Showing papers in "Health Affairs in 1991"

Patients evaluate their hospital care: a national survey.

Abstract: Respect for patients’ needs and wishes is central to a humane health care system. To better meet patients’ needs, providers have expressed increased interest in using patients’ evaluations and reports to complement other methods of quality assessment and assurance. Many hospitals routinely survey patients, but relatively little analysis of patients’ evaluations of hospital care has been published. Most of the literature on such evaluations is based on studies of outpatients. There have been some excellent descriptions of both the theoretical and practical issues involved in measuring patients’ assessments of inpatient care, but much more work in this area remains to be done. Project goals. The primary goals of the research on which this DataWatch is based were to determine which specific aspects of inpatient care are most important to patients and to document patients’ perceptions of those aspects of care in hospitals nationwide. Another goal was to assess the extent to which variations in reported quality of care might be related to characteristics of patients. In particular, we wanted to investigate whether patients with fewer resources, older patients, or patients in poorer health were more likely to report problems with their care. Here we report the results of a national telephone survey about selected aspects of care. We interviewed 6,455 adult patients recently discharged from the medical and surgical services of sixty-two hospitals selected to represent different hospital types and. all regions of the United States. The interview focused on events that indicate the quality of care in several clinically important areas of which patients are the best judges: patient education and communication with providers, respect for pa-

Reforming health care in seven European nations.

Abstract: Prologue: Most health care systems the industrialized world over share a number of common characteristics: they insure virtually all of their citizens, they allow patients to select their own physician, and they also constrain medical expenditures at some level that is deemed broadly acceptable to the polity. They also cope with a common reality: they operate in a state of continuous change, striving to adjust to the economic, political, and social demands of the moment. In this essay, Jeremy Hurst provides a glimpse of the nature of change in the 1980s in seven West European nations, all of which have pretty much stabilized the growth of their health care spending to a level that is commensurate with the growth of their national economies. Hurst is a senior economic adviser in the Department of Health, which oversees Britain's National Health Service. He was one of the early pioneers among a small group of economists, health services researchers, and other analysts who have studied the health care system...

Health Care Systems in Twenty-Four Countries

Abstract: Prologue: Changes in the way health care systems finance services are often driven by some combination of data, public pressure, payer receptivity, and the expressed views of the medical profession and allied disciplines. In this paper, two of the most seasoned observers of comparative health system research and a colleague provide the latest data and some commentary upon them for the health care enterprises of the twenty-four countries that are members of the Organization for Economic Cooperation and Development (OECD). George Schieber is director of the Office of Research at the U.S. Health Care Financing Administration (HCFA). Jean-Pierre Poullier is principal administrator, Directorate for Social Affairs, Manpower, and Education for the OECD in Paris. Leslie Greenwald is a health policy analyst in the HCFA Office of Research and also a doctoral candidate in public policy at the University of Virginia. The OECD's health database provides the most current road map available to compare the status of the ...

Change and growth in managed care.

Abstract: Prologue: One of the most rapidly growing segments of the managed health care market is the insurer-owned managed care plan. Although health maintenance organizations (HMOs) and other managed care plans have existed for decades, their association with commercial insurers has shifted from being direct competitors to being one of several lines of insurers business. Many insurers have staked the future of their business on managed care; new data from the Health Insurance Association of America (HIAA) show that from 1982 to 1990, managed care grew from less than 1 percent to more than 25 percent of all HIAA member business. These data come from the HIAA Managed Care Survey, a biannual survey of all HIAA-member insurance companies. Here, Elizabeth Hoy, Rick Curtis, and Tom Rice examine and analyze these data and their implications for the future of managed care. According to their analysis, nearly half of these insurers now offer some sort of managed care product. This portion of their business is growing, as ...

A Plan for ‘Responsible National Health Insurance’

Abstract: Prologue: In December 1975, at a hearing convened by a House health panel, Chairman Paul Rogers declared: “Today the Subcommittee on Health and the Environment begins its consideration of national health insurance—a concept which was articulated more than 25 years ago by President Truman and one which, as health care costs spiral and as more and more gaps in health care coverage are identified, has far-ranging implications for every segment of our society…. At the same time that this country is spending nearly $120 billion each year—or about $547 per person per year for health care—approximately 25 million Americans have no health care coverage, public or private.” The numbers have changed since 1975, but the issues remain largely the same: How to provide universal access to medical care to all Americans at a politically acceptable cost? During that fifteen-year period, the confidence in the capacity of government to effectively administer a national health plan has diminished, thus giving proposals that ...

A Different View of Queues in Ontario

Abstract: Prologue: Every health care system, regardless of how rich the country in which it operates, rations medical services, because no nation has the resources to match the insatiable demand for services. In the variety of approaches to rationing that nations employ, as David Naylor points out in this paper, the United Kingdom and the United States represent the extremes, Britain's National Health Service (NHS), which offers patients medical care that is free at the point of service, practices queue-based rationing. People face time delays before medical problems are addressed. In the United States, those with health insurance rarely have to wait long for treatment. But those without insurance have no ready access to care and must fend for themselves in public hospitals and other institutions prepared to accept charity cases. Canada prides itself on developing a health care system that strikes a middle ground. It is publicly funded and universally available, but care is privately provided. Administration and d...

Rationing Care in Oregon: The New Accountability

Abstract: Prologue: Oregon's effort to explicitly ration the medical care resources it is prepared to allocate for the poor has triggered widespread interest in the United States. Essays that have dealt with it are rarely free of the opinions and values that authors bring to this controversial subject. For this article, Daniel Fox and Howard Leichter approached the topic with every intention of dealing with it in a balanced fashion. Readers can judge for themselves how well the authors achieved this objective. Fox is president of the Milbank Memorial Fund in New York City, Before his appointment to that post in January 1990, he was professor of social sciences in medicine and director of the Center for Assessing Health Services at the State University of New York, Stony Brook, Fox, who trained in history and public administration at Harvard University, characterizes his calling as that of a “contemporary historian” who works at the intersection of policy analysis, political science, and history. He is the author, c...

Japanese Health Care: Low Cost Through Regulated Fees

Abstract: Prologue: Japans health care system represents an enigma for Americans. The system incorporates features that Americans value highly: employment-based health insurance, free consumer choice of phys...

Soviet health care from two perspectives.

Abstract: Prologue: During the summer of 1991, the Soviet people brought the Communist party to its knees, demanding an end to centralized control and autonomy for the Soviet republics. Even before these dra...

The national politics of Oregon's rationing plan.

Abstract: Prologue: Medicaid, a program that pays providers of medical and chronic care on behalf of eligible beneficiaries, was created in 1965 as a part of Lyndon B. Johnsons “Great Society.” But in the ensuing years, one of the great inequities of American health care has evolved not between the nonpoor and the poor, but between the insured poor and the uninsured poor. Medicaid provides financial protection against the consequences of illness not to “the poor,” but to selected groups of low-income individuals and families who meet its arbitrary and confusing eligibility standards. In 1990, at any given time, 29 percent of adults whose income was below the federal poverty standard ($6,620) were covered by Medicaid, 14 percent had employer-provided health insurance, and 40 percent had no private or public health insurance. Enter Oregon, and what a New York Times editorial called its “Brave Medical Experiment” (12 May 1990): providing all its poor population with some health care benefits, rather than the current i...

Internal market reform of the British National Health Service.

Abstract: Prologue: In 1984, Gordon McLachlan, then director of the Nuffield Provincial Hospitals Trust in London, invited Stanford professor Alain Enthoven to spend a month in the United Kingdom reviewing the British National Health Service (NHS). At the end of his visit, Enthoven was to give a talk to the Nuffield board of trustees, offering his views on which direction the NHS should head as the British government contemplated its reform. Enthoven's findings were published in 1985 as Reflections on the Managment of the National Health Service , a document that eventually reached the hands of then Prime Minister Margaret Thatcher and her advisers. “Enthoven's notion of an 'internal market 1 in the NHS … looks remarkably like the solution adopted by the government four years later,” Rudolf Klein and Patricia Day have noted. In this article, Enthoven examines the concept of internal market reform, which is designed to address the perverse economic incentives that have existed for years in the NHS. “The NHS is inten...

Britain's health care experiment.

Abstract: Prologue: Changing political and economic tides during the 1980s forced the British government to examine anew its National Health Service (NHS). Former Prime Minister Margaret Thatcher's Conservat...

A New Look At Rising Mental Health Insurance Costs

Abstract: The news media have recently focused a great deal of attention on insurance coverage for treatment of mental disorders. Reports of unusually large increaces in expenditures for mental health care under private insurance plans have appeared in major newspapers and trade publications. These reports have pointed to mental disorders, defined to include psychiatric and substance abuse diagnoses, as disproportionate contributors to rising health insurance premiums. Reports from benefits consulting firms such as A. Foster Higgins have cited increases of between 18 and 27 percent Curing 1987–1989. These data form the basis of proposals to devote special attention to mental health care use via managed care arrangements and to place new limits on insurance coverage for treatment of mental disorders. These claims are based on surveys of insurance benefits managers for major employers, not on any direct observation of use and expenditures. The Foster Higgins survey has attracted the most attention. Only 18 percent of the benefits managers responding to the survey answered the question regarding mental health costs. Among those who did respond, approximately half indicated that they did not know the cost of mental health care. In this DataWatch, we examine recent changes in mental health care spending and usage, using information obtained directly from insurance and hospital records. We address these issues by relying on (1) a sample composed of the claims experience of employees of midto large-sized U.S. firms during 1986–1989, and (2) data from two state hospital discharge abstract data systems. Our review of these data produces a much more complicated view of recent trends in use of mental health care than has appeared in the popular press. The implication here is that solutions to rising expenditures for mental health care require targeted interventions aimed at

National health care spending, 1989

Abstract: Health care spending continues to command a larger proportion of the nation’s resources, In 1989, health care consumed 11.6 percent of U.S. output (Exhibit 1), as measured by gross national product (GNP). With few exceptions, national health expenditures grew at faster rates than GNP over the past three decades. Since 1960, when national spending for health accounted for 5.3 percent of GNP, significant increases in this ratio have occurred at various points in time. During the early 1960s, pressure for a national program to finance health care was building. In 1966, both Medicare and Medicaid began operation, and health’s share of GNP equaled 5.9 percent. By 1971,

Impact of managed care on prescription drug use.

Abstract: Differences between the health services utilization patterns of persons enrolled in health maintenance organizations (HMOs) and those receiving care under fee-for-service have been well documented. But unlike other aspects of care, there is little empirical evidence on the impact of HMOs on the use of prescription drugs. This relative lack of attention is due partly to the fact that pharmaceuticals account for less than 7 percent of U.S. health care expenditures and often represent an even smaller proportion of an HMO’s budget. However, “little-ticket” items can add up. In 1990, Americans spent an estimated $40 billion on prescription drugs and related expenditures. In addition, pharmaceuticals have importance beyond their expense. In the delivery of ambulatory medical care, medications are the most common of therapeutic modalities; over 60 percent of all physician visits result in a prescription. The use (or misuse) of medications can have profound implications for the patient and the system, in terms that are both clinical and economic. Organization and financing may influence physicians’ prescribing and consumers’ demand for pharmaceuticals. The results of the RAND Health Insurance Experiment show that the degree of health insurance coverage can dramatically affect drug use. In that study, persons with full insurance coverage–paying for all drugs and ambulatory doctor visits– had 50 percent more prescriptions filled than persons with no coverage (5.4 versus 3.6 per year), even though the two groups had essentially the same health status. Because most ambulatory contacts result in a prescription, it can be postulated that this increased rate of drug use was due not only to the consumer’s lower out-of-pocket pharmacy costs, but also to

Tracing the cycle of health insurance.

Abstract: Prologue: In November 1991, a new study by KPMG Peat Marwick, international accountants and consultants, documented that the cost of health benefits rose 11.5 percent between 1990 and 1991, the lowest rate of increase in three years. But, like many developments in the unpredictable world of health care finance, the news is neither as good as it might seem at first glance nor as bad as it might become in the next several years. The reason is a phenomenon largely unknown to the health policy community that the industry terms the “health insurance underwriting cycle.” Over the past several decades and largely without fail, private insurers have generally experienced three consecutive years of underwriting gains, followed by three consecutive years of losses in the group health business. The cycle holds for both commercial insurers and nonprofit Blue Cross and Blue Shield plans. Authors Jon Gabel, Roger Formisano, Barbara Lohr, and Steven DiCarlo examine the relationship between the profitability cycle of pri...

A new policy agenda for home care.

Abstract: Prologue: Thirty years of research and current estimates on the high and escalating costs of services demonstrate that home care is neither cost-effective nor efficacious in improving long-term hea...

National Health Insurance Revisited

Abstract: Prologue: America's occasional flirtations with national health insurance have been a footnote to our history for most of the twentieth century. Once again, as health costs soar for people with insurance and access to care erodes for the disenfranchised, the United States is discussing health financing reforms. One of our nations most astute observers of this long saga is Victor Fuchs, the Henry J. Kaiser, ]r. Professor at Stanford University. In this essay, Fuchs revisits the subject in the context of a paper he wrote fifteen years ago entitled, “From Bismarck to Woodcock: The ‘Irrational’ Pursuit of National Health Insurance.” When Fuchs began to practice health economics in the mid-1960s, it was little more than a gleam in the eye of the broader discipline of economics. In the ensuing years, it has taken U.S. health policy making by storm, leaving the allied disciplines of the social sciences, for better or worse, in the dust. One of the many interesting messages Fuchs has sought to deliver over the ye...

Safe Medical Devices Act of 1990

Abstract: The Safe Medical Devices Act of 1990 (P.L. 101-629) was signed by President Rush on 28 November 1990. It is the first important device amendment to the federal Food, Drug, and Cosmetic Act since the Medical Device Amendments of 1976. The new law caps eight years of congressional review of implementation of the 1976 statute and gives to the Food and Drug Administration (FDA) significant new authority for regulating the safety and effectiveness of medical devices and diagnostic products. The 1976 device law established a regulatory system based on the degree of risk posed by a product, as classified by FDA. New high-risk products were subjected to a premarket procedure similar to that for new drugs. This procedure required FDA approval based on clinical experience before a device could be marketed. “Me-too” products and product modifications were not required to adhere to this process if the product as introduced or modified was substantially equivalent to a product on the market before the 1976 enactment date. High-risk products on the market prior to that date were “grandfathered” but were supposed to be subjected eventually to premarket approval requirements. All products, regardless of the category of risk, were subject to a variety of controls, chief of which were adherence to good manufacturing practices and reporting of defects related to product

The consumer movement takes hold in medical care.

Abstract: Most Americans encounter the medical system only occasionally, through routine check-ups and maintenance, processes usually provoking no more anxiety than general dental care. But when serious illness strikes, patients often experience it as an assault on identity and sense of self. Both seriously ill and seriously worried patients crave information. They can experience powerful sensations and dire fears, but they often do not know how to interpret them. They want to know what medicine can do and what they can do for themselves to make the best of whatever their new reality is to be. Meanwhile, modern medicine too often behaves as if caring for such human needs is beyond its purpose. Medical education stresses pathophysiologic process to the exclusion of the social, personal, and even functional dimensions of health and illness. Residency training teaches diagnosis by biotechnological methods, rendering interpersonal skills and human performance measures anachronistic. Medical financing has followed suit: it so favors the biotechnological aspects of care that its implicit message to professionals is, “Deal with your patients’ concerns on your own time.” This disjuncture between the patient’s realities and the pursuits of modem medicine is moving toward a new alignment. This essay examines forces for change that are recognizable, formidable, and hard at work. Change will come because millions more aging American families will experience serious illness and insist on it, because researchers are facilitating it, and because medical practitioners and organization leaders are beginning to see the rewards of providing it. But the driving force for change is competition in medical care delivery. Competition is leading to a redefinition of business purpose and quality