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PubMed1992

Back to direct payment: German dentists lobby to leave the national sickness fund scheme.

Oral health care in Germany is delivered by private dentists working predominantly in solo practice. Services are financed indirectly by sickness funds for 89 percent of the population. With caries rates declining, dentists' numbers increasing, and federal policies changing the remuneration regulations to enhance preventive behavior in consumers, dentists are concerned about their shrinking incomes. In an attempt to secure their professional interests, a faction among dentists advocates to return to direct payment and to opt out of the sick fund scheme. Their strategy and professional goals are described and the chances of succeeding discussed.

Dentists↗

PubMedDate not supplied

Attitudes of program directors toward women in pediatric dentistry training programs.

The number of women entering pediatric dentistry graduate programs is increasing. A formal survey was conducted in the fall of 1990 to determine what impact, if any, this increase is having on the programs. The survey sample consisted of the 57 pediatric dentistry graduate program directors from the United States and Canada. The survey form included program data about gender distribution in the current and previous classes, and female faculty distribution within the programs. The survey requested information about the attitudes of various groups of individuals who interacted with the residents relative to the gender of the resident and again, relative to whether the resident was pregnant. Inquiry was made concerning maternity leave policies and selected treatment scenarios involving pregnant residents. Finally, questions were asked about motivational factors, personal priorities, and policy change for female vs. male residents. Fifty forms were returned for a return rate of 88%. The 48 forms analyzed revealed that 52% of current classes are female and 51% of applicants for 1991 were female. Women comprise 23% of full-time and 26% of part-time faculty. There was no single issue perceived by program directors as a group to be a significant concern or problem relating to gender. Program directors would consider removing pregnant females from contact with combative patients (83%) and environmental hazards (85%), but fewer would consider removing them from contact with for HIV+ or Hb+ patients.

Administrative Personnel↗

PubMed1992

Assessing the impact of patient care policies using simulation analysis.

Simulation models are ideal for assessing the performance of strategic, tactical, and operational policies for hospitals. Simulation can validate a proposed policy, uncover fallacies of a proposal, or determine the sensitivity of the response to a policy change. A simulation model was developed to analyze the complex interactions comprising patient placement processes, beginning with patient arrivals and continuing through discharge. The model reflects current and potential patient assignment policies at a major southeastern general hospital. The system developed was utilized to assess proposed policies for the hospital. The simulated results of the hospital policy proposals, as well as other proposals, demonstrate the usefulness of simulation analysis in hospital policy decision-making.

Bed Occupancy↗

PubMed1992

A national survey of the home visiting practice and attitudes of family physicians and internists.

BACKGROUND: Over the past decade, while physician home visiting has continued to decline, the home care industry has been experiencing dramatic growth. In response, several major physician organizations have been encouraging increased physician education and involvement in home care and urging related health policy changes. This study provides the first in-depth, nationally representative descriptive data on the current home visiting practice and related attitudes of physicians. METHODS: Data were gathered through a structured 15-minute telephone survey, consisting of 141 items covering physician's general practice, personal home visiting practice, interaction with other home care providers, and attitudes regarding home care issues. Subjects were a nationally representative, randomly selected sample of 2200 family practice physicians (FPs) and internal medicine physicians (IMs) currently in active practice with at least 10 hours per week of professional time spent in ambulatory care. RESULTS: Sixty-five percent of eligible participants completed the survey. Of all physicians surveyed, 65% of FPs and 44% of IMs reported that they may make house calls (P less than .001). Mean number of visits per year was 21.2 (median, 10) for FPs, and it was 15.7 (median, 6) for IMs. Physicians in rural practice were more likely to make home visits (P less than .001). Physician attitudes related to home care reflect a strong dissatisfaction with reimbursement, but positive opinions about the use of other home care professionals and the importance of home visits for selected patients. Logistic regression analysis comparing home-visiting physicians with non-visiting physicians allowed for prediction of the correct classification 73% of the time, and it revealed six variables that were significant predictors of home visiting. The strongest of these predictors were the physician's positive attitude regarding the importance of home visits for selected patients and his or her perception of having time available for home visits. Other significant variables predictive of home visiting were family practice specialty, rural location of practice, greater numbers of referrals to home care agencies, and, interestingly, dissatisfaction with reimbursement. CONCLUSIONS: Although the great majority (over 75%) of FPs and IMs still regard the physician home visit as important for the care of selected patients, only about half report making one or more home visits within a 12-month period. Family physicians generally report a greater involvement in home care than do IMs. Physician reimbursement for home visits is perceived to be inadequate, and almost half (45%) indicate that they would do more home visits if reimbursement were increased. Most physicians (over 80%) have the opinion that home care agencies should be used more.

Adult↗

PubMed1992

Health Care Linkage Project: improving access to care.

The primary objective of the Health Care Linkage Project, funded by a grant from the Chicago Community Trust, is to develop, implement, and evaluate a primary health care linkage network within the city of Chicago that creates formalized linkages between community health centers, the Chicago Department of Health clinics, and hospitals. Six linkage networks are currently operational, with an additional two sites phased in during 1991. The success of the pilot project has been demonstrated by hundreds of patients receiving primary care and ancillary services on a more timely basis, by greater coordination between the public and private sector, by cost-savings to both patients and providers through reducing inappropriate use of services, and by a variety of spin-off projects which have improved the quality and accessibility of services. A second important objective is the development of a Health Care Linkage Manual that describes the practical experience and lessons gained from the linkages, the status of comparable arrangements in other U.S. cities, replicability of the linkage models, and recommendations for policy changes which will make linkages more effective.

Chicago↗

PubMed1992

Controlling a syphilis epidemic.

In 1986 the rate of infectious syphilis (primary and secondary) in Los Angeles County began to rise from previously stable levels of about 23.5 per 100,000 to peak at 55.6 per 100,000 in 1987. The incidence of congenital syphilis increased from 205 cases in 1987 to 575 cases in 1989. The county's Sexually Transmitted Disease Program instituted a disease-specific plan to address the epidemic. Factors considered in designing the program included the high morbidity and mortality associated with congenital infection, the existence of latent infection, self-limiting symptoms, and the availability of an inexpensive screening test and curative treatment. Policy changes implemented comprised expanded screening, expanded surveillance, increased contact tracing, and the initiation of condom promotion programs. To evaluate the relative effectiveness of Los Angeles County's syphilis control efforts, the epidemic curve for infectious syphilis was compared with trends in other urban areas. Although the rate of infectious syphilis climbed a year earlier in Los Angeles than in other cities, it returned to baseline levels when other cities' rates remained at epidemic levels.

Health Education↗

PubMed1992

Income allowance policies of state Medicaid agencies as work incentives or disincentives for ICF/MR residents.

Results of a survey of six Midwestern states demonstrated that although some state Medicaid agencies have had work incentive policies for ICF/MR residents for some time, others continue to utilize policies that are a disincentive to work. Policy changes toward employment incentives in state Medicaid agencies should improve work opportunities for workers with mental retardation at little expense to the government.

Adult↗

PubMed1992

Volume responses to exogenous changes in Medicare's payment policies.

The purpose of this study is to obtain estimates of the "volume offset," which is the slippage in the costs or the savings that would, in the absence of behavioral responses, result from exogenous changes in Medicare's payment policies. An estimate of this offset is essential to accurate cost estimation for fee proposals under Medicare. Estimates are obtained using Medicare claims data from Colorado for 1976 and 1978, before and after implementation of an abrupt and substantial change in the way Medicare's fees were determined. Reliable estimates could be obtained only for two specialty groups-general practitioners and internists. For these physicians, the results indicate that about half of an initial drop in their Medicare receipts caused by a change in payment policy would be offset by an increase in their volume of services. For physicians whose receipts would increase because of the policy change, the best estimates indicate that about a third of their initial gain would be offset by a fall in the volume of services they provide. The difference in response between gaining and losing practices is not a statistically significant one, however. One could conclude from this study that--for both gaining and losing practices--changes in volume would offset about half of any initial change in receipts caused by a payment change.

Colorado↗

PubMed1992

The prevalence and aeromedical certification considerations of contact lens use by civilian pilots.

Federal Aviation Regulations permit the routine use of contact lenses by civilian pilots to satisfy the distant visual acuity requirements for obtaining medical certificates. Specific information identifying the prevalence of contact lenses in the civil airman population is required to guide future medical certification decisions, policy changes, and education safety programs to aviation personnel. A descriptive, retrospective epidemiologic study was performed of active airmen by 5-year intervals for a 20-year period (1967-1987) using FAA data-bases and publications. The percentage of airmen who use contact lenses quadrupled during the study period. When stratified by class of medical certificate and age, the prevalence rates for airmen with first-class medical certificates and older airmen showed the largest increases. A summary is provided of aeromedical certification factors that an optometrist and/or ophthalmologist should consider while fitting an airman with contact lenses. The increasing use of contact lenses indicates a need for ongoing review of adverse changes and safety consequences for pilots. Key words: vision; contact lens; epidemiology; medical certification.

Adult↗

PubMed1992

Long-term effect of a protocol for the diagnosis and treatment of urinary tract infection. Working Group for Urinary Tract Infection in Children of the Friuli Venezia Giulia Region (Italy).

We evaluated the policy changes of 10 pediatric departments in the Friuli Venezia Giulia region following the implementation of a new protocol for the diagnosis and treatment of urinary tract infection. Clinical data concerning 1,059 infants and children with a first episode of urinary tract infection were recorded in three periods, before (A), during (B), and after (C) implementation of the protocol application. We observed a significant increase in the total number of urinary tract infections (288 in period A, 464 in C) from period A to C, with particular regard to pyelonephritis (36.8% in period A, 64.3% in C). As radiological investigations were carried out more frequently, there was a significant increase in the number of cases of vesicoureteral reflux recorded (from 23 in period A to 76 in period C). Finally, a better therapeutic approach was progressively achieved: errors in the choice of antibiotics and the duration of treatment have been almost completely avoided in period C. In our opinion, these results demonstrate a long-term improvement of pediatricians' awareness of this frequent pediatric pathology and their policies to control it.

Child↗

PubMed1991

Pharmacology of the drugs of abuse and the development of public policy.

It is fascinating that the morality, ethics, and effectiveness of current drug prohibition policies are being criticized in an era when drug use is declining in most segments of society. The current era is also marked by increasingly restrictive policies against drug use and users, including much enhanced interdiction efforts, calls for tougher penalties and more jails, and extensive drug screening programs at the work site. Summary dismissal of workers or students who use drugs is increasingly advocated. Two distinct and opposing currents advocating policy change have emerged, one for legalization, the other for greater restriction. The current inner-city rise in drug use, particularly of cocaine and "crack," and the remarkable increase in drug-related crime is probably providing the impetus for both lines of thinking. Yet both views appear extreme and neither seems to offer a promising social policy. It is critical that we continue to attempt to develop effective strategies for reducing the impact of drug taking on the individual and society. Whereas I am sensitive to the ethical and legal perspectives of the proponents of legalization, pharmacologic and social issues persuade me that legalization of heroin and cocaine would lead to a marked increase in drug dependence and an increase in drug-related disability and crime. In response to the idea that the legalization and taxation of drug use would provide resources for more effective research, prevention, and treatment, my sense is that we should not wait for legalization but should embark on that long and expensive course immediately.(ABSTRACT TRUNCATED AT 250 WORDS)

Arousal↗

PubMed1991

Legalizing drugs: lessons from (and about) economics.

Although applications of cost-benefit analysis (CBA) to the problem of drug policy are few in number and relatively primitive, they illustrate both the potential and limitations of CBA to produce critical insights that might improve drug policy making. But even the ideal CBA of drug policy could never produce a definitive conclusion about the desirability of drug legalization. Another tool of economics, analysis of price elasticity of demand, holds the potential to generate understanding of the likely effects of policy changes in the monetary and psychological prices associated with policy reforms.

Cost-Benefit Analysis↗

PubMed1991

The effect of owning private long-term care insurance policies on out-of-pocket costs.

This article examines the effect of owning long-term care insurance policies on the amount of out-of-pocket costs incurred by the elderly during their nursing home stays, and the importance of different policy features and restrictions. Data were drawn from the 1985 National Nursing Home Survey, and from copies of long-term care insurance policies collected from 11 leading companies during the spring and summer of 1988. The study results show a great deal of uncertainty concerning amounts the policies are likely to pay toward nursing home stays. This implies that the policies collected did not adequately fulfill one of the primary purposes of insurance: a reduction in risk and uncertainty. To examine whether rapid policy changes in recent years have made a difference, we assessed each of seven policy features and found that the two most important restrictions in long-term care insurance policies are prior hospitalization and level-of-care requirements. Recently, the National Association of Insurance Commissioners (NAIC) recommended that states prohibit the sale of policies containing these restrictions. Our findings confirm the wisdom of this recommendation. We did find, however, that two other policy restrictions--policy maximums and lack of inflation adjustment--are problematic. We recommend that the NAIC expand its model regulations to require that policy maximums be a minimum of four years, and that some form of inflation protection be incorporated into policy benefit structures.

Aged↗

PubMedDate not supplied

New York State's two-dose schedule for measles immunization.

In April 1989, New York became the first State in the United States to adopt a two-dose schedule for routine measles immunization. Although a two-dose schedule had been under discussion for the previous 10 years, this policy change was finally prompted in New York State by widespread measles outbreaks in 1989 among college and high school students who had been appropriately vaccinated with a single dose of measles vaccine. These outbreaks affected 21 college and secondary school campuses with 91 cases of measles and led to the administration of 53,093 doses of vaccine at a cost in excess of $859,000 for vaccine alone. In addition, there were major disruptions of intercollegiate athletic and scholastic events and physician and public confusion over the different recommendations for "outbreak" versus "routine" measles immunization. In response, the New York State Department of Health adopted a policy of two doses of measles vaccine required for entrance into kindergarten and college beginning in the fall of 1990. This report describes the data and process that were used in reaching this policy decision.

Adolescent↗

PubMed1991

Differences in hospital resource allocation among sick newborns according to insurance coverage.

OBJECTIVE: To assess whether newborns' insurance coverage was associated with differences in the allocation of hospital services. DESIGN: Retrospective analysis of computerized hospital discharge data, comparing resource allocation among newborns according to insurance status, controlling for race/ethnicity, diagnoses, hospital characteristics (ownership, teaching status, nursery level), and disposition. SETTING: All California civilian acute-care hospitals. PATIENTS: Population-based sample, excluding out-of-hospital and military hospital births. Resource allocation was studied among all newborns discharged in 1987 with evidence of serious problems (N = 29,751). MAIN OUTCOME MEASURES: Length of stay, total charges, and charges per day. RESULTS: Sick newborns without insurance received fewer inpatient services than comparable privately insured newborns with either indemnity or prepaid coverage. This pattern was observed across all hospital ownership types. Mean stay was 15.7 days for all privately insured newborns (15.6 days for those with indemnity and 15.7 days for those with prepaid coverage), 14.8 days for Medicaid-covered newborns, and 13.2 days for uninsured newborns (P less than .001). Length of stay, total charges, and charges per day were 16%, 28%, and 10% less, respectively, for the uninsured than for all privately insured newborns (P less than .001). Resources for newborns covered by Medicaid were generally greater than for the uninsured and less than for the privately insured. Both uninsured and Medicaid-covered newborns were found to have more severe medical problems than the privately insured. CONCLUSIONS: The findings cannot be explained by differences in medical need or by differences in non-medically indicated services; they constitute prima facie evidence of inequities that need to be addressed by policy changes.

California↗

PubMed1991

Educating physicians in home health care. Council on Scientific Affairs and Council on Medical Education [corrected].

A growing proportion of health care, especially long-term care, should best and most appropriately be provided in the home setting. Physicians have largely remained on the periphery of this reemerging area of health care. Yet if home health care is to reach its full potential, physicians must fulfill their essential role as members of the home health team. Direct physician input and participation are needed to ensure that home health care is safe and medically appropriate. Physician involvement will enhance the supervision of medical care in the home, and physicians' expertise is also much needed for home health care quality assurance and clinical research. Role models and training experiences must be developed for new physicians so that they can integrate home health care skills and values into their future practices. Although most of the usual physician objections to home health care involvement can be addressed by education, the problem of inadequate reimbursement is substantive and must be addressed by policy change.

American Medical Association↗

PubMed1991

The public health policy advocate: fostering the health of communities.

The community health clinical nurse specialist (CNS) is unique among CNSs in defining the client as a community of people. This nurse specialist operates in partnership with the community using policy development and policy advocacy in nursing interventions. These nursing interventions enable and empower communities to explore pathways to public policy change. Such changes include improving accessibility, availability, and affordability of health services, and changing social conditions found at the root of many health problems. A case study is presented to illustrate the application of this CNS role.

Community Health Nursing↗

PubMed1991

Implications of smoking bans in the workplace. A nursing perspective.

1. The occupational health nurse is in a strategic position to promote changes in smoking policies, participate in effective planning and implementation of policy changes, and encourage workers to participate in smoking cessation programs. 2. Nursing process, including data collection and assessment, development of a plan, implementation, and evaluation, provides a framework for action for the informed occupational health nurse. 3. Those policies that are part of an overall health promotion program, including individualized health risk assessment, are most successful in encouraging employees to stop smoking. 4. Development of or changes in smoking policies are emotionally laden issues that require considerable planning, effective communication, and involvement of employees at every level of the organization.

Ethics, Nursing↗