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PubMed1999

Geographic variation in physician visits for uninsured children: the role of the safety net.

CONTEXT: Although an extensive literature exists comparing national access to health care for uninsured vs insured children, few data exist regarding differences in access across states. OBJECTIVE: To examine variation in access to physician services for uninsured children in 10 states, the safety net's role in explaining this variation, and the potential effects of the State Children's Health Insurance Program (CHIP) on insurance coverage and access. DESIGN AND SETTING: The population-based Robert Wood Johnson Foundation Family Health Insurance Survey, conducted between summer 1993 and spring 1994 in 10 states (Colorado, Florida, Minnesota, New Mexico, New York, North Dakota, Oklahoma, Oregon, Vermont, and Washington), with a response rate of families by state ranging from 61% to 83%. PARTICIPANTS: A total of 8565 children who were uninsured (1586), covered by Medicaid (2723), or covered by employer-sponsored private insurance (4256) for 1 full year prior to the survey. MAIN OUTCOME MEASURES: Percentage of low-income children who are uninsured and predicted annual physician visits by state if insurance was provided to uninsured children in families with incomes of less than 200% of poverty level. RESULTS: In the 10 study states, low-income children ranged from 61% to 86% of all uninsured children and the uninsured rate for low-income children varied from 9% to 31%. On average, providing public coverage would increase annual physician visits from 2.3 to 4.6 (a 105% increase), but the increase would range from 41% to 189% across states. The annual physician visit rate in the 3 states with the highest access for the uninsured was 160% of that in the 3 lowest-access states. Safety net capacity in the high-access states ranged from 120% to 220% of that in the low-access states. CONCLUSIONS: Our data suggest that the potential effects of CHIP vary substantially across states. Notably, improvements in access to health care by uninsured low-income children should be greater in states with the fewest safety net resources.

Child↗
PubMedDate not supplied

Interdisciplinary research is key to understanding sex differences: report from the Society for Women's Health Research Meeting on understanding the biology of sex differences.

Progress in sex-based biology, the study of biological and behavioral differences between males and females, and the impact of those differences on health and disease will require collaboration across research disciplines and medical specialties and among all research approaches, from molecular biology to epidemiology. The importance of sex-based biology to healthcare necessitates a bench-to-bedside approach that is built on integration of research findings from studies at the cellular level, in animals, and in human subjects. Barriers to interdisciplinary collaborations are being addressed in a variety of ways by public and private funders. The J.D. and C.T. MacArthur Foundation supports interdisciplinary research networks that address broad questions in health and behavior. The National Institute of Mental Health supports cross-disciplinary research networks investigating the hypothalamic-pituitary-adrenal network. The National Institute of Child Health and Human Development offers grants for Building Interdisciplinary Research Careers in Women's Health. The National Science Foundation Directorate for Biological Sciences sponsors Research Coordination Networks in Biological Sciences. Among the challenges faced by interdisciplinary research programs are appropriate peer review, career advancement for young investigators with interdisciplinary training, and acceptance of interdisciplinary research reports by high-quality scientific publications.

Female↗
PubMed1994

An examination of reforms on the social security system of retirement based on practices in Hainan province.

"The first task of this article is to analyze and dissect the seven major drawbacks of the current disjointed retirement system [in China] characterized by collection of pension for immediate distribution. This will be followed by an introduction of the reforms on the social security system of elderly support for enterprise retirees carried out in Hainan Province and specific social security and elderly support practices by private businesses in Haikou, capital city of Hainan Province....Special inquiries are made regarding the necessity and feasibility of establishing a national uniform social security system of elderly support covering civil servants, enterprise workers, private business owners, managers, and employees and farmers."

Asia↗
PubMedDate not supplied

Career development and training in geriatric mental health: report of an NIMH workshop.

At a National Institute of Mental Health (NIMH)-sponsored meeting, the participants discussed means of increasing the pool of late-life mental-illness researchers. Approaches identified included encouraging retention of junior scientists through greater mentoring and support; creation of research postdoctoral programs by investigators and institutions that lack late-life emphasis; earlier commitment to late-life research with predoctoral training mechanisms; recruitment of ethnic and racial minority scholars into late-life research; and recruitment of newly established researchers through postdoctoral training mechanisms. Federal, public, and private mechanisms need to be better leveraged to grow late-life mental-illness research infrastructure and meet increasing demand and scientific opportunities.

Aged↗
PubMedDate not supplied

Nutrition at school: preparing for the future. The Thirteenth Annual Nutrition Symposium.

Two of the best ways to improve the quality of childhood nutrition are (a) more collaboration at the national, State, and local levels and (b) adoption of innovative and multimedia learning methods, according to the leaders of nutrition education. These themes were discussed at the 13th Annual Nutrition Symposium, which was held March 9, 1994, in Washington, DC. In recognition of National Nutrition Month, a collaborative effort of the Public Health Service's Office of Disease Prevention and Health Promotion and the Centers for Disease Control and Prevention, the meeting was attended by more than 300 public and private sector nutrition educators and public health professionals. Their assignment was to analyze school-based nutrition education programs and the research being conducted on nutrition. Keynote speaker Surgeon General M. Joycelyn Elders, MD, issued the challenge for all Federal and State agencies to work with schools and nutrition education professionals to overcome limited resources and children's current eating habits to improve the nutritional status of children. Responding to that challenge, speakers from the Department of Health and Human Services, the agency sponsoring the meeting, the Department of Agriculture, the Department of Education, as well as from the Congress, business, and public schools addressed several initiatives.

Adolescent↗
PubMed1991

Health care economic factors and the effects of benefits plan design changes.

Medical benefits costs now exceed 13% of payroll, up from 5% in the early 1980s. Full reimbursement for more expensive hospital-based care, a technology and specialist supply explosion funded by Medicare and Medicaid, and cost shifting from these programs to private insurance have fueled this rapid growth. Benefits plans, which had provided essentially free care, have been changed slowly and incrementally to increase cost sharing and, thus, cost sensitivity on the part of employees. Many insurance plans also limit coverage by requiring that treatment be "nonexperimental" and "medically necessary." Long-term inquiry demonstrates that total expenditures, hospitalization rates, ambulatory visit rates, dental visits, and prescription drug use were significantly higher for free care than for plans with substantial copayments. A study sponsored by a business coalition in Houston showed that increased deductibles shifted care to the inpatient setting, raising total costs. Higher contribution rates reduced both inpatient and outpatient costs. Caps on payment for certain services, such as mental health care, reduced costs significantly with apparently minimal adverse effects on health.

Deductibles and Coinsurance↗
PubMed1975

A core city problem: recruitment and retention of salaried physicians.

The professional and personal characteristics of all physicians recruited into a large urban governmentally sponsored health system were evaluated and correlated to staff retention and loss. The results were tabulated for 84 physicians, approximately 90 per cent of the physician work force, over a three-year period. Eighty per cent resided in either Denver or the state of Colorado prior to entry. This is further reflected in a significant percentage being enrolled in the local medical school or training programs prior to entry. These facts suggest a possible source of manpower for beginning programs. Twenty-six per cent came from private practice, 32 per cent from the military and 14 per cent from the Public Health Service. The turnover rate averaged 6.2 per cent per year, with 4.4 per cent being initiated by the physician and 1.8 per cent leaving because of administrative pressure. Data from other studies are reviewed. Factors which appear to influence retention positively were residency training (pediatricians), sex (females), age (over 38) and those with team experience. These factors suggest directions as to the type of physician who, if recruited, tend to reduce turnover. The establishment of a group practice atmosphere with rewards for clinical skills and the offering of unusual specialty opportunities are proposed as positive factors in the retention of staff.

Adult↗
PubMed1998

Infertility treatment: lack of consensus plagues an unregulated field.

Each year, in an attempt to stimulate journalism students' interest in medical writing, CMAJ sponsors the Amy Chouinard Memorial Essay Prize. The $750 award is in memory of Amy Chouinard, a longtime and valued contributor to CMAJ and the Canadian Journal of Surgery. Students from any recognized journalism program at a Canadian college or university are eligible to enter, and the deadline for 1998 entries is June 1. The 1997 winner, Megan Easton, presents a well-written and thorough account of the issues surrounding infertility treatment. Interest in the topic came naturally enough--her father, Dr. William Easton, is a urogynecologist in private practice in Scarborough, Ont.

Biomedical Research↗
PubMed2004

HIV prevention nongovernmental organizations in Central and Eastern Europe: programs, resources and challenges.

HIV incidence is rising more rapidly in some areas of Central and Eastern Europe than anywhere else in the world. Carrying out effective HIV prevention programs requires the presence of "bridges" that can reach community populations most vulnerable to the disease. Nongovernmental organizations (NGOs) are in a natural role to conduct HIV prevention programs. The Directors of 29 HIV prevention NGOs representing almost all countries in Central and Eastern Europe participated in in-depth interviews by telephone. The broad topics of these interviews included descriptions of the three largest programs conducted by each NGO during the past six months, at-risk target populations served, major barriers faced, and funding sources that sponsored HIV prevention activities. NGO programs most often targeted injection drug users (IDUs); other stigmatized groups were less frequently served by NGOs in the sample. The most common types of prevention activities were needle exchange, HIV prevention peer education, and delivering AIDS presentations and distributing educational materials. Among the major barriers that hampered effective conduct of HIV prevention programs were a shortage of available financial resources, governmental indifference or opposition, and AIDS-related stigma. National governments rarely provided substantial funds for NGO programs, and most funding came from United Nations agencies or private foundations. The information sources reported to be most helpful in assisting NGOs in program development were sharing ideas with other NGOs, participating in conferences, and accessing information from the Internet. A number of programs reported by the NGO Directors were innovative, outstanding, and comprehensive. Five such exemplary programs are described in this article. HIV epidemics in the region are still potentially controllable. NGOs need immediate support so that they can carry out their community-based activities on a larger scale.

Communicable Disease Control↗
PubMed2004

National health data warehouse: issues to consider.

A national data warehouse that links public and private data could be used to monitor trends in healthcare costs, utilization, quality of care, and adherence to quality guidelines and changes in treatment protocols. The development of the data warehouse, however, would require overcoming a number of political and technical challenges to gain access to private insurance data. This article outlines recommendations from a national conference sponsored by the Agency for Healthcare Research and Quality (AHRQ) on the private sector's role in quality monitoring and provides an operational outline for the development of a national private sector health data warehouse.

Confidentiality↗
PubMed2005

Health care market trends and the evolution of hospitalist use and roles.

OBJECTIVE: To describe local health care market dynamics that support increasing use of hospitalists' services and changes in their roles. DESIGN: Semistructured interviews in 12 randomly selected, nationally representative communities in the Community Tracking Study conducted in 2002-2003. Interviews were coded in qualitative data analysis software. We identified patterns and themes within and across study sites, and verified conclusions by triangulating responses from different respondent types, examining outliers, searching for corroborating or disconfirming evidence, and testing rival explanations. SETTING: Medical groups, hospitals, and health plans in 12 representative communities. PARTICIPANTS: One hundred seven purposively sampled executives at the 3-4 largest medical groups, hospitals, and health plans in each community: medical directors and medical staff presidents; chief executive and managing officers; executives responsible for contracting, physician networks, hospital patient safety, patient care services, planning, and marketing; and local medical and hospital association leaders. MEASUREMENTS AND MAIN RESULTS: We asked plan and hospital respondents about their competitive strategies, including their experience with cost pressures, hospital patient flow problems, and hospital patient safety efforts. We asked all respondents about changes in their local market over the past 2 years generally, and specifically: hospitals' and physicians' responses to market pressures; payment arrangements hospitals and physicians had with private health plans; and physicians' relationships with plans and hospitals. We drew on data on hospitalist practice structures, employment relationships, and productivity/compensation from the Society for Hospital Medicine's 2002 membership survey. Factors that fomented the creation of the hospital medicine movement persist, including cost pressures and primary care physicians' decreasing inpatient volume. But emerging influences made hospitalists even more attractive, including worsening problems with patient flow in hospitals, rising malpractice costs, and the growing national focus on patient safety. Local market forces resulted in new hospitalist roles and program structures, regarding which organizations sponsored hospitalist programs, employed them, and the functions they served in hospitals. CONCLUSIONS: These findings have important implications for patients, hospitalists, and their employers. Hospitalists may require changes in education and training, develop competing goals and priorities, and face new issues in their relationships with health plans, hospitals, and other physicians.

Arizona↗
PubMed1993

Access to care in the Indian Health Service.

The Indian Health Service (IHS) is unique among U.S. private and public health programs in that free comprehensive health services are provided to eligible American Indians and Alaska Natives regardless of their ability to pay. However, resource limitations may compel some eligible persons to go outside of the IHS system to receive health care. Although IHS eligibles have comparatively low rates of private or public health care coverage, and much of this population lives in underserved areas, over half of IHS-eligible persons had some type of out-of-plan use in 1987. Furthermore, services received through private providers appear to supplement those received through IHS-sponsored providers. Overall, persons who use both IHS and non-IHS providers have higher levels of health care use than do those who rely exclusively on the IHS.

Adolescent↗
PubMed2002

Working families' health insurance coverage, 1997-2001.

Despite a booming U.S. economy, falling unemployment and moderate health insurance premium growth, the percentage of working Americans and their families with employer-sponsored health insurance failed to increase substantially between 1997 and 2001, according to findings from the Center for Studying Health System Change (HSC) Community Tracking Study Household Survey. There were, however, dramatic changes in the insurance status of people who lacked access to or did not take up employer coverage: fewer uninsured, more public program enrollment and a decline in coverage by individual insurance and other sources. While the State Children's Health Insurance Program (SCHIP) clearly reduced uninsurance among low-income children, evidence also suggests a fair amount of substitution of public insurance for private coverage.

Adult↗
PubMed2001

Family income and crowd out among children enrolled in Massachusetts Children's Medical Security Plan.

OBJECTIVE: To assess whether participation in a state publicly financed health insurance program, Massachusetts Children's Medical Security Plan (CMSP) , which is open to children regardless of income, was associated with disenrollment from private insurance. DATA SOURCES/STUDY DESIGN: A survey of participants in CMSP who were enrolled as of April 1998 was used. We conducted analyses to detect differences in access to and uptake of private insurance between Medicaid-eligible and in eligible children, and between children eligible for the State Children's Health insurance Program (SCHIP) and in eligible children. DATA COLLECTION METHODS: A stratified sample of children was drawn from administrative files. the sampling strategy allowed us to examine crowd out among children based on in come and eligibility for publicly funded coverage: those who were Medicaid-eligible (income pound 133 percent of the federal poverty level [FPL]) , those who were SCHIP-eligible (134-200 percent of FPL) , and those with family in comes that exceed SCHIP eligibility criteria (> 200 percent of FPL). The majority of telephone interviews were conducted with the child's parent/guardian between November 1998 and March 1999. The overall response rate was 61.8 percent , yielding a sample of 996 children. PRINCIPAL FINDINGS: Of the children in our sample whose recent health coverage was employer-sponsored insurance (59 percent), 70 percent were no longer eligible. Few children who had employer-sponsored insurance at enrollment dropped this coverage to enroll in CM SP (1 percent, 4 percent, and 2 percent by income). Compared to Medicaid-eligible children, children with incomes > 133 percent of FPL were significantly more likely to be eligible for employer-sponsored insurance but they were no more likely to have purchased offered coverage. Access to employer-sponsored insurance was limited (19 percent), and uptake was low (13 percent). We found no significant difference between SCHIP-eligible children and those whose family incomes exceeded SCHIP guidelines. CONCLUSIONS: The Massachusetts experience suggests that (1) coverage could be expanded to children with incomes up to 200 percent of FPL with little direct substitution of public coverage for private insurance, and (2) substitution among children with incomes > 200 percent of FPL, who paid a premium that may have restrained crowd out, did not differ from that among SCHIP-eligible children.

Adolescent↗
PubMed2000

Corporate action to reduce air pollution--Atlanta, Georgia, 1998-1999.

Ground-level ozone, a colorless gas, is a major constituent of smog. Since the early 1980s, controlled studies have demonstrated that exposure to elevated levels of ozone reduces inspiratory capacity in humans. In addition, ecologic analyses have indicated that daily emergency department visits for asthma exacerbations are elevated following days of high ozone pollution. The Partnership for a Smog-Free Georgia (PSG) is a state-sponsored program to reduce the number of days that ground-level ozone exceeds the national ambient air quality standard (NAAQS) in metropolitan Atlanta by providing federal and state subsidized commuting alternatives for local business employees. This report summarizes commuter data from three PSG partners to estimate reductions in emissions and monthly vehicle miles traveled that were associated with enrollment in PSG.

Air Pollution↗
PubMedDate not supplied

[Hormonal contraception in 46 public family clinics in Rome].

This study investigates the role of 46 public Consultori of Rome, as far as the hormonal contraception with "pill', the most common contraceptive method used by roman women, is concerned. With a series of phone calls, a hypothetic potential customer asked for an appointment directly with the gynaecologist for getting adviced to use "pill" for the first time. The results show that, although the wait for the first appointment directly the gynaecologist is not long (11,3 days as an average), it is very difficult to get it and this was possible only in 12 cases out of 46. We have noted that the first appointment for "pill" was offered with no-medical personnel, like social assistants, sanitary assistants or midwives, in most 16 of cases, and that in a significant number of Consultori was not possible to obtain an appointment whatever. In public Consultory of Rome we have found a different attitude in giving appointment to women for contraception with pill, even inside the same USL (Local Sanitary Unit, the basic structure of public health in Italy, in which Consultori have the role of prevention and promotion of maternity and tutelage of infancy). From this study the need emerges of uniformity in the attitude of Consultori staff in managing the customers, in order to avoid that women, finding so many difficulties, give up referring to these public structure for beginning contraception and choose private professionals or decide not to use the "pill".

Appointments and Schedules↗
PubMed2005

Economic burden on families of childhood type 1 diabetes in urban Sudan.

The aims of this study were to estimate the direct costs of childhood diabetes in a low income country, Sudan, and to assess the effectiveness of care paid for by the families. For this purpose, socio-economic and demographic data on families were obtained from the parents of 147 children with type 1 diabetes, attending public or private clinics in Khartoum State, Sudan. The median annual income of the families of diabetic children was US dollars (US$) 1222 (range 0-14,338) of which 16% was received as financial help from relatives and friends. The median annual expenditure of diabetes care was US$ 283 per diabetic child of which 36% was spent on insulin. Of the family expenditure on health, 65% was used for the diabetic child. Families of diabetic children who were attending private clinics had a significantly higher total expenditure on health and home blood glucose monitoring than those who were attending the public clinics. However, there was no difference in total income between the two groups and glycaemic control was poor in 86% of the patients, regardless of whether care was being given by private or public clinics. The occurrence of the disease and its poor control appeared to exert a negative impact on the school performance of the diabetic child. In conclusion, the low direct costs reflect the minimal care given to the diabetic patients. Under the present economic conditions, families pay a considerable part of their income to sponsor the health of their diabetic children and receive little support other than that from relatives and friends. The present organization of diabetes care does not provide the patient with empowerment, knowledge and self-care ability. Well-trained diabetic teams and education programs may improve this situation.

Adolescent↗