Building a psychoanalytic psychotherapy practice through collaborations with primary care physicians.

Primary care physicians (PCPs) represent an important, and largely untapped, source of referrals for psychoanalysts. Other mental health professionals have built successful relationships with PCPs by adapting their interventions to the rushed, medicalized world of primary care by making treatments short-term and symptom-focused. In contrast, the present article describes a model of collaboration between psychoanalysts and PCPs that does not require a similar compromise of psychoanalytic treatment methods or values. The collaboration is built on the analyst being user friendly to the PCP by being: responsive (return PCP and patient calls the same day), relevant (do not minimize the importance of symptom relief), and responsible (for all referrals received, even if some patients are eventually referred to another clinician). PCPs benefit in this collaboration in that they get help with meeting patient needs. Primary care patients benefit in that they get effective treatment from psychoanalytic psychotherapists who are skilled in listening, understanding and empathizing. Finally, the psychoanalyst benefits from having the opportunity to help an interesting and diverse group of patients using psychoanalytic psychotherapy and psychoanalysis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The collision of economics and politics in Medicaid managed care: reflections on the course of reform in Maryland

One of the most dynamic areas of health policy is the transition of Medicaid programs to managed care and market competition. Maryland has been a leader in this trend, initiating three different systems of managed care for the Medicaid population during the 1990s as it searched for an ideal plan. The Maryland experience illustrates the complex new demands that policy makers are facing. Health plans are expected not only to deliver budgetary savings, but also to improve the quality of their services and guarantee a place for safety-net providers in their delivery systems. As a result, there is a sizable gap between the original savings projected for the new Maryland system and its actual capacity for cost containment. The apparent collision between economic assumptions and political realities, however, may point the way to a constructive synthesis--a form of managed care that balances economy with important community, professional, and personal values.     

薄板坯连铸连轧工艺技术发展的概况

薄板坯连铸连轧工艺问世１０年来发展迅速，ＣＳＰ、ＩＳＰ、ＦＩＳＲ为代表的各种工艺技术的发展各具特色。总的发展趋势是，提高铸机生产能力充分发挥后部连轧机的生产能力；改进品种质量，提高产品的市场覆盖率，采用无头轧制工艺、生产超薄规格产品，以取代部分冷轧产品的市场；应用范围扩大，越来越多的在以高炉铁水为原料的大型联合企业中得到应用，为该工艺的发展开拓了更广阔的前景。     

Rehabilitation psychology practice, ethics, and a changing health care environment.

Rapid changes in the health care environment have brought about ethical and professional challenges for rehabilitation and rehabilitation psychology. The response of rehabilitation psychologists to the threats and opportunities of these challenges will have an impact on the welfare of persons with disabilities and the future of the profession. Managed care organizations have focused their efforts on the management of acute illness. Ethical concerns are being raised about patient access to care, self-determination, confidentiality, provider accountability, and marketing in managed care systems. Rehabilitation psychologists' skills in program development and outcome evaluation place them in a key position to influence the changes in the health care environment. To be effectual, however, fundamental changes must be made in research psychology practice, education and training, research focus, and professional activities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of the growth of managed care on academic medical centers and graduate medical education

The author offers insights into how the proliferation of competitive health care financing and service delivery systems based on managed care affects the financial support available to academic medical centers (AMCs), especially to their programs in graduate medical education (GME). The paper is based largely on case studies of AMCs conducted by the author in the summer of 1994 in the health care markets of San Diego, California, Minneapolis-St. Paul, Minnesota, and Washington, D.C., complemented by a review of the literature. In sum, the investigator found consensus among all parties that in the current market, managed care plans neither are willing nor feel able to pay much, if any, premium for the services of AMCs, particularly when established, respected alternatives exist, as they typically do for most services in major urban markets. Relatively few short-term adverse effects on AMCs were found from the growth of competitive systems, but AMCs are nevertheless very concerned that managed care will put them at a disadvantage. They are thus seeking ways to position themselves for the future. The AMCs are concerned that at some point, the cost reductions they are making will hinder the fulfillment of their unique traditional mission, since they believe that the costs of their GME programs can be reduced only so far without harming residents' training. Many managed care plans, however, question the AMC mission, taking issue particularly with the training AMCs provide and its relevance to current needs for primary and ambulatory care. The investigators also found considerable support for pooled funding for GME among diverse parties, but no consensus on how this funding should be structured, who should receive it, or what it should support. Potential conflicts were also identified between national, state, and market objectives for provider supply and specialty distribution because these objectives can embody different criteria for assessing the handling and locations of specialists' training. In addition, the findings indicate that it could be unwise to consider AMC policy independent of workforce objectives; doing so could create conflicts about the kinds of physicians who should be trained. The author concludes with a list of approaches to future research that may be constructive.     

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.     

Critical review: synthesis and recommendations for research, education, and policy

This paper briefly critiques each of four papers presented at the symposium, relates how these papers contribute additional information on the realities of rural older women, and the implications for future research, policy, and outreach. The critique points out that the realities of rural women's lives can best be understood through their lens in combination with objective observations. Further, most of the conflictual findings in this literature can be attributed to a lack of melding of findings across diverse studies. It is concluded that effective research, policy, and outreach must be predicated on culturally sensitive interpretations of older rural women's realities.     

Advanced marketing strategies to build the esthetic dental practice

Esthetic dentistry is truly a major part of the future of the fee-for-service practice. There are still many patients who seek high-quality elective care and these individuals need to be swayed to make an initial appointment with you. Whether you reach them through your present patients or through outreach to the community, the important key is your method of handling each of these patients as they join your practice. Customer service needs to be stronger and more obvious than ever before in order to differentiate your practice from others and to attract more referrals. The days of waiting for patients to arrive have clearly come to an end. Managed care and a decline in the need for traditional services has eroded a significant component of the dental market. When you combine that with the realization that only 50% of the population visits the dentist even once a year (and far less in many countries outside the United States), then it becomes obvious that the total available market for the elective services of esthetic dentistry has declined. Esthetic dentistry programs must be better defined, with an ongoing focus to educate present patients and to attract new patients. As I state in my seminars, I firmly believe that any practice today can still be highly successful. I do not feel that I will be making that statement three to five years from now. The time to begin positioning your practice for future growth of esthetic dentistry is now. As managed-care programs increase, it will become more difficult to turn around a declining practice. Having a quality marketing program already in place will make the difference for your esthetic practice. The new patient phone call is critical. It is there that you will begin to help patients understand fully the overall attitude and policies of your office. Successful management of new patients is to win their trust by giving them ultimate customer service while convincing them to fit your present system and schedule. When a new patient calls the practice, you want to get them scheduled within a reasonable time frame while their motivation is still positive. Remember, you only get one first chance to make a great impression. Each office should decide which questions are appropriate to ask. The front desk coordinator should ask these questions calmly and clearly so that the new patient has an opportunity to answer them without feeling that they are going through the inquisition. At the same time, the more information you have about this patient, the easier it will be to gain treatment acceptance because of your understanding of the new patient's needs. Many offices will ask new patients how they came to choose their particular office. Since many practices gain new patients from existing patients, it is appropriate to know when this has occurred and properly thank the referral patient. By thanking the patient who referred the new patient, you will encourage further referrals.     

Transition from paediatric to adult-orientated care for adolescents with cystic fibrosis

Adolescence is a time of major physical and psychological change. Young teenagers need to become comfortable with their developing sexuality, to begin moving towards independence with a greater reliance on peer group acceptance, to face the future and to make important decisions about their education, career and goals. Difficulties inherent in all of these steps to adult life are magnified by chronic ill health. It is harder for adolescent patients to break family ties, harder to feel accepted by their peer group, harder to plan realistically for the future. It must be the overriding aim of the professional health carers to encourage these patients to confront the problems of adolescence and to help them maintain their physical and emotional stability throughout this challenging period. Parents also must be supported, and encouraged gradually to devolve to their child responsibilities for decision making and for taking prescribed medication. A planned and sensitive transition from a paediatric to an adult health-care system will aid a successful evolution to an independent adult life. The paediatric hospital environment is not best equipped to deal with the problems of adolescence. Just as parents must allow their child to move on, so the paediatric caring team must loosen its ties with the patient and allow transfer to the adult team. There are several ways of effecting this transfer of care. None of them is proven to be better than any other, but the transfer should always be planned, smooth, efficient and expected by the patient. Ideally, all patients should have the opportunity to transfer to a properly equipped and properly staffed adult cystic fibrosis centre where they can continue to receive the highest standards of care from an experienced multidisciplinary team.     

The relationship of the changing structure of families and the health of children

The changing family structure impacts on the physical and mental health, emotional state and academic performance of children. Children reared in other than a family with both biological parents have increased difficulties. Pediatric dentists will need to consider these realities in their treatment of an increasing diverse population of children.     

A Long-Term Strategy for Latin America

Latin American countries are developing at a healthy pace, and the major ones like Brazil and Argentina seem to have achieved a stability that is worthy of the trust of international finance institutions and the private investors despite recent shakeouts. The entire continent requires major investment in infrastructure ranging from roads to power plants to telecommunication to restoration projects to reverse the ravages of ill conceived investment and development strategies of the past. In order for the US engineering-consulting companies to take full advantage of the potential of this market, an integrated market and resource development strategy should be adopted. The strategies which may have worked in the past, where the foreign company obtained the contract with the help of an "agent", worked the project with minimal local help, using expatriates in the country supported by home office personnel will no longer work because of the increasing competitiveness of the market and emergence of sizable local companies with technical capability and political clout. A more effective strategy is to develop local manpower fully integrated with the core US staff, who is capable of developing and executing work. In order to successfully apply this strategy, a number of generic issues (each with its nuances changing from country to country) must be resolved. These issues are: language, culture, understanding of local politics, cost of training and development, cost of manpower, and legal liability. The strategies successfully applied by several companies to deal with these issues, are: Use of bilingual local staff, training them in parent company offices, thus fully integrating them into the parent company organization and subsequently basing them in their home country, selecting suitable Spanish or Portuguese speaking US employees and integrating them into the local organization, developing duplicate databases (key marketing materials and basic tools of trade) in Spanish and Portuguese to minimize dependence on translations, and developing local strategic alliances and the necessary diplomatic skills to deal with regional sensitivities and legal issues. This paper develops the issues and strategies, based on the experience of the author and selected reference material.     

The impact of managed care on clinical research: a preliminary investigation

Rapid growth in managed care enrollment is likely to affect clinical research at the nation's academic medical centers (AMCs). Our site visit interviews indicate that managed care has not markedly reduced coverage for research-related care. However, market competition in some areas has limited AMCs' ability to subsidize research activities with clinical revenues. As they gain market share, managed care organizations will have a growing influence on research priorities. Therefore, it is important for the academic community to work with managed care leaders to identify areas for collaboration and an agenda for moving forward in the future.     

Consumer demands concerning meat between price and ethics

A review is given about consumer demands on meat. Mainly the problems of decreasing meat consumption, health aspects and special questions of ecological products are considered. The market gives evidence of a further drop in meat consumption and a more consistent differentiation of product lines. Eco-products, emphasising the animal welfare aspect, will have their place in that context but persist in the state of a minor market segment. Nevertheless it has to be expected, that also the conventional products will increasingly comply to modern consumer demands.     

Evaluating health plans and marketing the gastroenterology practice under managed care

More patients will have managed care in the future. Therefore, every practice should have a strategy for working with managed care organizations (MCOs). Learn how to evaluate an MCO and how to obtain detailed information about MCOs in your area. Know how to market your practice and build relationships between your group and MCOs. Develop a practice profile that outlines all the benefits that your group can bring to an MCO. Plan how you will respond when an MCO says, "No."     

Building healthier communities in a managed care environment: opportunities for advanced practice nurses

Two paradigm shifts are occurring in health care: managed care and community partnerships. The distinct principles and trends of each paradigm are certain to determine the future practice of advanced practice nurses (APNs). The impact of managed care and community partnerships will affect the resource management, clinical decision making, and time management of APNs. Concomitantly, APNs will have opportunities to influence practice guidelines, individual and community decision making, cultural competence, and the cost-effectiveness of care in communities. Capitalizing on these opportunities will enhance the value of APNs to their managed care plan employer and their community.     

Managed care credentialing of advanced practice nurses

The enormous and rapid changes taking place in health care delivery are forcing institutions, organizations, and individual providers of care to reexamine their relationships and create new methods of assuring both quality of care and safety for consumers. One result has been the emphasis on systematic methods of credentialing, privileging, and measuring and evaluating an individual's qualifications and actual performance. This article discusses the credentialing and privileging processes that are either in place or evolving for physicians in the managed care health care systems. With the continued evolution of managed care in this country, advanced practice nurses may need to expand their credentialing process. This article provides information on the evolutionary events leading to credentialing and privileging, current and anticipated credentialing measures, sources of measurements, medicolegal issues, and suggestions for expansion of nurse credentialing. A comprehensive credentialing system will provide additional evidence of the nursing profession's capacity to play a major role in the reformed health care system.     

Changing Nonferrous Metals Markets

Fundamental changes in the market place and in production processes in the past ten years have affected metal demand and will continue to do so. Aluminum, copper, lead and zinc industries, the major components of the nonferrous metals sector, have experienced declines in the United States in the past decade. Substantial declines have occurred in consumption, intensity of use, production, employment and profitability. The United States is on the edge of a materials revolution. New technologies have brought innovative products and materials to the market which are in competition with ferrous and nonferrous metals. These new materials include fiber optics, ceramics, composite materials, and engineered plastics. The key lo survival for the metals industry is to maintain existing markets under the threat of continued product substitution, while developing new markets to expand metal consumption.     

The new child health insurance expansions: how will school-based health centers fit in?

In June 1998, the Making the Grade National Program Office and the National Assembly on School-Based Health Care sponsored a workshop on the relationship between the State Child Health Insurance Program (SCHIP) and school-based health centers. Workshop participants used the health centers' experience with Medicaid managed care as a window for understanding their prospects for negotiating contracts with health plans under SCHIP. Speakers representing the federal perspective, state agencies, health plans, and local school-based health centers offered their views on the challenges of developing contracts, incentives, and disincentives that health plans have to contract with school-based health centers, and what has accounted for success where relationships are moving forward. Experiences in Colorado and Connecticut were presented as case studies on these evolving issues.     

The challenges of health care restructuring

Since the late 1980s, virtually every developed, and many developing, countries have re-examined the structure of their health care systems. Health care reform has become a truly global phenomenon with considerable potential for cross-nation lesson-learning. In countries where the state has been the central actor in the health sector, its role is being reassessed and, in some cases, reconfigured. The introduction of market principles to health care is a feature of many countries: market romantics believe markets in health care will improve efficiency, empower consumers, control costs, and overthrow monolithic bureaucracies. But will they? The evidence, such as it is, suggests otherwise. The greatest pressure for change and for introducing markets into health care has been in the relative role of the private sector in the operation, and in some countries also the financing of health care services. But it is not a simple case of the state versus the market. The issues are much more complex and various hybrid models are emerging involving some sort of public-private mix. The move is towards greater diversity and pluralism, an inevitable consequence of which is growing fragmentation in the funding and provision of care with all the associated on-costs in terms of increased coordination and management that this entails. The policy aim is to harness the benefits of market behaviour without also adopting the inherent weaknesses of markets with regard to questions of distributive justice and equity.