Primary care physicians' attitudes to health care reform in England

Primary care organisation in England has been subject to particularly extensive and far-reaching reform in recent years. In 1991, a quasi-market was introduced into the National Health Service and general practitioners were offered the opportunity to manage independent budgets from which to purchase and deliver care services. Practitioners joined the scheme in increasing numbers, although it was eventually abandoned following a change of government in 1997. This paper reports the results of two surveys of primary care physicians' opinions on the English health care reforms, conducted in 1997 and 2000. It concludes that, first, those opting for discretionary budgets were significantly more supportive of the policy than those not joining the scheme and this support continued long after the scheme had been abolished. Second, professional attitudes, with respect to other terms of service in primary care, remained homogenous to a considerable degree over time. Finally, physicians in favour of imposing user charges tend to be those with responsibility for more patients, suggesting a perceived need to manage patient demand.     

Factors affecting primary care physicians' perceptions of health system reform in Israel: professional autonomy versus organizational affiliation

This paper examines primary care physicians' perceptions of a National Health Insurance Law that introduced managed competition into Israel's health care system, and the factors affecting their perceptions. Between April and July 1997, we conducted a mail survey of primary care physicians employed by Israel's four health plans (which are managed care organizations). Eight hundred questionnaires were returned, representing a response rate of 86%. The findings indicate that, overall most physicians support the components of the National Health Insurance Law with statistically significant differences among physicians by health plan. Multivariate analysis revealed that, contrary to theoretical expectations, a perceived decrease in professional autonomy and in the status of the profession following reform did not significantly affect attitudes toward national health insurance. These findings highlight the need for additional empirical studies to further examine theoretical contentions about the implications of infringing on the professional autonomy and the dominant status of physicians. The principal and most interesting finding of this study was the independent effect of health plan affiliation on physicians' attitudes toward each of the five components of the National Health Insurance Law, after controlling for background characteristics, for the reform's perceived effect on the physicians' autonomy and status in the health plan, and for the reform's perceived effect on the level of health plan services and the health plan's financial situation. We found that physicians' perceptions tended to conform to the formal position of their health plan, suggesting the need to analyze the attitudes of physicians in their organizational context, rather than treating them as members of a uniform professional community.     

The political economy of health system reform in Israel

On June 15, 1994, the Israeli Parliament voted to enact the National Health Insurance bill (NHI). The bill marks the end of a process that lasted for virtually as long as Israel's almost 50 year history. Israel's attempts at health reform began long before the current spate of reforms in many Western countries. Faced with many of the same problems of access, equity and cost control common to many of its counterparts, Israel initiated a reform process based on the recommendations of a prominent State Commission of Inquiry into the Israeli Health System (the Netanyahu Commission) which reported to the Government in 1990.² The Commission's proposals were based on a diagnosis indicating that the major problems of the system stem from the lack of clarity regarding the rights of citizens to health care, the lack of a clear allocation of responsibility and accountability among government, insurance or sick funds, and providers in the system, and undue centralization of system operations. This diagnosis led to three major planks for reform: (1) enactment of national health insurance legislation granting a basic package of care to each citizen and hence bringing most of the system's finance under public auspices; (2) divesting the Government from the organization, management and provision of care; hence integrating the management of preventive and psychiatric services provided by the government with the primary and other services provided by sick funds, and granting financial and operational independence to at least government hospitals; and (3) restructuring the Ministry of Health. As is often the case in public policy, more consensus surrounds the diagnosis than the solutions. As a result, nearly four years of implementation efforts have only recently resulted in a major breakthrough. In this paper we make an effort to outline the inherent weaknesses of the Israeli health care system that have led to the crisis in the mid 1980s, summarize the recommendations of the State Commission for structural change in the system, and review the politics of implementing the recommended reforms.     

Physicians' attitudes towards prevention: importance of intervention-specific barriers and physicians' health habits

BACKGROUND: Several studies have explored physicians' attitudes towards prevention and barriers to the delivery of preventive health interventions. However, the relative importance of these previously identified barriers, both in general terms and in the context of a number of specific preventive interventions, has not been identified. Certain barriers may only pertain to a subset of preventive interventions. OBJECTIVES: We aimed to determine the relative importance of identified barriers to preventive interventions and to explore the association between physicians' characteristics and their attitudes towards prevention. METHODS: We conducted a cross-sectional survey of 496 of the 686 (72.3% response rate) generalist physicians from three Swiss cantons through a questionnaire asking physicians to rate the general importance of eight preventive health strategies and the relative importance of seven commonly cited barriers in relation to each specific preventive health strategy. RESULTS: The proportion of physicians rating each preventive intervention as being important varied from 76% for colorectal cancer screening to 100% for blood pressure control. Lack of time and lack of patient interest were generally considered to be important barriers by 41% and 44% of physicians, respectively, but the importance of these two barriers tended to be specifically higher for counselling-based interventions. Lack of training was most notably a barrier to counselling about alcohol and nutrition. Four characteristics of physicians predicted negative attitudes toward alcohol and smoking counselling: consumption of more than three alcoholic drinks per day [odds ratio (OR) = 8.4], sedentary lifestyle (OR = 3.4), lack of national certification (OR = 2.2) and lack of awareness of their own blood pressure (OR = 2.0). CONCLUSIONS: The relative importance of specific barriers varies across preventive interventions. This points to a need for tailored practice interventions targeting the specific barriers that impede a given preventive service. The negative influence of physicians' own health behaviours indicates a need for associated population-based interventions that reduce the prevalence of high-risk behaviours in the population as a whole.     

AIDS: family physicians' attitudes and experiences

A study was developed to examine the current experiences and opinions of a national sample of family physicians with regard to acquired immunodeficiency syndrome (AIDS). The survey response rate was 72.5% (757 questionnaires were returned out of a sample of 1044). Approximately 47% of respondents have cared for an HIV-infected patients. This percentage varied from a low of 31.4% in the Midwest to as high as 56.1% on the East Coast. Thirty-two percent of family physicians practicing in communities of fewer than 2500 have dealt with this illness, while 60% of those in communities of greater than 100,000 have done so. Seventy-seven percent of respondents are willing to provide care to HIV-infected individuals; 62.9% believe that physicians have a right to refuse to care for a patient because he or she is infected with the AIDS virus. Forty percent believe that they would lose patients if it were known that they were caring for an AIDS patient in their office. Finally, the vast majority of those surveyed favor required partner notification and would inform the sexual partner of an HIV-positive patient if the patient refused to do so.     

Dually-eligible working-age adults with disabilities: Issues and challenges as health reform is implemented

This special section on working-age adults with disabilities dually eligible for Medicare and Medicaid is based on two panel presentations at the June 2012 meeting of the AcademyHealth Disability Research Interest Group. The papers included here consider the issues of health care access and outcomes as well as employment for this group of approximately four million individuals, many with complex health care needs and high costs.     

Impact of health care system on physicians' discontent

This study was designed to investigate the impact of physicians' perceptions of the health care system on their discontent with their profession. By using a random digit dialing technique, a structured telephone interview was conducted with 401 generalist physicians (343 men, 56 women) who were practicing medicine at least for five years and were younger than 65 years. Physicians' willingness to choose medicine again was correlated with their perceptions of different aspects of the health care system. Of the total participants, 288 (72 percent) indicated that they would choose medicine again, 91 (23 percent) would not choose medicine, and 22 (5 percent) were not sure. Results of the stepwise logistic regression showed that after adjustment for physicians' gender and age, those who would not choose medicine again were more than twice as likely as other physicians who would choose medicine to believe that the health care environment will deteriorate more in the future (odds ratio = 2.1, p < .01), were less than half as likely to believe that physicians nowadays share more responsibilities with other health care professionals (odds ratio = .42, p < .01), and were less than half as likely to confirm that patients understand their health insurance better than before (odds ratio = .46, p < .01). Findings suggest that physicians' discontent can be predicted by their negative perceptions of the health care environment. Findings have implications for improving the quality of professional and personal life of the physician, thus improving the quality of care and satisfaction of the patient.     

Abortions in rural Idaho: physicians' attitudes and practices.

This study surveyed all family physicians, obstetrician-gynecologists, and general surgeons practicing in rural Idaho in 1994. Although most respondents provided a wide range of reproductive health services, less than 4% performed abortions, so most rural Idaho women wanting abortions must travel long distances for this procedure. Physicians report that they do not provide abortion services because of both their own moral objections and local community opposition to the procedure. Yet 26% of the respondents indicated interest in using RU-486 for abortions when it becomes available. This suggests that the development of acceptable medical abortifacients may improve access to this procedure even in very conservative rural areas.     

医药卫生体制改革需要帕累托改进

帕累托改进存在和作用于社会的一切领域,同样也适用于当前正在深入进行的医药卫生体制改革。具体地说,是需要对一些政策作出更具“刚性”的规定,特别是对公共卫生机构和基层医疗机构的财政补助政策要“硬化”、对公立医院的财政补助政策要“实化”、对卫生人员的经费补助政策要“细化”。     

Prevention in Poland: health care system reform.

Despite the political and economic reforms that have swept Eastern Europe in the past 5 years, there has been little change in Poland''s health care system. The Ministry of Health and Social Welfare has targeted preventive care as a priority, yet the enactment of legislation to meet this goal has been slow. The process of reform has been hindered by political stagnation, economic crisis, and a lack of delineation of responsibility for implementing the reforms. Despite the delays in reform, recent developments indicate that a realistic, sustainable restructuring of the health care system is possible, with a focus on preventive services. Recent proposals for change have centered on applying national goals to limited geographic areas, with both local and international support. Regional pilot projects to restructure health care delivery at a community level, local health education and disease prevention initiatives, and a national training program for primary care and family physicians and nurses are being planned. Through regionalization, an increase in responsibility for both the physician and the patient, and redefinition of primary health care and the role of family physicians, isolated local movements and pilot projects have shown promise in achieving these goals, even under the current budgetary constraints.     

医疗体制改革的理论思考

近来有关中国医疗体制改革的讨论，逐渐涉及公共经济学、卫生经济学理论层面的一些基本理念和基础概念，解决中国医疗体制改革缺陷的不少主张，也因为对基本理论、概念的混淆和对医改问题的历史成因认识不清，而对医疗服务中政府与市场作用的边界，以及在公平与效率的关系上陷入形而上学的思维方式。因此，有必要从理论和历史的视角上正确理解医疗服务性质、合理定位医疗体制改革，避免出现将政府作用神化和市场作用神化两个极端，重新厘定政府与市场、公平与效率在医疗体制改革进程中的均衡。     

Dimensions of health system reform

During recent years there has been a growth of worldwide interest in health system reform. Countries at all levels of economic development are engaged in a creative search for better ways of organizing and financing health care, while promoting the goals of equity, effectiveness, and efficiency. Together with economic, political, and ideological reasons, this search has been fueled by the need to find answers to the complexities posed by the epidemiologic transition, whereby many nations are facing the simultaneous burdens of old, unresolved problems and new, emerging challenges. In order to better understand reform attempts, it is necessary to develop a clear conception of the object of reform: the health system. This paper presents the health system as a set of relationships among five major groups of actors: the health care providers, the population, the state as a collective mediator, the organizations that generate resources, and the other sectors that produce services with health effects. The relationships among providers, population, and the state form the basis for a typology of health care modalities. The type and number of modalities present in a country make it possible to characterize its health system. In the last part, the paper proposes that health system reform operates at four policy levels: systemic, which deals with the institutional arrangements for regulation, financing, and delivery of services; programmatic, which specifies the priorities of the system, by defining a universal package of health care interventions; organizational, which is concerned with the actual production of services by focusing on issues of quality assurance and technical efficiency; and instrumental, which generates the institutional intelligence for improving system performance through information, research, technological innovation, and human resource development. The dimensions of reform offer a repertoire of policy options, which need to be enriched by cross-national comparison of experiences and rigorous social experimentation. Maybe then reform will be a more systematic effort, and nations will be better able to learn from each other.     

Health promotion: physicians' beliefs, attitudes, and practices

There is a paucity of research describing the health-promotion beliefs, attitudes, and practices of physicians. Self-reported data from a survey of 1,040 primary care physicians showed that a majority of physicians (97 percent) believed they should modify patients' behaviors to minimize risk factors and rated a variety of health behaviors as important in promoting health. While most physicians gathered information about risk factors and believed they were prepared to counsel patients, only a small percentage (3-18 percent) reported being very successful in helping patients achieve behavioral change. However, given appropriate support, physicians reported that they could be up to six times more successful in influencing behavioral change. This study indicated that physicians have strong beliefs and interests in health promotion, are interested in continuing education about health promotion topics, and desire a variety of new skills to help patients modify their health behaviors.     

英国全民医疗服务体系的改革及启示

一、英国全民医疗服务体系（National Health Service System,NHS）简介英国是最早实行全民免费医疗保障的国家,早在《贝弗里奇报告》出台之后,英国就设计了＂从摇篮到坟墓＂的一整套福利政策。     

以色列政府主导下的市场化医疗保障体系

介绍以色列医疗保障体系的保障范围和机构组成、经费的筹集和管理以及各机构的职能和相互关系。说明以色列的医疗保障体系是由政府主导，筹集经费，通过医疗保险公司完成付费和监督，从而让医院和诊所实现医疗健康保障任务的医疗保障系统。由于医疗保险公司之间、医院之间、医疗保险公司与医院之间存在政府监控下的商业化竞争，从而使整个体系得以经济有效地运行。