The Chinese health care system: lessons for other nations

This paper examines China's health care from a system perspective and draws some lessons for less developed nations. A decade ago, Chinese macro-health policy shifted its health care financing and delivery toward a free market system. It encouraged all levels of health facilities to rely on user fees to support their operations. However, China continued its administered prices and hospitals continued to be operated by the government. These financing, pricing and organizational policies were not coordinated. The author found these uncoordinated policies created serious dissonance in the system. Irrational prices distorted medical practices which resulted in overuse of drugs and high technology tests. Market-based financing created more unequal access to health care between the rich and poor. Public control of hospitals and poor management caused inefficiency, waste and poor quality of care. The disarray of the Chinese health system, however, had not caused a measurable decline in health status of the Chinese people. One explanation was that the government had maintained its level of funding (per capita) for public health and prevention. Another possible explanation was that rapid rising income in China had improved nutrition, clean water and education which offset any adverse impacts of poorer medical services to the low-income populations. Nonetheless, the Chinese experience showed that its increasing expenditure per person for health care through user fees and insurance had not produced commensurate improvement in health status. China'a experience holds several lessons for less developed nations. First, there is a close linkage between financing, price and organization of health care. Uncoordinated policies could exacerbate inequity and inefficiency in health care.(ABSTRACT TRUNCATED AT 250 WORDS)     

Review of The health planning predicament.

Reviews the book, The health planning predicament by Victor G. Rodwin (1984). There are many different ways health care can be distributed and paid for. Medical care utilization is an important behavior widely studied by health services researchers and by economists. Planning in health care requires an understanding of the need for services and the mechanisms required to pay for them. In this book, Rodwin presents a thoughtful analysis of the new challenges for health planners in four Western countries. Most Western cultures are guided by the assumption that medical care is good. Thus, most developed countries have increased access to medical care by creating systems for third-party payment of expenses. As a result, the availability of services for underserved groups has greatly improved. In addition, health care costs have steadily increased in most Western countries. A growing number of critics now argue that developed countries spend too much on health care and that ease of access has created new problems, including increased iatrogenic illness and threats to economic solvency. Rodwin addresses these and other questions by comparing health services systems in the United States, France, Canada, and England. Although these four countries have similar cultural and economic characteristics, they differ in the way they distribute health care services. The differences among the systems considered by Rodwin provide for many interesting comparisons of physician behavior, and of patient service utilization. They also provide a new basis for the evaluation of different health care policies. In summary, Victor Rodwin has produced an interesting and readable comparison of health planning in different countries. Despite different approaches to the same problem, all four governments are faced with a health planning predicament. The book is full of interesting insights and may stimulate new thinking about some very serious policy questions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Opportunities in public policy to support infant and early childhood mental health: The role of psychologists and policymakers.

Infant and early childhood mental health practices can be supported by policies and professional standards of care that foster the healthy development of young children. Policies that support infants and toddlers include those that strengthen their families to provide a family environment that promotes mental wellness. Policy issues for infants, toddlers, and young children have come to the forefront of thinking as children need a “voice” to advocate for their support and care. This article (a) highlights several important policy areas that support the social–emotional development of very young children and (b) gives examples of current policy accomplishments and challenges. The article offers a policy agenda to promote the mental health of infants and young children and suggests ways that psychologists can engage with policymakers to promote policies that foster infant mental health, including contributing to the knowledge base that informs policy decisions, educating the public and policymakers about early childhood development and mental wellness, forming community partnerships to identify and address infant mental health risks, and participating in the development of policy recommendations that improve access to evidence-based practices in infant mental health. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mental health policy: Observations from Europe.

Reviews policies and practices based on a study of 5 European countries (Switzerland, England, Denmark, Sweden, and the Netherlands) with respect to deinstitutionalization and community support and rehabilitation services, health and social security benefits, financing mechanisms, and care for the homeless and young adult chronic populations. Common trends in European mental health and social welfare policies are summarized. Relative to the US, the coordinated system of care in these countries is supported by a strong social welfare system allowing for community-based care administered by the mental health service system. (19 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Costs and use of mental health services before and after managed care

This paper tracks access, utilization, and costs of mental health care for a private employer over nine years during which mental health benefits were carved out of the medical plan and managed care was introduced. Prior to the carve-out, mental health costs increased by around 30 percent annually; in the first year after the change, costs dropped by more than 40 percent; in the six follow-up years, costs continued to decline slowly. This cost reduction was not attributable to decreased initial access, as the number of persons using any mental health care increased following the change. Instead, the cost reduction was the result of (1) fewer outpatient sessions per user, (2) reduced probability of an inpatient admission, (3) reduced length-of-stay for an inpatient episode, and (4) substantially lower costs per unit of service.     

Health policy reforms and their impact on the practice of tropical medicine

This paper addresses the consequences of reforming health policies on the practice of tropical medicine. It briefly reviews the historical development of health systems in poor, tropical countries before summarising current trends in the reform of financing and management. Reforms considered include decentralising management, broadening choices in health financing, particularly introducing user fees, introducing 'managed competition' principles, and working with the private sector. Experiences in different countries are used to highlight some of the dangers inherent in current reform trends. It is suggested that while monopolistic and centralised systems of public provision are unlikely to come back into fashion, much can be done to build on the more positive aspects of current reforms and to minimise their undesirable side effects. Key issues are developing mechanisms that ensure that services are responsive to users, avoiding polarisation of services between rich and poor, and improving systems of regulation, supervision and monitoring.     

Improving the processes of care and outcomes in obstetrics/gynecology

BACKGROUND: The obstetrics/gynecology department of York Hospital (York Health System, York, Pennsylvania) initiated a program to improve the processes of care and control costs for common women's and newborns' health care services. Twelve clinical policies were established between June 1993 and February 1995. CONDUCTING THE QUALITY IMPROVEMENT (QI) PROJECTS: Using the plan-do-check-act (PDCA) improvement cycle method, the QI group established clinical pathways for high-volume conditions or procedures known to have low rates of complications and clinical guidelines for those conditions or procedures not requiring coordinated efforts of a group of health care professionals. EXAMPLE--PYELONEPHRITIS IN PREGNANCY: The literature had indicated that the prevalence of pyelonephritis can be decreased by identifying and treating asymptomatic bacteriuria early in prenatal care. After the validity of the clinical policy was demonstrated in the resident service, the policy was extended to all private obstetric practices. Dissemination of the finding that most of the admissions for pyelonephritis were for referred patients (for whom we had no control over prenatal care) or for patients referred by private physicians who were not yet following the guidelines quickly led to complete compliance by our obstetricians and other health care providers referring patients to the York Health System. RESULTS: The 12 clinical policies resulted in the elimination of 113 admissions and 5,595 inpatient days and in the reduction of the cost of patient care by $1,306,214 for the years 1994-1995 and 1995-1996 combined, without apparent adverse effects on patient health. CONCLUSION: A voluntary clinical policies program can change the culture of a department and lead to cost-effectiveness and better quality of patient care.     

When will managed care come to anesthesia?

Managed care has begun to reshape many areas of health care practice, but anesthesia is not yet among them. The economics of anesthesia care are characterized by widespread inefficiency in the allocation of labor, and a unique market structure that poses special challenges to managed care influence. The potential for savings is great, perhaps as much as a one percent decrease in commercial health costs. But these savings can only be realized if managed care organizations are able to restructure the incentives facing anesthesia professionals to promote innovation, cooperation, and shared benefits of efficiency improvements.     

Biophysical characterization of the interaction of the beta-lactamase TEM-1 with its protein inhibitor BLIP

Health care expenditures on the elderly tend to grow about 4 percent per year more rapidly than the gross domestic product (GDP). This could plunge the nation into a severe economic and social crisis within two decades. This paper describes recent growth in age/sex-specific health care utilization by the elderly and discusses the important role of technology in that growth. It also explores the potential for the elderly to pay for additional care through increases in work and savings. Efforts to "save Medicare" will prove to be "too little, too late" unless they are embedded in broader policy initiatives that slow the rate of growth of health care spending and/or increase the income of the elderly.     

Is there convergence between Britain and the United States in the organisation of health services?. Interview by Penny Newman

Is the organisation of health care in Britain becoming similar to that in the United States? Since the introduction of the internal market radical change has gripped the NHS. In the United States, despite the failure to implement coherent health care reform, a health care revolution is under way, driven by cost containment. At the centre of these changes is managed competition. Alain Enthoven, Marriner S Eccles professor of public and private management at Stanford University, has been the principal proponent of managed competition in both countries. His writings inspired the NHS reforms in 1989 and President Clinton's advisers to adopt managed competition in 1994, though ultimately he became opposed to the Clinton plan. In this interview with Penny Newman he redefines managed competition, explores the similarities and differences that have arisen between Britain and the United States, and describes recent trends in the United States, many of which are being mirrored in Britain. He illustrates a degree of convergence between the two countries. This was unthinkable 10 years ago when comparing the fee for service system in the United States with the NHS.     

Pathobiological significance of colony morphology in Mycobacterium avium complex

There have been considerable political and organizational moves to involve 'consumers' (patients, carers, service users, potential users, local communities and the public at large) in the provision, planning and monitoring of health services. Such developments beg the question 'what constitutes good practice in user involvement?'. Taking user views into account relates not only to obtaining feedback on 'hotel' aspects of care (issues such as food and cleanliness) but also to the potential for patient input to clinical audit and the standards by which care itself is measured. Recent policy statements specifically advocate involving users in the process and product of clinical audit. In practice, 'involvement' has meant anything from passing on information to full and active participation in partnership with professionals. This paper outlines some of the issues raised in the published literature on user involvement in clinical audit. Suggesting that real involvement refers to users as active participants, not passive recipients, the paper documents the increasing policy commitment to user involvement and considers issues that influence how the rhetoric is put into practice.     

Third world medicine in first world cities: capital accumulation, uneven development and public health

This paper addresses issues of public health and access to care for the urban poor in the context of current U.S. urban, economic and industrial policy. The pathologies that threaten "inner city" neighborhoods are the result of decades of political neglect, economic exploitation and resource withdrawal, which themselves stem directly from public and corporate sector strategies to facilitate capital accumulation and consolidation. The resulting conditions of uneven development between wealthy and impoverished local sectors mirror similar relationships between First and Third World countries. These same patterns are reflected and reproduced in the health care "industry" itself, where growing corporate dominance has developed alongside a concomitant reduction in support for public sector and community-based care. These trends create and exacerbate conditions that place poor and minority populations at risk. Community development and political empowerment, as well as the overall corporate hegemony that increasingly characterizes the political economy of the U.S.A., are essential public health considerations that must be included in any meaningful health policy or health care reform proposals.     

Federal civil rights policy and mental health treatment access for persons with limited english proficiency.

As noted in the supplement to the U.S. Surgeon General's report on mental health (U.S. Department of Health and Human Services, 2001), overcoming language access barriers associated with limited English proficiency (LEP) should help to eliminate racial and ethnic disparities in mental health care access and quality. Federal policy requires remedial action to overcome language barriers: Under Title VI of the Civil Rights Act of 1964, Medicaid and other federally funded programs must provide assistance to LEP persons. Some state-level public and mental health authorities have responded by instituting "threshold language" policies. The history and terms of federal civil rights policy, and of threshold-language-policy-inspired initiatives, should be understood by everyone concerned with overcoming ethnic disparities in mental health services use. Concerned parties should promote implementation of required measures for language assistance and help to evaluate their implementation and effectiveness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Risk equalization, competition, and choice: a preliminary assessment of the 1993 German health reforms

Risk adjustment and/or equalization has become a central issue in the health care reform initiatives of many countries, including Germany, Switzerland, the Netherlands, Israel, the U.K. and the U.S. Risk adjustment is widely seen as essential to prevent cream skimming and to promote fair competition. In this vein, the 1993 German health reforms require implementation of a risk-based contribution rate equalization scheme by 1996. This paper provides a preliminary assessment of the risk equalization methodology currently proposed for Germany. Recent research in the U.S. and the Netherlands is used to examine whether the sociodemographic factors being used in Germany are likely to be effective. Research findings from both countries indicate that risk formulas based only on socio-demographic factors predict only one-tenth to one-fourth of the maximum possible explainable variance. If the current formula is used, sickness funds with higher concentrations of high risk groups are likely to be substantially under compensated, and to face serious enrollment and financial problems. The authors conclude that improvements in the formula through measures based on diagnosis and prior hospitalization, disability status, and regional variations in utilization and cost are urgently needed before the system is implemented. The German experience is also relevant to other countries that have relied to date on socio-demographic measures for risk adjustment.     

General practitioner funding policy: from where to whither?

Six public policy objectives relating to general practitioner (GP) funding since 1938 have been identified. They concern national health insurance, rural GP shortages, care for the poor, health promotion, cost effectiveness and community control. Each of these objectives is examined in turn, focusing on the extent to which each has been met. In all cases past policies have been, at best, only partially successful in meeting their objectives and have required little in the way of dismantling prior to the introduction of new GP funding initiatives subsequent to 1993. Theoretical principles relating to the development of efficient and coherent public policy are discussed. New Zealand policy relating to funding of GP services has rarely conformed to such principles. There is an emerging consensus between social democrats and libertarians that targeted programmes for the poor is the equitable and efficient way to proceed. A key policy decision concerns the balance between planned primary care services for low income groups and more traditional market style arrangements for others.     

Professional classifications of American nurses, 1910 to 1935

The growing corporate dominance in U.S. medical care has been a major factor in the increasingly inequitable distribution of health care resources and the declining public health conditions in poor and minority urban communities. Alongside this trend has been a parallel phenomenon of economic disinvestment and political neglect in these same at-risk neighborhoods. This article analyzes these trends as related components of austerity, retrenchment, and capital consolidation policies that have characterized the U.S. political economy for several decades. Emphasized are the relationships among corporatization, capital consolidation, deindustrialization of the workforce, and medical indigence; the resulting economic stress placed upon community hospitals and other caregivers in poor and minority communities; and the marked discrepancy between conditions of development and underdevelopment in American cities. It is argued that the effects of these policies are pathogenic in nature: they place populations at risk for disease and social dysfunction, they reduce access to necessary preventive and curative services, and they weaken coping mechanisms. Community economic development, empowerment, and a direct challenge to the growing concentration of wealth and power in the corporate class are proposed as essential elements of public health policy.     

Brief intervention, treatment, and recovery support services for Americans who have substance use disorders: An overview of policy in the Obama administration.

The Obama Administration plans to reinvigorate the U.S. system of care for substance use disorders through new health insurance parity regulations, the historic health care reform law (formally known as “The Affordable Care Act of 2010”), and the President's National Drug Control Strategy. Parity regulations and health care reform will significantly expand the availability of health insurance, and the proportion of health insurance plans that provide adequate benefits for substance use disorder care. The President's National Drug Control Strategy and Fiscal Year 2011 budget request make investments that will build on this foundation, including broad dissemination of screening, brief intervention and referral to treatment (SBIRT) techniques, integration of care for substance use disorders into Federally Qualified Health Centers and the Indian Health Service, augmentation of reentry programs and drug courts, creation of a pay for performance treatment quality initiative, and expansion of the Access to Recovery voucher program. Collectively, these policies will improve the quantity and quality of substance use disorder care and thereby promote public health and public safety. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Children's mental health problems and services: Current federal efforts and policy implications.

This article discusses the current federal role in the collection of information about the mental health problems of children and the provision of mental health services to children. It also describes the federal programs that help finance mental health services, support their coordination, and provide funding for research and training of mental health researchers and clinicians. Recent changes in federal policy are also described. This article, and the Office of Technology Assessment report on which it is based, conclude that although it is in some ways considerable, the federal role in providing mental health services to children is fragmented. This lack of cohesive policies toward children and across service programs may create difficulties for those who would move public policy toward the continuum of care that many observers conclude is needed to address children's mental health needs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Volunteerism and the reorientation of health services

Volunteers are increasingly viewed as health agents. This seems to be linked to the reorientation towards primary health care and the current reforms in the health services. Seen as a way of breaking down social and cultural barriers between the formal health care system and the client community it also claims to cut the cost of services. OBJECTIVE: To know the roles of volunteers in promoting health and the practical aspects of implementation and evaluation. DESIGN: This paper is based on a review of published and sentinel papers from the bibliographic databases, MEDLINE (1991-1995), ERIC (1982-1995) and ERIC INTERNATIONAL (1965-1995). We have also reviewed the IME (until 1997) and the Spanish journals in MEDLINE to know the Spanish context (from 1995-98). RESULTS: The practical experiences from developing countries, the USA and the UK were reviewed within the framework of health promotion. A wide variety of experiences exist. There is a striking difference between activities in these countries, depending of the health service provision. In developing countries the aim is to bring primary health care services to areas with few professional resources. In developed countries, however, experiences have developed in response to failings in the formal health care system, to facilitate illness prevention and health promotion. The settings are different but the process is the same, factors fundamental to performance have therefore been identified in: recruitment, training, monitoring, continuing support and evaluation. The impact on health improvements and the quality of services in both systems, developed and developing countries, seems to be positive. We haven't found too much details from the Spanish experience, then, it emphasizes the need to know abroad experiences. CONCLUSIONS: Finally, the benefits and constraints derived from this type of voluntary action in the health field have been raised. Some specific social changes and health care system reforms contribute to establish volunteering in the health system, but we have to remark organization, coordination and community participation.