Significance of serum surfactant protein-D (SP-D) level in patients with pulmonary tuberculosis

BACKGROUND: In 1992, 15 employers in Minneapolis-St Paul, operating as the Business Health Care Action Group (BHCAG), combined their self-insured plans. To successfully bid for the BHCAG contract, three competing group practices and a health plan cooperated, operating like a fully integrated care system to measure outcomes, develop practice guidelines, and meet other BHCAG requirements. To accomplish this, a new organization, the Institute for Clinical Systems Integration (ICSI), was conceived. ICSI IN THE EVOLVING MINNEAPOLIS MARKETPLACE: From a business standpoint, ICSI members stood to gain market share by being members of ICSI and the "chosen" consortium. From a professional standpoint, they could realize the fulfillment and satisfaction of knowing that they were innovating, improving care, reducing waste, and sharing their knowledge with others. A NEW MARKET MODEL: To drive the same kind of change for the entire care delivery system in the region, not just for the subset that happened to win the original bid, BHCAG changed the purchase model in February 1995--enrollees could now choose among 16 to 20 discrete care delivery systems instead of preferentially channeling them to the ICSI-HealthPartners network of group practices. All the care systems had become competitors on every level, including quality of care. The "special" customer-supplier relationship between BHCAG and the ICSI medical groups was no longer present. LESSONS LEARNED: Despite major changes in the market dynamics, with the marked decline in the business reason for collaboration which had prompted ICSI to form in the first place, physicians, nurses, and administrative staff from participating medical groups continue to devote massive effort to the development and implementation of best practices.     

Completing advance directives for health care decisions: Getting to yes.

The concept of advance directives for health care decision making has been judicially condoned, legislatively promoted, and systematically implemented by health care institutions, yet the execution rate of advance directives remains low. Physicians should discuss with their patients advance care planning generally and end-of-life issues specifically, preferably when patients are in good health and not when they face an acute medical crisis. The physician–hospital relationship poses particular challenges for the optimal implementation of advance directives that must be addressed. Hospital administrators must improve education of patients and physicians on the value of such documents as well as internal mechanisms to ensure better implementation of directives. Health insurance plans may be better able to ensure optimal gathering and implementation of directives. Patients must become more familiar and more comfortable with advance care planning and the reality of death and dying issues. Full acceptance of the value of directives ultimately rests on achieving full participation of all involved—providers, patients, families, and payors—in this most profound process. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

When medical group and HMO part company: disenrollment decisions in Medicare HMOs

Medicare beneficiaries who enroll in "risk contract" Health Maintenance Organizations (HMOs) are covered for services only if they are provided or approved by the HMO. Thus, their enrollment decisions involve selecting a health care delivery system and may be influenced by whether the HMO has contracts with particular providers. Disenrollment decisions, in turn, may be influenced by breaks in contracts between the HMO and its medical groups. This study examines decisions made by Medicare HMO enrollees when their HMO terminated its relationship with a major medical group; the group then signed a contract with a competing HMO. Beneficiaries were forced to choose between remaining with their HMO and switching to another provider, and switching to the competing HMO where they could keep their provider. Beneficiaries demonstrated considerable loyalty to their providers; nearly 60% switched to the competing HMO. Previous research on health care coverage decisions has been based on models which did not address consumers' knowledge, options, and information sources. In this decision context, we found that knowledge and information sources were the most important determinants of beneficiary decisions.     

Rehabilitation Psychology, Medical Psychology, Health Psychology, and Behavioral Medicine.

In their recent article, "The Distinctiveness of Rehabilitation Psychology," Shontz and Wright (see record 1981-26520-001) attempt to differentiate rehabilitation psychology from other areas of applied and professional psychology in health settings. Although the authors' historical recounting of early research and theory in rehabilitation psychology is informative, too little emphasis is placed on the relationship between rehabilitation psychology and "mainstream" professional psychology, particularly with regard to its health-setting applications. There appear to be more similarities than differences. The authors' argument runs full circle, namely, that rehabilitation psychology is distinct because of its philosophy, but its philosophy and "principles are valuable to psychologists in many specialties" (p. 919). The notion of involving a patient in his/her care and treatment planning also is not unique to rehabilitation psychology. Shontz and Wright state that rehabilitation psychology is not medical psychology; however, instead of defining medical psychology, they go on to talk about medical care. Medical care is not medical psychology. Further confusion is added by the statement that medical psychology should be a component of rehabilitation psychology. The authors are using medical psychology, health psychology, and behavioral medicine as if they are synonymous, when they are not. Each discipline is made distinct here. Shontz and Wright do not address what the majority of psychologists in rehabilitation do, that is, provide services. In short, although the authors complain about the unfamiliarity of rehabilitation psychology relative to the profession as a whole, their article does little to promote rehabilitation psychology as an area of interest important to professional psychologists in health care and/or rehabilitation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Accountability for quality in managed care

BACKGROUND: It is often difficult to understand where responsibility lies for monitoring and improving quality in managed care. From 1996 through 1998 a group of individuals convened by the Institute of Medicine's (Washington, DC) National Roundtable on Health Care Quality developed a model of accountability for the quality of care provided by managed care organizations (MCOs). Each of three overarching forms of accountability (professional, market, and regulatory) has a set of tools for imposing accountability and-because accountability relationships are not self-enforcing-sanctions for failures of accountability. PROFESSIONAL ACCOUNTABILITY: Fiduciary relationships in medicine are an essential part of any quality accountability mechanism, and it will be important to maintain the strength of the professional model in the changing health care system. Yet it is not easy to preserve the strength of the professional model in an MCO environment in which professionals are not dominant, and there is likely to be increasing pressure to weaken their autonomy. MARKET ACCOUNTABILITY: The primary assumption of market accountability is that consumers will select options based on perceived value to them and will make new choices based on their information and experience. Market accountability requires choice among competing providers and information to inform choice. In health care, however, individuals rarely have the information they need and often do not have choice. Accountability for quality generally has not been a major feature in contracts. REGULATORY ACCOUNTABILITY: There is a widespread perception of defects in a market-based health care system. Many believe there is a need for a regulatory structure to correct market failures. The use of regulation to impose accountability for quality requires that a regulatory framework, penalties for violations, and effective enforcement mechanisms are all established. PUBLIC GOODS: The model of accountability for quality in managed care does not promote public goods such as education, research, public health, or care for the uninsured. Indeed, the locus of responsibility to the community when markets fail to supply these public goods is controversial. Nevertheless, such responsibility should be considered by MCOs and policy makers. COLLABORATION TO IMPROVE QUALITY OF CARE: Given market-driven models of health care financing and delivery, it might be feasible and desirable to encourage collaboration among MCOs to improve quality, whether at the national or local market level. The health professions in general, and the medical profession in particular, are and must be accountable to society for providing leadership in the development of knowledge about effective medical care, in defining high-quality care, and in advocating for and improving the quality of care. CONCLUSION: Establishing effective accountability for quality involves multiple entities and many different kinds of accountability relationships. The three forms of accountability interact, and all operate at once.     

Reengineering health care materials management

Health care executives across the country, faced with intense competition, are being forced to consider drastic cost cutting measures as a matter of survival. The entire health care industry is under siege from boards of directors, management and others who encourage health care systems to take actions ranging from strategic acquisitions and mergers to simple "downsizing" or "rightsizing," to improve their perceived competitive positions in terms of costs, revenues and market share. In some cases, management is poorly prepared to work within this new competitive paradigm and turns to consultants who promise that following their methodologies can result in competitive advantage. One favored methodology is reengineering. Frequently, cost cutting attention is focused on the materials management budget because it is relatively large and is viewed as being comprised mostly of controllable expenses. Also, materials management is seldom considered a core competency for the health care system and the organization performing these activities does not occupy a strongly defensible position. This paper focuses on the application of a reengineering methodology to healthcare materials management.     

The Evolution of Behavioral Primary Care.

The financing, organization, and delivery of behavioral health care services has undergone dramatic change in the past 25 to 30 years. The authors trace the evolution of behavioral health care delivery in the United States over the past several decades and find (a) that the value of mental health "carve-outs" has diminished greatly and that they are being replaced by "carve-ins," (b) that primary care physicians (PCPs) are becoming a primary source of mental health care secondary to the introduction of new medications, and (c) that PCP treatment of mental health disorders is suboptimal. The authors conclude that the behavioral health care system is entering an era of flux as it experiments with ways of integrating behavioral and primary care. Opportunities for psychologists are explored. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Management service organizations: effective strategy to assume and manage full risk agreements?

A management services organization (MSO) has emerged as one structure to manage professional and hospital risk agreements. Health plans and direct payers are transferring traditional functions to medical groups and health systems under these agreements. How does a hospital and affiliated medical group develop a strategy to assume, manage, and mutually benefit from these agreements? When do market forces dictate whether an MSO is the most appropriate organizational model to utilize? The development of an MSO can offer an effective organizational strategy to capture capitated contracts and assume responsibility for population-based medical services. This article explores the features of such an organization, areas for potential collaboration between the medical group and hospital, as well as the impact on patient care.     

The dynamics of market-level change

Health care exhibits a competitive dynamic today that increasingly resembles that in other service industries. Organizations are becoming larger to achieve scale economies and to increase market power. Vertical integration, whether through ownership or complex contracts, is also being pursued both to seek efficiencies and to improve the bargaining position of the organization. External forces that are driving these changes include more aggressive activities on the part of purchasers to contain their costs, developments in information technology, management innovation in other service industries, and advances in medical technology. Within the health care industry, there is a pattern of organizations taking the initiative to respond to these external forces--often in anticipation of them--and other organizations then responding to the pressures in turn placed on them. Although information on strategies is communicated rapidly throughout the country, what is attempted and what succeeds differs a great deal across communities. The nature of current health care institutions in the community, including the presence of large entities with extensive capital and strong management in a particular segment of the health system and the community's experience with managed care are important factors in the path that change takes.     

Brain lipid composition of the rat with experimental morphine dependence

OBJECTIVE: To develop and validate a prediction rule screening instrument, easily incorporated into the routine hospital admission assessment, that could facilitate discharge planning by identifying patients at the time of admission who are most likely to need postdischarge medical services. DESIGN: Prospective cohort study with separate phases for prediction rule development and validation. SETTING: Urban teaching hospital. PATIENTS/PARTICIPANTS: General medical service patients, 381 in the derivation phase and 323 in the validation phase, who provided self-reported medical history, health status, and demographic data as a part of their admission nursing assessment, and were subsequently discharged alive. MEASUREMENTS AND MAIN RESULTS: Use of postdischarge medical services such as visiting nurse or physical therapy, medical equipment, or placement in a rehabilitation or long-term care facility was determined. A prediction rule based on a patient's age and Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) physical function and social function scores stratified patients with regard to their risk of using postdischarge medical services. In the validation set, the rate of actual postdischarge medical service use was 15% (15 of 97), 36% (39 of 107), and 58% (57 of 98) among patients characterized by the prediction rule as being at "low", "intermediate," and "high" risk of using postdischarge medical services, respectively. CONCLUSIONS: This prediction rule stratified general medical patients with regard to their likelihood of needing discharge planning to arrange for postdischarge medical services. Further research is necessary to determine whether prospective identification of patients likely to need discharge planning will make the hospital discharge planning process more efficient.     

The effect of cost sharing on the use of chiropractic services

OBJECTIVES: Chiropractic care is increasing in the United States, and there are few data about the effect of cost sharing on the use of chiropractic services. This study calculates the effect of cost sharing on chiropractic use. METHODS: The authors analyzed data from the RAND Health Insurance Experiment, a randomized controlled trial of the effect of cost sharing on the use of health services. Families in six US sites were randomized to receive fee-for-service care that was free or required one of several levels of cost sharing, or to receive care from a health maintenance organization (HMO). Enrollees were followed for 3 or 5 years. All fee-for-service plans covered chiropractic services. Persons assigned to the HMO experimental group received free fee-for-service chiropractic care; persons in the HMO control group had 95% cost sharing for chiropractic services. The authors calculated the mean annual chiropractic expense per person in each of the fee-for-service plans, and also predicted their chiropractic expenditures using a two-equation model. Chiropractic use among persons receiving HMO and fee-for-service care were compared. RESULTS: Chiropractic care is very sensitive to price, with any level of coinsurance of 25% or greater decreasing chiropractic expenditures by approximately half. Access to free chiropractic care among HMO enrollees increased chiropractic use ninefold, whereas access to free medical care decreased fee-for-service chiropractic care by 80%. CONCLUSIONS: Chiropractic care is more sensitive to price than general medical care, outpatient medical care, or dental care, or and nearly as sensitive as outpatient mental health care. A substantial cross-price effect with medical care may exist.     

Woman-centered information on menopause for health care providers: findings from the Midlife Women's Health Survey

Despite their growing numbers, midlife women continue to feel marginalized by a health care system that is unresponsive to their needs for current information about the perimenopausal experience and for egalitarian, woman-centered care. In this article, the authors call upon physicians, health educators, nurses, counselors, and other health providers to meet the consumer needs of this ever-growing clientele. To this end, they provide data-based information derived from the responses of more than 400 middle-aged women from across the United States to annual Midlife Women's Health Surveys from 1990 to 1993. The authors focus on enhancing the sensitivity of health care providers toward their midlife clients by offering data describing the normal menopausal transition and the feelings and concerns of this group.     

The blending of competitive and regulatory strategies: a second opinion

A comparison of the 10 states that as of 30 June 1994 witnessed the highest and lowest percent of health maintenance organization market penetration, and the findings reported in the Dartmouth Atlas of Health Care in the United States, both illustrate dramatic differences among the various states in the distribution, utilization, and cost of hospital and other health services. This article thereafter focuses on the implications of these findings in the context of the states eventually blending competitive and regulatory strategies to constrain hospital expenditures-a conceptual framework that is consistent with Americans being advocates of pluralism when organizing and financing their health care system.     

Mental disorders and access to medical care in the United States

OBJECTIVE: The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults. METHOD: The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables. RESULTS: While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were no less likely to have a primary care provider but were about two times more likely to report having delayed seeking needed medical care because of cost or having been unable to obtain needed medical care. CONCLUSIONS: People who reported mental disorders experienced significant barriers to receipt of medical care. Efforts to measure and improve access to health care for this population may need to go beyond simply providing insurance benefits or access to general medical providers.     

Healthy aging. A women''s issue

In this thesis, Korean prisoners' health behavior and the characteristics of their medical utilization were surveyed and analysed. Because prisoners are inclined to be mediators of communicable diseases or unhealthy behaviors between prison institution and the outside world, health care for prisoners is directly related to the national population. Data were collected through a self-administered survey of 5 Korean prisons out of a total of 38 correctional facilities and analysed in accordance with a causal model based on a path frame, by serial multiple regressions on health behavior, health status, and medical utilization, etc. According to the survey analysis, while prisoners were generally concerned with their health much more than they were before imprisonment, they perceived that their health status had deteriorated after imprisonment, and that their need for health services was increasing gradually during their time in prison. In the path analysis on the causal relations among variables related to the prisoners' health status and medical utilization, the prisoners' characteristics affected their health concern and health behavior, and subsequently affected their health status and medical utilization, respectively. To sum up these exploratory studies on prisoners' health behavior and health service utilization, some efforts to organize a health care system embracing the correctional institution and health care administration should be made on the level of establishing a health care delivery system for special social groups like prisoners.     

Projected needs of health manpower in Saudi Arabia, 1974-90

Although our projections are not completely accurate, due to inadequate data and crude methods of approximation, three conclusions are inescapable: 1. The nation should give priority to planning new schools for health administrators and rural health workers, and to generally expanding present schools for paramedicals. 2. Plans should proceed rapidly for the two new medical schools. 3. A Health Manpower plan based on census information and special studies should be developed over the next 2 years. This plan should have input from all concerned ministries. (The Ministry of Health has regarded a proposal from University Associate "a group of Harvard, Johns Hopkins and A.U.B. professors" for technical cooperation in health services planning.)     

Background and prospects of the Community Health Act

Japan was defeated in World War II and almost all of the nation was demoralized by the destruction and damage to much of the nation. The medical and health care system during and before World War II needed to be reformed radically and fundamentally since almost all medical and health institutes were destroyed. On the other hand, many health personnel came back from overseas after the war. Japanese modern medicine had developed on the basis of German medicine; however, many aspects of American medicine, including public health and democracy, were rapidly introduced following the end of World War II. The American type of health center was established and many laws concerning medical and health care were enacted in 1947-1948. One of them was "The Health Center Law." The National Health Insurance Act was enacted in 1958 and the total population has been covered by health insurance plans since 1961. Many physicians quit the health centers and they have worked as clinicians under the National Health Insurance scheme, because health centers were introduced before adequate education and research existed in the field of public health. On the other hand, the health insurance scheme was in its golden age during the high economic growth period of the 1960s. Japan has succeeded in all forms of modern technology and economy for the past 30 years and is now one of the top nations in the field of medical and health care, such as the numbers of clinics and hospitals and beds, the frequency of consulting with a doctor, length of hospital stay, examinee rates in mass health examinations in the community and workplace and so on. Health conditions have changed drastically from the 1950s to the present. Therefore, health centers do not fit current health needs. For example, mortality from tuberculosis, acute infections diseases and also stomach and uterus cancers and apoplexy have decreased rapidly while mortality from chronic diseases, especially lung, breast and rectal cancers, and myocardial infarction have increased gradually. Changes of life style resulting from rapid economic growth are suspected to be important causes of the change in the prevalence of these diseases. Mass health examination was important and effective as a preventive measure against tuberculosis, especially as a means of early detection and early treatment. However, it is not now effective against chronic diseases. The screening examination has resulted in identifying many patients suspected of being ill. Every examiner must be able to distinguish pathologic findings from physiologic changes of aging. Every patient must, therefore, understand his/her individuality and evaluate the result of his/her efforts to improve life style by receiving a health examination. Accordingly, the aim of health examination has changed from early detection to health support for the examinee. During the decades when life expectancy was less than 50 years of age, it was not necessary for people to plan for retirement. Moreover, there was little burden on younger generations to provide care for the aged people because there were few old people more than 70 years of age and the birth rate was high. Nowadays, elderly people face many years of life after retirement and there are too many aged people in relation to the number of younger persons. As for medical care services, many new medical needs have emerged in recent years, including "quality of life," "palliative medicine in terminal care," "establishment of a primary care system" and "comprehensive care connecting health and medical care with welfare" etc. Improved living standards resulting from economic growth, called the "economic miracle" internationally, have helped to bring about a rapid and wide range of change in daily lifestyle, such as eating habits, working conditions and environment. The Ministry of Health and Welfare has made every effort to revise the laws in relation to health and medical care systems, in order to adjust to recent     

Mental health services in managed care: quality questions remain

Primary care physicians are often the professionals to whom older patients turn for advice about medical coverage in Medicare managed care health plans. To assist in this dialogue, these authors outline current characteristics and financial arrangements for psychiatric and mental health services in Medicare managed care. Advantages and disadvantages of Medicare managed care for enrollees with mental disorders are outlined. Mental health "carve-out" and "carve-in" models are defined, and questions are raised about the number of psychiatrists and other mental health care providers needed to provide appropriate care for a plan's enrollees.     

Adaptation of medical care to the changing disease spectrum of adolescents

The spectrum of diseases affecting today's children and adolescents has changed. Today's urgent health problems are no longer acute and infectious disorders but much rather psychosomatic and chronic disorders. However, the present health delivery system has not adapted its structure to this changed spectrum of disease. This paper reports on a study carried out by the project "Health Risks and Structures of Medical and Mental Health Care." The project belongs to the North Rhine-Westphalian Consortium for Public Health, and the study was carried out in cooperation with the Special Research Unit 227: "Prevention and Intervention in Childhood and Adolescence." Results show that a small proportion of adolescents actually consult general practitioners. Inadequate cooperation between medical and mental health care services as well as insufficient links between these services and the life world of adolescents have led to a situation in which the use of professional assistance meets with barriers. As a result, adolescents continue to avoid visiting a physician even when they have already become ill. For this reason, there is an increasingly strong need to consider how to change the structures of medical and mental health care. Proposals are developed that meet the needs of adolescents and are oriented toward the requirements arising from the changing spectrum of disease.