Beyond competition: the normative implications of consumer-driven health plans

Navigating Poorly Charted Territory

American health care is complex, fragmented, and arcane rather than being patient centered. Many patients have considerable difficulty navigating this system. As a result, care is less timely, safe, effective, and efficient. Since navigation problems are more likely for those who are sicker and less educated, they contribute to inequity. Early solutions proposed for this problem focused on the use of yet another specialized professional, the “navigator,” to help individuals find their way through the system so they get the care they need. The author defines the patient navigation problem and its probable consequences and argues that research and action are needed to (a) document the problem empirically, (b) identify underlying organizational structures and behaviors that can make navigation easy or difficult, and (c) assess whether and how policies, regulations, and improvement strategies can influence these structures and behaviors.

Between liberal aspirations and market forces: Obamacare's precarious balancing act

The 2010 Affordable Care Act (ACA) represents a milestone in U.S. health care policy. The ACA moves the American health care system away, in important respects, from market-driven health care, including imposing new regulations on health insurers. Yet the ACA also relies, in other respects, on market forces to achieve its aims, including its embrace of health plan competition and high-deductible insurance. This article explores how the ACA balances liberal aspirations and market principles, and the implications for health reform implementation and the future of U.S. health care.

Emerging Therapeutic Enhancement Enabling Health Technologies and Their Discourses: What Is Discussed within the Health Domain?

So far, the very meaning of health and therefore, treatment and rehabilitation is benchmarked to the normal or species-typical body. We expect certain abilities in members of a species; we expect humans to walk but not to fly, but a bird we expect to fly. However, increasingly therapeutic interventions have the potential to give recipients beyond species-typical body related abilities (therapeutic enhancements, TE). We believe that the perfect storm of TE, the shift in ability expectations toward beyond species-typical body abilities, and the increasing desire of health consumers to shape the health system will increasingly influence various aspects of health care practice, policy, and scholarship. We employed qualitative and quantitative methods to investigate among others how human enhancement, neuro/cognitive enhancement, brain machine interfaces, and social robot discourses cover (a) healthcare, healthcare policy, and healthcare ethics, (b) disability and (c) health consumers and how visible various assessment fields are within Neuro/Cogno/Human enhancement and within the BMI and social robotics discourse. We found that health care, as such, is little discussed, as are health care policy and ethics; that the term consumers (but not health consumers) is used; that technology, impact and needs assessment is absent; and that the imagery of disabled people is primarily a medical one. We submit that now, at this early stage, is the time to gain a good understanding of what drives the push for the enhancement agenda and enhancement-enabling devices, and the dynamics around acceptance and diffusion of therapeutic enhancements.

Strategic responses to fiscal constraints: a health policy analysis of hospital-based ambulatory physical therapy services in the Greater Toronto Area (GTA)

PURPOSE

Ambulatory physical therapy (PT) services in Canada are required to be insured under the Canada Health Act, but only if delivered within hospitals. The present study analyzed strategic responses used by hospitals in the Greater Toronto Area (GTA) to deliver PT services in an environment of fiscal constraint.

METHODS

Key informant interviews (n = 47) were conducted with participants from all hospitals located within the GTA.

RESULTS

Two primary strategic responses were identified: (1) "load shedding" through the elimination or reduction of services, and (2) "privatization" through contracting out or creating internal for-profit subsidiary clinics. All hospitals reported reductions in service delivery between 1996 and 2003, and 15.0% (7/47 hospitals) fully eliminated ambulatory services. Although only one of 47 hospitals contracted out services, another 15.0% (7/47) reported that for-profit subsidiary clinics were created within the hospital in order to access other more profitable forms of quasi-public and private funding.

CONCLUSIONS

Strategic restructuring of services, aimed primarily at cost containment, may have yielded short-term financial savings but has also created a ripple effect across the continuum of care. Moreover, the rise of for-profit subsidiary clinics operating within not-for-profit hospitals has emerged without much public debate and with little research to evaluate its impact.

Employer-sponsored health insurance and the promise of health insurance reform

The central role that employers play in financing health care is a distinctive feature of the U.S. health care system, and the provision of health insurance through the workplace has important implications well beyond its role as a source of health care financing. In this paper, we consider the "goodness of fit" of employer-sponsored health insurance (ESI) in the current economic and health insurance environments and in light of prospects for a vigorous national debate over the shape of health care reform. The main issue that we explore is whether ESI can have a viable role in health system reform efforts or whether such coverage will need to be significantly modified or even abandoned as reform seeks to address important issues in the efficient provision and equitable distribution of health insurance coverage.

Delisting publicly funded community-based physical therapy services in Ontario, Canada: a 12-month follow-up study of the perceptions of clients and providers

Publicly funded community-based physical therapy (PT) services in Canada's most populous province of Ontario were partially delisted, or deinsured, in April 2005. Two previous studies examined the short-term effects from the client and provider perspectives; and in this study, we follow up with participants from these preceding studies to assess long-term consequences of this policy. Sixteen of 18 providers (89%) and 64 of 98 clients (65%) agreed to participate in a follow-up telephone interview. Our results indicate that 12 months following delisting, and despite government assurances that access would be preserved, clients rendered ineligible for publicly funded services report ongoing access barriers across Ontario. Clients in this study also express concern about their overall health and report an increased use of other insured health professionals (e.g., physicians) and services (e.g., hospitals). On the other hand, providers within the network of publicly funded clinics report an important decrease in demand for PT services, whereas those from other settings report little change. We conclude that delisting policies may have long-term consequences on uninsured or underinsured clients and that evidence-based policy planning is warranted to ensure that the goals of reform are aligned with the desired outcomes at the client, provider, and system levels.

Evidence-based medicine: the fourth revolution in American medicine?

SUMMARY

The use of evidence has become a force in American medicine to improve the quality of health care. Funding decisions from payers will demand studies with high-level evidence to support many of the costly interventions in medicine. Plastic surgery is certainly not immune to this national tidal wave to revamp the health care system by embracing evidence-based medicine in our practices. In scientific contributions of plastic surgery research, application of evidence-based principles should enhance the care of all patients by relying on science rather than opinions. In this article, the genesis of evidence-based medicine is discussed to guide plastic surgery in this new revolution in American medicine.

Competencia en el sector salud: análisis de la reforma sueca (1992 - 1995)

El artículo revisa los éxitos y fracasos de la reforma sueca de salud, así como las lecciones que dejó en su afán de alcanzar mejores resultados financieros y estándares de calidad.

Toward ethical review of health system transformations

Efforts to transform health systems constitute social experiments on a population. Like clinical research, they deploy measures that are unproven in the context of the reform, and they often impose significant risks on some people in order to achieve a social goal: the improvement of health delivery. The rationale for proactively evaluating clinical experimentation on human subjects also applies to these social experiments. We used the "benchmarks of fairness" methodology to illustrate the elements such an evidence-based review should encompass, leaving open the question of who should perform it. The review must include the ethical objectives of reform, namely, an integrated approach to equity, accountability, and efficiency; the fit between measures taken and these objectives; and the governance of the reform.