Showing papers in "Journal of Health Care for the Poor and Underserved in 1994"

Illiteracy among Medicaid Recipients and Its Relationship to Health Care Costs.

Abstract: Poor literacy is associated with poor health status, but whether illiteracy is also linked to higher medical care costs is unclear. We characterized the literacy skills of 402 randomly selected adult Medicaid enrollees to determine if there was an association between literacy skills and health care costs. Each subject's literacy skills were measured with a bilingual (English/Spanish) reading-assessment instrument. We also reviewed each subject's health care costs over the same one-year period. The mean reading level of this Medicaid population was at grade 5.6. Mean annual health care costs were $4,574 per person. There was no significant relationship between literacy and health care costs. While there are compelling reasons to improve poor reading skills among Medicaid enrollees, illiteracy in this population does not appear to contribute to the high cost of providing government-sponsored care.

Cultural Issues in the Development of Cancer Control Programs for American Indian Populations

Abstract: Cancer is the third-leading cause of death among American Indians. The persistent disadvantage in cancer survival rates among American Indian populations emphasizes the importance of developing effective cancer control programs for prevention and early detection. However, substantial cultural differences between American Indians and whites can affect the success of these programs. This paper examines the concept of cultural sensitivity in the context of developing cancer control programs for American Indian populations. It explores fundamental differences in beliefs, behaviors, and values between American Indian and white majority cultures, and presents examples of culturally sensitive health education programs. The paper highlights insights and experiences gained in developing the North Carolina Native American Cervical Cancer Prevention Project, and gives recommendations for the development of future programs.

Access to infant immunizations for poor, inner-city families: what is the impact of managed care?

Abstract: California plans to enroll half of its Medicaid population, 75 percent of which are children, into managed care. To measure the impact of managed care on utilization of preventive services, we surveyed 867 families in two inner-city areas of Los Angeles and assessed the relationship between insurance type, source of care, andaccess to immunization services. Compared to children in public health clinics, those in private physicians' offices or health maintenance organizations (HMOs) had odds of being up-to-date on immuni- zations of 0.43 (p<.01 ) and 0.24 (p<.01), respectively. We conclude that in the absenceofmeaningful financial incentives to encourageprivatephysicians and HMOs to provide immunizations to inner-city children, managed care is unlikely to improve immunization rates among this vulnerable population.

Impact of managed care organizations on ethnic Americans and underserved populations.

Abstract: Health care reform focuses on cost containment, which in turn focuses on managed care organizations (MCOs). MCOs use strict utilization review and financial risk-shifting to assure that doctors and providers act as gatekeepers to health care services. The gatekeepers are assumed to continue to order necessary care and to eliminate only "unnecessary" care. However, significant potential for abuse exists. In fact, the very foundations on which MCO decisions are made are culturally biased, because they are based on information from largely middle-class, European-American, healthy males. Ultimately, MCOs will change the perceptions and expectations of society regarding health care. These altered perceptions may be contrary to the needs of ethnic Americans, and without safeguards, could worsen existing disparities in health status.

Evaluation of a managed care program for the non-Medicaid urban poor.

Abstract: In 1988, Detroit and surrounding Wayne County, Michigan, began CountyCare, an innovative managed care program designed to deliver health care services to the very poor while reducing excessive emergency-room and inpatient care. We interviewed 279 former CountyCare participants to assess differences in off-program utilization, use of clinical services, hospitalization, and patient satisfaction among respondents assigned to one of four CountyCare provider groups. Patients responded favorably to CountyCare, although off-program utilization was substantial and emergency-room and inpatient care were not significantly reduced. We conclude that how such a program is managed and administered, and a provider's degree of motivation, govern the extent to which it succeeds in reducing health care costs and increasing patient satisfaction.

Alcohol and Drug Abuse Treatment of Homeless Persons: Results from the NIAAA Community Demonstration Program

Abstract: In a national evaluation, we assessed the implementation and outcomes of a multisite demonstration program for homeless persons with alcohol and other drug problems. We developed comprehensive case studies from data on client characteristics, utilization of services, implementation of interventions, and community systems of care at nine project sites. Client-level outcome data were analyzed to estimate the effectiveness of the interventions in a subset of projects with experimental or quasi-experimental evaluation designs. After controlling for baseline predictors, treatment clients in the majority of sites were significantly more likely than comparison clients to report improvement on one or more outcome dimensions. On alcohol use, for example, under conservative assumptions the average treatment client was drinking less at follow-up than were 57 percent of comparison clients. Analyses of predictor-by-treatment interactions suggested that clients with fewer problems benefited most from the interventions. The implementation analysis yielded a number of lessons for policymakers and program planners.

Patterns of Hospital and Physician Utilization among the Uninsured

Abstract: Despite numerous studies of access to care by the uninsured, few researchers have examined whether access to hospitals among the uninsured differs from access to physicians. This study employs a correlational, two-group design (n=102,055) to analyze cross-sectional data from the 1989 National Health Interview Survey. Multiple logistic regression was used to compare the likelihood of hospitalization for the uninsured and insured in chronically ill, acutely ill, and well nonelderly subpopulations. When compared to data from a previous study on physician visits, disparities in hospitalization among the three subgroups differed in both magnitude and relative order from disparities in physician visits. The disparities between the insured and uninsured clustered at 38 percent for hospitalization, and 20 percent for physician visits. Overall, being uninsured resulted in a larger difference for hospital utilization than for physician utilization. These findings suggest that the uninsured face even greater access barriers for hospitalization than they do for physician care.

Implications of Health-Care Reform Proposals for Black Americans

Abstract: A recent increase in the number of black Americans who lack public or private health insurance means that current proposals to reform the U.S. health-care system have particular relevance for the black community. This paper reviews the major reform proposals offered by President Clinton and Congressional leaders with an eye toward estimating the possible impact on black Americans. The proposals offer concepts ranging from managed competition and "play or pay" to caps on health-insurance premiums, incentives for primary-care providers, "sin" taxes, and outcomes analysis. Though some of these concepts offer opportunities for improving black Americans' access to quality care, most have potential shortcomings that could worsen health status in the black community.

Saving rural health care: strategies and solutions

Abstract: Health care for rural populations has been threatened in recent years by a significant number of hospital closures and a scarcity of primary care providers. While some factors that influence hospital closures lie beyond the reach of individual facilities, others, such as low occupancy rates and poor management, can and should be addressed through hospital networking, strategic planning, and well-focused marketing. To recruit and retain physicians, communities should develop financial-incentive packages and such alternatives to the traditional fee-for-service medical practice as recruiting older providers, establishing a community-based health maintenance organization, or founding a community-owned and -operated medical clinic staffed by primary care providers. Improving rural health care requires community involvement and commitment, and good planning.

Public hospitals and managed care.

Abstract: Managed health care is used increasingly in the public and private sectors to control rising health-care costs and to assure quality of care. While current proposals for health-care reform promote even wider application of managed care as a component in cost control, the formal use of managed care by public hospitals has not been fully explored. This article identifies possible reasons for providing managed care within a public-hospital system, explores the implications of managed care for public hospitals and their patients, and addresses some of the barriers to implementing managed care in a traditional public-hospital setting.

Post-hospital care for the underserved: a review.

Abstract: Policies that encourage rapid discharge of hospitalized patients often fail to consider barriers that underserved populations face in gaining access to post-discharge facilities such as nursing homes. Because of these barriers, long-stay patients (LSPs) remain hospitalized even after the successful treatment of their acute medical conditions. While the number of LSPs has increased in recent years, the plight of these patients has not been thoroughly examined. This review summarizes the characteristics of LSPs, the obstacles they encounter in obtaining post-acute care, and the potential impact of health care reform on access for underserved LSPs. It also discusses issues that policymakers must address to improve this populations's access to post-acute care.

Does Subsidizing Rural Community Health Centers Hurt Private Practice Physicians

Abstract: One reason for the shortage of primary care physicians in rural areas may be these physicians' reluctance to compete for patients with federally subsidized Community Health Centers (CHCs). Yet little is known about the relationship between private practice physicians and physicians in federally subsidized practices who share service areas. We used surveys from a two-state subset of a nationally representative sample to compare practice characteristics of three types of physicians: those who work in CHCs; those in private practice within CHC service areas; and private practice physicians in other rural areas. We found that rural physicians who compete with CHCs earn incomes comparable to physicians in rural areas who do not compete with CHCs, and that the percentage of Medicaid and uninsured patients seen in private physician practices does not increase when a CHC is not in the county. We conclude that CHCs do not provide competitive barriers to physicians in private practice, although we do not know if the presence of a CHC inhibits new private physicians from entering practices in these communities.

A Public-Sector HMO in a Competitive Market: Ensuring Equity for the Poor

Abstract: While managed care is still a new concept in much of the country, it has been a reality in the Minneapolis-St. Paul area for more than three decades. Metropolitan Health Plan (MHP), a public-sector, county-owned health maintenance organization (HMO), was developed 10 years ago as a mechanism to ensure retention of the county hospital's historical patient base if the state of Minnesota were to mandate managed care for public-assistance patients (which occurred in 1985). Because MHP's chief provider organization was Hennepin County Medical Center, which has a long history of serving the poor, it had an advantage over its more established competitors. MHP's greater knowledge of the population and sensitivity to ethnic and cultural diversity has enabled it to develop programs and systems to streamline access to services, many of which are unique to MHP.

Managed Care: Theoretical or Practical

Abstract: Managed care organizations that serve the poor face unique challenges. Not only must they empower their enrolled populations with awareness and knowledge about the benefits of being enrolled, but they must also provide significant outreach, offer services that are sensitive to urban and rural concerns, and stress health education and disease prevention. The managed care model offers efficiency and effectiveness that can place providers on the leading edge of not only providing solutions that address the needs of the underserved, but being competitive in servicing these populations.

Managed Care and the Poor

Abstract: While the momentum for health care reform stems from the concerns of the middle class rather than the poor, we should recognize that managed care—at least as an ideal—can still represent an improvement over the fee-for-service system. For the reality of managed care to approach its promise for underserved communities, issues surrounding cost-sharing, preventive health, traditional providers for the poor, and premium adjustment must be resolved.

Walkin' Over Medicine: Traditional Health Practices in African-American Life

Abstract: Research ON African-American ethnomedicine (commonly referred to as \"folk medicine\") frequently contains an insidious but powerful bias: that African-American ethnomedicine represents an interesting, but inherently erroneous, ragtag collection of superstitions instead of a well-developed, integrated system of beliefs and practices that provides people with a meaningful account of health, illness, and disease as well as practical relief. Walkin' Over Medicine confronts this bias head-on by presenting a richly detailed ethnographic account of African-American ethnomedicine based on 25 years of primary research conducted by Michigan State University anthropology professor Snow and her students, and an extensive examination of research conducted by others. The result is a dense portrayal that not only traces the traditional foundations of African-American ethnomedicine, but also demonstrates its uses and functions in the everyday lives of its adherents. In doing so, the book makes several ineluctable points. First, as Snow makes abundantly clear, health is considered a seamless web of body, mind, and spirit that must be maintained in harmonious balance. A disorder in one realm therefore necessarily affects the other two. This means that Cartesian duality (the dichotomous split between physiological properties on the one hand, and emotional and mental ones on the other hand), which constitutes an essential epistemological underpinning of biomedicine, carries little meaning in this system. Moreover, the accent on spirituality and the degree to which African-Americans rely on spiritual guidance as a vital means of maintaining health and overcoming illness find no counterpart in biomedical practice. Second, Snow effectively dispels popular and prevalent myths concerning which segments of the African-American population rely on the traditional wisdom of ethnomedicine, and under which circumstances they use it. Although it is commonly assumed that only the elderly, rural, or those with limited

Public/Private Partnerships in Managed Care

Abstract: Although public/private partnerships are often viewed as mechanisms for using private monies to finance public needs, partnerships among health care providers, the business and legal communities, and the public sector offer promise as a way to realign the provision of health care to special-needs communities in the present era of managed care. In Nashville, Tennessee, such a partnership promises to provide efficient, state-of-the-art medical care through a centralized city-wide clinic for HIV-positive individuals.

Community Health Organizing Revisited

Abstract: To the editor: Elizabeth Kelly and colleagues [Vol. 4, No. 4:358-62] describe a model of community health organizing that is built from the grassroots up rather than from the top down. I used a similar approach to help increase access to care among Hispanic women at Boston's Codman Square Neighborhood Health Center (CSHC). Codman Square is located in Dorchester, a neighborhood of poor and working-class Hispanics, African-Americans, and whites. Hispanic women represent one of the poorest cohorts in the community. When I arrived at the CSHC in 1991 as a Spanish-speaking family nurse practitioner, the facility had been historically underutilized by the Hispanic community. While Hispanics made up 15 percent of the community, they were only four percent of CSHC patients. Some complained that Hispanics did not frequent the CSHC because of cultural isolation, feeling that CSHC staff members were unfriendly and that few spoke their language. Others had no health insurance. Still others did not know where the facility was located. Using the principles of Community-Oriented Primary Care1,1 established a cluster committee of Spanish-speaking patients, Spanish-speaking staff members, and other Hispanic community leaders. In a series of meetings to discuss the health needs of the Hispanic community, the most common concern was lack of access to the CSHC. The cluster committee recommended several

The clinton health-care reform plan: does it serve the underserved?

Abstract: During the 1992 presidential campaign, Governor Clinton promised, if elected, to provide leadership from the Oval Office for sweeping, comprehensive reform of the U.S. health-care system to benefit all Americans. The President's ambitious blueprint, as outlined on September 22, 1993, falls short of this pledge. For the majority of the nation's poor and underserved, the proposed plan insufficiently ensures universal access, social equity, comprehensiveness of benefits, affordability, and high-quality health-care services. Requiring all employers to provide, and employees to share the cost of, health-insurance coverage could decrease take-home pay for many of the working poor. In addition, the President's proposed cost-containment efforts, which include global budgetary targets and reductions in Medicare and Medicaid reimbursement, could result in the elimination of over 1.0 million positions in the healthcare field. These potential outcomes are alien to the President's earlier axioms to reform the U.S. health-care system, and to improve the nation's economic climate to foster the creation of more and better-paying jobs.

Managed Competition for the Poor: More Promise than Value?

Abstract: President Clinton and many other elected officials have proposed that managed companion be the cornerstone of health care reform. However, experiences of Medicaid recipients with managed care plans are at best mixed. These capitated programs report higher costs than do fee-for-service arrange- ments. Fortunately, these additional expenditures are partially offset by at least a perception of improved access to care. Due to difficulties in determining eligibility, delivering benefits, paying for needed services, and similar con- cerns, providing care for the poor and underserved will be complicated and expensive for the proposed sponsors of managed competition plans.

Effects on Navajo Birthrate from Loss of the Intrauterine Device

Abstract: The concerns of relatively powerless groups may not be adequately addressed by health-care decisions based on market forces and on considerations of the general population. Calculations of the number of Navajo women at risk of unintended pregnancy suggest that several hundred such pregnancies would have occurred as a result of the withdrawal of intrauterine devices from the United States' market. Analysis of birthrate data confirms this estimate: approximately four to five percent of Navajo births in 1988 may have been due to this market withdrawal. Available data are limited in their ability to assess impacts on small groups of health-policy decisions made for the population as a whole. A mechanism for surveilling such effects needs to be established to protect the interests of such groups, particularly when they have restricted alternatives.

Consumer responsibility in the HMO environment.

Abstract: Successful managed care requires two-way responsibility. Providers must design health plans that market services intelligently, communicate with enrolled clients effectively, solicit frequent feedback from consumers, and are genuinely responsive to the needs of patients. Consumers are responsible for demonstrating self-care, consuming medical resources wisely, and exercising personal initiative to help make managed care work.

Economic Issues in Managed Care

Abstract: Economic issues abound in managed care. The advent of health insurance in the United States, which was created to ensure payment to hospitals, diminished an early emphasis on charity care. Escalating health care costs have ensued. Today, economic considerations dictate the need to control health care expenditures while guaranteeing responsible care. Managed care organizations can achieve both goals by establishing financial partnerships with physicians while instituting quality-control audits, management review teams, and home-care arrangements.

Managed care: implications for underrepresented physicians

Abstract: The advent of health care reform has brought uncertainty to the lives of underrepresented physicians and their patients. Managed care prom- ises increased numbers of primary care physicians and fewer specialists; increased numbers of group practices and health maintenance organizations (HMOs); and combinations of health care plans and insurance plans. Solo practice fee-for-service physicians will find it more difficult to compete. Many physicians will retire or change careers; some will be left out of managed care plans altogether. To cope, underrepresented physicians must encourage the enrollment of more minorities in medical schools and residency training programs. They must become involved in the management and administration of managed care programs. They must become involved in politics. Finally, they must combine forces to become competitive in the changing health care market.

Increasing the Pool of Minority Providers

Abstract: The University of Arkansas has trained African-American medical students for 46 years. Today the school continues to place a high premium on recruiting and retaining minority medical students. Recruitment efforts involve comprehensive programs to target junior high schools in African-American communities throughout Arkansas, and initiatives to attract African-American faculty and residents. Through such retention-oriented activities as lenient first-year grade requirements, study groups, and a board-preparation course, African-American students have scored above the national average on Part I of the National Medical Board Examination despite matriculating in medical school with below-average scores on the Medical College Admission Test.

Future management opportunities for minorities in managed care.

Abstract: Current proposals for health care reform emphasize managed care in an effort to achieve universal coverage and access to health care for all Americans. One of the many strategies to achieve this goal is to create a new health care workforce by supporting the recruitment and education of health professionals from population groups underrepresented in health care. To help insure that the managed care industry will be adequately prepared to face the challenges of reform, the Group Health Foundation of the Group Health Association of America, Inc., has crafted an innovative Minority Training Program—a management training program in the field of managed care. The program involves resident fellows who will train in select health maintenance organizations (HMOs) in the Washington, DC/Baltimore metropolitan area. To augment training, the fellows will simultaneously participate in a comprehensive didactic program especially designed to prepare each fellow for a first or middle-management position in an HMO or a similar managed care organization. Following successful completion of the first years in Washington, DC, the program will be broadened to other geographical areas.

The Pharmaceutical Industry and Health Care Reform

Abstract: While the goals of President Clinton's health care reform plan— to expand access to health care by the underserved and reduce the unacceptably high cost of care—areimportant,hisproposedmechanismsfordoingsoinclude provisions that are counterproductive. Blacklisting certain drugs from the Medicare program, imposing red tape on physicians who participate in Medicare, and establishing a Medicare rebate tax wA¼l hurt the pharmaceutical industry's ability to conduct research on new medications. In the end, the Administration's plan will injure the very population—the elderly, the poor, and minorities—that needs health care reform the most.