Viewpoint: public versus private health care delivery: beyond the slogans.
In most settings, a 'public' health service refers to a service which belongs to the state. The term 'private' is used when health care is delivered by individuals and/or institutions not administered by the state. In this paper it is argued that such a distinction, which is based on the institutional or administrative identity of the health care provider, is not adequate because it takes for granted that the nature of this identity automatically determines the nature of the service delivered to the population. A different frame of classification between public and private health services is proposed: one which is based on the purpose the health service pursues and on the outputs it yields. A set of five operational criteria to distinguish between health services guided by a public or private purpose is presented. This alternative classification is discussed in relation to a variety of existing situations in sub-Saharan Africa (Mali, Uganda, Zimbabwe). It is hoped that it can be used as a tool in the hands of the health planner in order to bring more rationality in the current altercation between the public and the private health care sector. (+info)
The myths of emergency medical care access in the managed care era.
In this paper, we examine the perception that emergency care is unusually expensive. We discuss the myths that have fueled the ineffective and sometimes deleterious efforts to limit access to emergency care. We demonstrate the reasons why these efforts are seriously flawed and propose alternate strategies that aim to improve outcomes, including cooperative ventures between hospitals and managed care organizations. We challenge managed care organizations and healthcare providers to collaborate and lead the drive to improve the cost and clinical effectiveness of emergency care. (+info)
Outcomes research: collaboration among academic researchers, managed care organizations, and pharmaceutical manufacturers.
Medical and pharmaceutical outcomes research has been of increasing interest in the past 10 to 15 years among healthcare providers, payers, and regulatory agencies. Outcomes research has become a multidisciplinary field involving clinicians, health services researchers, epidemiologists, psychometricians, statisticians, psychologists, sociologists, economists, and ethicists. Collaboration among researchers in different organizations that offer different types of services and various research expertise is the essential element for any successful outcomes project. In this article we discuss collaboration on outcomes research among academic researchers (mainly those who work in colleges of pharmacy), managed care organizations, and research-based pharmaceutical manufacturers, with a focus on the opportunities and challenges facing each party. The pharmaceutical industry needs information to make product and promotion decisions; the managed care industry has data to offer but needs analysis of these data; and pharmacy schools, among other academic institutions, have skilled researchers and data-processing capacity but require projects for revenue, research training, experience, and publications. Challenges do exist with such endeavors, but collaboration could be beneficial in satisfying the needs of the individual parties. (+info)
The effects of group size and group economic factors on collaboration: a study of the financial performance of rural hospitals in consortia.
STUDY QUESTIONS: To determine factors that distinguish effective rural hospital consortia from ineffective ones in terms of their ability to improve members' financial performance. Two questions in particular were addressed: (1) Do large consortia have a greater collective impact on their members? (2) Does a consortium's economic environment determine the degree of collective impact on members? DATA SOURCES AND STUDY SETTING: Based on the hospital survey conducted during February 1992 by the Robert Wood Johnson Hospital-Based Rural Health Care project of rural hospital consortia. The survey data were augmented with data from Medicare Cost Reports (1985-1991), AHA Annual Surveys (1985-1991), and other secondary data. STUDY DESIGN: Dependent variables were total operating profit, cost per adjusted admission, and revenue per adjusted admission. Control variables included degree of group formalization, degree of inequality of resources among members (group asymmetry), affiliation with other consortium group(s), individual economic environment, common hospital characteristics (bed size, ownership type, system affiliation, case mix, etc.), year (1985-1991), and census region dummies. PRINCIPAL FINDINGS: All dependent variables have a curvilinear association with group size. The optimum group size is somewhere in the neighborhood of 45. This reveals the benefits of collective action (i.e., scale economies and/or synergy effects) and the issue of complexity as group size increases. Across analyses, no strong evidence exists of group economic environment impacts, and the environmental influences come mainly from the local economy rather than from the group economy. CONCLUSION: There may be some success stories of collaboration among hospitals in consortia, and consortium effects vary across different collaborations. RELEVANCE/IMPACT: When studying consortia, it makes sense to develop a typology of groups based on some performance indicators. The results of this study imply that government, rural communities, and consortium staff and steering committees should forge the consortium concept by expanding membership in order to gain greater financial benefits for individual hospitals. (+info)
Barriers to guideline adherence. Based on a presentation by Michael Cabana, MD.
Successful implementation of the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI) should improve quality of care by decreasing inappropriate variation and by disseminating new advances to everyday practice. A key component of this process is physician adherence to JNC-VI guidelines. However several reports in the literature show a discrepancy between hypertension guidelines and actual practice. The factors that influence physician behavior change and optimal use of practice guidelines are poorly understood. A combined model that uses the Awareness-to-Adherence Model and Social Cognitive Theory identifies five sequential steps that lead to adherence to a guideline--awareness, agreement, self-efficacy, outcome expectancy, and presence of a cueing mechanism. Barriers to implementation may occur at any of these steps and can be identified with this model. Programs can then be designed to overcome specific barriers. By conceptualizing the underlying issues in physician adherence, the combined model should be useful to guideline developers, practice directors, and health services researchers. (+info)
Hypertension and managed care. Based on a presentation by Robert P. Jacobs, MD, MBA.
A shift in principles has accompanied the evolution of healthcare delivery from a fee-for-service system to managed care. Managed care organizations have to make decisions on the allocation of healthcare resources that will enhance the care of the entire population. Cost reduction has been a major driver for managed care, but this is increasingly being supplanted by other goals such as increasing the quality of care and the value of health services and providing accountability. As the population ages, management of chronic lifelong illness will pose an increasing challenge. Hypertension is a common chronic illness that, if left untreated, imposes an enormous economic burden on society. These and other aspects of the disease and its management make it eminently suitable for intervention in a managed care setting. Challenges and opportunities exist for disease management initiatives for hypertension in the managed care environment. As health plans enhance their data systems and begin to focus on the long-term benefits of chronic disease management, hypertension will certainly be an early target for intervention and control. (+info)
Selfish sentinels in cooperative mammals.
Like humans engaged in risky activities, group members of some animal societies take turns acting as sentinels. Explanations of the evolution of sentinel behavior have frequently relied on kin selection or reciprocal altruism, but recent models suggest that guarding may be an individual's optimal activity once its stomach is full if no other animal is on guard. This paper provides support for this last explanation by showing that, in groups of meerkats (Suricata suricatta), animals guard from safe sites, and solitary individuals as well as group members spend part of their time on guard. Though individuals seldom take successive guarding bouts, there is no regular rota, and the provision of food increases contributions to guarding and reduces the latency between bouts by the same individual. (+info)
Systematic reviews and meta-analyses are the best approaches available for summarizing the available evidence concerning the efficacy of therapies. Although the renal field has been slow to use these techniques, they are being used increasingly. In March 1997, the Cochrane Renal Group was formed, and this group aims to produce and maintain up to date systematic reviews of the evidence on the effectiveness of therapies used to treat patients with renal diseases. This group is part of the Cochrane Collaboration which is an international structure grouping collaborators together, with the aim of preparing, maintaining and disseminating systematic reviews of the effects of health care in all areas of medicine. (+info)