Providers and staff respond to Medicaid managed care: the unintended consequences of reform in New Mexico

In 1997 a new Medicaid managed care (MMC) program called Salud! was implemented by the State of New Mexico. This article serves as an introduction to a special issue of Medical Anthropology Quarterly that assesses the unintended consequences of this reform and its impact on providers and staff who work in clinics, physician offices, and emergency rooms where Medicaid patients are served. MMC fused state and corporate bureaucracies, creating a complex system where enrollment and access was difficult. The special issue focuses on providers' responses to these new structures, including ways in which staff buffer the impact of reform and the role of the discourses of medical necessity and accountability in shaping the way in which MMC functions.     

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.     

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.     

Ideologies of aid, practices of power: lessons for Medicaid managed care

The articles in this special issue teach valuable lessons based on what happened in New Mexico with the shift to Medicaid managed care. By reframing these lessons in broader historical and cultural terms with reference to aid programs, we have the opportunity to learn a great deal more about the relationship between poverty, public policy, and ideology. Medicaid as a state and federal aid program in the United States and economic development programs as foreign aid provide useful analogies specifically because they exhibit a variety of parallel patterns. The increasing concatenation of corporate interests with state and nongovernmental interests in aid programs is ultimately producing a less centralized system of power and responsibility. This process of decentralization, however, is not undermining the sources of power behind aid efforts, although it does make the connections between intent, planning, and outcome less direct. Ultimately, the devolution of power produces many unintended consequences for aid policy. But it also reinforces the perspective that aid and the need for it are nonpolitical issues.     

Confronting utilization review in New Mexico's Medicaid mental health system: the critical role of "medical necessity"

The insertion of managed care into Medicaid services for the mentally ill has created contention about clinical decision making. At the center of this debate is the matter of what constitutes a medical necessity. Employing ethnographic methodology, this study examines utilization review (UR), the context in which decisions concerning the authorization of mental health care services are made. Interviews carried out in the study contrast ideological underpinnings of providers and advocates of the mentally ill, on the one hand, with employees and administrators of managed care institutions, on the other. The result is an exploration into the ways discourses surrounding the mental health care needs of New Mexico's Medicaid population are being constructed and are determining the actual care they receive.     

Oral health care issues in aged care facilities in Western Australia: resident and family caregiver views

Objective: To investigate resident and family perceptions and attitudes towards oral health care and access to dental services for aged care facility residents. Method: Focus groups and individual interviews with residents and family caregivers were conducted at aged care facilities in the Perth Metropolitan Area, Western Australia. Results: There were 30 participants from twelve aged care facilities (21 residents and nine family caregivers). Five focus groups comprising both residents and family caregivers were conducted in addition to three face‐to‐face interviews with residents. Both groups considered oral health very important to overall health and quality of life. Family caregivers noted a lack of dental check‐ups and specialised professional oral care, particularly in high‐care facilities. Low care residents were more likely to have regular dental check‐ups or dental treatment and off‐site dental visits were straightforward due to their mobility and family member assistance. Family caregivers noted time limitations and lack of expertise in oral health care amongst staff in high‐care facilities, and the challenges of maintaining oral care for residents with poor mobility or cognitive impairment. It was considered important that staff and management liaise with family caregivers and family members in provision of oral care. Conclusion: Regular oral care, assessment and treatment were considered limited, particularly for residents in high care. There is a need for comprehensive, ongoing oral health programmes involving appropriately trained and empathetic dental health professionals and staff to improve oral health care in Perth’s aged care facilities.     

A new record of amphisexual care in an insect with exclusive paternal care: Rhynocoris tristis (Heteroptera: Reduviidae)

We describe the first record of amphisexual care in an insect with uniparental male care. Male Rhynocoris tristis are noted for aggressively guarding multiple egg masses. When a male is unable or unwilling to guard eggs, a female that has previously contributed eggs returns to the egg mass and defends it until the eggs hatch. We compared the frequency and intensity of parental aggression in both sexes and found no difference in either form of guarding behavior. Evidence of amphisexual care in R. tristis provides an opportunity to quantify the cost of care in both sexes within a single species.An erratum to this article can be found at     

Brood desertion in Kentish plover: the value of parental care

To understand the evolution of parental care, one needs to estimatethe payoffs from providing care for the offspring and from terminatingcare and deserting them. In this study we estimated the payofffrom care provision, and in a companion paper we analyze thepayoff from offspring desertion. In the current study we experimentallyinvestigated the influence of the number and sex of attendingparents on growth and survival of offspring in the Kentish ploverCharadrius alexandrinus, in two sites (A and B). Either the maleor the female parent was removed from some broods at hatchingof the chicks (female-only and male-only broods, respectively),whereas in control broods both parents were allowed to attendtheir young. At site A survival of the chicks was lower in uniparental(male-only and female-only) broods than in control broods, whereaswe found no difference in brood survival at site B. Brood survivaldecreased over the season. Removal of either parent did not influencethe growth of the young, although growth varied over the breeding season,and it was significantly different between the sites. Theseresults suggest that the payoff from parental care decreasesover the breeding season and that the value of parental care(i.e., the contribution of parents to the survival of theiryoung) may depend on the environment.     

Antipredator defense as a limited resource: unequal predation risk in broods of an insect with maternal care

The allocation of parental investment is a potential sourceof conflict within broods whenever offspring are able obtaindifferential access to the parental resource. Unlike the provisioningof food, parental antipredator behavior is usually considereda resource that benefits all offspring simultaneously. In thethornbug treehopper (Umbonia crassicornis), offspring formaggregations in exposed positions on host-plant stems. Theyare subject to intense predation, and maternal defense is theirprimary means of protection. I examined the distribution ofrisk within these offspring groups, using natural variationin the outcome of more than 500 predation attempts (324 recordedon videotape) by vespid wasps (Pseudopolybia compressa) on18 U. crassicornis aggregations. I found three influences onan individual offspring's risk of predation. The first wasthe presence of a defending female: as expected, offspringwere much more likely to survive contact with a wasp if thefemale was present than if the female had disappeared. Thesecond influence was position relative to other offspring: when wasps were successful in removing an individual, they almostalways removed it from the edge of the group. The third influencewas distance from the female: the closer an offspring was tothe female at the time it was contacted by a wasp, the higherits likelihood of survival. The distribution of risk is determinedlargely by the behavior of defending females and the prey-searchingbehavior of wasps. The nature of risk within these aggregations sets the stage for two forms of sibling rivalry: selfish herdbehavior and competition for access to maternal defense. Italso raises the question of how a parent should allocate defenseamong offspring when it is unable to defend them all simultaneously.     

重症监护病房脑膜脓毒金黄杆菌医院感染的调查分析

目的通过对重症监护病房（Intensive Care Unit,ICU）内脑膜脓毒金黄杆菌（Chryseobacterium meningosepticum）医院感染的临床特征和耐药性调查分析,为临床更好地预防和治疗该细菌所引起的感染提供参考。方法对我院2007年1月至2008年12月重症监护病房脑膜脓毒金黄杆菌医院感染的47例患者进行回顾性调查。结果45例（95．7％）患者均有严重的基础疾病,与感染相关的因素还包括侵入性操作、深静脉置管、环境污染及长期广谱抗菌药物的应用;47株脑膜脓毒金黄杆菌全部检测出金属β-内酰胺酶,具多重耐药性。体外抗菌活性较好的抗菌药物依次为万古霉素（100．0％）、头孢哌酮／舒巴坦（83．0％）、哌拉西林／他唑巴坦（57．1％）、替卡西林／克拉维酸（52．4％）和复方新诺明（45．2％）,其余所检测的抗菌药物体外抗菌活性均在6．4％-0。结论缩短住院时间、加强病区环境和空气监控、尽量减少侵入性操作和合理使用抗生素是减少脑膜脓毒金黄杆菌感染发生的重要措施。治疗脑膜脓毒金黄杆菌,可选用万古霉素、头孢哌酮／舒巴坦、哌拉西林／他唑巴坦、替卡西林／克拉维酸和复方新诺明。     

Depression case management by practice nurses in primary care: an audit

Introduction Depression is a common and debilitating condition. A body of evidence exists about improving depression outcomes in primary care, using collaborative care models. Such approaches, however, have not been routinely adopted within general practice settings. In this paper we outline the results of an audit of an enhanced care initiative that trained practice nurses to deliver such approaches.Method An audit of symptom outcome and satisfaction was conducted in depression case-management clinics run by practice nurses. Results were then benchmarked against appropriate randomised trial data. The cost of practice nurse time devoted to the delivery of the service was estimated by multiplying time by unit cost.Results A mean change of 9.07 (standard deviation (SD) 6.67, 95% confidence interval (CI) 7.93-10.22, P < 0.001) points on the Patient Health Questionnaire (PHQ9) score was observed in those who were using/had used the service. Clinical change demonstrated a shift from moderate-to-severe to mild depression. The results reflect the changes seen in randomised controlled trial data from similar interventions in similar samples, and are superior to expected treatment as usual outcomes. Overall, respondents were 'very satisfied' with the service on offer. The mean cost of practice nurse time was estimated at ￡45 per patient.Discussion While acknowledging the limitations of audit data, practice nurses in general practice appear to be able to offer effective and acceptable case management to patients experiencing depression.     

Quality of oral health services in residential care: towards an evaluation framework

Background: There is widespread neglect of oral healthcare, and uncertainty about how best to organise and evaluate the impact of oral health services in long‐term care (LTC) facilities. Consequently, there is need for an evaluation framework to improve and account for the quality of oral healthcare in the facilities. Objectives: This paper: (i) identifies basic concepts of quality of care and evaluation in healthcare; (ii) reviews the methods used to evaluate the operation and effectiveness of oral healthcare in LTC facilities and (iii) recommends change to assure oral health‐related quality and accountability for frail elders. Method: A literature review provided insights to the theoretical basis and practical applications for assessing the quality of healthcare relevant to oral healthcare for frail elders. Results: Oral health‐related programmes in LTC facilities could be improved by using a combination of quality assurance and health programme evaluation that: (i) engages everyone involved; (ii) seeks multiple attributes of quality; (iii) evaluates the structure, process or activities, and outcome of the oral health programme; (iv) uses formative and summative methods to provide both quantitative and qualitative evidence of care and (v) transfers new knowledge for appropriate consideration and action. Conclusions: This theoretical framework can be applied in dentistry in LTC to provide an assessment model specific to oral healthcare for frail elders in residential care.     

Short Communication Seasonal distribution of Rhipicephalus sanguineus ticks (Acari: Ixodidae) on dogs in an urban area of Morelos, Mexico

Between 1993 and 1995, we examined 1742 dogs at two veterinary clinics in Cuernavaca City in Mexico for the presence of Rhipicephalus sanguineus ticks. The overall tick infestation prevalence was 20% and there were no significant differences (p > 0.05) between different years. The prevalence was somewhat higher in spring, summer and autumn (20% or more) than in winter (13.7%). A positive correlation (p < 0.01) was found between prevalence of ticks and rainfall in spring, summer and autumn, whereas in winter there was only a correlation with temperature. Different stages of the tick were found and it was calculated that 2.5 generations could be completed each year. It is concluded that the enviromental conditions of Cuernavaca City favour development and maintenance of R. sanguineus ticks throughout the year and that its role as a vector of diseases poses a threat to dogs and may have potential zoonotic risks. © Rapid Science Ltd. 1998     

Variable postfledging care in a cooperative bird: causes and consequences

Prolonged postfledging care is a commonly observed behaviorin many cooperatively breeding species and has been shown toprovide young with both survival and developmental benefits.However, the causes of intraspecific variation in postfledgingcare and the consequences of this variation on the developmentof young remain unclear. Here we investigate factors affectingthe duration of postfledging care in the cooperatively breedingpied babbler (Turdoides bicolor). We show that the durationof care is variable (40–97 days) and is determined primarilyby the cost of care. Adults in groups with a low adult:fledglingratio were unable to maintain body mass during the period ofchick provisioning and subsequently ceased care of young earlier.This had a strong influence on offspring development: fledglingsthat received longer periods of care attained higher foragingefficiency and body mass than their counterparts at 6 monthsof age. The duration of postfledging care also had long-termeffects, with individuals that received longer periods of postfledgingcare more likely to successfully disperse from their natal group.This had important fitness implications as successful dispersersbecame reproductively active at an earlier age than their "failed-disperser"counterparts. These findings highlight the importance of consideringlong-term influences when assessing the benefits of prolongedpostfledging care on offspring fitness and development in cooperativesocieties.     

Evolutionary pathways in shorebird breeding systems: sexual conflict, parental care, and chick development

Sexual selection, mating opportunities, and parental behavior are interrelated, although the specific nature of these relationships is controversial. Two major hypotheses have been suggested. The parental investment hypothesis states that the relative parental investment of the sexes drives the operation of sexual selection. Thus, the sex that invests less in offspring care competes more intensely and monopolizes access to mates. The sexual conflict hypothesis proposes that sexual selection (the competition among both males and females for mates), mating opportunities, and parental behavior are interrelated and predicts a feedback loop between mating systems and parental care. Here we test both hypotheses using a comprehensive dataset of shorebirds, a maximum-likelihood statistical technique, and a recent supertree of extant shorebirds and allies. Shorebirds are an excellent group for these analyses because they display unique variation in parental care and social mating system. First, we show that chick development constrains the evolution of both parental care and mate competition, because transitions toward more precocial offspring preceded transitions toward reduced parental care and social polygamy. Second, changes in care and mating systems respond to one another, most likely because both influenced and are influenced by mating opportunities. Taken together, our results are more consistent with the sexual conflict hypothesis than the parental investment hypothesis.     

Long term effects of an integrated care intervention on hospital utilization in patients with severe COPD: a single centre controlled study

Abstract

Chronic obstructive pulmonary disease (COPD) is one of the main causes of morbidity and mortality globally. In Trondheim in 2008 an integrated care model (COPD-Home) consisting of an education program, self-management plan, home visits and a call centre for patient support and communication was developed. The objective was to determine the efficacy of an intervention according to the COPD-Home model in reducing hospital utilization among patients with COPD stage III and IV (GOLD 2007) discharged after hospitalization for acute exacerbations of COPD (AECOPD).

Methods

A single centre, prospective, open, controlled clinical study comparing COPD-Home integrated care (IC) with usual care (UC).

Results

Ninety-one versus 81 patients mean age 73.4 ± 9.3 years (57% women) were included in the IC group (ICG) and the UC group (UCG) respectively, and after 2 years 51 and 49 patients were available for control in the respective groups. During the year prior to study start there were 71 hospital admissions (HA) in the ICG and 84 in the UCG. There was a 12.6% reduction in HA in the ICG during the first year of follow-up and a 46.5% reduction during the second year (p = 0.01) compared to an 8.3% increase during the first year and no change during the second year in the ICG. During the year prior to study start, the number of hospital days (HD) was 468 in the ICG and 479 in the UCG. In the IC group, the number of HD was reduced by 48.3% during the first year (p = 0.01), and remained low during the second year of follow-up (p=0.02). In the UC group, the number of HD remained unchanged during the follow-up period. There was a trend towards a shorter survival time among patients in the ICG compared to the UCG, hazard ratio 1.33 [95% CI 0.77 to 2.33].

Conclusion

Intervention according to the COPD-Home model reduced hospital utilization in patients with COPD III and IV with a persisting effect throughout the 2 years of follow-up. However, there was a trend towards a shorter survival time in the intervention group.     

Parents and offspring in an evolutionary game: the effect of supply on demand when costs of care vary

Current models of parent-offspring communication do not explicitly predict the effect of parental food supply on offspring demand (ESD). However, existing theory is frequently interpreted as predicting a negative ESD, such that offspring beg less when parental supply is high. While empirical evidence largely supports this interpretation, several studies have identified the opposite case, with well-fed offspring begging more than those in poorer condition. Here, we show that signalling theory can give rise to either a negative or a positive ESD depending on the precise form of costs and benefits. Introducing variation among parents in the cost of care, we show that the ESD may change sign depending upon the quantitative relation between two effects: (i) decreased supply leads to increased begging because of an increase in marginal fitness benefit of additional resources to offspring, (ii) decreased supply leads to reduced begging because it is associated with a decrease in parental responsiveness, rendering begging less effective. To illustrate the interplay between these two effects, we show that Godfray's seminal model of begging yields a negative ESD when care is generally cheap, because the impact of supply on the marginal benefits of additional resources then outweighs the associated changes in parental responsiveness to begging. By contrast, the same model predicts a positive ESD when care is generally costly, because the impact of care costs on parental responsiveness then outweighs the change in marginal benefits.     

Divergence in parental care, habitat selection and larval life history between two species of Peruvian poison frogs: an experimental analysis

Changes in the nature of the ecological resources exploited by a species can lead to the evolution of novel suites of behaviours. We identified a case in which the transition from large pool use to the use of very small breeding pools in neotropical poison frogs (family Dendrobatidae) is associated with the evolution of a suite of behaviours, including biparental care (from uniparental care) and social monogamy (from promiscuity). We manipulated breeding pool size in order to demonstrate experimentally that breeding habitat selection strategy has evolved in concert with changes in parental care and mating system. We also manipulated intra- and interspecific larval interactions to demonstrate that larval adaptation to the use of very small pools for breeding affected the evolution of larval competition and cannibalism. Our results illustrate the intimate connection between breeding pool ecology, parental care and mating strategies in Peruvian poison frogs.