加大保障力度,改善医疗服务公平性——新农合与医疗救助制度的衔接机制及成效分析

提高低收入人群医疗服务公平性和可及性,是中国医疗保障制度的重要目标,经过10多年的实践,该领域取得了举世瞩目的成绩,为广大人民群众所称道。世行贷款/英国赠款中国农村卫生发展项目(简称"卫十一项目"),利用资金、管理和人力优势,以新农合与医疗救助制度有效衔接、探索重大疾病救助制度为主题开展了一系列项目活动,部分地区在医疗救助对象确认、优化管理实现新农合与医疗救助制度"无缝衔接"、探索重大疾病救助制度尤其是增加筹资渠道建立"重大疾病救助基金"、强化配套监管等方面进行了一系列探索实践。结果表明,项目地区医疗救助对象服务利用情况明显改善,医疗保障水平大幅度提高,群众满意度明显提升。     

Connecting Our Resources: Louisiana's Approach to Community Health Network Development

ABSTRACT: Louisiana's rural community health systems are in crisis because of pressures fueled by the rising costs of health care, sustained poor health status, state budget shortfills and changes in priorities, and a sliding rural economy. The development of community health networks is providing new infrastructure and capacity for communities to reprioritize, formulate innovative partnerships, and leverage new resources. Successful elements of Louisiana's network development experience include community commitment to engage in study and action; the availability of capable and motivated technical assistance; an approach that involves open-engagement, community-driven decision-making; and data-driven problem definition, prioritization, and solutions. Louisiana's experiences illustrate the benefits of developing networks along with, or as a result of, a community health plan. When a community owns its health improvement plan, it is more likely to support the new network as a structure for implmentation. Broad-scale participation is also a principle of success. When social service agencies are included along with health agencies, more comprehensive strategies result, and they bring additional resources, resulting in more holistic solutions. The cases of 2 networks are presented as illustrations. One involves the facilitation of a community planning process for an existing network. The plan helped to expand the networks community connections and support and provided the content for a successful application for a Health Resources and Services Administration Community Access Program grant. In the second case, a new network was developed, and it leveraged federal finds from the federal Office of Rural Health Policy's Network Development Grant Program.     

Increasing access to care for the uninsured: considering the options in California counties

We interviewed California county health agency staff and administered a 58-county survey in 2002 and 2004 to inventory programs designed to improve access to care for the uninsured, and to assess county ability to meet the needs of California's uninsured during slow economic periods. Most counties have established means to connect people to existing public insurance programs and services have been expanded. Growth in new health care insurance programs for children and modest growth for adults are apparent. Counties pursue funding opportunities by a variety of strategies (e.g., leveraging of existing funding to secure new funds such as federal Healthy Community Access Program (HCAP) grants). While counties vary in their resources, political will, and barriers to care, they share a strong commitment to access to care. The implications of local efforts for state and federal policymaking are significant. In the absence of federal or state reform, county initiatives, particularly children's coverage expansions, may coalesce into state-level reform. Second, the state may move closer to access to health care for all as it recognizes the complementarity of county programs.     

Using Medicaid/SCHIP to insure working families: the Massachusetts experience

Massachusetts was the first State to implement a premium subsidy program for employer-sponsored health insurance, using both Medicaid and State Children's Health Insurance Program (SCHIP) funding. The Insurance Partnership (IP) provides subsidies directly to small employers, and the Premium Assistance Program provides subsidies to their low-income employees. Approximately 3,500 small firms currently participate, most of them offering health insurance coverage for the first time. Approximately 10,000 adults and children are covered through the program, the majority of whom had been uninsured prior to enrolling. Massachusetts' successful experience with premium subsidies offers important lessons for other States wishing to implement similar programs.     

Getting From Here to There: Evaluating West Virginia's Rural Nonemergency Medical Transportation Program

ABSTRACT: With funding from the 21st Century Challenge Fund, the West Virginia Rural Health Access Program created Transportation for Health, a demonstration project for rural nonemergency medical transportation. The project was implemented in 3 sites around the state, building on existing transportation systems—specifically, a multicounty transit authority, a joint senior center/transit system, and a senior services center. An eualuatim of the project was undertaken to answer 3 major questions: (1) Did the project reach the population of people who need transportation assistance? (2) Are users of the transportation project satisfied with the service? (3) Is the program sustainable? Preliminary results from survey data indicate that the answers to questions 1 and 2 are affirmative. A break‐even analysis of all 3 sites begins to identify programmatic and policy issues that challenge the likelihood of financial sustainability, including salary expenses, unreimbursed mileage, and reliance on Medicaid reimbursement.     

Implementation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grant Program: A Process Evaluation

The Community Health Promotion Grants Program, sponsored by the Henry J. Kaiser Family Foundation, represents a major health initiative that established 11 community health promotion projects. Successful implementation was characterized by several critical factors: (1) intervention activities; (2) community activation; (3) success in obtaining external funding; and (4) institutionalization. Analysis of the program was based on data from several sources: program reports, key informant surveys, and a community coalition survey. Results indicate that school-based programs focusing on adolescent health problems were the most successful in reaching the populations they were targeting. The majority of the programs were able to attract external funding, thereby adding to their initial resource base. The programs were less successful in generating health promotion activities and in achieving meaningful institutionalization in their communities.     

Improving Access to Capital for Health Care Infrastructure: The Experience of the Southern Rural Access Program's Revolving Loan Fund

ABSTRACT: Lack of access to affordable capital is a formidable barrier that compromises rural health care infrastructure development in poor rural areas. Commercial lending institutions are often limited in their ability to respond to those needs due to traditional lending criteria: creditworthiness, equity, management ability, experiences, and cash flow or profits. In the Southern Rural Access
Program, a development model more frequently used in other sectors has been successfully applied to health care to help clear these hurdles. This paper describes the 5 operational loan funds in Arkansas, Louisiana, Mississippi, South Carolina, and West Virginia receiving support from the Southern Rural Access Program. Two models of loan funds have evolved: those led by health agencies and those led by community development finance institutions whose mission is rural economic development. This paper outlines major distinctive features of these 2 approaches and describes major implementation challenges these loan funds fce. Key accomplishments are highlighted, including the ability to leverage additional resources from state, federal, philanthropic, and private sources through these funds. These loan fund programs provide models for other states interested in improving access to capital to help build the rural health care infrastructure while making health care more economically viable through integration with other community development initiatives.     

Recruitment of Rural Health Care Providers: A Regional Recruiter Strategy

ABSTRACT: Context: Access to care in rural areas is a major problem. Despite more than 20% of the US population residing in these areas, only 9% of physicians practice there. Extensive research has documented multiple issues that affect where physicians decide to locate and maintain practices. Creative strategies have been used to influence these recruitment and retention decisions. An emerging strategy, borne out of the Robert Wood Johnson Foundation's Southern Rural Access Program (SRAP), effectively uses a targeted regional approach to assist rural Communities and health care facilities in assessing health care needs and recruiting primary care providers. Purpose: This article examines the issues surrounding recruitment and retention of primary care providers to rural areas and describes the experiences of the regional recruitment strategy in several states and in particular in the Mississippi Delta region of Arkansas. Methods: A case study approach is used to examine the targeted regional recruiter strategy in the Mississippi Delta region of Arkansas. Findings: The regional recruiter strategy, which combines traditional recruitment efforts with community development activities, has been successful in recruiting health care providers to rural communities. The cost-effective strategy can be easily replicated in other rural states. Conclusions: Community factors affect provider decisions on practice locations. Addressing community factors in recruitment efforts through community development activities may increase their success.     

AIDS funding bills now before House-Senate conferees

The U.S. House and Senate are working to meet a September 30, 1997 deadline for completion of the Labor/Health and Human Services appropriations bill. The bill funds key AIDS programs such as the Centers for Disease Control and Prevention (CDC) and the Ryan White CARE Act. The House and Senate disagree on the level of funding for the Ryan White Care Act. Both the House and Senate agreed to spend more than the $1,036 billion proposed by President Clinton for AIDS drug assistance. The House approved $622 million for the CDC prevention program and the Senate approved $646.8. The Senate approved $217 million for AIDS Drug Assistance Programs (ADAP) spending. This year's bill contains one key amendment: a ban on Federal funding for needle-exchange programs. A Senate conference committee will determine whether or not the amendment remains. Neither the House nor Senate offered to increase funding for drug rehabilitation programs, however, each agreed to boost the budget for the Housing Opportunities for People with AIDS Program (HOPWA).     

Evaluation of the Florida coordinated school health program pilot schools project

ABSTRACT: The Florida Department of Education, with CDC funding, designed the Florida Coordinated School Health Program Pilot Schools Project (PSP) to encourage innovative approaches to promote coordinated school health programs (CSHP) in Florida schools. Each of eight pilot schools received $15,000 in project funding, three years of technical assistance including on-site and off-site assistance, a project office resource center, mailings of resource materials, needs assessment and evaluation assistance, and three PSP Summer Institutes. Project evaluators created a context evaluation, approaching each school independently as a “case study” to measure the school's progress in meeting goals established at baseline. Data were collected using the How Healthy is Your School? needs assessment instrument, a School Health Portfolio constructed by each school team, a Pilot Schools Project Team Member Survey instrument, midcourse team interviews, final team interviews, and performance indicator data obtained from pilot and control schools. The PSP posed two fundamental questions: “Can financial resources, professional training, and technical assistance enable individual schools to create and sustain a coordinated school health program?” and “What outcomes reasonably can one expect from a coordinated school health program, assuming programs receive adequate support over time?” First, activities at the eight schools confirmed that a coordinated school health programs can be established and sustained. Program strength and sustainability depend on long-term resources, qualified personnel, and administrative support. Second, though coordinated school health programs may improve school performance indicators, the PSP yielded insufficient evidence to support that belief. Future projects should include robust measurement and evaluation designs, thereby producing conclusive evidence about the influence of a coordinated school health program on such outcomes.     

Congress nears final action on fiscal 1996 funding

Congress and the Clinton administration are negotiating a continuing resolution to keep Federal AIDS programs funded and in operation through the remainder of the 1996 fiscal year. The House of Representatives approved a bill that includes $52 million in emergency appropriations for the AIDS Drug Assistance Program. The Senate is considering a bill that provides emergency funding if the administration cuts funding in another program. The House and the Senate differ on how funding for AIDS research will be allocated at the National Institutes of Health (NIH).     

Using lay health workers: Case study of a community-based prenatal intervention

This article reports on the design and implementation of a prenatal outreach and education intervention for low income, Hispanic women living in three migrant and seasonal farmworker communities in Arizona. The program included three major elements: a Spanish language prenatal curriculum; a group of mature Hispanic women recruited from the target communities and trained as Comienzo Sano (healthy beginning) Promotoras (health promoters), and the organization of a support network of local health professionals. The rationale for the demonstration is reviewed, and the structure of the intervention is described. Factors which facilitated and constrained implementation of the program are identified, and guidelines are provided for other health care providers and health educators interested in developing similar programs.Joel S. Meister is Director, Southwest Border Rural Health Research Center, Member, Arizona Cancer Center: Louise H. Warrick is Research Assistant Professor of Family Medicine; Jill Guernsey de Zapién is Program Coordinator of Community Health; Anita H. Wood is Research Assistant in Rural Health; all in the Department of Family and Community Medicine, College of Medicine, University of Arizona, Tucson, Arizona 85724.The authors gratefully acknowledge the support and continued interest of the A.L. Mailman Family Foundation, which provided the initial funding for this project, of the March of Dimes, which has made possible the project's continuation by providing support for the promotoras, and of the Arizona Department of Health Services, Maternal and Child Health Division, for providing funding for the ongoing administration of the project. The Yuma County Health Department has provided the staff to supervise the program. We also wish to recognize the contribution made by the project's first coordinator and supervisor, W. Marie Roberts, RNP, CNP. During the latter phases of the project's first year, E. Lee Rosenthal, a graduate student intern from the School of Public Health, University of California at Berkeley, provided invaluable assistance, and, more recently, anthropological field work was conducted by Tamar Gottfried, a medical student at the University of Arizona.     

Rural Affordable Care Act Outreach and Enrollment: What We Learned During the First Marketplace Open Enrollment Period

As part of the Patient Protection and Affordable Care Act (Affordable Care Act) of 2010, 2 new opportunities for health care coverage were established for many uninsured individuals beginning on January 1, 2014. The first opportunity was through Medicaid expansion where states had the opportunity to expand Medicaid coverage to individuals with household incomes up to 133% of the federal poverty level. The second opportunity was through the establishment of Health Insurance Marketplaces where individuals could purchase private health plans and potentially qualify for financial assistance in paying for their plans. The Office of Rural Health Policy (ORHP) provided supplemental grant awards to help stimulate Affordable Care Act outreach and education efforts in rural communities that were being served by the Rural Health Care Services Outreach (Outreach) Grant Program. As a result, Outreach grantees enrolled 9,300 rural Americans during the initial Open Enrollment period. Valuable outreach and enrollment lessons were learned from rural communities based on discussions with the Outreach grantees who received the supplemental funding. These lessons will help rural communities prepare for the next Open Enrollment period.     

Leaders' Experiences in Planning,Implementing, and Evaluating Complex Public Health Nutrition Interventions

ObjectiveTo explore California local health department leaders’ experiences planning, implementing, and evaluating nutrition promotion and obesity prevention programs for low-income families.DesignQualitative, cross-sectional study using semi-structured in-depth interviews and panel interviews conducted in 2015–2016.SettingCalifornia local health departments (LHDs) funded by the California Department of Public Health to implement Supplemental Nutrition Assistance Program–Education (SNAP-Ed).ParticipantsThe authors recruited SNAP-Ed leaders from all 58 California LHDs implementing SNAP-Ed. Leaders from 49 LHDs participated: 36 in hour-long, in-depth interviews and 13 in 1 of 3 90-minute group panel interviews.Phenomenon of InterestProcesses, facilitators, and barriers connected to delivering SNAP-Ed reported by leaders in planning, implementing, and evaluating local programs.AnalysisInterviews were transcribed, coded, and analyzed using Dedoose software.ResultsLeaders grappled with introducing, implementing, and integrating policy, systems, and environmental change interventions (PSEs). Information used to make planning decisions varied widely across LHDs. Partnership with nontraditional organizations was described as a resource- intensive, nonlinear process with recognized potential for benefit. Rural programs reported specific and different experiences compared with their urban counterparts.Conclusions and ImplicationsImplementing new, complex interventions to improve diet and activity environments and behaviors is both exciting and challenging for local leaders. They expressed a desire for additional resources and capacity building to facilitate success, particularly related to policy, systems, and environmental change programs. Attention to the specific needs of rural counties is needed.     

Medicaid Managed Behavioral Health in Rural Areas

As of 2000, 21 states had implemented Medicaid managed behavioral health (MMBH) programs for a significant portion of their rural population. It is not clear how MMBH programs may work in rural areas since they are primarily designed to control mental health utilization. In rural areas the challenge is often to enhance service delivery, not to reduce it. MMBH programs may also affect important features of rural delivery systems, including access to care and coordination of primary care and specialty mental health providers. This article describes the implementation of MMBH programs in rural areas based on an inventory of states implementing MMBH programs in rural counties conducted between June 1999 and June 2000. The experience of MMBH programs in rural areas is also described based on case studies conducted in six states. All 21 states included the general Medicaid population (Temporary Assistance for Needy Families); 17 states included special Medicaid populations (adults with serious and persistent mental illness and children with serious emotional disturbances). Slightly less than half the states integrated (carved-in) behavioral health with physical health services in serving the general Medicaid population; only one state integrated these services for the special Medicaid population. Access to mental health care in rural areas had generally not been restricted. MMBH had little impact on the linkage between primary care and mental health. Local Managed Behavioral Health Organizations, formed by public sector entities and providers, played an increasingly important role in the evolution of MMBH.     

The Rural Dental Health Program: The Long-Range Effect of a School-Based Enriched Dental Health Program on Children's Oral Health*

ABSTRACT: In November 1985, 406 children ages 15 to 19 were clinically examined, answered survey questions covering dental attitudes and behaviors, and were tested to determine their dental knowledge. This group included 56 percent of the 725 first through third graders who participated in the Rural Dental Health Program beginning in the fall of 1975. The Rural Dental Health Program was a study designed, in part, to measure the effect of a school-based dental health program on the oral health of children in a rural, underserved Pennsylvania county. Measures taken on 406 children, six and one-half years after the educational program ended were used to test for its possible long-term impact on oral health. Evidence obtained from analysis of covariance supports the hypothesis that dental health education had a positive effect on children's oral health.     

Meaningful Use of an Electronic Health Record in the New York City Jail System

Use of electronic health records (EHRs) is an important innovation for patients in jails and prisons. Efforts to incentivize health information technology, including the Medicaid EHR Incentive Program, are generally aimed at community providers; however, recent regulation changes allow participation of jail health providers. In the New York City jail system, the Department of Health and Mental Hygiene oversees care delivery and was able to participate in and earn incentives through the Medicaid EHR Incentive Program. Despite the challenges of this program and other health information innovations, participation by correctional health services can generate financial assistance and useful frameworks to guide these efforts. Policymakers will need to consider the specific challenges of implementing these programs in correctional settings.     

Enrolling and Retaining Uninsured and Underinsured Populations in Public Health Insurance Through a Service Integration Model in New York City

Innovative strategies to identify uninsured and underinsured populations are critical to successful enrollment and retention in public health insurance. The New York City Department of Health and Mental Hygiene’s Office of Health Insurance Services has partnered with the department’s Early Intervention Program to implement a Service Integration Model to enroll special needs children, aged 0 to 3 years, into public health insurance. This model uses data from program databases and staff from children’s programs to proactively identify uninsured and underinsured children and facilitate their enrollment into public health insurance. The model overcomes enrollment barriers by using consumer-friendly enrollment materials and one-on-one assistance, and shows the benefits of a comprehensive and collaborative approach to assisting families with enrollment into public health insurance.

KEY FINDINGS

■ Partnerships across government programs and agencies offer opportunities to enroll hard-to-reach populations into public health insurance.■ The Office of Health Insurance Services Service Integration Model has 3 key components allowing for comprehensive and continuous coverage for children with special health care needs: integration of program messages within the Early Intervention Program, data matching with child program data (Early Intervention data, Medicaid data), and incorporation of program staff (Office of Health Insurance Services child benefit advisors) to work directly with parents.■ The combination of access to child program data to identify children and one-on-one assistance to complete public health insurance applications has successfully assisted more than 5000 families in the New York City Early Intervention Program.IN NEW YORK STATE, AN estimated 12.7% of children have special health care needs.1 According to McPherson et al., children with special health care needs are defined as

those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.2 ^(p.138)

The 2005–2006 National Survey of Children With Special Health Care Needs found that 38% of families with special needs children had inadequate health insurance coverage.1 Data indicate that 16% of children with special health care needs did not receive any health care services in the past year; 45% of uninsured children with special health care needs needed at least 1 service not received, compared with 22% of publicly insured children, 19% of children with dual coverage (public and private), and 11% of privately insured children. Services not received included dental care, mental health care, therapies, and specialty care.In New York City, almost 40 000 children per year with a diagnosed developmental delay or disability receive services through the Early Intervention Program—a federal entitlement program for children aged 0 to 3 years. In New York City, the Early Intervention Program is administered through the New York City Department of Health and Mental Hygiene (DOHMH). Programs for children with special health care needs, such as the National Early Intervention Program, have been created to ensure that infants and children with developmental disabilities or delays receive needed services. To be eligible for services, children must be younger than 3 years and have a confirmed disability or established developmental delay, as defined by the state, in 1 or more of the following areas of development: physical, cognitive, communication, social-emotional, and adaptive.3 These children receive services free of charge for developmental disabilities or delays. The Early Intervention Program bills the child’s health insurance if the program is aware of the health insurance status of the child, including Medicaid and private or employer-based insurance. Parents are not responsible for paying for any services received through the Early Intervention Program. However, the Early Intervention Program does not cover services for routine medical care or specialized medical services (non-developmental disabilities or delays).The Office of Health Insurance Services at the New York City DOHMH was created to expand the city’s health insurance enrollment capacity, maximize client choice regarding health plan and provider selection, and promote health care use and preventive health behaviors. Since 2000, the Office of Health Insurance Services has been a New York State–approved facilitated enrollment lead agency in New York City. The New York State Department of Health–facilitated enrollment program provides funding, through a Request for Application process, to community-based organizations and local entities to provide eligibility screening and application assistance services to New York State residents applying for public health insurance.In 2009, the Office of Health Insurance Services assisted more than 10 000 applicants throughout New York City with a 97% enrollment success rate. The Office of Health Insurance Services maintains a presence at 9 New York City DOHMH centers and serves clients throughout the 5 boroughs, from all racial and ethnic backgrounds and with limited English proficiency.The challenge of ensuring that children with special health care needs receive comprehensive and continuous health insurance coverage requires innovative strategies. Although New York State has made considerable progress in reducing barriers to enrollment in public health insurance for adults and children, challenges remain. To maximize comprehensive insurance coverage for children with special health care needs, a Service Integration Model was formed between the Office of Health Insurance Services and the Early Intervention Program at the New York City DOHMH.

INCLUSION OF INFORMATION ON SERVICES PROVIDED BY THE OFFICE OF HEALTH INSURANCE SERVICES TO THE EARLY INTERVENTION PROGRAM

Information about services provided by Office of Health Insurance Services included in Early Intervention Program trainings and print materials“Early Intervention Welcome Letter” to parents“NYC Early Intervention Program Policy and Procedure Manual” for Early Intervention Program provider agenciesOffice of Health Insurance Services brochure and poster for Early Intervention Program provider agenciesLetter to Early Intervention Program providersData MatchingEarly Intervention Program dataNew York State Medicaid dataCensus dataIncorporation of Office of Health Insurance Services Staff to Work Directly With Parents of Children in Early Intervention ProgramOne-on-one in-person or telephone assistanceAvailable in multiple languagesAvailable at hours and locations convenient to parentsEducate families on public health insurance productsHelp them apply for coverage     

Rural and remote health research: Does the investment match the need?

Objective

To determine the percentage of research projects funded by the National Health and Medical Research Council in the period 2000–2014 that aimed specifically to deliver health benefits to Australians living in rural and remote areas and to estimate the proportion of total funding this represented in 2005–2014.

Design

This is a retrospective analysis of publicly available datasets.

Setting

National Health and Medical Research Council Rural and Remote Health Research 2000–2014.

Outcome measures

‘Australian Rural Health Research’ was defined as: research that focussed on rural or remote Australia; that related to the National Health and Medical Research Council's research categories other than Basic Science; and aimed specifically to improve the health of Australians living in rural and remote areas. Grants meeting the inclusion criteria were grouped according to the National Health and Medical Research Council's categories and potential benefit. Funding totals were aggregated and compared to the total funding and Indigenous funding for the period 2005–2014.

Results

Of the 16 651 National Health and Medical Research Council‐funded projects, 185 (1.1%) that commenced funding during the period 2000–2014 were defined as ‘Australian Rural Health Research’. The funding for Australian Rural Health Research increased from 1.0% of the total in 2005 to 2.4% in 2014. A summary of the funding according to the National Health and Medical Research Council's research categories and potential benefit is presented.

Conclusion

Addressing the health inequality experienced by rural and remote Australians is a stated aim of the Australian Government. While National Health and Medical Research Council funding for rural health research has increased over the past decade, at 2.4% by value, it appears very low given the extent of the health status and health service deficits faced by the 30% who live in rural Australia.     

Effectiveness of a grant program's efforts to promote synergy within its funded initiatives: perceptions of participants of the Southern Rural Access Program

Background  

Foundations and public agencies commonly fund focused initiatives for individual grantees. These discrete, stand-alone initiatives can risk failure by being carried out in isolation. Fostering synergy among grantees' initiatives is one strategy proposed for promoting the success and impact of grant programs. We evaluate an explicit strategy to build synergy within the Robert Wood Johnson Foundation's Southern Rural Access Program (SRAP), which awarded grants to collaboratives within eight southeastern U.S. states to strengthen basic health care services in targeted rural counties.