User charges for health care: a review of recent experience.
(9/1744)
This paper reviews recent experiences with increases in user charges and their effect on the utilization of health care. Evidence from several countries of differences in utilization between rich and poor is presented, and recent accounts of sharp, and often sustained, drops in utilization following fee increases, are presented and discussed. Fee income, appropriately used, represents a small but significant additional resource for health care. Recent national experiences appear to have concentrated on achieving cost recovery objectives, rather than on improving service quality and health outcomes. Appraisal of financing changes must be linked to probable health outcomes. Successful large-scale experience in linking these two is in short supply. (+info)
Gender, work and illness: the influence of a research unit on an agricultural community in The Gambia.
(10/1744)
Changes in employment opportunities and medical services are exploited by men and women in different ways. This paper examines gender-based variation in the selective use of employment and health opportunities in a Gambian village which has been the subject of medical and nutritional research by the Medical Research Council (MRC) for 43 years. The seasonal workloads of 105 men and women in Keneba were compared during one calendar year. Women carried a heavier burden of agricultural labour, while men had a higher rate of waged employment. The impact of the MRC field station on the local economy was assessed and evidence of associated male dependence on MRC employment found. Illness reporting patterns and the treatment choices of men and women were examined. Women made greater use of the MRC medical service, while men resorted more frequently to local remedies and healers. Female dependence on the MRC medical services is suggested by the data, and may be linked to the greater attention paid to them by researchers and medical practitioners. (+info)
The role of private medical practitioners and their interactions with public health services in Asian countries.
(11/1744)
This paper aims to review the role of private practitioners and their interactions with public health services in developing countries, focusing largely on the Asian region. Evidence on the distribution of health facilities, manpower, health expenditures and utilization rates shows that private practitioners are significant health care providers in many Asian countries. Limited information has been published on interactions between public and private providers despite their co-existence. Issues related to enforcement of regulations, human resources, patient referrals and disease notifications, are examined. (+info)
An innovative approach to reducing medical care utilization and expenditures.
(12/1744)
In a retrospective study, we assessed the impact on medical utilization and expenditures of a multicomponent prevention program, the Maharishi Vedic Approach to Health (MVAH). We compared archival data from Blue Cross/Blue Shield Iowa for MVAH (n = 693) with statewide norms for 1985 through 1995 (n = 600,000) and with a demographically matched control group (n = 4,148) for 1990, 1991, 1994, and 1995. We found that the 4-year total medical expenditures per person in the MVAH group were 59% and 57% lower than those in the norm and control groups, respectively; the 11-year mean was 63% lower than the norm. The MVAH group had lower utilization and expenditures across all age groups and for all disease categories. Hospital admission rates in the control group were 11.4 times higher than those in the MVAH group for cardiovascular disease, 3.3 times higher for cancer, and 6.7 times higher for mental health and substance abuse. The greatest savings were seen among MVAH patients older than age 45, who had 88% fewer total patients days compared with control patients. Our results confirm previous research supporting the effectiveness of MVAH for preventing disease. Our evaluation suggests that MVAH can be safely used as a cost-effective treatment regimen in the managed care setting. (+info)
A critical review of priority setting in the health sector: the methodology of the 1993 World Development Report.
(13/1744)
The 1993 World Development Report, Investing in Health, suggests policies to assist governments of developing countries in improving the health of their populations. A new methodology to improve government spending is introduced. Epidemiological and economic analyses from the basis for a global priority setting exercise, leading to a recommended essential public health and clinical services package for low- and middle-income countries. Ministries of Health in many countries have expressed an interest in designing a national package of essential health services, using the methodology. Given the apparent importance attached to the study and its far reaching potential consequences, this article provides an overview of the method, the main issues and problems in estimating the burden of disease as well as the cost-effectiveness of interventions. Strengths and weaknesses in the databases, value judgements and assumptions are identified, leading to a critical analysis of the validity of the priority setting exercise on the global level. (+info)
The prevalence and health burden of self-reported diabetes in older Mexican Americans: findings from the Hispanic established populations for epidemiologic studies of the elderly.
(14/1744)
OBJECTIVES: The prevalence and health burden of self-reported adult-onset diabetes mellitus were examined in older Mexican Americans. METHODS: Data from the Hispanic Established Populations for Epidemiologic Studies of the Elderly were used to assess the prevalence of self-reported diabetes and its association with other chronic conditions, disability, sensory impairments, health behaviors, and health service use in 3050 community-dwelling Mexican Americans 65 years and older. RESULTS: The prevalence of self-reported diabetes in this sample was 22%, and there were high rates of obesity, diabetes-related complications, and diabetic medication use. Myocardial infarction, stroke, hypertension, angina, and cancer were significantly more common in diabetics than in nondiabetics, as were high levels of depressive symptoms, low perceived health status, disability, incontinence, vision impairment, and health service use. Many of the rate differences found in this sample of older Mexican Americans were higher than those reported among other groups of older adults. CONCLUSIONS: Our findings indicate that the prevalence and health burden of diabetes are greater in older Mexican Americans than in older non-Hispanic Whites and African Americans, particularly among elderly men. (+info)
The case of disability in the family: impact on health care utilization and expenditures for nondisabled members.
(15/1744)
Families with a disabled member undergo heightened emotional and financial stress, which can arise from caring for the person with one or more disabilities over the life course or at the end of life. Because health care resources are strained by the needs of the disabled family member, nondisabled members are often limited in health care access and utilization when they are most in need of care. This analysis uses the National Medical Expenditure Survey to describe families with disabled members, based on multiple definitions of disability, and to examine health care utilization and expenditures by nondisabled family members. Indications of higher use of medical care by adult, nondisabled members of such families support the frequent reports in the literature of stress occurring in these situations. The signals of a household rationing effect for families near and at poverty levels should alert policy makers to consider the needs of the whole family when creating or modifying assistance programs. (+info)
Effect of incentives on the use of indicated services in managed care.
(16/1744)
In managed care, financial incentives and utilization review create conflicts of interest for physicians. We sought to determine whether these incentives would lead physicians to deny indicated services. We surveyed internists practicing in areas with at least 30% penetration of managed care. Our questionnaire included four scenarios in which a test or referral is indicated according to clearly established practice guidelines. We randomly assigned physicians to receive one of five versions of the questionnaire, which differed only in the type of reimbursement incentive and utilization review that applied to the scenarios. We received responses from 710 (70%) of 1,009 internists. Although physicians underutilized services regardless of incentives in all scenarios, physicians whose questionnaires depicted full capitation said that they would order fewer services than physicians whose questionnaires depicted fee-for-service. In the scenario in which an x-ray of the lumbosacral spine is indicated for a patient with low back pain, 86% of physicians randomized to the full capitation version said that they would order the test compared to 94% in the fee-for-service version. Similarly, physicians randomized to scenarios requiring utilization review said that they would order fewer services than those randomized to scenarios requiring completion of an insurance form. Scenarios depicting managed care incentives caused consistent, modest underutilization compared to fee-for-service scenarioes, although physicians underutilized services under all financial incentives and utilization review. In response, physicians must develop better methods for detecting underutilization and devise programs to increase the provision of indicated services. (+info)