Complementary and alternative medicine: opportunities and challenges

Complementary and alternative medicine (CAM) has emerged as a significant sector within the health care industry as patient demand has increased, as the number and diversity of providers has grown, and as more providers deliver evidence-based CAM modalities to patients. The challenges confronting health care organizations that offer CAM are both similar and dissimilar to organizations that do not offer CAM. The unique challenges will be described in a way to provide academics and health care finance practitioners with a plan to address these challenges which range from lack of third-party coverage to lack of knowledge about financing CAM among patients and providers. Not only will the unique challenges be described but the distinctive opportunities to finance CAM will be highlighted. These opportunities will be discussed from both a financial perspective and innovation perspective with the aim of providing academics and health care financial practitioners with a rationale to offer CAM to patients and get compensated for providing these services.     

Can we make sense of multidisciplinary co‐operation in primary care by considering routines and rules?

Although it is widely acknowledged that the complex health problems of chronically ill and elderly persons require care provision across organisational and professional boundaries, achieving widespread multidisciplinary co-operation in primary care has proven problematic. We developed an explanation for this on the basis of the concepts of routines (patterns of behaviour) and rules, which form a relatively new yet promising perspective for studying co-operation in health-care. We used data about primary care providers situated in the Dutch region of Limburg, a region that, despite high numbers of chronically and elderly persons, has traditionally few healthcare centres and where multidisciplinary co-operation is limited. A qualitative study design was used, in which interviews and documents were the main data sources. Semi-structured interviews were conducted with providers from six primary care professions in the Dutch region of Limburg; relevant documents included co-operation agreements, annual reports and internal memos. To analyse the evidence, several data matrices were developed and all data were structured according to the main concepts under study, i.e. routines and rules. Although more research is needed, our study suggests that the emergence of more extensive multidisciplinary co-operation in primary care is hampered by the organisational rules and regulations prevailing in the sector. By emphasising individual care delivery rather than co-operation, these rules stimulate the perseverance of diversity between the routines by which providers perform their solo care delivery activities, rather than the creation of the amount of compatibility between those routines that is necessary for the current, rather limited shape of multidisciplinary co-operation to expand. Further research should attempt to validate this explanation by utilising a larger research population and systematically operationalising the rules existing in the legal and--more importantly--organisational environment of primary care.     

Using the deductible for patient channeling: did preferred providers gain patient volume?

In market-based health care systems, channeling patients to designated preferred providers can increase payer’s bargaining clout, other things being equal. In the unique setting of the new Dutch health care system with regulated competition, this paper evaluates the impact of a 1-year natural experiment with patient channeling on providers’ market shares. In 2009 a large regional Dutch health insurer designated preferred providers for two different procedures (cataract surgery and varicose veins treatment) and gave its enrollees a positive financial incentive for choosing them. That is, patients were exempted from paying their deductible when they went to a preferred provider. Using claims data over the period 2007–2009, we apply a difference-in-difference approach to study the impact of this channeling strategy on the allocation of patients across individual providers. Our estimation results show that, in the year of the experiment, preferred providers of varicose veins treatment on average experienced a significant increase in patient volume relative to non-preferred providers. However, for cataract surgery no significant effect is found. Possible explanations for the observed difference between both procedures may be the insurer’s selection of preferred providers and the design of the channeling incentive resulting in different expected financial benefits for both patient groups.     

‘Just doing the best we can’: health care providers’ perceptions of barriers to providing care to Marshallese patients in Arkansas

ABSTRACT

Introduction: Marshallese migrating to the United States encounter challenges in accessing health care. Previous literature has investigated Marshallese participants’ perceptions of the barriers they face in accessing health care. For this study, health care providers managing the care of Marshallese patients were interviewed to understand the providers’ perception of barriers that their Marshallese patients encounter.

Methods: A qualitative research design was utilized to explore health care providers’ perceptions of and experiences with the barriers faced by their Marshallese patients when accessing the US health care system.

Results: The primary barriers identified were: (1) economic barriers; (2) communication challenges; (3) difficulty understanding and navigating the western health care system; and (4) structural and system barriers.

Conclusion: This study provides insight on the barriers Marshallese patients face in accessing health care as well as the barriers providers face in delivering care to Marshallese patients. A better understanding of these barriers can help health care providers and educators to begin initiating improvements in the delivery of care to Marshallese patients.     

Challenges to Effective Primary Care-Specialty Communication and Coordination in the Mental Health Referral and Care Process for Publicly Insured Children

Publicly insured children needing referral to mental health (MH) services often do not access or receive services. The objective of this study was to identify gaps in communication and coordination between primary care providers (PCPs) and MH providers during the MH referral and care process for publicly insured children. Thirteen semi-structured interviews were conducted with 10 PCPs and staff from a federally qualified health center (FQHC) and 6 MH providers and staff from two local MH clinics. Interview participants identified multiple gaps in communication throughout the care process and different phases as priorities for improvement. PCPs described primary care-MH communication challenges during early phases, while MH providers described coordination challenges in transferring patients back to primary care for ongoing mental health management. Strategies are needed to improve primary care-specialty MH communication and coordination throughout all phases of the referral and care process, particularly at initial referral and transfer back to primary care.     

Intercultural Communication Between Patients and Health Care Providers: An Exploration of Intercultural Communication Effectiveness,Cultural Sensitivity,Stress, and Anxiety

Cultural diversity is becoming increasingly more important in the workplace. This is particularly true in health care organizations facing demographic shifts in the patients served and their families. This study serves to aid the development of intercultural communication training programs for health care providers by examining how cultural sensitivity and effective intercultural communication, besides helping patients, personally benefit health care providers by reducing their stress. Effective intercultural communication and cultural sensitivity were found to be related. Health care providers' levels of intercultural anxiety also were found to correlate with effective intercultural communication.     

Issues with medication supply and management in a rural community in Queensland

Objective: To identify the key issues reported by rural health‐care providers in their provision of medication supply and related cognitive services, and in order to advise health workforce and role development and thus improve the quality use of medicines in rural communities. Design: Exploratory semistructured interview research. Setting: A rural community comprising four towns in a rural health service district in Queensland, Australia. Participants: Forty‐nine health‐care providers (medical practitioners, pharmacists, nurses and others) with medication‐related roles who serviced the study community, identified through databases and local contacts. Main outcome measures: Medication‐related roles undertaken by the health‐care providers, focusing on medication supply and cognitive services; challenges in undertaking these roles. Results: Medical and nursing providers reported challenges in ensuring continuity in supply of medications due to their existing medical workload demands. Local pharmacists were largely involved in medication supply, with limited capacity for extended cognitive roles. Participants identified a lack of support for their medication roles and the potential value of clinically focused pharmacists in medication management services. Conclusions: Medication supply may become more efficient with extended roles for certain health‐care providers. The need for cognitive medication management services suggests potential for clinical pharmacists' role development in rural areas.     

The interpersonal experience of health care through the eyes of patients with diabetes

Patients with chronic illness often face challenges navigating the US health care system because of the system's lack of coordination and continuity. Patients with more difficulty relying on others and with reluctance in engaging frequently or in-depth with providers, face even greater challenges obtaining optimal health care in this system. Using a self-report measure of attachment style, we selected patients with varying degrees of comfort and trust in relationships. We conducted qualitative semi-structured interviews with a purposive sample of 27 patients with type 2 diabetes attending the University of Washington Diabetes Care Center in Seattle to explore issues of trust and collaboration in the health care setting. We used a constant comparative approach in which contemporaneous data collection and analysis took place. A subset of patients with fearful and dismissing attachment style reported having low levels of trust and an inability to collaborate with others of longstanding duration. Many aspects of the current health care system, such as its rushed, impersonal nature and a perceived "wall" between providers and patients were frustrating for most study patients. Patients with fearful and dismissing attachment style reported that these aspects of the health care system often interfered with their ability to partner with providers but also reported that patient-centered attitudes and behaviors by providers could improve their trust and ability to engage in the health care system. Implications of using a conceptual model of attachment theory to improve patient-centered care and customer service are discussed.     

The interpersonal experience of health care through the eyes of patients with diabetes

Patients with chronic illness often face challenges navigating the US health care system because of the system's lack of coordination and continuity. Patients with more difficulty relying on others and with reluctance in engaging frequently or in-depth with providers, face even greater challenges obtaining optimal health care in this system. Using a self-report measure of attachment style, we selected patients with varying degrees of comfort and trust in relationships. We conducted qualitative semi-structured interviews with a purposive sample of 27 patients with type 2 diabetes attending the University of Washington Diabetes Care Center in Seattle to explore issues of trust and collaboration in the health care setting. We used a constant comparative approach in which contemporaneous data collection and analysis took place. A subset of patients with fearful and dismissing attachment style reported having low levels of trust and an inability to collaborate with others of longstanding duration. Many aspects of the current health care system, such as its rushed, impersonal nature and a perceived “wall” between providers and patients were frustrating for most study patients. Patients with fearful and dismissing attachment style reported that these aspects of the health care system often interfered with their ability to partner with providers but also reported that patient-centered attitudes and behaviors by providers could improve their trust and ability to engage in the health care system. Implications of using a conceptual model of attachment theory to improve patient-centered care and customer service are discussed.     

Antitrust policy in the Dutch health care system and the relevance of EEC competition policy and U.S. antitrust practice

Dutch health care policy is undergoing a radical shift from a planning-oriented towards a market-oriented approach. A fundamental restructuring of the health care financing system should bring about workable competition among providers and among health insurers. As the result of both government regulation and anticompetitive self-regulation strong cartels and dominant positions are deeply rooted in the present Dutch health care system. In order to be successful structural reforms should be supported by an effective antitrust policy. However, present Dutch antitrust policy is too lenient to fulfil this necessary condition. EEC competition policy is far more stringent, but for several reasons its relevance will be limited. For an effective enforcement of national antitrust policy in health care, the so far unique American experience in this field provides some useful lessons.     

“If Only Someone Had Told Me …”: Lessons From Rural Providers

Purpose: Health care providers face challenges in rural service delivery due to the unique circumstances of rural living. The intersection of rural living and health care challenges can create barriers to care that providers may not be trained to navigate, resulting in burnout and high turnover. Through the exploration of experienced rural providers’ knowledge and lessons learned, this study sought to inform future practitioners, educators, and policy makers in avenues through which to enhance training, recruiting, and maintaining a rural workforce across multiple health care domains. Methods: Using a qualitative study design, 18 focus groups were conducted, with a total of 127 health care providers from Alaska and New Mexico. Transcribed responses from the question, “What are the 3 things you wish someone would have told you about delivering health care in rural areas?” were thematically coded. Findings: Emergent themes coalesced into 3 overarching themes addressing practice‐related factors surrounding the challenges, adaptations, and rewards of being a rural practitioner. Conclusion: Based on the themes, a series of recommendations are offered to future rural practitioners related to community engagement, service delivery, and burnout prevention. The recommendations offered may help practitioners enter communities more respectfully and competently. They can also be used by training programs and communities to develop supportive programs for new practitioners, enabling them to retain their services, and help practitioners integrate into the community. Moving toward an integrative paradigm of health care delivery wherein practitioners and communities collaborate in service delivery will be the key to enhancing rural health care and reducing disparities.     

Made in the USA: the import of American Consumer Assessment of Health Plan Surveys (CAHPS) into the Dutch social insurance system

BACKGROUND: In the Netherlands, managed competition between health plans has been introduced. For Dutch health plans this implies that they need to collect data about their own performance and that of the care providers they contract. To that end, Consumer Assessment of Health Plan Surveys (CAHPS) instruments have recently been adopted by a large Dutch health plan. OBJECTIVES: This paper presents the results of a validation study of the Dutch version of the CAHPS Adult Commercial questionnaire. The questions addressed are as follows: Can this questionnaire be adapted for use in the context of the Dutch insurance system? and Can it generate valid information about the quality of health care and the performance of Dutch health plans? METHODS: The translated questionnaire has been mailed to a sample of 977 enrollees. The psychometric properties of the translated instrument have been studied, and the results have been compared with those of other Dutch and American studies. RESULTS: The net response rate was 51% (n = 500). In general, the questionnaires were filled out completely and consistently. Principal component analyses revealed a factor that can be labelled as patient-centredness in the primary process. It contains the domains that in the CAHPS literature are described as 'courteous/helpful staff' and 'doctors communicating well'. CONCLUSIONS: The translated version of the CAHPS Adult Commercial questionnaire is a promising tool for Dutch health plans. More research is needed on the external and the content validity of these questionnaires in the Dutch context.     

Is there a business case for quality in The Netherlands? A critical analysis of the recent reforms of the health care system

Major reforms of the health insurance system and reimbursement systems for care providers are currently taking place in The Netherlands. These market-oriented health care reforms will transform the current central supply-driven system to a system of managed competition both among health care insurers and care providers. The reforms are not systematically linked to the discussions about quality of care and together with consumers who might be more interested in lower premiums; they offer almost no incentive for health care insurers and providers to steer on quality. Dutch policy makers should, therefore, be more explicit whether competition should take place on quality or price, and if the former is the case, additional incentives as part of the system reforms, are needed to create a business case for quality.     

Serving Families on the Frontline: Challenges and Creative Solutions in Rural Hospice Social Work

Focus on the social service and health care needs of rural dwellers has emerged due to changing demographics and advocacy efforts. All rural health providers are faced with numerous unique challenges. As a valuable part of hospice teams, social workers are well equipped to have an integral role in understanding and addressing the specific challenges in end-of-life care in rural communities. In this study, a Web-based survey was completed by 339 hospice social workers spanning 40 states in the United States. Both quantitative and qualitative methods and data analysis strategies were utilized. The results reveal environmental and cultural challenges impacting social work practice. The results also unveil solutions and suggestions for addressing challenges such as creative use of resources and increased collaboration within the local resident, health care, and social work communities. Implications include potential strategies for enhanced social work practice in rural areas, yielding a quality end-of-life care for individuals and families.     

Telehealth for Contraceptive Services During the COVID-19 Pandemic: Provider Perspectives

BackgroundTelehealth use rapidly increased during the COVID-19 pandemic, including for contraceptive care (e.g., counseling and method provision). This study explored providers’ experiences with contraceptive care via telehealth.MethodsWe conducted a survey with open-ended responses among contraceptive providers across the United States. The study population included physicians, nurse practitioners, health educators, and other health professionals (n = 546). Data were collected from April 10, 2020, to January 29, 2021. We conducted qualitative content analysis of the open-ended responses.ResultsProviders highlighted the benefits of telehealth, including continuing access to contraceptive services and accommodating patients who faced challenges attending in-person contraceptive visits. Providers at school-based health centers reported telehealth allowed them to reach young people while schools were closed. However, many providers noted a lack of patient awareness about the availability of telehealth services and disparities in access to technology. Providers felt there was less personal connection in virtual contraceptive counseling, noted challenges with confidentiality, and expressed concern about the inability to provide the full range of contraceptive methods through telehealth alone.ConclusionsThe pandemic significantly impacted contraceptive health care delivery. Telehealth has sustained access to contraception in important ways, but has been accompanied by various challenges, including technological access and confidentiality. As hybrid models of care evolve, it is important to assess how telehealth can play a role in providing contraceptive care while addressing its barriers.     

A Model for Training Community-Based Providers for Children with Special Health Care Needs

ABSTRACT: Children with special health care needs pose many challenges for community-based providers. Programs such as school, child care, and Head Start provide services to children that previously would have been delivered in hospitals or at home. The need for a system of care to assure safe, quality services for these children is paramount. While health procedure manuals for schools have been developed, few recommendations address the actual training of providers or the trainers of providers. This article describes a system of training which includes steps in managing the care of children with special health care needs, levels of training, and expected competencies for the care providers of children with special health care needs.     

Inspectors’ ethical challenges in health care regulation: a pilot study

There is an increasing body of research on what kind of ethical challenges health care professionals experience regarding the quality of care. In the Netherlands the Dutch Health Care Inspectorate is responsible for monitoring and regulating the quality of health care. No research exists on what kind of ethical challenges inspectors experience during the regulation process itself. In a pilot study we used moral case deliberation as method in order to reflect upon inspectors’ ethical challenges. The objective of this paper is to give an overview of the ethical challenges which health care inspectors encounter in their daily work. A thematic qualitative analysis was performed on cases (n = 69) that were collected from health care inspectors in a moral case deliberation pilot study. Eight themes were identified in health care regulation. These can be divided in two categories: work content and internal collaboration. The work of the health care inspectorate is morally loaded and our recommendation is that some form of ethics support is provided for health care inspectors.     

Understanding and improving communication and decision-making in palliative care for Turkish and Moroccan immigrants: a multiperspective study

Objective. The aim of this study is to explore how communication and decision-making in palliative care among Turkish and Moroccan patients is influenced by different styles of care management between Turkish and Moroccan families and Dutch professional care providers. Problems as well as solutions for these problems are highlighted. Design. A qualitative design was used, totally interviewing 83 people (6 patients, 30 relatives and 47 care providers) covering 33 cases of incurable cancer patients receiving palliative care. Data were analysed thematically and contextually. Results. The analysis reveals that problems in decision-making are partly related to differences in ethnic-cultural views on 'good care' at the end of life: Dutch palliative care providers prefer to focus on quality of life rather than on prolonging life, while Turkish and Moroccan families tend to insist on cure. Another barrier is caused by conflicting views on the role of the 'care management group': Dutch care providers see the patient as their primary discussion partner, while in Turkish and Moroccan families, relatives play a major part in the communication and decision-making. Moreover, the family's insistence on cure often leads to the inclusion of additional care providers in communication, thus complicating joint decision-making. Conclusion. Care providers need to understand that for Turkish and Moroccan patients, decision-making is seldom a matter of one-to-one communication. Next to acknowledging these patients' different cultural backgrounds, they must also recognise that the families of these patients often function as care management groups, with an 'equal' say in communication and decision-making. In addition, professionals should optimise communication within their own professional care management group.     

Barriers to payment reform: Experiences from nine Dutch population health management sites

Population health management (PHM) initiatives aim for better population health, quality of care and reduction of expenditure growth by integrating and optimizing services across domains. Reforms shifting payment of providers from traditional fee-for-service towards value-based payment models may support PHM. We aimed to gain insight into payment reform in nine Dutch PHM sites. Specifically, we investigated 1) the type of payment models implemented, and 2) the experienced barriers towards payment reform. Between October 2016 and February 2017, we conducted 36 (semi-)structured interviews with program managers, hospitals, insurers and primary care representatives of the sites. We addressed the structure of payment models and barriers to payment reform in general. After three years of PHM, we found that four shared savings models for pharmaceutical care and five extensions of existing (bundled) payment models adding providers into the model were implemented. Interviewees stated that reluctance to shift financial accountability to providers was partly due to information asymmetry, a lack of trust and conflicting incentives between providers and insurers, and last but not least a lack of a sense of urgency. Small steps to payment reform have been taken in the Dutch PHM sites, which is in line with other international PHM initiatives. While acknowledging the autonomy of PHM sites, governmental stewardship (e.g. long-term vision, supporting knowledge development) can further stimulate value-based payment reforms.     

Commentary on Gurewich et Al, "comparative performance of community health centers and other usual sources of primary care": community health centers: valuable partners for state medicaid programs

Community health centers are well positioned to bring needed primary care to populations experiencing the most acute health disparities. Health centers already care for 1 in 7 Medicaid beneficiaries and 1 in 5 low-income, uninsured individuals. And they generate $24 billion in annual savings to the entire health care system, including $6 billion for Medicaid programs. Health center patients are distinctly different from patients of other providers, and successfully meet the challenges associated with serving those who have special needs that require more time and resources to address. For this reason, health centers provide a much more comprehensive array of services, both health care and services that facilitate access to care, compared to private practice physicians. With more beneficiaries joining the Medicaid rolls under health reform, and the limited number of providers available to serve the most complex, hard-to-reach, and underserved patients, health centers will play an increasingly important partnership role with state Medicaid programs. Continued investments are necessary to effectively serve at-risk patients.