Medicaid managed care and provider consolidation

In the thrust toward constructing economic value, health care provider firms have been consolidating at a marked rate. Medicaid managed care programs have been rapidly emerging with the objectives of containing health care costs and improving services for beneficiaries. However, there are concerns that the trend toward achieving market efficiency through merger is largely incongruent with the economic and health value objectives of Medicaid managed care programs in the states. Discordance among value objectives arises primarily because of inefficient and market concentrating horizontal merger strategies employed by firms and disruptions in quality of care that occur during the transition to integrated health care systems. By promoting vertical integration strategies and filling in the quality gaps created by an active merger environment, Medicaid offices advance state objectives of cost containment and quality while recognizing that providers operate in a complex and competitive environment that necessitates consolidation for organizational survival.     

Tracking the changing provider landscape: implications for health policy and practice

Throughout the 1990s health care providers were interested in developing organized delivery systems. However, industry observers have increasingly questioned the sense of these efforts. Using an established taxonomy of health networks and systems, we examined whether there was a nationwide trend away from the vertical and horizontal arrangements that serve as the backbone to organized delivery systems. Studying 1994-1998, we found that both health networks and systems became less centralized in their hospital services, physician arrangements, and insurance product development. We did not find a general pathway to disintegration but instead found considerable experimentation in organizational form.     

Vertical and horizontal aspects of socio-economic inequity in general practitioner contacts in Scotland

Health status varies across socio-economic groups and health status is generally assumed to predict health care needs. Therefore the need for health care varies across socio-economic groups, and studies of equity in the distribution of health care between socio-economic groups must compare levels of utilisation with levels of need. Economic studies of equity in health care generally assume that health care needs can be derived from the current health-health care relationship. They therefore do not consider whether the current health-health care relationship is (vertically) equitable and the focus is restricted to horizontal inequity. This paper proposes a framework for incorporating the implications of vertical inequity for the socio-economic distribution of health care. An alternative to the current health-health care relationship is proposed using a restriction on the health-elasticity of health care. The health-elasticity of general practitioner contacts in Scotland is found to be generally negative, but positive at low levels of health status. Pro-rich estimates of horizontal inequity and vertical inequity are obtained but neither is statistically significant. Further analysis demonstrates that the magnitude of vertical inequity in health care may be larger than horizontal inequity.     

To achieve "health for all" we must shift the world's paradigm to "primary care access for all".

Since the early 1950s, the World Health Organization has proposed programs to promote primary health care around the world. From the 1978 Alma-Ata Declaration to the current promulgation of the Millennium Development Goals, the World Health Organization has tried to improve health in developing countries through a focus on disease-oriented (vertical) programs. The World Health Organization and other organizations have not focused on the horizontal role of primary care. The expectations created by these programs have not been met. Evidence demonstrates that the advent of health care through a base of primary care improves health better than through the traditional vertical disease-oriented health programs used around the globe. The global "family" of family medicine must advocate for a shift from the current solutions to one in which the family doctor is part of a well-trained health care team that can function in networks that incorporate the vertical programs into a broad horizontal approach for better access to primary care. Perhaps in this way "health for all" can be achieved.     

2000-2015年中国孕产妇死亡率变化趋势及与孕产期保健措施的关系研究

目的通过描述中国2000-2015年孕产妇死亡率变化趋势,分析其与孕产期保健措施间的关系,为改善孕产妇死亡状况提供科学依据。方法采用动态数列法描述2000-2015年中国孕产期保健状况的变化趋势,应用Spearman相关分析探讨孕产妇死亡率与孕产期保健措施的关系。结果2000-2015年中国孕产妇死亡率呈明显下降趋势。各项孕产妇保健指标均呈上升趋势,其中高危产妇比重增长相对较快。全国孕产妇死亡率与各项孕产期保健措施均呈负相关,其中高危产妇比重与孕产妇死亡率关系最密切。结论中国孕产妇死亡状况已明显改善,有关部门应致力于各项孕产期保健措施的均衡发展,为未来可持续发展目标奠定基础。     

Public trust in health care: a performance indicator?

PURPOSE: If public trust in health care is to be used as a performance indicator for health care systems, its measurement has to be sensitive to changes in the health care system. For this purpose, this study has monitored public trust in health care in The Netherlands over an eight-year period, from 1997 to 2004. The study expected to find a decrease in public trust, with a low point in 2002. DESIGN/METHODOLOGY/APPROACH: Since 1997, public trust in health care was measured through postal questionnaires to the "health care consumer panel". This panel consists of approximately 1500 households and forms a representative sample of the Dutch population. FINDINGS: Trust in health care and trust in hospitals did not show any significant trend. Trust in medical specialists displayed an upward trend. Trust in future health care, trust in five out of six dimensions of health care and trust in general practitioners actually did show a decrease. However, only for trust in macro level policies and trust in professional expertise this trend continued. For the remaining trust objects, after 1999 or 2000, an upward trend set in. RESEARCH IMPLICATIONS/LIMITATIONS: No support was found for our overall assumption. Explanations for the fact that trust did increase after 1999 or 2000 are difficult to find. On the basis of these findings the study questions whether the measure of public trust is sensitive enough to provide information on the performance of the health care system. ORIGINALITY/VALUE: The aim of this research is to study public trust in health care on its abilities to be used as a performance indicator for health care systems.     

Coordinating patient care services in regional health systems: the challenge of clinical integration

Regional health systems attempting to achieve the vertical integration of health services ultimately must achieve clinical integration. The thesis of this article is that vertical integration in health care involves the coordination of inputs (equipment, supplies, human resources, information, and technology) and intermediate outputs (preventive, diagnostic, acute, chronic, and rehabilitative services) to attain the end goal of optimal personal health. Given this perspective on vertical integration, the coordination of specialty services and primary care within a system structure--that is, the clinical integration of patient care--is central to the realization of vertically integrated regional health systems. Institution-level and environmental factors that facilitate and challenge the attainment of clinical integration are elucidated, and a set of clinical integrating mechanisms are outlined with presentation of real-world examples of those mechanisms. The analysis concludes by summarizing the next steps in realizing the vision of clinically integrated, regional systems of health care.     

Health security and disease control: lessons from Mexico

This paper discusses the controversy between top-down, disease-focused, vertical programs, on the one hand, and activities that have been horizontally integrated into health services, on the other, using as a reference the public health initiatives developed in Mexico in the context of a recent comprehensive health care reform. The main message is that it is possible to achieve a synthesis between vertical and horizontal strategies, and also between public health and personal health care programs. Public health and personal care are the two sides of the health system coin, and both are central to a comprehensive concept of health security. Investments in epidemiological surveillance and response clearly contribute to the control of threats facing nation-states, such as pandemics and biological warfare. At the same time, investments in the protection of individuals from threats that endanger their health would also make our world a safer place.     

Vertical equity: weighting outcomes? or establishing procedures?

Considerations of equity in the health policy literature have in the main focussed on horizontal equity (the equal treatment of equals) and as a consequence have tended to overlook vertical equity (the unequal, but equitable, treatment of unequals). There is evidence from earlier, if preliminary, work carried out by the authors and a colleague that health care decision makers may well want to embrace concerns for vertical equity in the allocation of health service resources. This paper examines some possibilities for incorporating vertical equity into health care policy through distributive and/or procedural justice. While no firm solutions are offered, it is suggested that the idea of fitting John Broome's notion of 'claims' within a communitarian framework holds promise.     

我国乡村卫生一体化管理模式与比较

通过剖析乡村卫生一体化管理的内涵和政策目标,将其归纳出乡村卫生组织一体化和乡村卫生服务一体化两种模式;对两种模式的推进障碍因素和优劣进行了比较;提出新医改政策背景下推进乡村卫生服务一体化的建议是：分步分类推进、把连续的卫生服务作为一体化管理的落脚点、由国家层面建立乡村两级卫生服务规范“管理包”,以及县级卫生行政部门要积极发挥主动作用。     

Malaria eradication and the selective approach to health care: some lessons from Ethiopia.

Analysis of the failure of the World Health Organization's global malaria campaign has contributed to the formulation of the primary health care concept as the basic international strategy for health improvement. The Primary Health Care Conference held in Alma-Ata in 1978 was to have ended the period of vertical disease control programs, such as the one against malaria, stressing instead the integration of these programs into horizontal community-based health systems. Malaria control programs, however, have not been integrated well--or in some cases at all--into primary health care networks. An analysis of the Ethiopian experience, as part of the worldwide malaria eradication program, illustrates the political and economic forces that have worked against the move from vertical to integrated malaria control activities, and from vertical to integrated health programs more generally.     

24年住院分娩围产保健质量变化趋势分析

目的:对海淀区妇幼保健院1983年10月~2007年9月间107 023例住院分娩产妇围产保健质量的主要监测指标进行统计分析,旨在寻找现行工作的差距,明确今后围产保健工作的重点。方法:采用描述性研究(计算各种率和比)和分析性研究(计数资料的卡方检验),分析差异的显著性。结果:24年间各种监测指标总的发生率分别是:孕产妇死亡率为6.54/10万;围生儿死亡率为8.53‰;妊高征发生率为7.64%;产后出血发生率为4.73%;早产发生率为4.16%;新生儿窒息发生率为1.25%;出生低体重发生率为3.69%;出生缺陷发生率为129.95万/。孕产妇死亡率的控制处于先进水平,围生儿死亡率前10年呈现逐年下降趋势,后10年下降趋势不明显;妊高征发生率呈现下降趋势,且表现出明显的季节性差异;剖宫产率呈现快速增长态势,剖宫产率存在明显月份差异;出生缺陷、早产发生率呈现上升态势;低出生体重发生率呈现下降趋势;新生儿窒息发生率不同年份波动较大,后期下降趋势明显。结论:该院围产保健工作质量呈现整体提高态势,今后围产保健工作重点为:继续巩固现有围产保健工作成果,使孕产妇死亡率、围生儿死亡率维持在低水平,深入开展有关早产、出生缺陷、低出生体重、新生儿窒息发生的病因学及防治对策研究,以便采取针对性围产保健措施,使指标稳中有降,采取综合性防控措施有效降低剖宫产率,预防和减少以妊高征及产后出血为主的产科并发症的发生,全面提高围产保健综合质量。     

Corporate health care and social welfare

The trend toward health care as big business has been noted with concern by various observers of the health care scene. In this report on the growth of corporate enterprise in health services, the dominance of the corporation is examined, along with the implications of this trend for social service personnel.     

2003—2018年兰州市孕产妇死亡率变化及保健状况主成分分析

目的 分析兰州市2003—2018年孕产妇死亡率变化和孕产妇保健状况,为兰州市妇女保健工作提供依据。 方法 采用动态数列和Mann-Kendall趋势检验分析兰州市2003—2018年孕产妇死亡率变化趋势和孕产妇保健状况,运用主成分分析综合评价2003—2018年孕产妇保健状况。 结果 兰州市2003—2018年孕产妇死亡率总体呈下降趋势,平均增长速度为-3.46%,但趋势变化无统计学意义(Z=-0.855,P=0.392),且期间波动明显;2003—2018年兰州市孕产妇产检率、早检率、产后访视率、系统管理率、住院分娩率总体呈上升趋势,平均增长速度分别为0.76%、1.97%、0.61%、2.06%、1.65%;高危孕产妇比重呈下降趋势,年均下降2.86%。主成分分析显示兰州市2003—2008年孕产妇保健水平低于2003—2018年平均水平,2011—2013年产检率、早检率、产后访视率、系统管理率、住院分娩率等孕产妇基本保健服务利用较好,2014—2018年较2011—2013年高危孕产妇比重减少,但基本保健服务利用率降低。 结论 2003—2018年兰州市孕产妇保健工作取得了良好进展,但2016—2018年孕产妇死亡率仍高于全国平均水平,仍应继续加强孕产妇保健服务,提高妇女保健服务的利用度。     

Equity in health care access to: assessing the urban health insurance reform in China

This study evaluates changes in access to health care in response to the pilot experiment of urban health insurance reform in China. The pilot reform began in Zhenjiang and Jiujiang cities in 1994, followed by an expansion to 57 other cities in 1996, and finally to a nationwide campaign in the end of 1998. Specifically, this study examines the pre- and post-reform changes in the likelihood of obtaining various health care services across sub-population groups with different socioeconomic status and health conditions, in an attempt to shed light on the impact of reform on both vertical and horizontal equity measures in health care utilization.Empirical estimates were obtained in an econometric model using data from the annual surveys conducted in Zhenjiang City from 1994 through 1996. The main findings are as follows. Before the insurance reform, the likelihood of obtaining basic care at outpatient setting was much higher for those with higher income, education, and job status at work, indicating a significant measure of horizontal inequity against the lower socioeconomic groups. On the other hand, there was no evidence suggesting vertical inequity against people of chronic disease conditions in access to care at various settings. After the reform, the new insurance plan led to a significant increase in outpatient care utilization by the lower socioeconomic groups, making a great contribution to achieving horizontal equity in access to basic care. The new plan also has maintained the measure of vertical equity in the use of all types of care. Despite reform, people with poor socioeconomic status continue to be disadvantaged in accessing expensive and advanced diagnostic technologies. In conclusion, the reform model has demonstrated promising advantages over pre-reform insurance programs in many aspects, especially in the improvement of equity in access to basic care provided at outpatient settings. It also appears to be more efficient overall in allocating health care resources by substituting outpatient care for more expensive care at emergency or inpatient settings.     

The equity lens in the health care performance evaluation system

The main objective of this paper is to describe how indicators of the equity of access to health care according to socioeconomic conditions may be included in a performance evaluation system (PES) in the regional context level and in the planning and strategic control system of healthcare organisations. In particular, the paper investigates how the PES adopted, in the experience of the Tuscany region in Italy, indicators of vertical equity over time. Studies that testify inequality of access to health services often remain just a research output and are not used as targets and measurements in planning and control systems. After a brief introduction to the concept of horizontal and vertical equity in health care systems and equity measures in PES, the paper describes the ‘equity process’ by which selected health indicators declined by socioeconomic conditions were shared and used in the evaluation of health care institutions and in the CEOs' rewarding system, and subsequently analyses the initial results. Results on the maternal and child path and the chronicity care path not only show improvements in addressing health care inequalities, but also verify whether the health system responds appropriately to different population groups. Copyright © 2013 John Wiley & Sons, Ltd.     

The corporatization of health care: an evaluation and an alternative.

The corporatization of health care organizations has become a significant international trend. This paper examines that trend, comparing the development of corporate health care in the USA with the impact of the New Zealand health reforms. The paper traces the evolution of the organizations of health care systems and explains the emergence of the corporate form. We argue that the corporate model of work organization is unsuited to the complex and ambiguous nature of the medical task as it ignores inherent interdependencies. An alternative is needed which addresses work practices rather than just participation in decision making and is based on a concept of mutual interdependence and support in the execution of work.     

Vertical integration: the wave of the future?

In today's environment, health care facilities need to expend more resources in developing comprehensive and coordinated health care systems that provide, preferably on one site, ambulatory and acute care, long-term care, mental health, physical medicine and rehabilitation, home health, wellness centers, and an integrated prepayment plan as a joint venture with the institution's medical staff. The wave of the future (the next several years) will be toward vertical diversification because of increased price competition for a broad range of services, an industry with a surplus of acute care beds, and an interest by existing multihospital systems in improving their present positions by diversification rather than growth for growth's sake.     

China's health care sector in transition: resources, demand and reforms

Economic development and reforms have had profound impacts on China's health care sector. As a result, the health care sector in China is in transition. This report reviews the major changes, and the possible policy response to these changes in China's health care sector. It discusses resource availability in the Chinese health sector, and analyses the trend of household demand for health care goods and services. This study also examines the trade and investment situations in China's health sector and investigates the major forces that are driving the transition in health care and comments on the potential policy responses.     

中日老年服务模式的比较与思考

人口老龄化已成为21世纪一个世界性的问题。健康老龄化观点的提出,使老年人的医疗预防保健工作对老年护理的可持续发展问题提出了更高的要求。如何提高中国老年人的生命质量,增加生命的宽度,实现健康老龄化,已成了当前刻不容缓的新课题。本文通过对日本养老服务的初探,引发对中国社区老年保健工作的剖析与思考。