Attitudes of Washington State physicians toward health care reform.

Attitudes of Washington State physicians about health care reform and about specific elements of managed competition and single-payer proposals were evaluated. Opinions about President Clinton''s reform plan were also assessed. Washington physicians (n = 1,000) were surveyed from October to November 1993, and responses were collected through January 1994; responses were anonymous. The response rate was 80%. Practice characteristics of respondents did not differ from other physicians in the state. Of physicians responding, 80% favored substantial change in the current system, 43% favored managed competition, and 40% preferred a single-payer system. Of physicians responding, 64% thought President Clinton''s proposal would not adequately address current problems. Reduced administrative burden, a central element of single-payer plans, was identified by 89% of respondents as likely to improve the current system. Other elements of reform plans enjoyed less support. More procedure-oriented specialists than primary care physicians favored leaving the current system unchanged (28% versus 8%, P < .001). While physicians favor health care reform, there is no consensus on any single plan. It seems unlikely that physicians will be able to speak with a single voice during the current debates on health care reform.     

制度供给视角下的基本医疗体制改革之决策

基本医疗改革的财政投入模式应从单一关注医疗服务供给转向协同关注医疗服务产出，无过错医疗损害救济应纳入国家财政投入的预算体系。面对医疗损害的高发性，以救济为心的医疗侵权责任制度应向以预防中心的制度进行改革。医疗过失诉讼制度对医疗体系有着深刻的负面制约作用。基本医疗改革的决策应从更宏观的视角进行制度供给设计。     

Key issues in managed competition.

All managed competition proposals for health system reform must confront several key issues. The premiums paid to health care purchasing cooperatives will need to be subsidized for those who cannot pay full fare; the amount and sources of the subsidies are controversial political issues. The payments passed on by purchasing cooperatives to health plans must be risk adjusted to account for differences in the health care needs of their enrolled populations. This is essential to create a level playing field for competition and to eliminate incentives for plans to use risk assessment for attracting enrollees. The data and methods needed for risk adjustment, however, are not adequate at present. The Clinton Administration''s plan to limit expenditure increases raises a host of thorny issues. Maintaining quality of care will require health plan quality report cards to be supplemented by external quality assurance systems. Assuring quality will be particularly problematic for traditional indemnity plans. The structure and governance of the system, administration simplification, and other issues need to be addressed. The size and voluntariness of the purchasing cooperatives greatly influence all of these considerations. Physicians should inform their political representatives on how these issues should be resolved as compromise bills are drafted by the United States Congress this year.     

WPA guidance on steps,obstacles and mistakes to avoid in the implementation of community mental health care

This paper provides guidance on the steps, obstacles and mistakes to avoid in the implementation of community mental health care. The document is intended to be of practical use and interest to psychiatrists worldwide regarding the development of community mental health care for adults with mental illness. The main recommendations are presented in relation to: the need for coordinated policies, plans and programmes, the requirement to scale up services for whole populations, the importance of promoting community awareness about mental illness to increase levels of help-seeking, the need to establish effective financial and budgetary provisions to directly support services provided in the community. The paper concludes by setting out a series of lessons learned from the accumulated practice of community mental health care to date worldwide, with a particular focus on the social and governmental measures that are required at the national level, the key steps to take in the organization of the local mental health system, lessons learned by professionals and practitioners, and how to most effectively harness the experience of users, families, and other advocates.     

Why it's time for a national health program in the United States.

The United States lacks a coherent national health program. Current programs leave major gaps in coverage and recently have become more restrictive. Influential policies that have failed to correct crucial problems of the health-care system include competitive strategies, corporate intervention, and public-sector cutbacks with bureaucratic expansion. A national health program that combines elements of national health insurance and a national health service is a policy that would help solve current health-care problems. Previous proposals for national health insurance contained weaknesses that would need correction under a national program. Based on the experiences of other economically advanced countries, a national health program could provide universal entitlement to health care while controlling costs and improving the health-care system through structural reorganization. Current proposals for a national health program contain several basic principles dealing with the scope of services, copayments, financing, cost controls, physician and professional associations, personnel and distribution, prevention, and participation in policy making. Support for a national health program is growing rapidly. Such a program would help protect all people who live in this country from unnecessary illness, suffering, and early death.     

Coverage of genetic technologies under national health reform.

This article examines the extent to which the technologies expected to emerge from genetic research are likely to be covered under Government-mandated health insurance programs such as those being proposed by advocates of national health reform. Genetic technologies are divided into three broad categories; genetic information services, including screening, testing, and counseling; experimental technologies; and gene therapy. This article concludes that coverage of these technologies under national health reform is uncertain. The basic benefits packages provided for in the major health reform plans are likely to provide partial coverage of experimental technologies; relatively broad coverage of information services; and varying coverage of gene therapies, on the basis of an evaluation of their costs, benefits, and the degree to which they raise objections on political and religious grounds. Genetic services that are not included in the basic benefits package will be available only to those who can purchase supplemental insurance or to those who can purchase the services with personal funds. The resulting multitiered system of access to genetic services raises serious questions of fairness.     

Care management and mental health.

The community care reforms will produce a new kind of key worker who will organise and budget for packages of care: the care manager. Care management goes live in April 1993 but is still poorly rehearsed and its performance may yet disappoint. This overview sets out the origins of case management, its transformation into care management, and the principles guiding its practice. To spell out how the concept works, plans for care management in Southwark''s mental health services are described.     

Costs and coverage. Pressures toward health care reform.

Signs of discontent with the health care system are growing. Calls for health care reform are largely motivated by the continued increase in health care costs and the large number of people without adequate health insurance. For the past 20 years, health care spending has risen at rates higher than the gross national product. As many as 35 million people are without health insurance. As proposals for health care reform are developed, it is useful to understand the roots of the cost problem. Causes of spiraling health care costs include "market failure" in the health care market, expansion in technology, excessive administrative costs, unnecessary care and defensive medicine, increased patient complexity, excess capacity within the health care system, and low productivity. Attempts to control costs, by the federal government for the Medicare program and then by the private sector, have to date been mostly unsuccessful. New proposals for health care reform are proliferating, and important changes in the health care system are likely.     

Why not private health insurance? 2. Actuarial principles meet provider dreams

What do insurers and employers feel about proposals to expand Canadian health care financing through private insurance, in either a parallel stream or a supplementary tier? The authors conducted 10 semistructured, open-ended interviews in the autumn and early winter of 1996 with representatives of the insurance industry and benefits managers working with large employers; respondents were identified using a snowball sampling technique. The respondents felt that proposals for parallel private plans within a competitive market are incompatible with insurance principles, as long as a well-functioning and relatively comprehensive public system continues to exist; the maintenance of a strong public system was both socially and economically desirable. With the exception of serving the niche market for the private management of return-to-work strategies, respondents showed little interest in providing parallel coverage. They were receptive to a larger role for supplementary insurance but cautioned that they are not willing to cover all delisted services. As business executives they stated that they are willing to insure only services and clients that will be profitable.     

The safety net of the safety net: how federally qualified health centers "subsidize" Medicaid managed care

In this article, I examine the impact of neoliberalism and welfare reform on the delivery of Medicaid, specifically how the advent of Medicaid managed care (MMC) has been wrought with contradictions, placing increased burdens on primary safety-net organizations and impacting the many communities they serve. I argue that federally qualified health centers (FQHCs) operate as a primary safety net among safety-net providers, supporting and subsidizing New Mexico's MMC program financially and administratively. By presenting ethnographic data, I will demonstrate how FQHCs pay many of the hidden financial and institutional costs of the shift to managed care. Such findings uncover paradoxes inherent to neoliberal ideologies and privatization, raising questions about the efficacy of a managed care system for Medicaid as well as the future of the health care safety net and access to health care for the diverse populations it serves.     

The primary care workforce: a critical element in mending the fractured US health care system

A focus on the primary care workforce is critical when discussing plans to address the fractured United States health care system. However, we must first address the primary care physician shortage crisis when planning for health care reform which focuses on increasing access to the US population. Initial strategies may include improving reimbursement rates for primary care services, incentivizing medical schools in making primary care training a priority, and developing robust loan-forgiveness programs for those who enter and work in primary care specialties. Planning with congressional representatives about these elements will better ensure sustainable health reform efforts are implemented.     

Analysis of health services use for respiratory illness in Indonesian children: implications for policy

Respiratory illness continues to be a leading cause of paediatric morbidity and mortality in Indonesia. The Indonesian government is moving towards a more managed care-based approach as it reforms its health care system following the 1997 financial crisis. In order to better design contractual relationships between the payor and different providers, there needs to be a better understanding of the patterns and predictors of health services utilization for respiratory illness. This study uses the Indonesia Demographic and Health Survey to study the determinants of private, public and non-formal provider utilization for respiratory illness. Multinomial logistic regression models for predicting use were constructed using the Andersen Behavioural Model as the conceptual framework. The findings indicate that age, household size, maternal education, religion, the asset index, location and illness severity play a role in determining use of private, public or non-formal providers. The results indicate that from a policy perspective, the Indonesian government needs be inclusive rather than exclusive in the choice of providers that are contracted by the managed care plans, in order to safeguard the health of the under-five population.     

Challenges of Radiation Oncology in Spain Today

The increasing cost of health care delivery, coupled with reduced investments and budget cuts in European health care systems, has had a severe negative impact on health care delivery in Spain. This reduction in spending has had particularly negative effects on specialties that are heavily reliant on large capital investments to purchase the latest technologies needed to deliver optimal radiotherapy treatments. The Spanish Society of Radiation Oncology has been proactively working to mitigate the negative impact of budget cuts in Spain. In this paper, the authors describe a variety of solutions and proposals to overcome these challenges.     

Power, blame, and accountability: Medicaid managed care for mental health services in New Mexico

I examine the provision of mental health services to Medicaid recipients in New Mexico to illustrate how managed care accountability models subvert the allocation of responsibility for delivering, monitoring, and improving care for the poor. The downward transfer of responsibility is a phenomenon emergent in this hierarchically organized system. I offer three examples to clarify the implications of accountability discourse. First, I problematize the public-private "partnership" between the state and its managed care contractors to illuminate the complexities of exacting state oversight in a medically underserved, rural setting. Second, I discuss the strategic deployment of accountability discourse by members of this partnership to limit use of expensive services by Medicaid recipients. Third, I focus on transportation for Medicaid recipients to show how market triumphalism drives patient care decisions. Providers and patients with the least amount of formal authority and power are typically blamed for system deficiencies.     

Managed-care plans. Their future under national health insurance.

The nation''s health maintenance organizations, preferred-provider organizations, independent practice associations, and similar managed-care efforts are not well positioned to take a leadership role in a nationwide universal access or national health insurance plan. They--with the possible exception of some large staff and group health maintenance organizations--have been unable to show uniformly that they can contain costs, provide better access or higher quality of care, and achieve greater patient satisfaction than fee-for-service endeavors. As the United States pursues universal access as a step toward national health insurance, the managed-care plans will continue to increase their numbers of subscribers. They will not, however, be able to enroll large numbers of the young, low-income employees and their dependents who account for most of the 63 million people uninsured sometime during each year. Under national health insurance, there might be an option for some health maintenance organizations to negotiate capitated payments. The vast majority of the nation''s physicians, however, will reluctantly embrace a centrally managed fee-for-service approach rather than a salary or capitated reimbursement method, leaving only a trace of the competitive managed-care plan theme in a future, primarily monolithic, national health care system.     

Women in medicine: practice patterns and attitudes.

Increasing numbers of women are entering medicine in Canada. In 1959 women accounted for 6% of the medical school graduates, but by 1989 they accounted for 44%. Although there has been little systematic investigation of the impact of this increase on Canada''s health care system, there are grounds for believing that female physicians bring with them distinctive values and interests, which may be reflected in the way they conduct their professional practices. We used data from a recent national survey of 2398 Canadian physicians to examine differences between women and men in their practices and their attitudes toward health care issues. Significant differences were found in the organization and management of the practices. Women preferred group over solo practice and were overrepresented in community health centres, health service organizations and centres locaux de services communautaires in Quebec. One-third of the women, as compared with half of the men, were in specialties. Even after adjusting for differences in workloads the incomes of the women were significantly lower than those of the men. Only minor differences were observed in the assessment of the health care system and alternative modes of organizing health care services. We believe that the differences were due to the double workload of women as professionals and family caregivers and the powerful socialization effects of medical education. As women overcome their minority status in the medical profession, differences between the sexes may become more apparent. Thus, the extent and effects of the progressive increase in the number of women in Canadian medicine should be assessed on an ongoing basis.     

Mental health system in China: history, recent service reform and future challenges

This paper summarizes the history of the development of Chinese mental health system; the current situation in the mental health field that China has to face in its effort to reform the system, including mental health burden, workforce and resources, as well as structural issues; the process of national mental health service reform, including how it was included into the national public health program, how it began as a training program and then became a treatment and intervention program, its unique training and capacity building model, and its outcomes and impacts; the barriers and challenges of the reform process; future suggestions for policy; and Chinese experiences as response to the international advocacy for the development of mental health.     

建立适合中国国情的高效双向转诊机制

建立适应我国国情的高效双向转诊机制,对于推进我国的医疗体制改革具有至关重要的作用。本文通过对中西方现行卫生制度的对比,结合我国有中国特色的社会主义国家的国情,对我国的卫生制度中存在的问题进行了深入剖析,探讨如何才能有效地实现高效的双向转诊。目前,我国医疗卫生事业的问题覆盖多个方面：主要表现在医疗资源,医院管理,在岗医护人员的个人职业素质,卫生部门的监管,医疗资源的大量浪费,医院分级不平衡另多数患者普遍选择三级医院就诊,而选择二级以下医院就诊的患者则较少。如何在符合我国国情的基础上改变我国的医疗卫生现状、满足人民群众不断提高的医疗服务需求是我国医疗改革亟待解决的问题。建立高效率的双向转诊制度势在必行。目前,在双向转诊中遇到的问题：1．传统理念导致的对各级医疗机构职能的理解上存在偏差,2．医疗机构自身定位不明确,3．双向转诊制度的各项相关配套政策不完善,4．双向转诊制度的社会认同度低。高效双向转诊机制建立以后,可以节省大量的医疗资源,减少了不必要的浪费,推进了医疗资源的合理配置,减少了因地区差异引起的治疗时机延误,高效的双向转诊制度会使医疗卫生资源配置进一步优化、还可以加强医疗机构之间的协作、降低医疗费用支出、促进社区卫生服务迅速发展等有重大的意义。     

Reform of mental health care in Serbia: ten steps plus one

Disastrous events in the country and the region caused a 13.5% increase in the prevalence of mental and behavioral disorders in Serbia in the last few years, thus making them the second largest public health problem. Due to prolonged adversities, the health system has deteriorated and is facing specific challenges. However, the reform of mental health care has been initiated, with a lot of positive movements such as the preparation of a national policy for mental health care and a law for protection of mentally ill individuals. The transformation of mental health services has started, with an accent on community care, antistigma campaigns and continuing education. Based on an assessment carried out by the National Committee on Mental Health, service provision, number of professionals working in services, funding arrangements, pathways into care, user/carer involvement and other specific issues are reported.     

Managed care. Origins,principles, and evolution.

Managed care has entered the lexicon of healthcare reform, but confusion and ignorance surround its meaning and purpose. It seeks to cut the costs of health care while maintaining its quality, but the evidence that it is able to achieve these aims is mixed. As well as raising awareness and understanding of the issues surrounding managed care, this series considers whether managed care is desirable for the NHS. Developed in the United States as a response to spiralling healthcare costs and dysfunctional fragmented services, managed care is not a discrete activity but a spectrum of activities carried out in a range of organisational settings. Due to its constantly changing nature, managed care is a slippery concept--but all its permutations have in common an attempt to influence and modify the behaviour and practice of doctors and other health professionals towards cost effective care. Whatever potential managed care may hold in this regard, careful appraisal of its implications is essential.