CMA's Proposal for a Voluntary,Universally Available Health Benefits Program

The May 4, 1970 issue of the American Medical News contains an article on a report released in April by the British Medical Association following a two-year study of the British National Health Service. Although the BMA study is oriented to the specific program as it has evolved in Great Britain since 1946, its main thrust is in the development of a system of voluntary health insurance which would provide for greater consumer choice, based upon nationally determined guidelines and regulations. BMA''s recommendations would have the NHS utilize a combination of tax-supported and voluntary-supported mechanisms in providing medical services to various segments of the population, based upon categories of illness and income levels.Since the BMA proposal as reported in the AMA News parallels in some respects the one approved by the CMA House of Delegates and submitted to the AMA House of Delegates for its consideration, the reader will be interested in seeing the concept for a Voluntary Universally Available Health Benefits Program, independently developed by the California Medical Association. It is interesting to note that the CMA proposal attempts to avoid many of the problems with which the NHS has been identified, and at the same time would establish a single, coherent, integrated approach for development over the next decade, incorporating public programs into a unified system of medical care which utilizes the multiplicity of voluntary health insurance approaches and mechanisms.     

Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente

ObjectiveTo compare the costs and performance of the NHS with those of an integrated system for financing and delivery health services (Kaiser Permanente) in California.MethodsThe adjusted costs of the two systems and their performance were compared with respect to inputs, use, access to services, responsiveness, and limited quality indicators.ResultsThe per capita costs of the two systems, adjusted for differences in benefits, special activities, population characteristics, and the cost environment, were similar to within 10%. Some aspects of performance differed. In particular, Kaiser members experience more comprehensive and convenient primary care services and much more rapid access to specialist services and hospital admissions. Age adjusted rates of use of acute hospital services in Kaiser were one third of those in the NHS.ConclusionsThe widely held beliefs that the NHS is efficient and that poor performance in certain areas is largely explained by underinvestment are not supported by this analysis. Kaiser achieved better performance at roughly the same cost as the NHS because of integration throughout the system, efficient management of hospital use, the benefits of competition, and greater investment in information technology.

What is already known on this topic

Comparisons of healthcare systems in different countries have to be undertaken with great care but can be instructiveThe overall healthcare system in the United States is more expensive than the NHS and population health outcomes are no betterThe US healthcare system comprises many discrete and unique subsystems, including the health maintenance organisations

What this paper adds

An integrated, non-profit health maintenance organisation in California (Kaiser Permanente), with over six million members, costs about the same as the NHS but performs considerably betterKaiser''s superior performance is mainly in prompt and appropriate diagnosis and treatmentThese findings challenge the widely held view that the NHS is efficient and that its inadequacies are mainly due to underinvestment     

Rationing health care: its impact and implications for hematology-oncology.

Rationing of health care in the United States currently exists via the covert mechanism of restricting significant segments of medical care for many of those who cannot afford it. Provision of universal health care would necessitate explicit rationing of certain interventions and technologies, even though an individual could afford them. The British and Canadian experiences provide lessons from which America can profit, and the Oregon health plan is an experiment in this direction. The progressive "graying" of America has raised the question of the need for intergenerational charity as a form of rationing. The implications of these rationing plans would result in a major restructuring of the practice of hematology-oncology.     

Work in the European Union.

Continental Europe is now only 20 minutes away by train from mainland Britain, and moving ever closer politically. Mutual recognition of medical qualifications within the European Union is well established: working in other parts of Europe is, in principle, straightforward. Working in different health care systems can offer new perspectives on British medical practice and the NHS. But the cultural differences are not always easy to overcome.     

Twenty-first-century medical microbiology services in the UK

With infection once again a high priority for the UK National Health Service (NHS), the medical microbiology and infection-control services require increased technology resources and more multidisciplinary staff. Clinical care and health protection need a coordinated network of microbiology services working to consistent standards, provided locally by NHS Trusts and supported by the regional expertise and national reference laboratories of the new Health Protection Agency. Here, I outline my thoughts on the need for these new resources and the ways in which clinical microbiology services in the UK can best meet the demands of the twenty-first century.     

Health System Challenges in Organizing Quality Diabetes Care for Urban Poor in South India

Background

Weak health systems in low- and middle-income countries are recognized as the major constraint in responding to the rising burden of chronic conditions. Despite recognition by global actors for the need for research on health systems, little attention has been given to the role played by local health systems. We aim to analyze a mixed local health system to identify the main challenges in delivering quality care for diabetes mellitus type 2.

Methods

We used the health system dynamics framework to analyze a health system in KG Halli, a poor urban neighborhood in South India. We conducted semi-structured interviews with healthcare providers located in and around the neighborhood who provide care to diabetes patients: three specialist and 13 non-specialist doctors, two pharmacists, and one laboratory technician. Observations at the health facilities were recorded in a field diary. Data were analyzed through thematic analysis.

Result

There is a lack of functional referral systems and a considerable overlap in provision of outpatient care for diabetes across the different levels of healthcare services in KG Halli. Inadequate use of patients’ medical records and lack of standard treatment protocols affect clinical decision-making. The poor regulation of the private sector, poor systemic coordination across healthcare providers and healthcare delivery platforms, widespread practice of bribery and absence of formal grievance redress platforms affect effective leadership and governance. There appears to be a trust deficit among patients and healthcare providers. The private sector, with a majority of healthcare providers lacking adequate training, operates to maximize profit, and healthcare for the poor is at best seen as charity.

Conclusions

Systemic impediments in local health systems hinder the delivery of quality diabetes care to the urban poor. There is an urgent need to address these weaknesses in order to improve care for diabetes and other chronic conditions.     

The rationing agenda in the NHS. Rationing Agenda Group.

The Rationing Agenda Group has been founded to deepen the British debate on rationing health care. It believes that rationing in health care is inevitable and that the public must be involved in the debate about issues relating to rationing. The group comprises people from all parts of health care, none of whom represent either their group or their institutions. RAG has begun by producing this document, which attempts to set an agenda of all the issues that need to be considered when debating the rationing of health care. We hope for responses to the document. The next stage will be to incorporate the responses into the agenda. Then RAG will divide the agenda into manageable chunks and commission expert, detailed commentaries. From this material a final paper will be published and used to prompt public debate. This stage should be reached early in 1997. While these papers are being prepared RAG is developing ways to involve the public in the debate and evaluate the whole process. We present as neutrally as possible all the issues related to rationing and priority setting in the NHS. We focus on the NHS for two reasons. Firstly, for those of us resident in the United Kingdom the NHS is the health care system with which we are most familiar and most concerned. Secondly, focusing on one system alone allows more coherent analysis than would be possible if issues in other systems were included as well. Our concern is with the delivery of health care, not its finance, though we discuss the possible effects of changing the financing system of the NHS. Finally, though our position is neutral, we hold two substantive views--namely, that rationing is unavoidable and that there should be more explicit debate about the principles and issues concerned. We consider the issues under four headings: preliminaries, ethics, democracy, and empirical questions. Preliminaries deal with the semantics of rationing, whether rationing is necessary, and with the range of services to which rationing relates. Under ethics and democracy are the substantive issues of principle and theory. The final section deals with empirical questions and those relating to the practicality of various strategies.     

Control and prevention of tuberculosis in Britain: an updated code of practice. Subcommittee of the Joint Tuberculosis Committee of the British Thoracic Society.

A subcommitte was appointed by the Joint Tuberculosis Committee of the British Thoracic Society to review and bring up to date guidelines on control measures for tuberculosis. The updated code of practice emphasises that all cases of tuberculosis must be notified. A minority of patients need admission, and those with positive sputum smears should be regarded as infectious until they have received two weeks of chemotherapy. NHS staff at risk should be protected, and evidence of infectious tuberculosis should be sought as routine among certain prospective NHS employees, schoolteachers, and others. Contact tracing should be vigorously pursued, and all entrants to Britain from countries where tuberculosis is common should be screened. BCG vaccination should be offered in selected instances, and local organisation of tuberculosis services should be extended.     

'India Shopping': Indian Grocery Stores and Transnational Configurations of Belonging

The cost of health services within the USA has increased in recent years, limiting access for many Americans. In response, a growing number of Americans are traveling to medical border towns in Mexico to meet their needs. However, many US patients feel uncomfortable traveling to Mexico for healthcare because they are unsure how the system works and believe that Mexico is dangerous, unregulated, unsanitary, and premodern. To reconcile these beliefs with the need for quality medical care, Mexican medical providers appropriate aspects of the US medical system to encourage patronage and alleviate the concerns of patients. This paper examines how some Mexican dentists, pharmacists and physicians in the Mexican border town of Nuevo Progreso have broadened their appeal to American patients by (a) associating their procedures with US biomedical standards, (b) building facilities that shadow US counterparts, and (c) facilitating access to the Mexican medical system.     

Continuing professional development systems for medical physicists: A global survey and analysis

Continuing professional development (CPD) and continuing professional education (CPE) are seen as being necessary for medical physicists to ensure that they are up-to-date with current clinical practice. CPD is more than just continuing professional education, but can include research publication, working group contribution, thesis examination and many other activities. A systematic way of assessing and recording such activities that a medical physicist undertakes is used in a number of countries. This can be used for certification and licensing renewal purposes. Such systems are used in 27 countries, but they should be implemented in all countries where clinical medical physicists are employed.A survey of the CPD systems that are currently operated around the world is presented. In general they are quite similar although there are a few countries that have CPD systems that differ significantly from the others in many respects. Generally they ensure that medical physicists are kept up-to-date, although there are some that clearly will fail to achieve that.An analysis of what is required to construct a useful medical physics CPD system is made. Finally, the need for medical physicist professional organizations to cooperate and share in the production and distribution of CPD and CPE materials is emphasized.     

Community mental health care worldwide: current status and further developments

This paper aims to give an overview of the key issues facing those who are in a position to influence the planning and provision of mental health systems, and who need to address questions of which staff, services and sectors to invest in, and for which patients. The paper considers in turn: a) definitions of community mental health care; b) a conceptual framework to use when evaluating the need for hospital and community mental health care; c) the potential for wider platforms, outside the health service, for mental health improvement, including schools and the workplace; d) data on how far community mental health services have been developed across different regions of the world; e) the need to develop in more detail models of community mental health services for low‐ and middle‐income countries which are directly based upon evidence for those countries; f) how to incorporate mental health practice within integrated models to identify and treat people with comorbid long‐term conditions; g) possible adverse effects of deinstitutionalization. We then present a series of ten recommendations for the future strengthening of health systems to support and treat people with mental illness.     

Teaching and training in geriatric medicine in the European Union

In 1993 about 20% of the population in the 15 'old' member countries of the European Union (EU) was over 60 years of age and this percentage will increase to more than 25% in 2020. These developments play a key role for the investments in education and training to meet societies needs for health care services. In 2002 about 25% of the medical students in the 'old' EU did not receive any education in geriatric medicine. A question is who will provide the services for older people in related areas, like social care, community care, acute care in the hospitals, long-term care, permanent care and care for psychiatric patients? Geriatric medicine has been recognized as an independent specialty in 8 of the 15 member countries of the 'old' EU. In all EU member states the governments are autonomous regarding all aspects of health care services, including the recognition of specialties and specialist training programmes. A two years training in internal medicine has been recommended in the EU, followed by another four years of training in geriatric medicine. The specialist training has a hospital oriented character, however, it includes also community care and other institutionalised care like nursing homes. The curriculum should contain: biological, social, psychological and medical aspects of common diseases and disturbances in older people. A problem in many EU countries is the shortage of well trained researchers and leading persons for academic positions for geriatric medicine. In a number of countries chairs at the universities remain vacant for long periods of time or even disappear. Good services in the health care for older people need a high quality curriculum and training programme.     

Reforming the NHS reforms.

Rather than improving efficiency, the reforms imposed on the NHS have increased bureaucracy, reduced patient choice, limited the range of core services, and led to inequity of treatment. In this paper I examine how the medical profession might help to solve these problems. Priorities must be set for health care since no government can afford all the possibilities offered by medical science. It is essential to forge a consensus of patients, carers, professionals, the public, and government if a system of priorities is to be equitable and just. We also need to be able to measure quality of outcome in health care. This requires consensus on what is the desired outcome and the development of appropriate guidelines, audit, and performance review. This is primarily a task for the health professions supported by management and by adequate investment. Basically, the government must reinstate the three traditional values of the NHS--equity, consensus, and regard for representative professional advice.     

Beneath the calm surface: the changing face of physician-service use in British Columbia, 1985/86 versus 1996/97

BackgroundAlthough expenditures on health care are continually increasing and often said to be unsustainable, few studies have examined these trends at the level of services delivered to individual patients. We analyzed trends in the various components that contributed to changes in overall expenditures for physician services in British Columbia from 1985/86 to 1996/97.MethodsWe obtained data on all fee-for-service payments to physicians in each study year using the British Columbia Linked Health Data set and analyzed these at the level of individual patients. We disaggregated overall billing levels by year into the following components: number of physicians seen by each patient, number of visits per physician, number of services rendered on each visit and average price of those services. We removed the effect of inflation on fees by adjusting to those in 1988. We used direct age-standardization to isolate and measure the effect of demographic changes. We used the Consumer Price Index to determine the effects of inflation.ResultsTotal payments to fee-for-service physicians in British Columbia rose 86.3% over the study period. The increase was entirely accounted for by the combined effects of population growth (28.9%), aging (2.1%) and general inflation (41.4%). Service use per capita rose 10.5%; this increase was offset by a decline of 9.4% in inflation-adjusted fees. The average cost of age-adjusted per-capita services rendered by general or family practitioners (GP/FPs) increased very little (3.3%) over the 11-year period, compared with a nearly one-third (31.8%) increase for medical specialists. Although there was a dramatic increase in the number of GP/FPs seen on average by each patient (32.9%), this increase was offset by the combination of decreases in the number of visits per physician (–14.9%), the number of services provided per visit (–8.0%) and the “real cost” of each service provided (–3.5%). Visits to medical specialists increased by about 20% over the study period in all age groups. However, for each person 65 years of age or over receiving any services, the average fee-adjusted expenditures increased 24.8%, almost 4 times the rate of increase for people younger than 65. The use of surgical services grew 26.5% for seniors while declining –2.0% for people under age 65.InterpretationThese findings suggest a form of “homeostasis” in aggregate-level service use and cost. The supposed inflationary effects of population aging and increasing “abuse of the system” by patients were not found.The conventional wisdom, said John Kenneth Galbraith, is always wrong.¹ For decades, conventional wisdom, as presented in the national media, has held that health care costs are spiralling out of control because of an aging population and rising public expectations. The latest rhetoric is that the Canadian health care system is unsustainable. The objective of our study was to examine evidence from recent physician-service use in British Columbia to ascertain whether there is more than just rhetoric behind the claims.A number of previous studies exploring trends in expenditure on the various components of health care demonstrated the limited effect of demographic change.^2,3,4,5 Our study has reinforced those findings but extended the earlier work in 2 ways. First, the British Columbia Linked Health Data (BCLHD) set⁶ enabled the use of data for the individual, nonidentifiable patient rather than patient groups (e.g., age-specific) as our fundamental unit of analysis, which made it possible to do a more detailed exploration of the components underlying changes in aggregate expenditures. Second, our analysis covered a particularly turbulent period (1985/86 through 1996/97) for health care financing in British Columbia. A number of policies were introduced in the province in an attempt to contain the growth of medical care costs.^7,8 These might have been expected to be reflected in changes in the mix and numbers of patients seeing physicians and the types of services received. We disaggregated trends in overall expenditures into components representing changes in fee levels, practice patterns and activity levels.     

Intravenous antimicrobial therapy in the community: underused,inadequately resourced,or irrelevant to health care in Britain?

The NHS Executive is keen to promote "hospital at home" services in Britain, as part of its philosophy of keeping more care in the community and also to relieve the increasing demand for hospital beds. One such service is the provision of intravenous antimicrobial therapy in the community. Yet, compared with the United States, where home or outpatient intravenous antimicrobial therapy programmes are well developed, experience in Britain and Europe is limited, reflecting a difference in cultural attitudes and healthcare structures between the two continents. Only a few units in Britain currently run home intravenous antimicrobial therapy programmes, and several issues need to be addressed if more treatment is to be provided outside hospital. These include an assessment of the need for community intravenous antibiotic treatment and which patient groups many benefit. The main motive for community intravenous treatment should be better patient care and not simply a reduction in healthcare costs. At present the pace of change is being set by a few clinical enthusiasts and by commercial organisations, whereas the NHS deserves a more organised strategy for purchasing treatment with intravenous antibiotics in the community.     

REPRODUCTIVE TOURISM IN ARGENTINA: CLINIC ACCREDITATION AND ITS IMPLICATIONS FOR CONSUMERS,HEALTH PROFESSIONALS AND POLICY MAKERS

A subcategory of medical tourism, reproductive tourism has been the subject of much public and policy debate in recent years. Specific concerns include: the exploitation of individuals and communities, access to needed health care services, fair allocation of limited resources, and the quality and safety of services provided by private clinics. To date, the focus of attention has been on the thriving medical and reproductive tourism sectors in Asia and Eastern Europe; there has been much less consideration given to more recent ‘players’ in Latin America, notably fertility clinics in Chile, Brazil, Mexico and Argentina. In this paper, we examine the context‐specific ethical and policy implications of private Argentinean fertility clinics that market reproductive services via the internet. Whether or not one agrees that reproductive services should be made available as consumer goods, the fact is that they are provided as such by private clinics around the world. We argue that basic national regulatory mechanisms are required in countries such as Argentina that are marketing fertility services to local and international publics. Specifically, regular oversight of all fertility clinics is essential to ensure that consumer information is accurate and that marketed services are safe and effective. It is in the best interests of consumers, health professionals and policy makers that the reproductive tourism industry adopts safe and responsible medical practices.     

Reasons for Unmet Need for Child and Family Health Services among Children with Special Health Care Needs with and without Medical Homes

Objectives

Medical homes, an important component of U.S. health reform, were first developed to help families of children with special health care needs (CSHCN) find and coordinate services, and reduce their children’s unmet need for health services. We hypothesize that CSHCN lacking medical homes are more likely than those with medical homes to report health system delivery or coverage problems as the specific reasons for unmet need.

Methods

Data are from the 2005-2006 National Survey of Children with Special Health Care Needs (NS-CSHCN), a national, population-based survey of 40,723 CSHCN. We studied whether lacking a medical home was associated with 9 specific reasons for unmet need for 11 types of medical services, controlling for health insurance, child’s health, and sociodemographic characteristics.

Results

Weighted to the national population, 17% of CSHCN reported at least one unmet health service need in the previous year. CSHCN without medical homes were 2 to 3 times as likely to report unmet need for child or family health services, and more likely to report no referral (OR= 3.3), dissatisfaction with provider (OR=2.5), service not available in area (OR= 2.1), can’t find provider who accepts insurance (OR=1.8), and health plan problems (OR=1.4) as reasons for unmet need (all p<0.05).

Conclusions

CSHCN without medical homes were more likely than those with medical homes to report health system delivery or coverage reasons for unmet child health service needs. Attributable risk estimates suggest that if the 50% of CSHCN who lacked medical homes had one, overall unmet need for child health services could be reduced by as much as 35% and unmet need for family health services by 40%.     

Tertiary cancer services in Britain: benchmarking study of activity and facilities at 12 specialist centres.

OBJECTIVE--To collate information on current activity and facilities in British hospitals to assist the planning of future cancer services. DESIGN--12 hospitals delivering specialist cancer services provided information on the size of population served, activity levels related to non-surgical oncology for 1994-5, and facilities available. Inconsistencies in the recording of data were resolved through meetings of all participants. SETTING--Five single specialty NHS trusts and seven specialist cancer facilities within multispecialty trusts, serving a combined population of 24.3 million. MAIN OUTCOME MEASURES--Activity levels and facilities per million population served. RESULTS--The facilities available per million population served varied widely between centres. In contrast, the range in the number of new referrals per million population (seen either at the centre or in peripheral clinics) was relatively small. Considerable variations were observed in the number of attendances per patient and amount of radiotherapy and chemotherapy delivered. Overall it was estimated that 40-45% of all new cases of cancer are currently being referred to non-surgical oncologists. For the seven hospitals which could provide data on trends in activity, the average increase in chemotherapy day case episodes between 1992-3 and 1994-5 was 83%. CONCLUSIONS--The results of this study provide a benchmark both for purchasers and providers of cancer care. The increase in the use of chemotherapy points to an urgent need for a unified system for monitoring both activity and outcomes of treatment.     

Medical manpower two years on.

Medical manpower in Britain, with particular reference to the NHS, was analysed for 1976 and 1977. The output of British medical schools increased. The total of doctors in the NHS rose by 2% between 1975 and 1976 and by 2.4% between 1976 and 1977. The highest and lowest growth rates were in junior and senior hospital staff grades respectively, while the highest growth rate in career grades seemed to be in community medicine and health. The inflow of overseas doctors remained high, though few tended to remain permanently in Britain. Continuous evaluation of the medical manpower position is needed before long-term predictions can confidently be made.