Evidence-based purchasing of health promotion: methodology for reviewing evidence

In recent years, greater emphasis has been placed on evidence-basedpractice by health care purchasers, managers and practitionersaround the world. This is seen as a means of delivering greaterbenefits to patients and populations within existing resources.Evidence-based practice requires accessible information in aform that is relevant to the problems decision-makers face.The process of evidence-based practice needs to be informedby the best available research evidence of the effectivenessof health-promoting interventions combined with good judgementas to the applicability of that evidence and the feasibilityof implementation in the local context. The nature of evidencewhich can be brought to bear on the decision-making processmay vary in both quality and reliability. In the field of healthpromotion, the nature of problems requiring solutions is complex.Commonly there are multiple variables affecting multiple healthoutcomes. In addition, there is limited available evidence forthe effectiveness of interventions and it is of variable quality.These factors pose problems for ensuring evidence-based healthpromotion. This article describes New Zealand research commissionedby one of four regional purchasers of health services. The purchaserrequired the development of a framework to prioritize interventionsin 22 health promotion areas identified as priorities by theMinister of Health. Our framework was used to consider a broadrange of different kinds of evidence, including scientific research,organizational capacity, socio-cultural factors and local community-basedknowledge related to the determinants of health. Making explicitthe nature of our framework and the evidence we considered,enabled our recommendations about the most appropriate interventionsto be as valid and reliable as possible. Our judgement is thatas for evidence-based medicine, evidence-based health promotionmust employ both quantitative and qualitative evidence, andthat the final judgement about purchasing of health promotioninitiatives is essentially subjective and political.     

PBMA (programme budgeting marginal analysis)--its role in the future purchasing arrangements for health care services

The movement of the purchasing process in health care from a central to local level has to be accompanied by an accountability process which makes local purchasers accountable within an agreed national and area framework for their decisions and implementation of change. This paper focuses on PBMA and its applicability to health boards and general practitioner fundholders in future purchasing arrangements. It is argued that it is a useful tool which may provide a basis for more rational discussion about use of resources, both at a micro and macro level, than the current arrangements.     

Pricing health services for purchasers--a review of methods and experiences

This article reviews methodologies and international experience related to costing and pricing health services for health care purchasers. The main factors affecting price-setting methods are: (1) provider payment systems; (2) information available on actual costs, service volumes and outcomes; and (3) characteristics of providers and purchasers. These factors are strongly interrelated. Provider payment systems determine the unit of services to be priced. In order to minimize incentives for under- or over-utilization, the prices that purchasers pay for health care services should be related to the actual unit costs of services, but accurately calculating real unit costs is intensive in terms of resources and information. Pertinent provider characteristics influencing price-setting include provider autonomy, provider negotiating power, and the degree of competition. The article presents a series of examples that run through each of these three sets of factors. The examples are from Denmark, the UK, and Thailand (for capitation); Australia, Hungary, and the United States (for case-based payment); and Germany, Korea, and Taiwan (for fee-for-service payment mechanisms). From these experiences, the article concludes with appropriate lessons for low- and middle-income countries, where the principal constraint on the development of provider payments systems is the limited availability of information on costs, volumes, and patient characteristics.     

Prioritizing "psychological" consequences for disaster preparedness and response: a framework for addressing the emotional, behavioral, and cognitive effects of patient surge in large-scale disasters

While information for the medical aspects of disaster surge is increasingly available, there is little guidance for health care facilities on how to manage the psychological aspects of large-scale disasters that might involve a surge of psychological casualties. In addition, no models are available to guide the development of training curricula to address these needs. This article describes 2 conceptual frameworks to guide hospitals and clinics in managing such consequences. One framework was developed to understand the antecedents of psychological effects or "psychological triggers" (restricted movement, limited resources, limited information, trauma exposure, and perceived personal or family risk) that cause the emotional, behavioral, and cognitive reactions following large-scale disasters. Another framework, adapted from the Donabedian quality of care model, was developed to guide appropriate disaster response by health care facilities in addressing the consequences of reactions to psychological triggers. This framework specifies structural components (internal organizational structure and chain of command, resources and infrastructure, and knowledge and skills) that should be in place before an event to minimize consequences. The framework also specifies process components (coordination with external organizations, risk assessment and monitoring, psychological support, and communication and information sharing) to support evidence-informed interventions.     

A missing link? Workforce demand as the link between two health care related markets

Examines the links between workforce demand and two health care related markets, the first being the internal market between purchasers and providers of health care, and the second the market for education expressed between colleges of education as providers and NHS Trusts as purchasers of the courses. Workforce demand has to take account of the numbers of people on courses, but also specialist skills required to enable NHS Trusts to deliver changing health care needs of the future.     

The quality of health purchasing

Much has been written about quality in patient care and clinical support services, but very little about the quality of purchasing. This paper gives an overview of quality issues in purchasing, and offers guidelines and practical steps for purchasers to improve service quality--both their own and their providers'. It defines quality in purchasing and considers how purchasers can influence markets and work with providers to improve health services quality. The paper gives practical guidance for improving quality, which recognises the limited resources and skills which purchasers have for the task. It addresses some issues raised by purchaser/managers: How does a purchasing organisation measure and improve quality? Is there a better way of specifying and monitoring quality than the "shopping-list of standards" approach--what should be asked of providers? How can information about clinical quality, outcome and costs, be obtained in a form in which reliable comparisons can be made? Is quality accreditation or registration a good predictor of future quality?     

A Framework for Assessing the Performance of Integrated Health Delivery Systems

Competing demands for resources within the health care system require health care providers to ensure the most effective and efficient use of resources. The evidence from the United States, the United Kingdom and other jurisdictions suggests that integrated health delivery systems (IDS) may be a cost-effective way to meet the health care needs of a population. This article introduces a framework for use in monitoring and evaluating the performance of an integrated delivery system. The establishment of a consistently used evaluation framework for integrated delivery systems will provide the government, governing bodies and other evaluators with an effective assessment tool that will enable greater understanding of the impact of the IDS on the health care system. It will also provide information to enable ongoing performance improvements within the system.     

Needs assessment needs assessment...

Needs assessment is now a high priority, but it is conceptually muddled and technically difficult. In the past a variety of academic disciplines addressing different aspects of health care have produced a range of definitions on 'need' applicable to their own setting. In the context of the National Health Service Review, 'need' may best be defined as the ability to benefit from 'health care', which depends both on morbidity and on the effectiveness of care. An analysis of its relationship with 'demand', which is the health care that people ask for, and 'supply', which is provided, exposes the limitations of current information sources, and confirms that the formal assessment of needs will inevitably be a lengthy task. Despite these difficulties there is much that can and should be done incrementally to influence contracts between providers and purchasers towards meeting health care needs.     

Providing health care to Latino immigrants: community-based efforts in the rural midwest

We examined case studies of 3 rural Midwestern communities to assess local health care systems' response to rapidly growing Latino populations. Currently, clinics provide free or low-cost care, and schools, public health, social services, and religious organizations connect Latinos to the health care system. However, many unmet health care needs result from lack of health insurance, limited income, and linguistic and cultural barriers. Targeted safety net funding would help meet Latino health care needs in rural communities with limited resources.     

Core services and priority-setting: the New Zealand experience

Like people in other countries, New Zealanders have been struggling with the issue of how to decide which health services should be delivered and to whom. The government has established a Core Services Committee to advise on core services, that is, those health care and disability support services to be made available on affordable terms and without unreasonable waiting time. Such a core has a similar role to a standard package of benefits within a managed competition framework. Services not in the core would be left to individuals' own responsibility. Specific objectives for a core are to promote accountability of purchasers, to make explicit the services that are core and those that are not, to promote an efficient and equitable allocation of resources, to limit government expenditure on health care and to involve the public in decision-making. A number of different options for defining a core are identified, and the work undertaken so far is discussed. The original concept of a core has not been implemented in New Zealand. The Core Services Committee has established broad priorities and facilitated a series of consensus development conferences to provide advice on the effectiveness of services. Some of the committee's recommendations have been incorporated into policy guidelines, which set out what the government expects of purchasers. These guidelines include priority areas for health gains, service obligations and principles for purchasing. Service obligations are not sufficiently detailed to meet the specific objectives of a core and do not meet equity objectives, as they allow in effect each of the four purchasers to develop their own core of services. The key issue for the government now is to decide whether to allow RHAs flexibility in determining their own priorities or whether a national approach to efficiency and equity is to be preferred.     

The purchaser-driven reformation in health care: alternative approaches to leveling our cathedrals

Slowly mounting interest in the provider community in delivery system reform badly underestimates the extent to which major reconfiguration is already being engineered by aggressive purchasers. The once widely held view that provider-sponsored integrated firms represent the ideal health care system is being challenged by purchasers who are crafting, through short- and long-term selective contracting, provider networks that offer many of the same advantages ascribed to integrated firms. Three alternative approaches to restructuring delivery systems are examined and appraised in terms of how each may or may not be able to satisfy purchaser demands. The relentless pursuit of better cost management will have profound consequences for health care providers and their managers. Major redeployment of resources will occur as the industry converts from a hospital-centered to a continuum of care-centered management philosophy.     

Economics, public health and health care purchasing: reinventing the wheel?

In this paper, a framework for using economics in health care priority setting is outlined. This framework is known as programme budgeting and marginal analysis (PBMA). Programme budgeting involves an assessment of how health care resources are currently distributed amongst programmes and within programmes. Such data can be used along with other information on local needs to decide on the main areas of change in service delivery. As resources are fixed, areas of change requiring more resources will be funded from service reductions within the same programme or within another programme. Candidates for more resources should be compared with each other and with candidates for service reduction to determine whether and what changes should go ahead. This involves 'marginal analysis' of costs and benefits of the candidates. In the paper, the problems with implementing this approach are outlined and the contribution of the other papers in the volume described.     

Identifying needs and setting priorities: issues of theory, policy and practice

The National Health Service and Community Care Act 1990 signalled an explicit shift away from a service-driven to a needs-led pattern of delivery for both health and social care. However, a definitive meaning of ‘need’ is elusive. Where the work of health and social care agencies is related closely, as in community care, recognition and careful handling of different approaches to need is important for effective inter-sectoral collaboration and supply of appropriate care to service users. This paper examines three dimensions of need: theory, policy and practice. Some key components of the theoretical debate about the meaning of ‘need’ are explored briefly, particularly in relation to health, and a set of questions is extracted that underpin the construction of need in policy and practice. These questions are then applied to a comparison of policy guidance documents for needs assessment for health and social (community) care. While the documents demonstrate some similarities in their view of need, there are also material differences. These differences have implications for the supply of services at the boundary between health and social care, some examples of which are discussed. Given a lack of consensus in defining and measuring need, the paper concludes with a framework of key questions which could enable purchasers and providers of health care to be more explicit about the bases upon which ‘needs-led’ services are defined and delivered.     

Quality-of-Care Challenges for Rural Health

The purpose of this article is to examine the issue of quality of care in rural America and to help others examine this issue in a way that is consistent with the very real challenges faced by rural communities in ensuring the availability of adequate health services. Rural citizens have a right to expect that their local health care meets certain basic standards. Unless rural providers can document that the quality of local health care meets objective external standards, third-party payers might refuse to contract with rural providers, and increasingly sophisticated consumers might leave their communities for basic medical care services. To improve the measurement of health care quality in a rural setting, a number of issues specific to the rural environment must be addressed, including small sample sizes (volume and outcome issues), limited data availability, the ability to define rural health service areas, rural population preferences and the lower priority of formal quality-of-care assessment in shortage areas. Several current health policy initiatives have substantial implications for monitoring and measuring the quality of rural health services. For example, to receive community acceptance and achieve fiscal stability, critical access hospitals (CAHs) must be able to document that the care they provide is at least comparable to that of their predecessor institutions. The expectations for quality assurance activities in CAHs should consider their limited institutional resources and community preferences. As managed care extends from urban areas, there will be an inevitable collision between the ability to provide care and the ability to measure quality. As desirable as it might be to have a national standard for health care quality, this is not an attainable goal. The spectrum and content of rural health care are different from the spectrum and content of care provided in large cities. Accrediting agencies, third-party carriers and health insurance purchasers need to develop rural health care quality standards that are practical, useful and affordable.     

Health and immigration: new situations and challenges

The new social and demographic framework in Spain that has appeared since the arrival of new migrant populations, raises the need to improve the knowledge of their health status and to identify preventive measures and priorities in heath services.A bibliographic review of the available information on migration and health in Spain is performed, together with an analysis of their contents from a Public Health point of view. The high proportion of new borns from foreign mothers, the mental needs, deficits in oral and dental health, and the increase of tuberculosis in migrants, together with limited vaccine coverage in children, define the main health needs of these populations. The analysis of health services, reveals a high use of pediatric, obstetric and gynecologic resources by migrant populations. Conclusions; although no particular health needs have been identified for migrants, special attention for tuberculosis, mother and child health and health promotion and prevention, have to be funded for specific migrant populations. Health resources and services have to be reinforced with health agents, human resources, and specialized education for health professionals.     

Specifying quality in health care

Quality should be a central issue in the commissioning and provision of health care. This requires a systematic approach to defining and monitoring quality. Such an approach should address: quality characteristics such as efficiency, accessibility, effectiveness (which may conflict with each other); the several levels at which quality may be specified, from general (across all health care) to specific (particular conditions or patient groups); and the methods of quality monitoring which include documented policies, clinical audit, inspection visits/patient surveys, and routine information returns. Shows how a matrix for quality surveillance can be devised which provides a framework for purchasers and providers to work together in developing quality in health care.     

Quality of care in decentralized primary care clinics: a conceptual framework

In an attempt to provide high quality medical care, despite limited resources, health care providers in various countries have introduced decentralization into their health care services. It has been assumed that the delegation of authority to the local levels of the organization will enhance their ability to respond to local needs, and improve cost containment without compromising the quality of care. However, to date, few empirical studies have explored the relationship between decentralization and such projected outcomes. In this article we present a conceptual framework for analyzing possible consequences of decentralization on dimensions of quality of primary health care. We also suggest a framework for defining decentralization programs by their key components, and employ these frameworks to analyze a specific decentralization program being implemented in Israel's largest health maintenance organization (HMO). While we identify the dimensions most likely to be affected, we also conclude that data presently available do not permit a definitive prediction of whether the overall effect of decentralization on quality of care will be positive or negative. The potential reaction of a unit to the elements of change introduced by a decentralization program is influenced by the structural, cultural and management characteristics of that unit. Therefore, future attempts to decentralize health care organizations should be accompanied by close monitoring.     

The Business Case for Preconception Care: Methods and Issues

Only a limited number of economic evaluations have addressed the costs and benefits of preconception care. In order to persuade health care providers, payers, or purchasers to become actively involved in promoting preconception care, it is important to demonstrate the value of doing so through development of a “business case”. Perceived benefits in terms of organizational reputation and market share can be influential in forming a business case. In addition, it is standard to include an economic analysis of financial costs and benefits from the perspective of the provider practice, payer, or purchaser in a business case. The methods, data needs, and other issues involved with preparing an economic analysis of the likely financial return on investment in preconception care are presented here. This is accompanied by a review or case study of economic evaluations of preconception care for women with recognized diabetes. Although the data are not sufficient to draw firm conclusions, there are indications that such care may yield positive financial benefits to health care organizations through reduction in maternal and infant hospitalizations. More work is needed to establish how costs and economic benefits are distributed among different types of organizations. Also, the optimum methods of delivering preconception care for women with diabetes need to be evaluated. Similar assessments should also be conducted for other forms of preconception care, including comprehensive care.     

Publicly disclosed information about the quality of health care: response of the US public

Public disclosure of information about the quality of health plans, hospitals, and doctors continues to be controversial. The US experience of the past decade suggests that sophisticated quality measures and reporting systems that disclose information on quality have improved the process and outcomes of care in limited ways in some settings, but these efforts have not led to the "consumer choice" market envisaged. Important reasons for this failure include limited salience of objective measures to consumers, the complexity of the task of interpretation, and insufficient use of quality results by organised purchasers and insurers to inform contracting and pricing decisions. Nevertheless, public disclosure may motivate quality managers and providers to undertake changes that improve the delivery of care. Efforts to measure and report information about quality should remain public, but may be most effective if they are targeted to the needs of institutional and individual providers of care.