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1.
Canada''s medicare system has provided Canadians with high-quality health care for almost three decades. Now Canadian health care appears to be at risk of losing the single-payer system, which is the premise on which medicare is built. As medicare comes under increasing financial pressure, many are calling for the introduction of private care as a means of bolstering our health care system and maintaining its quality. Although it appears alluring to some politicians, physicians and commentators, privatization could very well lead to the demise of the principles and practices of the Canadian health care system as we know it, with little clear benefit to the public or physicians. 相似文献
2.
Robert A. Derzon 《The Western journal of medicine》1980,132(5):424-429
As the federal government shifted from its traditional roles in health to the payment for personal health care, the relationship between public and private sectors has deteriorated. Today federal and state revenue funds and trusts are the largest purchasers of services from a predominantly private health system. This financing or “gap-filling” role is essential; so too is the purchaser''s concern for the costs and prices it must meet. The cost per person for personal health care in 1980 is expected to average $950, triple for the aged. Hospital costs vary considerably and inexplicably among states; California residents, for example, spend 50 percent more per year for hospital care than do state of Washington residents. The failure of each sector to understand the other is potentially damaging to the parties and to patients. First, and most important, differences can and must be moderated through definite changes in the attitudes of the protagonists. 相似文献
3.
Introduction
Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.Methods and Findings
Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of “private sector” included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. “Competitive dynamics” for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.Conclusions
Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients. Please see later in the article for the Editors'' Summary 相似文献4.
The multiplication of separate governmental agencies providing health services to California''s children, the increasing difficulties in staffing tax-supported health agencies and the recent studies of the quality of care under these programs, have all pointed to an urgent need for prompt decisions on certain basic questions about the function of tax-supported medical care for children of dependent families.Fourteen separate kinds of health services are currently provided through public funds at an annual cost to California taxpayers of $52,000,000. These funds underwrite an uncoordinated, fragmented, patchwork quilt of medical care for some 500,000 children. Coordination and integration of these services through “one door” with uniform eligibility requirements and maximum utilization of private physicians'' services that meet appropriate standards is needed now. California physicians have an urgent responsibility to provide leadership in the development of more effective and more economical organization and distribution of higher quality medical care services for California''s children dependent on public support. 相似文献
5.
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. 相似文献
6.
If Canada''s medicare system has a home town it is probably Ottawa, where the system was first welded together 30 years ago. Charlotte Gray reports that there is a certain irony now that examples of private health care are sprouting up in the nations''s capital. 相似文献
7.
In this time of spending restraint, arguments for and against a two-tier medical system are common. Proponents say governments can no longer afford to supply all the health care we want and Canadians should have the right to purchase it, just as they purchases other services and commodities. Opponents fear that administrative costs will rise greatly if this happens, the best physicians will leave the public system and public support for medicare will erode. For this article, Charlotte Gray sought opinions on whether a parallel private system is a good option for Canadians to consider. 相似文献
8.
Charlotte Gray 《CMAJ》1996,154(4):541-543
All parts of Canada''s health care system are facing fiscal pressures these days, but they are particularly great at Canada''s medical schools. However, Dr. David Hawkins of the Association of Canadian Medical Colleges is optimistic that all 16 of Canada''s medical schools will remain open, mainly because of the huge impact they have on health care in their local communities. “We don''t just turn out students — we raise the standard of health care in a whole community,” he says. 相似文献
9.
P Sullivan 《CMAJ》1995,153(6):801-803
The CMA''s General Council has decided to withhold its stamp of approval for a "private parallel" health care system by voting against a motion to remove legislative barriers to private insurance. However, General Council did call on the CMA to take the issue directly to Canadians and conduct a national debate. General Council did pass a "Blueprint for Action"--16 resolutions spelling out the CMA''s views on ways to protect Canada''s medicare system. 相似文献
10.
E. P. Luongo 《The Western journal of medicine》1959,91(6):348-354
There are many nonmedical factors that contribute to employee absenteeism in industry. An employee''s total life situation or total environment may be a causative factor in excessive “sick absenteeism.” In many instances the cure for “abnormal” sickness absenteeism is within the province of supervisory personnel, who should look upon abuse of sick leave benefits among employees as morale problems and as evidence of possible maladjustment to the demands of the job or the industry. There are, however, many problems in mental and physical health affecting absence rates in which preventive psychiatry and medicine can make greater contributions. Even truancy and malingering may sometimes be conditions requiring professional medical care.The role of a private physician in determining and certifying the true state of a patient''s health is a most important one economically to industry and the community. The total problem of absenteeism for sickness, as it exists in industry today, points up the need for the most effective cooperation and communication possible between industrial and private physicians. Since no more than 25 per cent of the total work force is employed in industries having in-plant medical programs, the burden of responsibility for the control of absenteeism for sickness rests mainly with private practitioners. 相似文献
11.
Patrick Sullivan 《CMAJ》1995,153(11):1643-1644
The first part of the CMA''s efforts to spark a public debate on the future of Canada''s health care system is a “visioning exercise” in which the Board of Directors will attempt to spell out the association''s views on how the system should develop. The board also discussed CMA initiatives concerning two major public-health issues — smoking and blood transfusions. 相似文献
12.
California''s Medicaid program—Medi-Cal—attempted to implement the ideal of mainstream medical care for the poor by giving program beneficiaries a “credit card” for use in the private health care marketplace. This exposed the program to the perverse economic incentives of the fee-for-service, costplus health care system, and contributed to a high rate of increase in program costs. Attempts to control costs have been equally perverse, resulting in low payment rates, the second-guessing of physician professional judgments, the probing of medical and fiscal records, and the use of computerized surveillance systems.Attempts to shift to the use of more efficient delivery systems have had small success. Attempts to attain cost containment through restructuring the Medi-Cal program have been rejected in the name of the mainstream ideal. Costs have continued to escalate, with annual increases as high as 20 percent in some years. Medi-Cal now costs $4 billion per year, the largest single program in California state government.The taxpayer revolt in California is creating a fiscal crisis that will force rethinking of the premises of publicly funded health care for the poor, and a restructuring of strategies for reaching that objective. In the short run, it appears that the issue may not be whether the indigent will have access to mainstream medical care, but whether they will have access to any medical care. In the longer run, the crisis should represent an opportunity for building a system of health care that can serve the financially disadvantaged at a cost tolerable to our society. 相似文献
13.
The National Forum on Health''s final report appears to have said what Canadians--and the federal Liberal government wanted to hear about the health care system. It called for preservation of the single-payer model and the 5 principles of the Canada Health Act, and also recommended that medicare be expanded to embrace pharmaceuticals and home care. Edmonton internist Tom Noseworthy, chair of the forum''s steering committee, said public anxiety about medicare is caused by the rapid pace of change, not its direction. However, the CMA''s Dr. Judith Kazimirski was quick to challenge Noseworthy and his criticism of those who say a crisis exists. 相似文献
14.
Kimberly A. Koester Shane P. Collins Shannon M. Fuller Gabriel R. Galindo Steven Gibson Wayne T. Steward 《PloS one》2013,8(8)
Background
Research on gay and other men who have sex with men''s (G/MSM) preferences for sexual healthcare services focuses largely on HIV testing and to some extent on sexually transmitted infections (STI). This research illustrates the frequency and location of where G/MSM interface with the healthcare system, but it does not speak to why men seek care in those locations. As HIV and STI prevention strategies evolve, evidence about G/MSM''s motivations and decision-making can inform future plans to optimize models of HIV/STI prevention and primary care.Methods
We conducted a phenomenological study of gay men''s sexual health seeking experiences, which included 32 in-depth interviews with gay and bisexual men. Interviews were transcribed verbatim and entered into Atlas.ti. We conducted a Framework Analysis.Findings
We identified a continuum of sexual healthcare seeking practices and their associated drivers. Men differed in their preferences for separating sexual healthcare from other forms of healthcare (“fragmentation”) versus combining all care into one location (“consolidation”). Fragmentation drivers included: fear of being monitored by insurance companies, a desire to seek non-judgmental providers with expertise in sexual health, a desire for rapid HIV testing, perceiving sexual health services as more convenient than primary care services, and a lack of healthcare coverage. Consolidation drivers included: a comfortable and trusting relationship with a provider, a desire for one provider to oversee overall health and those with access to public or private health insurance.Conclusions
Men in this study were likely to separate sexual healthcare from primary care. Based on this finding, we recommend placing new combination HIV/STI prevention interventions within sexual health clinics. Furthermore, given the evolution of the financing and delivery of healthcare services and in HIV prevention, policymakers and clinicians should consider including more primary care services within sexual healthcare settings. 相似文献15.
Rufus A. Johnstone António M. M. Rodrigues 《Philosophical transactions of the Royal Society of London. Series B, Biological sciences》2016,371(1687)
In this paper, we draw the attention of biologists to a result from the economic literature, which suggests that when individuals are engaged in a communal activity of benefit to all, selection may favour cooperative sharing of resources even among non-relatives. Provided that group members all invest some resources in the public good, they should refrain from conflict over the division of these resources. The reason is that, given diminishing returns on investment in public and private goods, claiming (or ceding) a greater share of total resources only leads to the actor (or its competitors) investing more in the public good, such that the marginal costs and benefits of investment remain in balance. This cancels out any individual benefits of resource competition. We illustrate how this idea may be applied in the context of biparental care, using a sequential game in which parents first compete with one another over resources, and then choose how to allocate the resources they each obtain to care of their joint young (public good) versus their own survival and future reproductive success (private good). We show that when the two parents both invest in care to some extent, they should refrain from any conflict over the division of resources. The same effect can also support asymmetric outcomes in which one parent competes for resources and invests in care, whereas the other does not invest but refrains from competition. The fact that the caring parent gains higher fitness pay-offs at these equilibria suggests that abandoning a partner is not always to the latter''s detriment, when the potential for resource competition is taken into account, but may instead be of benefit to the ‘abandoned’ mate. 相似文献
16.
D. J. Leaper Jane C. Horrocks J. R. Staniland F. T. de Dombal 《BMJ (Clinical research ed.)》1972,4(5836):350-354
This paper reports a comparison between two modes of computer-aided diagnosis in a real-time prospective trial involving 472 patients with acute abdominal pain. In the first mode the computer-aided system analysed each of the 472 patients by referring to data previously collated from a large series of 600 real-life patients. In the second mode the system used as a basis for its analysis “estimates” of probability provided by a group of six clinicians. The accuracy and reliability of both modes were compared with the performance of unaided clinicians.Using “real-life” data the computer system was significantly more effective than the unaided clinician. By contrast, when using the clinicians'' own estimates the computer-aided system was often less effective than the unaided clinician—especially when diagnosing less common disorders. It seems, firstly, that future systems for computer-aided diagnosis should employ data from real-life and not clinicians'' estimates, and, secondly, that clinicians themselves cannot analyse cases in a probabilistic fashion, since often they have little idea of what the “true” probabilities are. 相似文献
17.
Daniel J. Barnett Ran D. Balicer Carol B. Thompson J. Douglas Storey Saad B. Omer Natalie L. Semon Steve Bayer Lorraine V. Cheek Kerry W. Gateley Kathryn M. Lanza Jane A. Norbin Catherine C. Slemp Jonathan M. Links 《PloS one》2009,4(7)
Background
Local public health agencies play a central role in response to an influenza pandemic, and understanding the willingness of their employees to report to work is therefore a critically relevant concern for pandemic influenza planning efforts. Witte''s Extended Parallel Process Model (EPPM) has been found useful for understanding adaptive behavior in the face of unknown risk, and thus offers a framework for examining scenario-specific willingness to respond among local public health workers. We thus aim to use the EPPM as a lens for examining the influences of perceived threat and efficacy on local public health workers'' response willingness to pandemic influenza.Methodology/Principal Findings
We administered an online, EPPM-based survey about attitudes/beliefs toward emergency response (Johns Hopkins∼Public Health Infrastructure Response Survey Tool), to local public health employees in three states between November 2006 – December 2007. A total of 1835 responses were collected for an overall response rate of 83%. With some regional variation, overall 16% of the workers in 2006-7 were not willing to “respond to a pandemic flu emergency regardless of its severity”. Local health department employees with a perception of high threat and high efficacy – i.e., those fitting a ‘concerned and confident’ profile in the EPPM analysis – had the highest declared rates of willingness to respond to an influenza pandemic if required by their agency, which was 31.7 times higher than those fitting a ‘low threat/low efficacy’ EPPM profile.Conclusions/Significance
In the context of pandemic influenza planning, the EPPM provides a useful framework to inform nuanced understanding of baseline levels of – and gaps in – local public health workers'' response willingness. Within local health departments, ‘concerned and confident’ employees are most likely to be willing to respond. This finding may allow public health agencies to design, implement, and evaluate training programs focused on emergency response attitudes in health departments. 相似文献18.
We present a dynamic network model of corrupt and noncorrupt employees representing two states in the public and private sector. Corrupt employees are more connected to one another and are less willing to change their attitudes regarding corruption than noncorrupt employees. This behavior enables them to prevail and become the majority in the workforce through a first-order phase transition even though they initially represented a minority. In the model, democracy—understood as the principle of majority rule—does not create corruption, but it serves as a mechanism that preserves corruption in the long run. The motivation for our network model is a paradox that exists on the labor market. Although economic theory indicates that higher risk investments should lead to larger rewards, in many developed and developing countries workers in lower-risk public sector jobs are paid more than workers in higher-risk private sector jobs. To determine the long-run sustainability of this economic paradox, we study data from 28 EU countries and find that the public sector wage premium increases with the level of corruption. 相似文献
19.
Tim Stokes Mary Dixon-Woods Kate C Windridge Robert K McKinley 《BMJ (Clinical research ed.)》2003,326(7402):1316
Objective To explore patients'' accounts of being removed from a
general practitioner''s list.Design Qualitative analysis of semistructured interviews.Setting Patients'' homes in Leicestershire.Participants 28 patients who had recently been removed from a
general practitioner''s list.Results The removed patients gave an account of themselves as having
genuine illnesses needing medical care. In putting their case that their
removal was unjustified, patients were concerned to show that they were
“good” patients who complied with the rules that they understood
to govern the doctor-patient relationship: they tried to cope with their
illness and follow medical advice, used general practice services
“appropriately,” were uncomplaining, and were polite with doctors.
Removed patients also used their accounts to characterise the removing general
practitioner as one who broke the lay rules of the doctor-patient
relationship. These “bad” general practitioners were rude,
impersonal, uncaring, and clinically incompetent and lied to patients.
Patients felt very threatened by being removed from their general
practitioner''s list; they experienced removal as an attack on their right to
be an NHS patient, as deeply distressing, and as stigmatising.Conclusions Removal is an overwhelmingly negative and distressing
experience for patients. Many of the problems encountered by removed patients
may be remediable through general practices having an explicit policy on
removal and procedures in place to help with “difficult”
patients. 相似文献
20.
For many years physicians, ethicists and members of the legal community have attempted to minimize ambiguity and unpredictability in making decisions to withhold or withdraw extraordinary life support. Recent developments in national and California law now afford medical care providers unparalleled protection from criminal and civil liability in surrogate decision-making situations. They also reinforce the concept of patient''s rights by providing medical care consumers with new and effective mechanisms for enforcing their “right to decide,” even after they have lost decision-making capacity. A case in point is California''s new Durable Power of Attorney for Health Care, which serves as a model for other jurisdictions that do not have such legislation. Thus, the medical and legal professions, working together, can contribute immeasurably to respectful medical decision making by educating the public about these developments and by adopting policies that reinforce these rights. 相似文献