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Mark Schlesinger

Publications and source records attributed to Mark Schlesinger.

At least 19 recordsLinked to original sources
PubMed2006

How nonprofits matter in American medicine, and what to do about it.

Skeptics question nonprofit health care on the grounds that nonprofits fail to distinguish themselves from their for-profit counterparts and do not reliably provide community benefits commensurate with their tax subsidies. Drawing on the most recent and comprehensive evidence, we assess these charges, judging them to be either wrong or incomplete. Although conventional critiques are therefore unconvincing, there are nonetheless important challenges facing the nonprofit sector in American medicine. To address these, we propose reformulating ownership-related policies to define both the appropriate forms of community benefit and the appropriate mix of ownership in terms of local markets and communities.

Community-Institutional Relations↗
PubMed2006

Sources of stigma for means-tested government programs.

Stigma has been shown to discourage participation in means-tested government programs. Prior research cannot explain why this deterrent effect varies in intensity across different individuals and programs. We develop a more comprehensive model of the possible determinants of stigma associated with means-tested programs than has previously been suggested by studies of welfare stigma. We test hypotheses using unique data based on interviews with 1405 respondents in 10 states and the District of Columbia, USA. The results suggest that there are two distinct forms of stigma related to participation in means-tested government programs: one related to self-identity, the other to the anticipation of negative treatment. Both forms of stigma are more pronounced for Welfare compared to Medicaid. The sources of stigma identified by conventional treatments of welfare stigma (e.g., individual attributions of responsibility for poverty) have significant explanatory power, but neglect other important influences. We find that stigma is exacerbated by poor health and by minority status. Stigma is also fostered by the ways in which means-tested programs are implemented, including negative interactions with case workers, long waiting times, and, for Medicaid, applications for benefits in alternative enrollment sites such as health centers or hospitals. These findings suggest new points of leverage for addressing the potentially deleterious consequences of stigma.

Adult↗
PubMed2006

Was there unmet mental health need after the September 11, 2001 terrorist attacks?

BACKGROUND: This study examined the use of professionals for mental health problems among New York City residents who were directly affected by the September 11, 2001 terrorist attacks on the World Trade Center (WTC) or had a probable diagnosis of post-traumatic stress disorder (PTSD) or depression in its aftermath. Correlates of help seeking from professionals for mental health problems after the attacks and barriers to care were also assessed. METHOD: Data were from a random digit dial telephone survey of 2,752 adults representative of the Greater New York Metropolitan area conducted 6 months after the September 11 terrorist attacks. RESULTS: Fifteen percent of those directly affected and 36% of those with probable PTSD or depression sought help from a professional for a mental health problem after the attacks. There was little new utilization of professionals for mental health problems after the attacks among persons who were not already receiving care prior to September 11. Barriers that prevented people from seeking help for mental health problems 6 months after the September 11 attacks included traditional barriers to care (e.g., cost) and barriers that are unique to the post-disaster context (e.g., the belief that others need the services more than oneself). CONCLUSIONS: This study suggests that there was potential unmet mental health need in New York City 6 months after the September 11 attacks on the WTC, but these findings should be tempered by research showing an apparent decrease in population-rates of PTSD. In the aftermath of a disaster, interventions should target persons with mental health needs who were not previously seeking help from a professional for a mental health problem.

Adolescent↗
PubMed2006

Patterns of diffusion of evidence-based clinical programmes: a case study of the Hospital Elder Life Program.

BACKGROUND: The effective translation of scientific evidence into clinical practice is paramount to improving the quality and safety of patient care. However, little is known about the patterns of diffusion of evidence-based programmes in healthcare. OBJECTIVES: To study the pattern of diffusion of an evidence-based programme to improve the quality and safety of care for hospitalised older adults. METHODS: The diffusion of the Hospital Elder Life Program (HELP), a multifaceted programme to reduce delirium in hospitalised adults, was examined. Using a survey of all hospitals that contacted the HELP Dissemination Project for more than 2 years, the proportion of hospitals that adopted the programme, the programme fidelity to the original design in terms of structure and process, and the perceived reasons for non-adoption were identified. RESULTS: Programme fidelity was highest among structural features (eg, staffing levels); programme modifications were more commonplace in processes of care (eg, the participation of volunteers in patient care interventions). Senior management support and the programme expense were the most commonly cited reasons for non-adoption of HELP. CONCLUSION: Diffusion and take-up rates for this evidence-based programme were substantial; however, programme fidelity was not complete and some hospitals did not adopt the programme at all. Clinicians, researchers and funding agents seeking to promote effective translation of research should be realistic about diffusion rates and recognise the critical ingredient of senior management support to propel adoption of evidence-based programmes to improve quality and safety.

Aged↗
PubMed2006

Racial and ethnic disparities in medical history taking: detecting substance use among low-income pregnant women.

OBJECTIVE: To determine whether providers' medical history-taking of substance use varies with their patients' race or ethnicity. DESIGN/SETTING/PARTICIPANTS: The medical records of 1083 low-income women who delivered at an urban teaching hospital over a 12-month period were reviewed and data were abstracted. The frequency with which the presence or absence of substance use was documented was compared among Black, Hispanic, and White women. Multivariate models predicting documentation of data on substance use were also built. RESULTS: Information on substance use was more often documented in the medical records of Black and Hispanic women than in those of White women. For example, 74% of Black women, 78% of Hispanic women, and 60% of White women had data on cocaine use documented in their medical records (P= .0001). Multivariate analyses found that, after controlling for other factors, Black (odds ratio [OR] 4.1) and Hispanic (OR 5.3) non-clinic patients were more likely than White non-clinic patients to have documented data on substance use history in their medical records. No racial/ ethnic disparities were found among clinic patients. Among White women, clinic patients were more likely than non-clinic patients to have documented data on substance use. Among other races and ethnicities, no disparities were found between places of care. CONCLUSIONS: The differential collection of information on women's medical histories may be influenced by organizational factors and/or provider factors. The standard implementation of history-taking protocols would reduce the influence of institutional and personal biases on the care provided to pregnant women and enable all patients to receive appropriate referrals to treatment.

Adolescent↗
PubMed2005

Profit-seeking, corporate control, and the trustworthiness of health care organizations: assessments of health plan performance by their affiliated physicians.

OBJECTIVE: To compare the relative trustworthiness of nonprofit and for-profit health plans, using physician assessments to measure dimensions of plan performance that are difficult for consumers to evaluate. DATA SOURCE: A nationally representative sample of 1,621 physicians who responded to a special topics module of the 1998 Socioeconomic Monitoring System Survey (SMS), fielded by the American Medical Association. Physicians assessed various aspects of their primary managed care plan, defined as the plan in which they had the largest number of patients. STUDY DESIGN: Plan ownership was measured as the interaction of tax-exempt status (nonprofit versus for-profit) and corporate control (single state versus multistate health plans). Two sets of regression models are estimated. The dependent variables in the regressions are five measures of performance related to plan trustworthiness: two related to deceptive practices and three to dimensions of quality that are largely hidden from enrollees. The first set (baseline) models relate plan ownership to trustworthy practices, controlling for other characteristics of the plan, the marketplace for health insurance, and the physician respondents. The second (interactive) set of models examines how the magnitude of ownership-related differences in trustworthiness varies with the market share of nonprofit plans in each community. DATA COLLECTION: The 1998 SMS was fielded between April and September of 1998 by Westat Inc. The average time required for a completed interview was approximately 30 minutes. The overall response rate was 52.2 percent. PRINCIPAL FINDINGS: Compared with more local nonprofit plans, for-profit plans affiliated with multistate corporations are consistently reported by their affiliated physicians to engage in practices associated with reduced trustworthiness. Nonprofit plans affiliated with multistate corporations have more physician-reported practices associated with trustworthiness than do for-profit corporate plans on four of five outcomes, but appear less trustworthy than locally controlled nonprofits on two of the five measures. The magnitude of these ownership-related differences declines as the market share of nonprofit plans rises: for two of the five measures, ownership-related differences in practices related to trustworthiness are entirely eliminated when the nonprofits enroll more than 30 percent of the local market. CONCLUSIONS: The combination of for-profit ownership and multistate corporate control appears to consistently and substantially reduce physician-reported measures related to the trustworthiness of health plans. Because this is the fastest growing form of managed care, these results raise concerns about further erosion of trust in American health care. Preserving a substantial market niche for nonprofit plans appears to reduce this erosion and should be considered by policymakers as a strategy for restoring trust in the health care system.

Adult↗
PubMed2005

Managed care and gender disparities in problematic health care experiences.

OBJECTIVE: To determine whether gender differences in reports of problematic health care experiences are associated with characteristics of managed care. DATA SOURCES: The 2002 Yale Consumer Experiences Survey (N=5,000), a nationally representative sample of persons over 18 years of age with private health insurance, Interstudy Competitive Edge HMO Industry Report 2001, Area Resource File 2002, and the American Hospital Association Annual Survey of Hospitals 2002. STUDY DESIGN: Independent and interactive effects of gender and managed care on reports of problematic health care experiences were modeled using weighted multivariate logistic regression. PRINCIPAL FINDINGS: Women were significantly more likely to report problems with their health care compared with men, even after controlling for gendered differences in expectations about medical care. Gender disparities in problem reporting were larger in plans that used certain managed care techniques, but smaller in plans using other methods. Some health plan managed care practices, including closed networks of providers and gatekeepers to specialty care, were associated with greater problem reporting among women, while others, such as requirements for primary care providers, were associated with greater problem reporting among men. Markets with higher HMO competition and penetration were associated with greater problem reporting among women, but reduced problem reporting among men. Women reported more problems in states that had enacted regulations governing access to OB/GYNs, while men reported more problems in states with regulations allowing specialists to act as primary care providers in health plans. CONCLUSIONS: There are nontrivial gender disparities in reports of problematic health care experiences. The differential consequences of managed care at both the plan and market levels explain a portion of these gender disparities in problem reporting.

Female↗
PubMed2005

After adoption: sustaining the innovation. A case study of disseminating the hospital elder life program.

OBJECTIVES: To examine key factors that influence sustainability in the diffusion of the Hospital Elder Life Program (HELP) as an example of an evidence-based, multifaceted, innovative program to improve care for hospitalized older adults. DESIGN: Longitudinal, qualitative study between November 2000 and November 2003 based on 102 in-depth interviews every 6 months during HELP implementation. SETTING: Thirteen hospitals implementing HELP. PARTICIPANTS: Forty-two hospital staff members (physician, nursing, volunteer, and administrative staff) implementing HELP, conducted 102 interviews. MEASUREMENTS: Staff experiences sustaining the program, including challenges and strategies that they viewed as successful in addressing these challenges. RESULTS: Of the 13 hospitals studied, 10 were sustaining HELP at the end of the study period; three terminated the program (after 24 months, 12 months, and 6 months). Critical factors were identified as influencing whether the program was sustained: the presence of clinical leadership, the ability and willingness to adapt the original HELP protocols to local hospital circumstances and constraints, and the ability to obtain longer-term resources and funding for HELP. CONCLUSION: Recognizing the need for sustained clinical leadership and funding as well as the inevitable modifications required to sustain innovative programs can promote more-realistic goals and expectations for health services researchers, clinicians, and policy makers in their laudable efforts to translate research into practice.

Aged↗
PubMed2004

Translating research into clinical practice: making change happen.

OBJECTIVES: To describe the process of adoption of an evidence-based, multifaceted, innovative program into the hospital setting, with particular attention to issues that promoted or impeded its implementation. This study examined common challenges faced by hospitals implementing the Hospital Elder Life Program (HELP) and strategies used to address these challenges. DESIGN: Qualitative study design based on in-depth, open-ended telephone interviews. SETTING: Nine hospitals implementing HELP throughout the United States. PARTICIPANTS: Thirty-two key staff members (physician, nursing, volunteer, and administrative staff) who were directly involved with the HELP implementation. MEASUREMENTS: Staff experiences implementing the program, including challenges and strategies they viewed as successful in overcoming challenges of implementation. RESULTS: Six common challenges faced hospital staff: (1) gaining internal support for the program despite differing requirements and goals of administration and clinical staff, (2) ensuring effective clinician leadership, (3) integrating with existing geriatric programs, (4) balancing program fidelity with hospital-specific circumstances, (5) documenting positive outcomes of the program despite limited resources for data collection and analysis, and (6) maintaining the momentum of implementation in the face of unrealistic time frames and limited resources. Strategies perceived to be successful in addressing each challenge are described. CONCLUSION: Translating research into clinical practice is challenging for staff across disciplines. Developing strategies to address common challenges identified in this study may facilitate the adoption of innovative programs within healthcare organizations.

Aged↗