Re-vitalizing public health care systems: a proposal for public competition in Sweden.

This article examines the health policy opportunities presented by building market-style incentives into the structure of a national public health system. The goal is to develop a service delivery model which can achieve simultaneously high levels of patient service, economic efficiency and social responsibility. The article develops its "public competition" approach implicitly, through a detailed case study of the Swedish health care system. The broad theory appears to hold promise for a variety of existing and emerging national public health systems in Europe.     

Determinants of integrated health care development: chains of care in Sweden

Local health care in Sweden is an emerging form of integrated care, linked together by chains of care. Experiences show, however, that the development of chains of care is making slow progress. In order to study the factors behind this development, an embedded multiple-case study design was chosen. The study compared six health authorities in Sweden, three with successful and three with unsuccessful chain of care development. Three major determinants of integrated health care development were identified: professional dedication, legitimacy and confidence. In more detail, space for prime movers and trust between participants were crucial success factors, while top-down approaches targeting at the same time a change of management systems were negative for the development of chains of care. Resistance from the body of physicians was a serious obstacle to such a development. Local health care depends on developed chains of care, but it seems that health care managers do not have the management systems necessary to run these clinical networks, mainly due to a lack of acceptance from the medical profession. This is an impossible situation in the long run, since the number of chains of care is likely to increase as a result of the emerging local health care.     

Working toward financial sustainability of integrated behavioral health services in a public health care system

The need, benefit, and desirability of behavioral health integration in primary care is generally accepted and has acquired widespread positive regard. However, in many health care settings the economics, business aspects, and financial sustainability of practice in integrated care settings remains an unsolved puzzle. Organizational administrators may be reluctant to expand behavioral health services without evidence that such programs offer clear financial benefits and financial sustainability. The tendency among mental health professionals is to consider positive clinical outcomes (e.g., reduced depression) as being globally valued indicators of program success. Although such outcomes may be highly valued by primary care providers and patients, administrative decision makers may require demonstration of more tangible financial outcomes. These differing views require program developers and evaluators to consider multiple outcome domains including clinical/psychological symptom reduction, potential cost benefit, and cost offset. The authors describe a process by which a pilot demonstration project is being implemented to demonstrate programmatic outcomes with a focus on the following: 1) clinician efficiency, 2) improved health outcomes, and 3) direct revenue generation associated with the inclusion of integrated primary care in a public health care system. The authors subsequently offer specific future directions and commentary regarding financial evaluation in each of these domains.     

Going down to the local: incorporating social organisation and political culture into assessments of decentralised health care

The social organisation and political culture of the society in which an organisation is embedded can have major effects on the way in which organisational policy is implemented and on how that organisation functions. Research on health sector reforms has paid scant attention to this aspect. If the claims made for decentralised management in the health sector are to be evaluated seriously, it is critical to develop concepts and methods to evaluate not only the formal organisation and the outputs of the health system, but also the aspects of local social organisation and political culture within which that local health system is embedded that may mediate their relationship. The paper explores three cases of district health systems in Northeast Brazil in order to identify aspects of local social organisation and political culture that appear to influence the implementation of the reforms and thereby potentially impact upon the quality of the care provided. The results of the study indicate the importance that aspects of local social organisation and political culture may exert on the operations of a decentralised health system. Key aspects identified are: the space for autonomy; the space for local voice in political life; personalized and institutionalised influences on autonomy and local voice; differences of involvement of health staff with the district; different spaces of acceptable practice and accountability. These factors are seen to moderate the intent of the health reforms at all stages in their implementation. Three possibilities are discussed for the nature of the interaction in terms of cause and effect between the formal organisation of the health system and its local context. Seeing this relationship as one of a dialogue offers some cautious optimism for the potential of the reform agenda. The paper closes with suggestions on how to take this line of research forward.     

Supplier inducement in a public health care system

The present paper examines whether supplier inducement exists for primary physicians' services in Norway. Our model assumes optimization behavior of the physician. The research design is adapted to the institutional setting of Norwegian primary physician services, where there is a fixed fee schedule. According to our model, the physician has three choices: to rational services, to supply an optimal amount of services, or to induce demand for services. The analyses revealed no indication of inducement with respect to physician-initiated visits. However, supplier inducement effects were found for provision of laboratory tests.     

Community assessment in a vertically integrated health care system

OBJECTIVES: In this report, the authors present a representative case of the implementation of community assessment and the subsequent application of findings by a large, vertically integrated health care system. METHODS: Geographic information systems technology was used to access and analyze secondary data for a geographically defined community. Primary data included a community survey and asset maps. RESULTS: In this case presentation, information has been collected on demographics, prevalent health problems, access to health care, citizens' perceptions, and community assets. The assessment has been used to plan services for a new health center and to engage community members in health promotion interventions. CONCLUSIONS: Geographically focused assessments help target specific community needs and promote community participation. This project provides a practical application for integrating aspects of medicine and public health.     

An integrated comprehensive occupational surveillance system for health care workers

BACKGROUND: Workers in the health care industry may be exposed to a variety of work-related stressors including infectious, chemical, and physical agents; ergonomic hazards; psychological hazards; and workplace violence. Many of these hazards lack surveillance systems to evaluate exposures and health outcomes. The development and implementation of a comprehensive surveillance system within the Duke University Health System (DUHS) that tracks occupational exposures and stressors as well as injuries and illnesses among a defined population of health care workers (HCWs) is presented. METHODS: Human resources job and work location data were used to define the DUHS population at risk. Outcomes and exposure data from existing occupational health and safety programs, health promotion programs, and employee health insurance claims, were linked with human resources data and de-identified to create the Duke Health and Safety Surveillance System (DHSSS). RESULTS: The surveillance system is described and four examples are presented demonstrating how the system has successfully been used to study consequences of work-related stress, hearing conservation program evaluation, risk factors for back pain and inflammation, and exposures to blood and body fluids (BBF). CONCLUSIONS: Utilization of existing data, often collected for other purposes, can be successfully integrated and used for occupational health surveillance monitoring of HCWs. Use of the DHSSS for etiologic studies, benchmarking, and intervention program evaluation are discussed.     

Values associated with public involvement in health and social care research: a narrative review

Background

Much has been written about public involvement (PI) in health and social care research, but underpinning values are rarely made explicit despite the potential for these to have significant influence on the practice and assessment of PI.

Objective

The narrative review reported here is part of a larger MRC‐funded study which is producing a framework and related guidance on assessing the impact of PI in health and social care research. The review aimed to identify and characterize the range of values associated with PI that are central elements of the framework.

Methods

We undertook a review and narrative synthesis of diverse literatures of PI in health and social care research, including twenty existing reviews and twenty‐four chapters in sixteen textbooks.

Results

Three overarching value systems were identified, each containing five value clusters. (i) A system concerned with ethical and/or political issues including value clusters associated with empowerment; change/action; accountability/transparency; rights; and ethics (normative values). (ii). A system concerned with the consequences of public involvement in research including value clusters associated with effectiveness; quality/relevance; validity/reliability; representativeness/objectivity/generalizability; and evidence (substantive values). (iii) A system concerned with the conduct of public involvement in including value clusters associated with Partnership/equality; respect/trust; openness and honesty; independence; and clarity (process values).

Conclusion

Our review identified three systems associated with PI in health and social care research focused on normative, substantive and process values. The findings suggest that research teams should consider and make explicit the values they attach to PI in research and discuss ways in which potential tensions may be managed in order to maximize the benefits of PI for researchers, lay experts and the research.     

Avoidable perinatal deaths and obstetric health care structure in the public health care system: a case study in a city in greater metropolitan Rio de Janeiro

This paper investigates the occurrence of potentially avoidable perinatal deaths by associating failures in obstetric care with structural deficiencies in four maternity hospital comprising the local health care system in a city in Greater Metropolitan Rio de Janeiro in 1994. Information sources were a questionnaire, interview, observation, and hospital records. A theoretical organizational model was applied in data analysis. The four maternity hospitals showed problems in the three groups of factors used in this study: physical infrastructure, services, and equipment; organizational and administrative characteristics; and professional organization. In two maternity hospitals, the delay in cesarean deliveries was explained by deficiencies in the group of factors that includes facilities, services, and equipment. Health care failures directly associated with the physician were explained by high percentages of negative predisposing factors (mainly in the two private hospital), skill-related problems (more clearly in the two public hospitals), and by absence of measures for redirecting practice.     

Economic incentives and diagnostic coding in a public health care system

We analysed the association between economic incentives and diagnostic coding practice in the Norwegian public health care system. Data included 3,180,578 hospital discharges in Norway covering the period 1999–2008. For reimbursement purposes, all discharges are grouped in diagnosis-related groups (DRGs). We examined pairs of DRGs where the addition of one or more specific diagnoses places the patient in a complicated rather than an uncomplicated group, yielding higher reimbursement. The economic incentive was measured as the potential gain in income by coding a patient as complicated, and we analysed the association between this gain and the share of complicated discharges within the DRG pairs. Using multilevel linear regression modelling, we estimated both differences between hospitals for each DRG pair and changes within hospitals for each DRG pair over time. Over the whole period, a one-DRG-point difference in price was associated with an increased share of complicated discharges of 14.2 (95 % confidence interval [CI] 11.2–17.2) percentage points. However, a one-DRG-point change in prices between years was only associated with a 0.4 (95 % CI \(-1.1\) to 1.8) percentage point change of discharges into the most complicated diagnostic category. Although there was a strong increase in complicated discharges over time, this was not as closely related to price changes as expected.     

An integrated program to train local health care providers to meet post-disaster mental health needs.

This paper describes a post-disaster mental health training program developed by the International Section of the Department of Psychiatry at Dalhousie University (Halifax, Canada) and delivered in Grenada after Hurricane Ivan struck the country in September 2004. This train-the-trainer program used an integrated community health model to help local health care providers develop the necessary skills for the identification and evidenced-based treatment of mental disorders occurring after a natural disaster. The approach also provided for ongoing, sustainable mental health care delivered in the community setting, as advocated by the World Health Organization and the Pan American Health Organization. This approach is in contrast to the largely ineffective and costly vertical whole-population psychosocial counseling activities that have often been used in the Caribbean following natural disasters.     

Restructuring health care: the social geography of public and private health care under the British Conservative Government

The 1979 election of the Conservative Government in Britain was not followed by the demolition of the welfare state. However, a variety of policy initiatives were introduced both to restructure National Health Service (NHS) expenditure, and to facilitate private provision of health services. This article considers the effects of such policies on the existing and future distribution of health care resources. A historical introduction discusses the main thrusts of conservative welfare policy. This is followed by an examination of the current financial situation of NHS authorities, at the regional and sub-regional scales; the political response to the 1983 manpower reductions is also considered. Events in the NHS are then contrasted with the deregulation of the private sector. The emergence and distribution of commercial acute hospitals are examined, as are other initiatives designed to transfer some of the financial burden of welfare provision away from the state. A concluding section compares and contrasts these developments and considers prospects for the future form of health care provision in Britain.     

Roles of local public health agencies within the state public health system.

OBJECTIVES: In this study we assessed the structure and function of local and district health agencies throughout the United States. We compared these findings with those from a previous national assessment done a decade earlier. METHODS: We surveyed the state health officers of all 50 states in the summer of 2001 in regard to the structures and functions of their state's local and district health agencies. RESULTS: Forty-seven states completed the survey for a 94 percent response rate. Forty-three percent have a regional or district structure in place. According to more than 80 percent of the respondents, local health departments serve all areas of their state. Local boards of health provide guidance and oversight in two thirds of the states. Most local health departments continue to perform a variety of traditional public health functions, as well as a variety of newly emerging responsibilities. Many local functions varied by geographic regions, population size, and organizational type. CONCLUSIONS: The study identified structural and functional changes in the local and district health agencies of state public health systems over the last decade. The stage is set for future work on the relationship between public health structure and function, and performance in the 21st century.     

公共卫生保障体系的建立与农村卫生改革

SARS的肆虐,使我们看到了建立公共卫生保障体系的迫切性;“三农”问题的日益突出,使农村卫生改革变得更加刻不容缓。把公共卫生保障体系的建立与农村卫生的改革有机地融合在一起,是一个新的思路,也是一个新的课题。本文试图对此作初步的探讨。     

Private sector health care organizations and essential public health services: potential effects on the practice of local public health.

This article focuses on the activities of eight private health care organizations undertaking public health and prevention activities. Few activities were motivated by or integrated into the business or operating strategy of the organizations and poor integration with the business strategy puts the long-term future of these activities in jeopardy. The lack of integrated activity can be attributed to: slow pace of managed care implementation; low penetrance of full-risk capitated reimbursement; and fragmented, competitive health care markets. Purchaser pressure, quality assurance requirements, community benefit standards, and government mandates are among the levers available to encourage such activities by the private sector.     

Managed care and the US health care system a social exchange perspective

Many countries are importing managed care and price competition from the US to improve the performance of their health care systems. However, relatively little is known about how power is organized and exercised in the US health care system to control costs, improve quality and achieve other objectives. To close this knowledge gap, we applied social exchange theory to examine the power relations between purchasers, managed care organizations, providers and patients in the US health care system at three interrelated levels: (1) exchanges between purchasers and managed care organizations (MCOs); (2) exchanges between MCOs and physicians; and (3) exchanges between physicians and patients. The theory and evidence indicated that imbalanced exchange, or dependence, at all levels prompts behavior to move the exchange toward power balance. Collective action is a common strategy at all levels for reducing dependence and therefore, increasing power in exchange relations. The theoretical and research implications of exchange theory for the comparative study of health care systems are discussed.     

Factors associated with health care utilization by the elderly in a public health care system

OBJECTIVE: The objective was to determine the factors associated with the use of health care services by the elderly residing in the community. METHODS: A cross-sectional study on 787 elderly people over 64 years of age from Albacete City (Castilla-La Mancha, Spain). The study was carried out by personal home interviews during a 9-month period. The dependent variables were: health care utilization, and characteristics. The independent variables were: self-reported health status, self-reported morbidity, medication use, functional status, mental health, lifestyle habits, social support, and sociodemographic status. RESULTS: The health care services were used by 74.5% in the last 3 months of which 59.4% were general practitioner visits, 18.4% were to nursing staff, and 16.5% were specialist visits. Laboratory tests were performed in 39.2% and radiological examinations in 24.9%. Emergency visits accounted for 2.4%, and hospitalization, 2.9%. Users of health care services among the elderly population were objectively more ill, although there was a group of healthy individuals who also visited the physician and a large group of elderly with considerable health problems who never saw their physician. In the multivariate analysis, general practitioner utilization was independently associated with a perceived unmet need for care (OR = 3.15), a negative self-reported health status (OR = 2.51), and a lower educational level (OR = 2.41). CONCLUSIONS: Subjective factors as perceived need for care, a negative self-reported health status and lower educational level are important factors that influence in the utilization of health care services.     

DRG-related prices applied in a public health care system--can Finland learn from Norway and Sweden?

In the early 1990s, DRG based hospital financing was introduced into some hospital districts in Finland. The 1993 state subsidy reform decentralising all hospital financing to municipalities, and the aim of improving productivity, were the driving forces for introducing DRG. This study addresses the pros and cons of DRG in hospital financing in the Finnish health care system and puts forward several solutions to avoid potential problems. We consider the objectives and optimal features of hospital financing systems in the context of the public health care system, where the public sector owns and finances hospitals. We analyse impacts of introducing different types of DRG based hospital financing systems, taking into account earlier experiences in countries such as Sweden and Norway, as well as Finnish system specific features. DRG could assist the Finnish municipalities to compare quality, costs and prices of services between hospitals, and related cost information might help them budget expenditure more accurately. System specific features mean that traditional uses of DRG in hospital pricing are not feasible in Finland. But some benefits of DRG could be exploited, for instance in the controlled contracts between municipalities and hospitals.