Showing papers in "Milbank Quarterly in 2001"

Improving the quality of health care in the United Kingdom and the United States: a framework for change.

Abstract: Fueled by public incidents and growing evidence of deficiencies in care, concern over the quality and outcomes of care has increased in both the United Kingdom and the United States. Both countries have launched a number of initiatives to deal with these issues. These initiatives are unlikely to achieve their objectives without explicit consideration of the multilevel approach to change that includes the individual, group/team, organization, and larger environment/system level. Attention must be given to issues of leadership, culture, team development, and information technology at all levels. A number of contingent factors influence these efforts in both countries, which must each balance a number of tradeoffs between centralization and decentralization in efforts to sustain the impetus for quality improvement over time. The multilevel change framework and associated properties provide a framework for assessing progress along the journey.

Trust in physicians and medical institutions: what is it, can it be measured, and does it matter?

Abstract: Despite the profound and pervasive importance of trust in medical settings, there is no commonly shared understanding of what trust means, and little is known about what difference trust actually makes, what factors affect trust, and how trust relates to other similar attitudes and behaviors. To address this gap in understanding, the emerging theoretical, empirical, and public policy literature on trust in physicians and in medical institutions is reviewed and synthesized. Based on this review and additional research and analysis, a formal definition and conceptual model of trust is presented, with a review of the extent to which this model has been confirmed by empirical studies. This conceptual and empirical understanding has significance for ethics, law, and public policy.

Partnership synergy: a practical framework for studying and strengthening the collaborative advantage.

Abstract: The substantial interest and investment in health partnerships in the United States is based on the assumption that collaboration is more effective in achieving health and health system goals than efforts carried out by single agents. A clear conceptualization of the mechanism that accounts for the collaborative advantage, and a way to measure it are needed to test this assumption and to strengthen the capacity of partnerships to realize the full potential of collaboration. The mechanism that gives collaboration its unique advantage is synergy. A framework for operationalizing and assessing partnership synergy, and for identifying its likely determinants, can be used to address critical policy, evaluation, and management issues related to collaboration.

Evidence-based management: from theory to practice in health care.

Abstract: This article describes the main principles of evidence-based health care, documents its increasing acceptance, and explores the reasons for its popularity. It discussed the applicability of the ideas of evidence-based practice to health care management, and presents a comparison of the culture, research base, and decision-making processes in the two domains, which helps to explain the slow progress of evidence-based management to date.

The Utility of Social Capital in Research on Health Determinants

Abstract: Social capital has become a popular subject in the literature on determinants of health. The concept of social capital has been used in the sociological, political science, and economic development literatures, as well as in the health inequalities literature. Analysis of its use in the health inequalities literature suggests that each theoretical tradition has conceptualized social capital differently. Health researchers have employed a wide range of social capital measures, borrowing from several theoretical traditions. Given the wide variation in these measures and an apparent lack of consistent theoretical or empirical justification for their use, conclusions about the likely role of “social capital” on population health may be overstated or even misleading. Elements of a research agenda are proposed to further elucidate the potential role of factors currently subsumed under the rubric of “social capital.”

Does the Chronic Care Model Serve Also as a Template for Improving Prevention

Abstract: Practical models of ways to enhance service delivery are sorely needed to help close the gap between research and practice. An evidenced-based model of chronic-illness management is shown to apply equally to preventive interventions. Successful examples of prevention programs in cancer screening and counseling for health behavior change illustrate the utility of the model for prevention and across different types of health care organizations. Although there are some important differences between interventions required for chronic disease management and prevention, there are a greater number of common factors. They share the need to alter reactive acute-care-oriented practice to accommodate the proactive, planned, patient-oriented longitudinal care required for both prevention and chronic care.

Theory and practice in the design of physician payment incentives.

Abstract: Combining the economic literature on principal-agent relationships with examples of marketplace innovations allows analysis of the evolution of methods for paying physicians. Agency theory and the economic principles of performance-based compensation are applied in the context of imperfect information, risk aversion, multiple interrelated tasks, and team production efficiencies. Fee-for-service and capitation are flawed methods of motivating physicians to achieve specific goals. Payment innovations that blend elements of fee-for-service, capitation, and case rates can preserve the advantages and attenuate the disadvantages of each. These innovations include capitation with fee-for-service carve-outs, department budgets with individual fee-for-service or “contact” capitation, and case rates for defined episodes of illness. The context within which payment incentives are embedded, includes such nonprice mechanisms as screening and monitoring and such organizational relationships as employment and ownership. The analysis has implications for health services research and public policy with respect to physician payment incentives.

Hospital restructuring and the work of registered nurses.

Abstract: American hospitals have undergone three waves of organizational restructuring in the past two decades. These changes have had direct effects on a key set of employees—nurses. A review of the relevant literature to identify the ways in which hospital restructuring affects the work of registered nurses focuses on three important structural characteristics of nursing work: nurses' work roles, workload, and control of work. The review concludes that the impact of restructuring on each of the characteristics affects nurses' satisfaction with their work and may also affect the quality of patient care. While much of the policy debate around restructuring focuses on the extent to which reductions in nurse staffing levels affects quality of care, it is important to examine not only changes in nurse staffing levels, but changes in the work performed by registered nurses, as well.

Capitation and Risk Adjustment in Health Care Financing: An International Progress Report

Abstract: In every system of health care, capitation payments have become the accepted tool used by health care purchasers in much of the developed world to determine prospective budgets. The policy prescription of capitation is perceived to address both equity objectives (of great importance in publicly funded systems of health care) and efficiency objectives (the dominant concern in competitive insurance markets). An examination of the current state of the art in 20 countries outside the United States in which health care capitation has been implemented confirms that capitation has assumed central importance within diverse systems of health care. In practice, however, the setting of capitation payments has been heavily constrained to date by poor data availability and unsatisfactory analytic methodology.

Public Roles for the Medical Profession in the United States: Beyond Theories of Decline and Fall

Abstract: The future role of national medical organizations as a moral voice in health policymaking in the United States deserves attention from both scholarly and strategic perspectives. Arguments for strengthening the public roles of organized professionalism include its long (if neglected) history of public service. Scholarship of the past 40 years has emphasized the decline of a profession imbued with self-interest, together with associated hteories of organizational conflict. Through new concepts and language, a different version of organized medicine from that of the past might be invented for the future—one that draws on multiple medical organizations, encourages more effective cooperation with other health care groups, and builds on traditional professional agendas through adaptation and extension.

The managed care backlash: perceptions and rhetoric in health care policy and the potential for health care reform.

Abstract: The focus on managed care and the managed care backlash divert attention from more important national health issues, such as insurance coverage and quality of care. The ongoing public debate often does not accurately convey the key issues or the relevant evidence. Important perceptions of reduced encounter time with physicians, limitations on physicians' ability to communicate options to patients, and blocked access to inpatient care, among others, are either incorrect or exaggerated. The public backlash reflects a lack of trust resulting from cost constraints, explicit rationing, and media coverage. Inevitable errors are now readily attributed to managed care practices and organizations. Some procedural consumer protections may help restore the eroding trust and refocus public discussion on more central issues.

Improving the quality of workers' compensation health care delivery: the Washington State Occupational Health Services Project.

Abstract: Researchers and health policy analysts in Washington State set out to determine the extent to which administrative process changes and delivery system interventions within workers' compensation affect quality and health outcomes for injured workers. This research included a pilot project to study the effects of providing occupationally focused health care through managed care arrangements on health outcomes, worker and employer satisfaction, and medical and disability costs. Based on the results, a new initiative was developed to incorporate several key delivery system components. The Washington State experience in developing a quality improvement initiative may have relevance for health care clinicians, administrators, policymakers, and researchers engaged in similar pursuits within the general medical care arena.

Do not delay: breast cancer and time, 1900-1970.

Abstract: Until the 1960s, the central public health message about breast cancer was that women should not delay seeking medical attention for breast problems. Epidemiological, pathological, public health, and clinical writings, movies, and doctor-patient correspondence are analyzed in order to understand the durability and centrality of this “do not delay” message. Problematic assumptions about the natural history of cancer, the efficacy of surgery, and individual responsibility for disease contributed to the durability of the “do not delay” message. More important, the message catalyzed or sustained changes in the routines of ordinary women, general practitioners, surgeons, and pathologists, which led to the perception that the campaign against cancer was working. Thus a powerful set of reinforcing perceptions and behaviors maintained the centrality of the “do not delay” campaign until the era of mammography.

The Effect of State Regulations on Motor Vehicle Fatalities for Younger and Older Drivers: A Review and Analysis

Abstract: Policymakers have had a long-standing interest in improving the motor vehicle safety of both younger and older drivers. Although younger and older drivers share the distinction of having more crashes and fatalities per mile driven than other age groups, the problems posed by these two groups stem from different origins and manifest in different ways. A number of state-level policies and regulations may affect the number of motor vehicle crashes and fatalities in these two high-risk groups. A critical review of the existing literature in regard to the risk factors and the effects of various policy measures on motor vehicle crashes in these two high-risk populations provides direction for policymakers and high-priority areas of interest for the research community.

Changes in the structure, composition, and activity of hospital governing boards, 1989-1997: evidence from two national surveys.

Abstract: Hospital governance arrangements affect institutional policymaking and strategic decisions and can vary by such organizational attributes as ownership type/control, size, and system membership. A comparison of two national surveys shows how hospital governing boards changed in response to organizational and environmental pressures between 1989 and 1997. The magnitude and direction of changes in (1) board structure, composition, and selection; (2) CEO-board relations; and (3) board activity, evaluation, and compensation are examined for the population of hospitals and for different categories of hospitals. The findings suggest that hospital boards are engaging in selective rather than wholesale change to meet the simultaneous demands of a competitive market and traditional institutional orientations to community, the disenfranchised, and philanthropic service. Results also suggest parallel increases in collaboration between boards and CEOs and in board scrutiny of CEOs.

What happened to long-term care in the health reform debate of 1993-1994? Lessons for the future

Abstract: During 1993 and 1994, the United States debated but did not enact major health care reform. Although the reform efforts focused on providing health coverage for the uninsured and controlling acute care costs, many proposals included substantial long-term care initiatives. President Clinton proposed creating a large home-care program for severely disabled people of all ages and all income groups, among several other initiatives. By stressing non-means-tested public programs, the president's plan was a major departure from the Medicaid-dominated financing system for long-term care. In designing the long-term care component, the Clinton administration addressed many of the basic policy choices that must be decided in all reform efforts, including whether initiatives should be limited to older people or cover people of any age, how to balance institutional and noninstitutional care, whether to rely on government programs or on the private sector, and how to control costs. Analyzing the political and intellectual history of long-term care during the health reform debate provides lessons for future reform.

Effects of alcohol consumption on disability among the near elderly: a longitudinal analysis.

Abstract: Data from four waves of the Health and Retirement Study are used to analyze the effects of alcohol use on disability, mortality, and income transfers from public programs. Cross-sectional analysis reveals a complex relationship, with a history of problem drinking clearly leading to higher rates of limitations, and a nonmonotonic relationship between current drinking and disability. In longitudinal analysis, problem drinking was predictive of disability onset, but not of transfer receipt or mortality. Heavy drinkers and problem drinkers, if anything, were less likely to receive public income support than abstainers or moderate drinkers. The likelihood that heavy drinkers received public transfers did not decrease relative to others following statutory changes in 1996 that sought to limit eligibility of alcoholics and drug abusers.

Perceived outcomes of public health privatization: a national survey of local health department directors.

Abstract: Almost three quarters of the nation's local health departments (LHDs) have privatized some services. About half of LHD directors who privatized services reported cost savings and half reported that privatization had facilitated their performance of the core public health functions. Expanded access to services was the most commonly reported positive outcome. Of those privatizing, over two-fifths of LHDs reported a resulting increase in time devoted to management. Yet, one-third of directors reported difficulty monitoring and controlling services that have been contracted out. Communicable disease services was cited most often as a service that should not be privatized. There is a pervasive concern that by contracting out services, health departments can lose the capacity to respond to disease outbreaks and other crises.

Health Promotion and the First Amendment: Government Control of the Informational Environment

Abstract: Government efforts to protect public health often include controlling health information The government may proscribe messages conveyed by commercial entities (eg, false or misleading), recommend messages from commercial entities (eg, warnings and safety instructions), and convey health messages (eg, health communication campaigns) Through well-developed, albeit evolving, case law, government control of private speech has been constrained to avoid impinging on such values as free expression, truthfulness, and autonomous decision making No simple legal framework has been developed for the government’s own health messages to mediate between the legitimate goals of health protection and these other values Nevertheless, government recommendations on matters of health raise difficult social and ethical questions and involve important societal trade-offs Accordingly, this article proposes legal and ethical principles relating to government control of the health information environment

Lessons from the Unexpected: The Importance of Data Infrastructure, Conceptual Models, and Serendipity in Health Services Research

Abstract: In examining the importance of data systems, conceptual models, and serendipity in understanding health services, the case is made for a vigorous and responsive data infrastructure and more emphasis on conceptual development. Particularly important is the development of data systems that can keep pace with changes in health care organization and patterns of care. Three examples—from managed care, deinstitutionalization, and physician remuneration—demonstrate the need to empirically examine seemingly obvious assumptions about health patterns and trends, and the lessons to be learned when assumptions are proved incorrect. Major future challenges include incorporating patient preferences into outcomes research, meaningful communication about treatment options and health plan choices, and understanding how organizational culture and norms affect decision processes.