Reforming health care for the elderly--the example of Vorarlberg.

Vorarlberg--Austria's most western province with a population of about 325,000--has always implemented forms of social policy in which the principles of subsidiarity and solidarity play an important role. This is reflected in the structure of the organizations traditionally providing social services as well as in the more recent programmes the government has developed for social policy. This paper discusses two cases in point: the private associations for home care (Krankenpflegerverb?nde)--which now exist in 65 Vorarlberg communities and cover 85% of the population in the province--offering nursing services at home to members or to persons who are willing to join the organization when they need care, and the new organizational model, called Gesunder Lebensraum Vorarlberg (GLV), which is successfully operating in a few pilot communities. GLV has spawned umbrella organizations, run by volunteers, and offering a variety of social services relevant to the elderly, for example visiting services or neighbourhood help in case of emergencies. The volunteers get organizational help from a profit-making firm financed by the government. The Vorarlberg models can be interpreted as a step towards demedicalization and deinstitutionalization of health care for the elderly. Nevertheless, they also show the problems that arise when professionals and volunteers must cooperate. The models may lead to savings for the governments involved, although details are still subject to future empirical investigations.     

Reforming the health care system: implications for health care marketers

Health care reform has become the dominant domestic policy issue in the United States. President Clinton, and the Democratic leaders in the House and Senate have all proposed legislation to reform the system. Regardless of the plan which is ultimately enacted, health care delivery will be radically changed. Health care marketers, given their perspective, have a unique opportunity to ensure their own institutions' success. Organizational, managerial, and marketing strategies can be employed to deal with the changes which will occur. Marketers can utilize personal strategies to remain proactive and successful during an era of health care reform. As outlined in this article, responding to the health care reform changes requires strategic urgency and action. However, the strategies proposed are practical regardless of the version of health care reform legislation which is ultimately enacted.     

Reforming health care in Hungary

Over the past two decades Hungary has initiated a series of social and economic reforms which have emphasized decentralization of control and the reintroduction of market mechanisms into the socialized economy. These reforms both reflect and reinforce a changing social structure, in particular the growing influence of upper class special interest groups. Market reforms are an expression of concurrent ideological shifts in Hungarian society. We examined the political significance of three recent proposals to reform health services against the backdrop of broader social and economic changes taking place. The first proposes a bureaucratic reorganization, the second, patient co-payments, and the third, a voucher system. The problems each proposal identifies, as well as the constituency each represents, reveal a trend toward consolidation of class structure in Hungary. Only one of these proposals has any potential to democratize the control and management of the heath care system. Moreover, despite a governmental push toward decentralization, two of these proposals would actually increase centralized bureaucratic control. Two of the reforms incorporate market logic into their arguments, an indication that the philosophical premises of capitalism are re-emerging as an important component of the Hungarian world-view. In Hungary, as well as in other countries, social analysis of proposed health care reforms can effectively illuminate the social and political dynamics of the larger society.     

Reforming health care in the Republic of Kazakstan

Kazakstan, as in other former communist countries, is currently replacing the soviet system of health care financing for a model based on medical insurance. The main initial purpose has been to generate additional revenue for a sector suffering considerably from reductions in state funding induced by economic transition. Two key issues need to be addressed if the new system is to produce genuine reform. First, the rural areas have suffered disproportionately from the changes. There is an urgent need to adapt the existing system so that adequate funding goes to redress this imbalance. Second, although the fund has concentrated on raising revenue, it will only induce real reform if it begins to exercise its role as an independent purchaser of health care. There is a need for the future roles of both health ministry and insurance fund to be clearly defined to ensure that wide access to medical care is preserved.     

Reforming health care in The Netherlands

Health reforms in The Netherlands have been introduced into a very different environment but with similar aims: efficient, effective, high quality care that addresses the needs of individual patients. Anne-Marie te Maarssen and Richard Janssen outline progress so far.     

Reforming health care: evidence from quantile regressions for counts

I consider the problem of estimating the effect of a health care reform on the frequency of individual doctor visits when the reform effect is potentially different in different parts of the outcome distribution. Quantile regression is a powerful method for studying such heterogeneous treatment effects. Only recently has this method been extended to situations where the dependent variable is a (non-negative integer) count. An analysis of a 1997 health care reform in Germany shows that lower quantiles, such as the first quartile, fell by substantially larger amounts than what would have been predicted based on Poisson or negative binomial models.     

Understanding informal payments for health care: the example of Bulgaria

INTRODUCTION: Throughout the 1990s, in response to funding deficits, out-of-pocket payment has grown as a share of total expenditure in countries in transition. A clear policy response to informal payments is, however, lacking. The current study explores informal payments in Bulgaria within a conceptual framework developed by triangulating information using a variety of methodologies. OBJECTIVE: To estimate the scale and determinants of informal payments in the health sector of Bulgaria and to identify who benefits, the characteristics and timing of payments, and the reasons for paying. DESIGN: Data were derived from a national representative survey of 1547 individuals complemented by in-depth interviews and focus groups with over 100 respondents, conducted in Bulgaria in 1997. Informal payments are defined as a monetary or in-kind transaction between a patient and a staff member for services that are officially free of charge in the state sector. RESULTS: Informal payments are relatively common in Bulgaria, especially if in the form of gifts. Informal cash payments are universal for operations and childbirth, clear-cut and life-threatening procedures, in hospitals or elite urban facilities or well-known physicians. Most gifts were given at the end of treatment and most cash payments-before or during treatment. Wealthier, better educated, younger respondents tend to pay more often, as a means of obtaining better-quality treatment in a de facto two-tier system. Since the transition, informal payments had become frequent, explicit, solicited by staff, increasingly in cash, and less affordable. Informal payments stem from the low income of staff, patients seeking better treatment; acute funding shortages; and from tradition. Attitudes to informal payments range from strongly negative (if solicited) to tolerant (if patient-initiated), depending on the circumstances. CONCLUSIONS: The study provides important new insights into the incidence and nature of informal payments in the health sector in Bulgaria. Payments were less than expected, very complex, organised in a chaotic, although adaptive, system, and relatively equitable. The timing of payment and the presence of compulsion is a key factor in distinguishing between informal payments given in gratitude or as a bribe, and the latter are seen as problematic, needing to be addressed. Paying informally appeared to be a product of socio-economic reality rather than culture and tradition. The study showed that the principle of comprehensive free coverage existing in Bulgaria until 1989 has been significantly eroded. Initiating a public debate on informal payments is important in a health care reform process that purports to increase accountability.     

Reforming health care financing in Bulgaria: the population perspective

Health financing reform in Bulgaria has been characterised by lack of political consensus on reform direction, economic shocks, and, since 1998, steps towards social insurance. As in other eastern European countries, the reform has been driven by an imperative to embrace new ideas modelled on systems elsewhere, but with little attention to whether these reflect popular values. This study explores underlying values, such as views on the role of the state and solidarity, attitudes to, and understanding of compulsory and voluntary insurance, and co-payments. The study identifies general principles (equity, transparency) considered important by the population and practical aspects of implementation of reform. Data were obtained from a representative survey (n=1547) and from 58 in-depth interviews and 6 focus groups with users and health professionals, conducted in 1997 before the actual reform of the health financing system in Bulgaria. A majority supports significant state involvement in health care financing, ranging from providing safety net for the poor, through co-subsidising or regulating the social insurance system, to providing state-financed universal free care (half of all respondents). Collectivist values in Bulgaria remain strong, with support for free access to services regardless of income, age, or health status and progressive funding. There is strong support (especially among the well off) for a social insurance system based on the principle of solidarity and accountability rather than the former tax-based model. The preferred health insurance fund was autonomous, state regulated, financing only health care, and offering optional membership. Voluntary insurance and, less so, co-payments were acceptable if limited to selected services and better off groups. In conclusion, a health financing system under public control that fits well with values and population preferences is likely to improve compliance and be more sustainable. Universal health insurance appears to attract most support, but a broader public debate involving less empowered people is needed to resolve misunderstandings and create realistic expectations.     

Reforming gendered health care: an assessment of change.

Health policy in the United States has changed dramatically over the past three decades, with the main concern shifting from expanded health care coverage to containment of health care costs. The current focus on providing cost-effective health services, reflected in the growth of managed care initiatives, has elevated concern about the quality of health care. The authors contend that quality of health care has always been the key focus in the women's health movement, which evolved in the late 1960s as the first significant challenge to modern medicine. In this article, they apply the analytic lens of gender to develop a fresh perspective on U.S. health care organizations and policies, examining the six broad demands of the feminist consumer model of health care, all of which hinge on the issue of quality care for women, to determine whether women's health needs are now being better addressed. The authors conclude that, despite some notable gains in the roles of women as consumers and providers of health care, many of the new health reforms have replicated and solidified the historical inequities in the health care system.     

Reforming American Indian/Alaska Native health care financing: the role of Medicaid

Chronic underfunding of American Indian and Alaska Native (AIAN) health care by the federal government has weakened the capacity of the Indian Health Service, tribal governments, and the urban Indian health delivery system to meet the health care needs of the AIAN population. I describe the current role of Medicaid in financing health care services for American Indians/Alaska Natives and offer 3 suggestions for reforming Medicaid financing of AIAN health care: (1) apply a 100% federal matching rate to the cost of Medicaid services furnished by urban Indian health programs; (2) apply a 100% federal matching rate to the cost of Medicaid services furnished by referral to AIAN patients of hospitals or clinics operated by the Indian Health Service, tribes, tribal organizations, or urban Indian health programs; and (3) exempt AIAN Medicaid beneficiaries who receive services from such hospitals or clinics from state reductions in Medicaid eligibility and benefits.     

Reforming Swedish health care in the 1990s: the emerging role of 'public firms'

A growing number of Swedish county councils have started to develop more flexible methods by which to produce and deliver health services. This paper explores the current status of this reform process both empirically and conceptually. Empirically, it draws upon data obtained by a 1990 questionnaire from all 26 county councils to chart the level of movement across the entire system. Conceptually, it distills from this reform activity a key element that provides an organizational basis for the future, namely the transformation of provider institutions into 'public firms'. The paper concludes that while the precise outcome may be hard to predict, the reform process itself is well underway.     

The influence of depressive mood on activities of daily living and health care utilization in the elderly--the MEMO study on the KORA platform Augsburg

Depression has a high prevalence in the general population and is often found as a comorbid condition in patient population with specific diseases. Little is known about health care resource use and depression impact on the daily life of community dwelling elderly. We assessed the prevalence of depression among 380 participants of the Memory and Morbidity in Augsburg Elderly Study, performed in 1997/98, a follow up project of the 1989/90 Augsburg MONICA survey S2, and evaluated the association with activities of daily living and health care utilisation. The prevalence of depressive symptoms severe enough to classify for manifest depression was 10.4 %. Women were twice as often affected. Participants with depression had a 3-fold higher probability for general practioner visits during the preceeding 4 weeks and were 3 to 4-fold more likely to have restrictions in their daily activities. In this study depression is associated with strong impairments in the daily life and more physician contacts of those affected.