission, linked to the operating inertia of a health care system that does not recognize these inequalities and has no plan to catch them up. To reverse this situation it seems necessary to act at the three levels of the health care system: to change the clinical paradigm at the micro level, tackle the organizations issues at the meso level, and pursue the reform of the entire health care system at the macro level.     

Assessment of appropriate child care at district level: how useful are mortality rates?

Where financial resources are sharply limited, routine process and health care output data could be used to assess district level child health care system appropriateness better than mortality data. The rural district health system serving Kasongo, Zaire was studied in reaching these conclusions. Appropriate systems were defined as affordable, acceptable, flexible, and effective. Each of these four characteristics should be met where a primary health care package of techniques and activities truly meets the needs of a given sociocultural setting. The authors do not accept mortality rates as the most suitable tools needed to determine if a system meets these criteria for appropriateness. Particular attention is called to the complexity of measuring system effectiveness. A decline in mortality rate may be an implicit system objective, but not the only goal of the program recognized by its users and workers. There is also a clear need for immediate care and relief from suffering in the community. Use of mortality rates as principle indicator of system effectiveness would not fully reflect positive steps in meeting the broader objectives of the system. Moreover, mortality rates lack sensitivity and specificity, lack relevance to indicators needed by decision-makers at the district level, and are otherwise costly and complex to accurately obtain. Instead of mortality rate determination and analysis, the authors call for a comparison of hospital admission rates between regions which do and do not have properly functioning rural health units accordingly. If health unit operations are conducted as effectively and efficiently as designed, hospital admission rates for illnesses readily treated at the rural level should decline over time. this information is readily and cheaply examined, and allows local decision makers to respond quickly and accurately to local needs.     

社会主义市场经济条件下医德建设探新

医德建设必须依靠医德教育，但仅靠医德教育是不行的。本文通过对医务人员从业情况的调查研究，提出还必须从改善医务人员的生存状态、理顺利益关系、加强院内制度建设和建立相应的社会机制等方面来加强医德建设。     

Quality indicators for cardiac care: national standards in a community context

OBJECTIVE: Public reporting of health data is well established in the United States and in the United Kingdom, and is assumed to promote better health care through informed choice by consumers. To be successful, reporting systems must have the support of physicians, but their opinions have been mixed. The purpose of this study was to explore with practising physicians the perceived usefulness of, and barriers to use of, quality indicators in the care of acute myocardial infarction and congestive heart failure, and the contexts in which these issues arise.METHODS: Six focus groups were conducted in small-, medium- and large-sized communities in two provinces in Canada. Subjects were family physicians, emergency physicians, internists and cardiologists. Data were analysed inductively.RESULTS: Our participants were generally supportive of the quality indicators, with concerns expressed regarding interpretation of data from measures created by "experts" but applied in the context of community hospitals and community-based practice. Content analysis disclosed that a majority of the indicators was acceptable; few were outright unacceptable. Inductive analysis revealed two contextual concerns: issues arising from the structure and organization of the health care system, such as equitable access to health care resources and discontinuity or fragmentation of the system, and patient-related issues, such as compliance with medications post-discharge and costs of medications.CONCLUSIONS: There is general support for this set of quality indicators, with the caveat that data should be carefully interpreted in the context of each community in which they are applied.     

The development of a quality information system: a case study of Mexico.

One of the primary obstacles in the implementation of continuous quality improvement (CQI) programmes in developing countries is the lack of timely and appropriate information for decentralized decision-making. The integrated quality information system (QIS) described herein demonstrates Mexico's unique effort to package four separate, yet mutually reinforcing, tools for the generation and use of quality-related information at all levels of the Mexican national health care system. The QIS is one element of the continuous quality improvement programme administered by the Secretariat of Health in Mexico. Mexico's QIS was designed to be flexible and capable of adapting to local needs, while at the same time allowing for the standardization of health care quality assurance indicators, and subsequent ability to measure and compare the quality performance of health facilities nationwide. The flexibility of the system extends to permit the optimal use of available data by health care managers at all levels of the health care system, as well as the generation of new information in important areas often neglected in more traditional information systems. Mexico's QIS consists of four integrated components: 1) a set of client and provider surveys, to assess specific issues in the quality of health services delivered; 2) client and provider national satisfaction surveys; 3) a sentinel health events strategy; and 4) a national Comparative Performance Evaluation System, for use by the Secretariate of Health for the quality assessment of state and provincial health care services (internal benchmarking). The QIS represents another step in Mexico's ongoing effort to use data for effective decision-making in the planning, monitoring and evaluation of services delivered by the national health care system. The design and application of Mexico's QIS provides a model for decentralized decision-making that could prove useful for developing countries, where the effective use of quality indicators is often limited. Further, the system could serve as a mechanism for motivating positive change in the way information is collected and used in the process of ensuring high quality health care service delivery.     

卫生服务体系整合的发展与实践

通过回顾国际和中国卫生服务体系整合的形式与发展实践,提出了卫生服务体系整合的内涵,阐述了整合的目的与意义以及政策含义。通过辽宁省等地卫生资源整合改革实践的分析,认为卫生服务体系整合不仅可以优化卫生资源配置和改善卫生服务公平性,而且是缓解＂看病贵、看病难＂问题的有效途径;同时,这种上下联动为特征的整合卫生服务体系变革,可以强化基层卫生服务体系建设,推进公立医院改革进程,改善卫生系统绩效。     

A framework for analysing migrant health policies in Europe

Evidence suggests migrants experience inequalities in health and access to health care. However, to date there has been little analysis of the policies employed to address these inequalities. This article develops a framework to compare migrant health policies, focusing on England, Italy, the Netherlands and Sweden. The first issue addressed in the framework is data collection. All four countries collect migrant health data, but many methodological limitations remain. The second issue is targeting of population groups. Countries typically focus either on first generation immigrants or on ethnic minorities, but not both, despite the often divergent needs of the two groups. Another issue is whether specific diseases should take priority in migrant health policy. While communicable diseases, sexual and reproductive health and mental health have been targeted, there may be a lack of attention paid to lifestyle related risk factors and preventive care. Fourthly, decisions about the mix of demand and supply-side interventions need to be made and evaluated. Finally, the challenge of implementation is discussed. Although migrant health policy has been elaborated in the four countries, implementation has not necessarily reflected this on the ground. These experiences signal important policy issues and options in the development of migrant health policies in Europe.     

Health Care Utilization by Canadian Women

HEALTH ISSUES: While women are reported to be more frequent users of health services in Canada, differences in women's and men's health care utilization have not been fully explored. To provide an overview on women's healthcare utilization, we selected two key issues that are important for public policy purposes: access to care and patterns of utilization. These issues are examined using primarily data from the 1998/99 National Population Health Survey, complemented by the 2000 Canadian Community Health Survey and the 2001 Health Service Access Survey. KEY FINDINGS: * Women are twice as likely as men to report a regular family physician, but that proportion is very low (15.8%).* Women report significantly shorter specialist wait times (20.9 days) than men (55.4 days) for mental health, while the reverse is true for asthma and other breathing conditions (10.8 for men, 78.8 for women).* Reported mean wait times are significantly lower for men than for women pertaining to overall diagnostic tests: for MRI, 70.3 days for women compared to 29.1 days for men. DATA GAPS AND RECOMMENDATIONS: * Measurement of possible system bias and its implication for equitable and quality healthcare for women requires larger provincial samples of the national surveys, along with a longitudinal design.* Either a national database on preventive services, or better alignment of provincial databases pertaining to health promotion and preventive services, is needed to facilitate data linkage with national surveys to undertake longitudinal studies that support gender based analyses.en are reported to be more frequent users of health services in Canada, differences in women's and men's health care utilization have not been fully explored. To provide an overview on women's healthcare utilization, we selected two key issues that are important for public policy purposes: access to care and patterns of utilization. These issues are examined using primarily data from the 1998/99 National Population Health Survey, complemented by the 2000 Canadian Community Health Survey and the 2001 Health Service Access Survey. KEY FINDINGS: * Women are twice as likely as men to report a regular family physician, but that proportion is very low (15.8%).* Women report significantly shorter specialist wait times (20.9 days) than men (55.4 days) for mental health, while the reverse is true for asthma and other breathing conditions (10.8 for men, 78.8 for women).* Reported mean wait times are significantly lower for men than for women pertaining to overall diagnostic tests: for MRI, 70.3 days for women compared to 29.1 days for men. DATA GAPS AND RECOMMENDATIONS: * Measurement of possible system bias and its implication for equitable and quality healthcare for women requires larger provincial samples of the national surveys, along with a longitudinal design.* Either a national database on preventive services, or better alignment of provincial databases pertaining to health promotion and preventive services, is needed to facilitate data linkage with national surveys to undertake longitudinal studies that support gender based analyses.     

The effect of information systems architecture on health care data quality

A rapidly increasing number of health care provider institutions is dealing with data architecture design issues that directly affect the quality of data within their heterogeneous information systems. These problems result from a failure to recognize that they are actually managing a loosely distributed yet integrated database among their many information system platforms. Understanding the issues surrounding data integration, the application available interface standards, and the tools available for implementation is critical to operating a successful distributed health care information systems environment today.     

Monitoring health reform: a report card approach

During the past several years, budget cuts have forced hospitals in several countries to change the way they deliver care. Gilson (Gilson, L. (1998). Discussion: In defence and pursuit of equity. Social Science & Medicine, 47(12), 1891-1896) has argued that, while health reforms are designed to improve efficiency, they have considerable potential to harm equity in the delivery of health care services. It is essential to monitor the impact of health reforms, not only to ensure the balance between equity and efficiency, but also to determine the effect of reforms on such things as access to care and the quality of care delivered. This paper proposes a framework for monitoring these and other indicators that may be affected by health care reform. Application of this framework is illustrated with data from Winnipeg, Manitoba, Canada. Despite the closure of almost 24% of the hospital beds in Winnipeg between 1992 and 1996, access to care and quality of care remained generally unchanged. Improvements in efficiency occurred without harming the equitable delivery of health care services. Given our increasing understanding of the weak links between health care and health, improving efficiency within the health care system may actually be a prerequisite for addressing equity issues in health.     

Burnout among workers in a pediatric health care system

Burnout among health care workers is recognized as an organizational risk contributing to absenteeism, presenteeism, excessive turnover, or illness, and may also manifest as decreased patient satisfaction. Pediatric health care may add stressors including worried parents of ill or dying children, child custody issues, child abuse, and workplace violence. The purpose of this study was to measure burnout among workers in a regional pediatric health care system and report whether burnout in a pediatric health care system is different from previously published data on human service workers. The Maslach Burnout Inventory-Human Services Survey (MBI-HSS) and the Copenhagen Burnout Inventory (CBI) were used to measure burnout. Pediatric health care workers expressed significantly less burnout as compared to published MBI-HSS scores and client-related CBI scores. Personal burnout CBI scores were not different, but work-related CBI scores were significantly higher than normative scores.     

Impact of enterprisewide data

The article provides an overview of initiatives relating to enterprisewide data collection. It discusses the meaning behind the term enterprisewide data and describes how health care entities are working to make the goal of enterprisewide data a reality by evaluating and employing such technologies as electronic data interchange, automated medical payment systems, and computerized patient records. It concludes with a discussion of data standardization in the health care industry and some issues that must be addressed by a health care entity as it strives to create an enterprisewide data system.     

Gesundheitsreform,rationale medizin und public health

The most important elements of the 1993 reform of the health care system in Germany are discussed as to whether they facilitate rational diagnostics and therapy oriented at scientific criteria. The result is that this is not a primary goal of the reform. It is rather targeted to cost control by administrative procedures and by instruments used in planned economies. Innovations in ambulatory care are hampered. Nevertheless, some useful elements for a more rational medical practice should be used. The instruments of public health are especially important for making the benefits of medical interventions and their comparison with risks and costs more transparent. Other important issues are quality control, evaluation research and the use of data that will be available for epidemiologic studies by new data processing procedures.     

ELFIN: a computer terminal providing health information and monitoring health concerns among general practice populations

Computer software (ELFIN) designed to provide health informationand to monitor patterns of use and unmet need has been developedfor the waiting area of health centres. ELFIN is linked viaa modem to a host computer at the University of Liverpool. Inthis way data on use and need can be gathered and used to modifythe information available at each site. Technical issues in the design of the system and the informationareas chosen for inclusion are considered, and the collectionand analysis of data from users, described. Experience withthe first four pilot installations, including examples of datagenerated, is reported. The role of a computer terminal in promoting health informationsensitive to local needs, is considered alongside more traditionalapproaches to health education in primary care.     

Public purchasers contracting external primary care providers in Central America for better responsiveness, efficiency of health care and public governance: issues and challenges

Several national health systems in Latin America initiated health reforms to counter widespread criticisms of low equity and efficiency. For public purchasing agencies, these reforms often consisted in contracting external providers for primary care provision. This paper intends to clarify both the complex and intertwined issues characterizing such contracting as well as health system performances within the context of four Central American countries. It results from a European Commission financed project lead between 2002 and 2005, involving participants from Costa Rica, Guatemala, Nicaragua, Salvador, United Kingdom, Netherlands and Belgium, whose aim was to promote exchanges between these participants. The findings presented in this paper are the results of a two stage process: (a) the design of an initial analytical framework, built upon findings from the literature, interlinking characteristics of contractual relation with health systems performances criteria and (b) the use of that framework in four case studies to identify cross-cutting issues. This paper reinforces two pivotal findings: (a) contracting requires not only technical, but also political choices and (b) it cannot be considered as a mechanical process. The unpredictability of its evolution requires a flexible and reactive approach. This should be better assimilated by national and international organizations involved in health services provision, so as to progressively come out of dogmatic approaches in deciding to initiate contractual relation with external providers for primary care provision.     

Ethics and financing: overview of the U.S. health care system

An overview of the financing decisions that occurred with the U.S. health system during the past five decades was presented in relation to the ethical issues which gave rise to and resulted from those financing decisions. This health system evolved from decision-making grounded in altruism through increasing the access and supply of resources to a position of caution and financial prudence. Recently the decision-making became grounded in pragmatism with the realization that attempts to provide everyone with all possible health services on demand cannot be achieved. Financing decision have resulted in a health care system based on acute care and sophisticated technology but with too many hospital beds and physicians, both geographically maldistributed. Since this acute care system has been successful in preventing premature deaths, our population now lives longer and develops chronic illnesses which require different interventions; the system has neglected to focus on prevention and adequate care for long-term diseases. It has created a growing population of uninsured who are unable to afford health care when illness occurs. Alternative strategies were discussed at three levels of the health system. At the overall system level, the following was proposed: consistent application of ethical principles most appropriate to allocation decisions and the creation of health policy which encompasses chronic care and disease prevention components. At the organizational level, health administrators and local community leaders must cooperatively address local health issues; medical education should focus on long-term care and disease prevention; and medical practice should reduce variation in treatment patterns. At the population level, healthy lifestyles must be encouraged in addition to the development of alternative reimbursement plans to maximize access to health care. Davis and Rowland (1990:298) have stated that our nation's image is strained" ... as a just and humane society when significant portions of the population endure avoidable pain, suffering and even death because of an inability to pay for health." These are turbulent times in health care but addressing the ethical issues at many levels may lead to successful alternatives and ultimately to a workable health strategy for this country.     

The news on health care funding: a study of reporting in the Australian print media for 1996

OBJECTIVES: To review the coverage of health care funding and resourcing issues in the quality printed media in Australia. METHODS: Content analysis of all articles in six major print publications with detailed commentary on four major issues. RESULTS: One thousand one hundred and fifty articles were published over 12 months, most in the front three pages. Coverage of many issues was prompted by an event, such as an election, government budget or policy announcement. Although issues were rarely personalized, the use of an individual authoritative spokesperson was, with some individuals becoming well recognised as experts. In general, these experts represented vested interest or lobby groups. The media discussion rarely dealt with the system as a whole, and generally approached a topic or issue in isolation from its inter-relationships with other issues. CONCLUSION: Health care funding stories are newsworthy but more for their political interest than as reflection of a social debate about values. Media reports rarely deal with the complexity of health policy issues, or challenge the assumptions and positions put forward.     

Medical tourism and its impact on the US health care system

The health care industry within the United States continues to face unprecedented increases in costs, along with the task of providing care to an estimated 46 million uninsured or underinsured patients. These patients, along with both insurers and employers, are seeking to reduce the costs of treatment through international outsourcing of medical and surgical care. Knows as medical tourism, this trend is on the rise, and the US health care system has not fully internalized the effects this will have on its economic structure and policies. The demand for low-cost health care services is driving patients to seek treatment on a globally competitive basis, while balancing important quality of care issues. In this article, we outline some of the issues facing legislators, health care policy makers, providers, and health service researchers regarding the impact of medical tourism on the US health care system.