An international consultation: the development of family medicine in Vietnam

An effective international consultation on health system reform can be approached using the five-step process of establishing goals, conducting a needs assessment, defining objectives, developing methods, and designing evaluation strategies. This structure provided guidance to a consultation we provided to the Ministry of Health, Socialist Republic of Vietnam (SRV) to review its current health care delivery system. The consultation examined all levels of health care delivery and medical education. The SRV has an extensive, but poorly staffed, "commune health center" system. There is a widespread perception that the quality of medical care is low in these health centers. People leave their communities to obtain health care elsewhere at more-specialized levels and more-expensive sites. Our consultation included an analysis of the potential effect of creating a primary health care delivery system based on the model of family medicine. In addition to consulting, part of the time spent in Vietnam was used to advocate for changes in the system to allow for movement toward a primary health care delivery system. The consultation culminated in the creation of the specialty of family medicine and in the establishment of the medical education system to train family physicians.     

Practices of excellent companies in the managed health care industry

The health care profession in the USA has traditionally attracted some of the best talent the country has to offer, with medical practitioners enjoying high incomes due to employer-paid medical indemnity insurance plans. There was no oversight process or quality standards governing the health care delivery process and no motivating factors to contain costs. Prior to the introduction of the Knox-Keene Act in the 1970s requiring employers to offer managed care as an alternative indemnity coverage, the only known managed care company was the Kaiser Permanente Medical Plan. Until just over a decade ago, the concept of managed care was stereotyped as a low quality method of health care delivery. Criticisms from providers themselves suggested managed care systems meant withholding medical care for the sake of profit; "production line" medicine, and compromise in the delivery of quality health care. In order to refute that notion and grow as an industry, managed health care companies were required to take steps to prove their integrity, high quality of care, and cost-effective methods. Today the industry is fast growing, setting management practices that are becoming benchmark standards for other industries too.     

卫生服务体系整合的发展与实践

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

The Health Care Home Model: Primary Health Care Meeting Public Health Goals

In November 2010, the American Public Health Association endorsed the health care home model as an important way that primary care may contribute to meeting the public health goals of increasing access to care, reducing health disparities, and better integrating health care with public health systems. Here we summarize the elements of the health care home (also called the medical home) model, evidence for its clinical and public health efficacy, and its place within the context of health care reform legislation. The model also has limitations, especially with regard to its degree of involvement with the communities in which care is delivered. Several actions could be undertaken to further develop, implement, and sustain the health care home.THE AMERICAN PUBLIC HEALTH Association (APHA) has 3 overarching policy priorities: rebuild the public health infrastructure, ensure access to care, and reduce health disparities.1,2 The health care home model contributes to these goals by improving health care delivery at the patient level through redesigning and expanding the scope of primary health care services and improving the interface between primary care practices and public health agencies.In November 2010, APHA endorsed the health care home model of primary care for its public health value. Health care home, a term used by the National Association of Community Health Centers, is a model also referred to as the medical home.3,4 The health care home is a vehicle by which patient- and family-level care at the point of delivery may contribute to meeting population-level goals of improving access to care, reducing health disparities, increasing preventive service delivery, and improving chronic disease management.5 Here we summarize the APHA health care home policy statement and suggest next steps for moving the model forward.     

Hills, Ridges, Mountains, and Roads: Geographical Factors and Access to Care in Rural Kentucky

Access to health care remains an important issue facing many individuals. Barriers to health care include financial factors, characteristics of the individuals and of the health care delivery system, as well as geographical factors. Using a telephone survey of Kentucky residents, this study investigated the relationship between the road quality and county elevation and access to health care for individuals in rural and urban areas of the state. Controlling the comparison for known individual characteristics, community characteristics, and medical infrastructure characteristics, this study uncovered that worse road conditions, measured by a road "rideability" index, were associated with longer times to reach medical care. It also found an association between higher county elevations and shorter times to reach medical care.     

Reflections on curative health care in Nicaragua.

Improved health care in Nicaragua is a major priority of the Sandinista revolution; it has been pursued by major reforms of the national health care system, something few developing countries have attempted. In addition to its internationally recognized advances in public health, considerable progress has been made in health care delivery by expanding curative medical services through training more personnel and building more facilities to fulfill a commitment to free universal health coverage. The very uneven quality of medical care is the leading problem facing curative medicine now. Underlying factors include the difficulty of adequately training the greatly increased number of new physicians. Misdiagnosis and mismanagement continue to be major problems. The curative medical system is not well coordinated with the preventive sector. Recent innovations include initiation of a "medicina integral" residency, similar to family practice. Despite its inadequacies and the handicaps of war and poverty, the Nicaraguan curative medical system has made important progress.     

Failure to seek needed medical care: results from a national health survey of Icelanders

The study focuses on access to outpatient medical care in Iceland--a socialized health care system. As in other systems of this sort, equal access to needed services (equity) is a fundamental principle. Despite governmental claims that access to health services is "easy" and "roughly equal", the study indicates substantial and rather extensive variations in equity of care. More specifically, younger individuals, the non-widowed, the economically troubled, individuals with inflexible daily schedules, the chronically ill, those who had incurred high out-of-pocket costs relative to their family income, and those who didn't have a physician care discount card, were more likely than others to postpone or cancel an MD visit they thought they needed. Furthermore, younger age, economic troubles, chronic medical conditions, no family physician, and no physician care discount card, were all related to under-utilization, based on medical specialist criteria of recommended medical care for symptoms. Although the results show that access problems originate in part outside the health care system, they also suggest revision of current health policy, in order to adequately address existent inequities in service delivery.     

What's going on in the real world

The health care marketplace has worked its magic, inspiring health care providers to transform strategies and operations from often inefficient and costly care and services to streamlined, often cooperative, integrated delivery systems. Transformation--a far better word than reform. The need to "reform" implies past failures, as in "reform school" for the unruly, even wicked child. A "transformation," however, implies re-invention, possibly of something that worked well already. Well, but not well enough. In the case of health care in the United States, even the most jaded observer will agree that our medical care system--including medical and pharmaceutical research and development--is the greatest gift this country has given to itself. Its quality is the benchmark for every society on earth. And yet--Happy New Year! Time moves on, and what worked well can work better, can be perfected, exquisite. It can also be exquisite while affordable.     

Lean Six Sigma in health care and the challenge of implementation of Six Sigma methodologies at a Veterans Affairs Medical Center

Six Sigma and Lean Thinking are quality initiatives initially deployed in industry to improve operational efficiency leading to better quality and subsequent cost savings. The financial rationale for embarking on this quality journey is clear; applying it to today's health care remains challenging. The cost of medical care is increasing at an alarming rate; most of these cost increases are attributed to an aging population and technological advances; therefore, largely beyond control. Furthermore, health care cost increases are caused by unnecessary operational inefficiency associated with the direct medical service delivery process. This article describes the challenging journey of implementing Six Sigma methodology at a tertiary care medical center. Many lessons were learned; however, of utmost importance were team approach, "buy in" of the stakeholders, and the willingness of team members to change daily practice and to adapt new and innovative ways how health care can be delivered. Six Sigma incorporated as part of the "company's or hospital's culture" would be most desirable but the learning curve will be steep.     

Alternative models for the delivery of rural health care: a case study of a western frontier state.

This is a case study illustrating the wide variety of models for rural health care delivery found in a western "frontier" state. In response to a legislative mandate, the University of Nevada School of Medicine created the Office of Rural Health in 1977. Utilizing a cooperative, community development approach, this office served as a resource, as well as a catalyst, in the development and expansion of a variety of alternative practice models for health care delivery to small, underserved rural communities. These models included small, single, and multispecialty group practices; self-supporting and subsidized solo practices; contract physicians; midlevel practitioners; and National Health Service Corps personnel. The rural health care system that was created featured regional and consortial arrangements, urban and medical school outreach programs, and a "flying doctor" service.     

Organization and quality of home care services after emergency calls in connection with pain in the cardiac area]

The results are provided of an in-depth study of the organization, quality and effectiveness of medical care provided at home to persons who referred to medical institutions for cardialgias. It has been shown that the real number of circulatory diseases while considering the complaints such as "pains in the heart area" is considerably less than the number of calls for outpatient home care. The influence is established of the amount and quality of home health care delivery on the effectiveness of outpatient care as a whole in cases of circulatory disease aggravation and of the possibility to reduce the duration of disability in the aggravation cases (and consequently the economic losses) at the expense of improving the medical care quality just at home. The improvement of the organization and quality of home health care is an important reserve for the perfection of outpatient care at large.     

Service delivery innovations at Mayo Clinic

Mayo Clinic has a long-standing reputation as a leader in the basic and clinical sciences. However, there is little in the published literature about Mayo Clinic's contributions to the delivery of health care services. This article is an overview of what Mayo brought to health care delivery between the 1860s and the 1980s, highlighting some of the lesser-known innovations that have influenced health care delivery on a national and international level such as the development of group practice and medical specialties, the creation of medical records, the use of allied health care providers, and facility design.     

The integration of public health and medicine

President Clinton's American Health Security Act proposes to reform and integrate the medical care and public health service delivery systems. Historically, there have been examples of efforts to integrate public health and medical activities. Yet, while many have acknowledged the inherent value of such an integrated approach to improving health, the fact is that these efforts have had only limited success. The "new deal" President Clinton has proposed for these health institutions is examined in this context. If the notion of integration is taken seriously--that is to mean the extent to which each system's diverse activities complement each other, fitting together to form an integrated whole--then it will not be easy to achieve. Review of the "visions" of public health and medicine and of examples of efforts to integrate public health and medicine in this country suggest five conditions that must be met if successful integration is to be achieved. While the resources necessary to integrate public health and medicine are great, of equal importance is the acceptance of a shared vision of an integrated health care system, and of the respective roles and responsibilities of public health and medical care in that system. The benefits to our nation's health of proceeding in this way, however, are enormous. As we move into the twenty-first century, an integrated system of public health and medical care services is our nation's best hope for not only improving the health of all our citizens, but for closing the "health gap" between socioeconomically disadvantaged groups and the rest of the population.     

Point-of-care systems, informatics, and health care delivery

Evolving information technology has had profound effects on business operations and the marketplace. The health care services industry, particularly hospitals, clinics, and medical offices, has historically lagged behind other industries in the implementation of comprehensive, integrated, computerized data management tools. Health care reformers are looking to the promises of the information technology "revolution" as a means of improving systemic efficiency and health care quality. This study discusses the impact of informatics, or information technology, on the delivery of health care services. We present the evolution of informatics and the predicted future benefits of integrated computerized patient records and point-of-care systems.     

Selling open access health care delivery to patients and administrators: what's the hook?

A new concept in health care delivery involves the use of Open Access Scheduling for patients. In an attempt to manage spiraling medical costs and patient care demands many medical practices and managed care organizations are looking for alternative delivery models for health care. Open Access Scheduling has been garnering many advocates and converts from past traditional medical service delivery models. Unfortunately, due to its limited penetration into the medical community, little of Open Access' essential characteristics are generally understood. This paper looks at Open Access from the perspectives of: patients, medical administrators, office staff and providers. We discuss the tenets of Open Access, the benefits from its use, its challenges, and the steps necessary to initiate this type of service delivery.     

Characterizing medical providers for jail inmates in New York State

Objectives. People who are incarcerated exhibit high rates of disease, but data evaluating the delivery of medical services to inmates are sparse, particularly for jail settings. We sought to characterize the primary medical care providers for county jail inmates in New York State.Methods. From 2007 through 2009, we collected data on types of medical care providers for jail inmates in all New York State counties. We obtained data from state monitoring programs and e-mail questionnaires sent to county departments of health.Results. In counties outside New York City (n = 57), jail medical care was delivered by local providers in 40 counties (70%), correctional medical corporations in 8 counties (14%), and public providers in 9 counties (16%). In New York City, 90% of inmates received medical care from a correctional medical corporation. Larger, urban jails, with a greater proportion of Black and Hispanic inmates, tended to use public hospitals or correctional medical corporations as health care vendors.Conclusions. Jail medical services in New York State were heterogeneous and decentralized, provided mostly by local physician practices and correctional medical corporations. There was limited state oversight and coordination of county jail medical care.In 1976, the US Supreme Court issued a landmark decision, Estelle v Gamble, granting prisoners a constitutional right to standard-of-care medical services.¹ In fact, prisoners are the only civilian subgroup in the United States with a constitutionally guaranteed right to health care. Delivering medical care to inmates and ensuring continuity of care after release are logistically complex and costly endeavors. A recent nationwide survey found high rates of medical and psychiatric conditions among US prisoners, with nearly 70% of inmates reporting at least 1 chronic illness.²The challenges of providing standard-of-care medical services to prisoners are manifold. In most states, the correctional system is 2-tiered, composed of prisons and jails. Prisons hold sentenced inmates for periods of a year or longer; jails confine pretrial detainees and inmates sentenced to periods of less than 1 year. Jails pose particular challenges to health care delivery because of the large volume and rapid turnover of inmates. These challenges include discontinuity of care,³ lack of timely access to medical records, lack of trust between patient and provider,⁴ withdrawal from addictive substances,⁵ poor discharge planning,⁶ and loss of medical insurance.⁷ Unfortunately, data evaluating the delivery of medical services to inmates are sparse, particularly in jail settings. In the neglected field of prison health research, jails constitute a doubly marginalized domain for evaluation and advocacy.Since the 1970s, US incarceration rates have increased dramatically, with 2.3 million people incarcerated in jails and prisons at the end of 2008.⁸ An estimated 9 million individual inmates are admitted to and released from jail annually.⁹ This volume represents an enormous population of medically and psychiatrically vulnerable individuals circulating through the nation''s jails.The delivery of health services within the correctional system ultimately depends on the availability of trained medical care providers. In general, correctional facilities do not constitute a broadly attractive practice setting for most physicians. Prisoners'' health needs are not routinely addressed in medical or nursing school curricula.¹⁰ After a careful review of publicly available information, we were unable to find any comprehensive information describing the sector (public vs private providers) or training level of medical care providers for any US state. Nor were we able to identify any comprehensive surveys of health care providers for county jail inmates in the medical, social science, or popular literature. The popular press has addressed the issue of correctional medical care through a focus on privatization of these services.^11,12 However, analyses characterizing medical service providers for inmates have not been published.We conducted a statewide survey of medical care providers for county jail inmates, using New York State (NYS) as our study setting. The aim of our study was to determine who provided primary medical care to county jail inmates in NYS. To our knowledge, this is the first statewide study attempting to characterize providers of medical care to county jail inmates.     

The key role of health insurance in a cost-effective health care system. Towards regulated competition in the Dutch medical market.

The previous two sessions of this Symposium have dealt with incentives for cost-effective provider behaviour. Although incentive-reimbursement, which rewards the providers for delivery medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not rewards the providers for delivering medical care in a cost-effective way, can be an important step towards a cost-effective health care system, it is not sufficient. As long as the insured consumers have both comprehensive health insurance coverage and freedom of choice of provider, providers will have great difficulty in resisting consumers' demand for ever more costly medical care, and politicians or other decision-makers will have great difficulty in restricting capacity and in preventing overcapacity. Fear of losing patients or voters might dominate. Therefore, in this session we shall focus on the key role of health insurance in a cost-effective health care system and on consumer incentives and insurer behaviour. If the consumers have a choice between several provider-insurer organizations. Although market forces do play an important role in a competitive health-care system, competition should not be confused with a "free market". Besides financial arrangements to protect the poor, pro-competitive regulation is needed to guarantee a "fair competition". Currently there is much consensus that the present Dutch health insurance system, in which 60% of the population is publicly insured and 40% is privately insured, should be replaced by a national health insurance scheme, which uniformly applies to the entire population. A few years ago, I made a proposal for such a scheme, which was based largely on the ideas of Ellwood, McClure, and Enthoven on competition between alternative delivery systems. The main features of this proposal will be discussed. In my opinion, the long-term prospects for regulated competition in the Dutch medical market seem rather favourable.     

Barriers Faced by the Health Workers to Deliver Maternal Care Services and Their Perceptions of the Factors Preventing Their Clients from Receiving the Services: A Qualitative Study in South Sudan

Objective The study objective was to explore challenges and barriers confronted by maternal and child healthcare providers to deliver adequate quality health services to women during antenatal care visits, facility delivery and post-delivery care. Methods We conducted 18 in-depth-interviews with maternal and child health professionals including midwives/nurses, trained traditional birth attendants (TBAs), gynecologists, and pediatricians in three public health facilities in Juba, South Sudan. We purposively selected these health professionals to obtain insights into service delivery processes. We analyzed the data using thematic analysis. Results Limited support from the heath system, such as poor management and coordination of staff, lack of medical equipment and supplies and lack of utilities such as electricity and water supply were major barriers to provision of health services. In addition, lack of supervision and training opportunity, low salary and absence of other forms of non-financial incentives were major elements of health workers’ de-motivation and low performance. Furthermore, security instability as a result of political and armed conflicts further impact services delivery. Conclusions for Practice This study highlighted the urgent need for improving maternal and child healthcare services such as availability of medical supplies, equipment and utilities. The necessity of equal training opportunities for maternal and child healthcare workers at different levels were also stressed. Assurance of safety of health workers, especially at night, is essential for providing of delivery services.     

Analysis of adequacy levels for human resources improvement within primary health care framework in Africa

Human resources in health care system in sub-Saharan Africa are generally picturing a lack of adequacy between expected skills from the professionals and health care needs expressed by the populations. It is, however, possible to analyse these various lacks of adequacy related to human resource management and their determinants to enhance the effectiveness of the health care system. From two projects focused on nurse professionals within the health care system in Central Africa, we present an analytic grid for adequacy levels looking into the following aspects:

Wagging the dog: an analysis of year 2000 workforce and education outcomes from recommendations of the 1995 Pew Commission report

Over-production in the number of hospitals and health care workers has led to increased cost of medical care and inequities within the health care delivery system. An increase in managed care penetration within the market-place is believed to mandate dramatic changes in the way that health care is structured and delivered. The 1995 Pew Commission report projected major changes in health care organizations and health manpower through the effects of managed care and public regulation. This paper describes the outcomes to health delivery organizations and the health care workforce five years since the Pew Commission Report and discusses the belief that market forces are more effective mechanisms for addressing health care delivery and workforce requirements than public regulatory initiatives.