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1.  Pediatrician Participation in Medicaid—Findings of a Five-Year-Follow-up Study in California and Elsewhere 
Western Journal of Medicine  1986;145(4):546-550.
Medi-Cal—California's Medicaid program—underwent significant changes during the period 1978 through 1983. Most notable were the imposition of new copayments, reductions in physician reimbursement and selective contracting for hospital services. The state-funded medically indigent program was transferred to the counties and the state began to experiment with bulk purchasing of drugs and supplies, a lock-in for overutilizers and primary care case management.
How have these changes affected primary care providers' participation in Medi-Cal? Surveys of California pediatricians in 1978 and 1983 suggest that while most continue to participate, the level of limited participation in Medi-Cal increased from 23% to 51%. Most pediatricians express discontent with the level of Medicaid payments and there is a growing sentiment that Medicaid regulations interfere with the provision of high quality medical care. Future Medi-Cal policy developments, such as contracting for physician services, should be structured in ways that maximize participation of primary care providers in the program.
PMCID: PMC1307011  PMID: 3538665
2.  Enrolling in Medicaid Through the National School Lunch Program: Outcome of a Pilot Project in California Schools 
Public Health Reports  2007;122(4):452-460.
California has several health insurance programs for children. However, the system for enrolling into these programs is complex and difficult to manage for many families. Express Lane Eligibility is designed to streamline the Medicaid (called Medi-Cal in California) enrollment process by linking it to the National School Lunch Program. If a child is eligible for free lunch and the parents consent, the program provides two months of presumptive eligibility for Medi-Cal and a simplified application process for continuation in Medi-Cal. For those who are ineligible, it provides a referral to other programs.
An evaluation of Express Lane shows that while many children were presumptively enrolled, nearly half of the applicants were already enrolled in Medi-Cal. Many Express Enrolled children failed to complete the full Medi-Cal enrollment process. Few were referred to the State Children's Health Insurance Program or county programs. Express Lane is less useful as a broad screening strategy, but can be one of many tools that communities use to enroll children in health insurance.
PMCID: PMC1888518  PMID: 17639647
3.  Capitation in California—An Analysis of At-Risk Financing of Medicaid Services 
Western Journal of Medicine  1986;145(2):258-262.
Recent legislative changes have fostered the growth of a highly competitive health care market in California. In addition to selective hospital contracting for Medicaid (Medi-Cal) services, the California Medical Assistance Commission is attempting to initiate pilot projects to capitate Medi-Cal beneficiaries in selected geographic areas throughout the state. Selective contracting with county capitated organized health systems is also underway in Santa Barbara County, with plans for other counties on the drawing boards. This paper describes these capitated programs as well as addressing problems that may arise in this transition from a fee-for-service to a capitated Medi-Cal system. Specifically considered are issues related to underutilization, quality of care, implementation, eligibility and effects on existing patterns of care.
PMCID: PMC1306907  PMID: 3532566
4.  The Impact of Health Insurance Policy Changes on Californians with Severe Chronic Disease 
Two recent changes in health policy will likely negatively impact state budgets and the health of low-income Californians with chronic disease. The new cost-sharing for medical visits, pharmaceuticals, and inpatient stays in California's Medcaid program (Medi-Cal) and the exclusion of the undocumented and individuals who have been legal residents for less than five years from the insurance expansions that The Patient Protection and Affordable Care Act of 2010 provides will reduce medical care utilization and may raise, rather than lower, state costs. Based on historical Medi-Cal utilization patterns, people living with HIV (PLWH) would average $514 in cost-sharing fees annually. The undocumented may lose coverage entirely and face even higher costs. The charges are high relative to the low incomes of both Medi-Cal recipients and the undocumented and are likely to discourage relatively inexpensive, but productive, medical care. Increasing patient costs harms patient health, harms public health, and increases state spending on medical care.
PMCID: PMC3828734  PMID: 24244803
Affordable Care Act; health policy; Medicare; Medicaid; health insurance
5.  Medi-Cal Hospital Contracting—Did It Achieve Its Legislative Objectives? 
Western Journal of Medicine  1985;143(1):118-124.
The 1982 Medi-Cal reforms and reductions established selective contracting with hospitals for inpatient care of Medi-Cal beneficiaries. The legislation established a special negotiator and criteria to be used in selecting contract hospitals. We report the findings of a study that analyzed the characteristics of contract and noncontract hospitals in Los Angeles County to assess how well these criteria were reflected in the outcome of the contracting process. We examine issues of beneficiary access to general inpatient care and to specialized services, the efficiency of contract hospitals compared with noncontract ones and quality-related issues.
PMCID: PMC1306262  PMID: 3898595
6.  Medicaid and the Mainstream: Reassessment in the Context of the Taxpayer Revolt 
Western Journal of Medicine  1980;132(6):550-561.
California's Medicaid program—Medi-Cal—attempted to implement the ideal of mainstream medical care for the poor by giving program beneficiaries a “credit card” for use in the private health care marketplace. This exposed the program to the perverse economic incentives of the fee-for-service, costplus health care system, and contributed to a high rate of increase in program costs. Attempts to control costs have been equally perverse, resulting in low payment rates, the second-guessing of physician professional judgments, the probing of medical and fiscal records, and the use of computerized surveillance systems.
Attempts to shift to the use of more efficient delivery systems have had small success. Attempts to attain cost containment through restructuring the Medi-Cal program have been rejected in the name of the mainstream ideal. Costs have continued to escalate, with annual increases as high as 20 percent in some years. Medi-Cal now costs $4 billion per year, the largest single program in California state government.
The taxpayer revolt in California is creating a fiscal crisis that will force rethinking of the premises of publicly funded health care for the poor, and a restructuring of strategies for reaching that objective. In the short run, it appears that the issue may not be whether the indigent will have access to mainstream medical care, but whether they will have access to any medical care. In the longer run, the crisis should represent an opportunity for building a system of health care that can serve the financially disadvantaged at a cost tolerable to our society.
PMCID: PMC1272170  PMID: 6996334
7.  Does “Mainstreaming” Guarantee Access to Care for Medicaid Recipients with Asthma? 
Recent reforms in the federal Medicaid program have attempted to integrate beneficiaries into the mainstream by providing them with managed care options. However, the effects of mainstreaming have not been systematically evaluated.
Cross-sectional survey.
A sample of 478 adult, nonelderly asthmatics followed by a large Northern California medical group.
We examined differences in self-reported access by insurance status. Compared to patients with other forms of insurance, patients covered by the state's Medicaid program (Medi-Cal) were more likely to report access problems for asthma-related care, including difficulties in reaching a health care provider by telephone, obtaining a clinic appointment, and obtaining asthma medication. Adjusting for relevant clinical and sociodemographic variables, Medi-Cal patients were more likely to report at least one access problem compared to non-Medi-Cal patients (adjusted odds ratio [AOR], 3.34; 95% confidence interval [CI], 1.43 to 7.80). Patients reporting at least one access problem were also more likely to have made at least one asthma-related emergency department visit within the past year (AOR, 4.84; 95% CI, 2.41 to 9.72). Reported barriers to care did not translate into reduced patient satisfaction.
Within this population of Medicaid patients, the provision of health insurance and care within the mainstream of an integrated health system was no guarantee of equal access as perceived by the patients themselves.
PMCID: PMC1495233  PMID: 11520386
Medicaid; Medicare; asthma; access to care; primary care
8.  Measuring the Impact of Outreach and Enrollment Strategies for Public Health Insurance in California 
Health Services Research  2011;46(1p2):319-335.
Objective and Study Setting
To evaluate the effectiveness of different approaches to outreach on public health insurance enrollment in 25 California counties with a Children's Health Initiative.
Data Source
Administrative enrollment databases.
Study Design
The use of eight enrollment strategies were identified in each quarter from 2001 to 2007 for each of 25 counties (county quarter). Strategies were categorized as either technology or nontechnology. New enrollments were obtained for Medi-Cal, Healthy Families, and Healthy Kids. Bivariate and multivariate analyses assessed the link between each strategy and new enrollments rates of children.
Data Collection
Methods Surveys of key informants determined whether a specific outreach strategy was used in each quarter. These were linked to new enrollments in each county quarter.
Principal Findings
Between 2001 and 2007, enrollment grew in all three children's health programs. We controlled for the effects of counties, seasons, and county-specific child poverty rates. There was an increase in enrollment rates of 11 percent in periods when technology-based systems were in use compared with when these approaches were inactive. Non-technology-based approaches, including school-linked approaches, yielded a 12 percent increase in new enrollments rates. Deploying seven to eight strategies yielded 54 percent more new enrollments per 10,000 children compared with periods with none of the specific strategies.
Conclusions and Implications
National health care reform provides new opportunities to expand coverage to millions of Americans. An investment in technology-based enrollment systems will maximize new enrollments, particularly into Medicaid; nontechnological approaches may help identify harder-to-reach populations. Moreover, incorporating several strategies, whether phased in or implemented simultaneously, will enhance enrollments.
PMCID: PMC3037785  PMID: 21054378
Outreach; health insurance; health care reform; Medicaid; Medi-Cal; CHIP; Healthy Kids; enrollment
9.  Determinants of Children's Participation in California's Medicaid and SCHIP Programs 
Health Services Research  2007;42(2):847-866.
To develop a comprehensive predictive model of eligible children's enrollment in California's Medicaid (Medi-Cal [MC]) and State Children's Health Insurance Program (SCHIP; Healthy Families [HF]) programs.
Data Sources/Study Setting
2001 California Health Interview Survey data, data on outstationed eligibility workers (OEWs), and administrative data from state agencies and local health insurance expansion programs for fiscal year 2000–2001.
Study Design
The study examined the effects of multiple family-level factors and contextual county-level factors on children's enrollment in Medicaid and SCHIP.
Data Collection/Extraction Methods
Simple logistical regression analyses were conducted with sampling weights. Hierarchical logistic regressions were run to control for clustering.
Principal Findings
Participation in MC and HF programs is determined by a combination of family-level predisposing, perceived need, and enabling/disabling factors, and county-level enabling/disabling factors. The strongest predictors of MC enrollment were family-level immigration status, ethnicity, and income, and the presence of a county-level “expansion program”; and the county-level ratio of OEWs to eligible children. Important HF enrollment predictors included family-level ethnicity, age, number of hours a parent worked, and urban residence; and county-level population size and outreach and media expenditure.
MC and HF outreach/enrollment efforts should target poorer and immigrant families (especially Latinos), older children, and children living in larger and urban counties. To reach uninsured eligible children, it is important to further simplify the application process and fund selected outreach efforts. Local health insurance expansion programs increase children's enrollment in MC.
PMCID: PMC1955353  PMID: 17362221
Medicaid; SCHIP; eligibility; outreach; enrollment
10.  Effect of insurance coverage on the relationship between asthma hospitalizations and exposure to air pollution. 
Public Health Reports  1999;114(2):135-148.
OBJECTIVE: Based on the assumption that people without health insurance have limited access to the primary care services needed to prevent unnecessary hospitalizations for asthma, the authors hypothesized that insurance is a factor in the strength of the association between hospital admissions for asthma and exposure to air pollution. They tested this hypothesis with 1991-1994 data from central Los Angeles. METHODS: The authors analyzed the effect of insurance status on the association between asthma-related hospital admissions and exposure to atmospheric particulates (PM10) and ozone (O3) using hospital discharge and air quality data for 1991-1994 for central Los Angeles. They used regression techniques with weighted moving averages (simulating distributed lag structures) to measure the effects of exposure on overall hospital admissions, admissions of uninsured patients, admissions for which MediCal (California Medicaid) was the primary payer, and admissions for which the primary payer was another government or private health insurance program. RESULTS: No associations were found between asthma admissions and O3 exposure. An estimated increase from 1991 to 1994 of 50 micrograms per cubic meter in PM10 concentrations averaged over eight days was associated with an increase of 21.0% in the number of asthma admissions. An even stronger increase--27.4%--was noted among MediCal asthma admissions. CONCLUSIONS: The authors conclude that low family income, as indicated by MediCal coverage, is a better predictor of asthma exacerbations associated with air pollution than lack of insurance and, by implication, a better predictor of insufficient access to primary care.
PMCID: PMC1308453  PMID: 10199716
11.  Use of Postpartum Care: Predictors and Barriers 
Journal of Pregnancy  2014;2014:530769.
This study aimed to identify actual and perceived barriers to postpartum care among a probability sample of women who gave birth in Los Angeles County, California in 2007. Survey data from the 2007 Los Angeles Mommy and Baby (LAMB) study (N = 4,075) were used to identify predictors and barriers to postpartum care use. The LAMB study was a cross-sectional, population-based study that examined maternal and child health outcomes during the preconception, prenatal, and postpartum periods. Multivariable analyses identified low income, being separated/divorced and never married, trying hard to get pregnant or trying to prevent pregnancy, Medi-Cal insurance holders, and lack of prenatal care to be risk factors of postpartum care nonuse, while Hispanic ethnicity was protective. The most commonly reported barriers to postpartum care use were feeling fine, being too busy with the baby, having other things going on, and a lack of need. Findings from this study can inform the development of interventions targeting subgroups at risk for not obtaining postpartum care. Community education and improved access to care can further increase the acceptability of postpartum visits and contribute to improvements in women's health. Postpartum care can serve as a gateway to engage underserved populations in the continuum of women's health care.
PMCID: PMC3945081
12.  Health Financing And Insurance Reform In Morocco 
Health affairs (Project Hope)  2007;26(4):1009-1016.
The government of Morocco approved two reforms in 2005 to expand health insurance coverage. The first is a payroll-based mandatory health insurance plan for public-and formal private–sector employees to extend coverage from the current 16 percent of the population to 30 percent. The second creates a publicly financed fund to cover services for the poor. Both reforms aim to improve access to high-quality care and reduce disparities in access and financing between income groups and between rural and urban dwellers. In this paper we analyze these reforms: the pre-reform debate, benefits covered, financing, administration, and oversight. We also examine prospects and future challenges for implementing the reforms.
PMCID: PMC2898512  PMID: 17630444
13.  Pediatric hospital admissions for measles. Lessons from the 1990 epidemic. 
Western Journal of Medicine  1996;165(1-2):20-25.
To examine the descriptive epidemiology of serious measles complications and associated hospital costs during a major epidemic, we used California population-based hospital discharge data to identify hospital admissions for measles during 1986 through 1990 (ICD-9 code 055, n = 4,201). We examined 5-year trends and, for 1990 pediatric epidemic cases (n = 2,234), sociodemographic and hospital admission financial data. Hospital admission rates for measles rose significantly between 1986 and 1990. During the 1990 epidemic, preschool children aged 1 to 5 years, Medi-Cal (California's Medicaid) beneficiaries, Hispanics, and those living in urban counties accounted for most hospital admissions. Young infants and residents of southern California and the San Joaquin Valley had the highest risks. Medi-Cal beneficiaries and Asian children were at an increased risk for death during the hospital stay. The average hospital admission cost was $8,201, and the average length of hospital stay was 4.6 days. Hospital costs amounted to $18 million, two thirds of which was paid for by Medi-Cal. Measles is a serious disease that can result in severe complications requiring lengthy and costly hospital stays. We must remain alert to its continuing threat, complications, and resulting financial burdens.
PMCID: PMC1307536  PMID: 8855680
14.  Psychiatric admissions of low-income women following abortion and childbirth 
Controversy exists about whether abortion or childbirth is associated with greater psychological risks. We compared psychiatric admission rates of women in time periods from 90 days to 4 years after either abortion or childbirth.
We used California Medicaid (Medi-Cal) records of women aged 13–49 years at the time of either abortion or childbirth during 1989. Only women who had no psychiatric admissions or pregnancy events during the year before the target pregnancy event were included (n = 56 741). Psychiatric admissions were examined using logistic regression analyses, controlling for age and months of eligibility for Medi-Cal services.
Overall, women who had had an abortion had a significantly higher relative risk of psychiatric admission compared with women who had delivered for every time period examined. Significant differences by major diagnostic categories were found for adjustment reactions (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.1–4.1), single-episode (OR 1.9, 95% CI 1.3–2.9) and recurrent depressive psychosis (OR 2.1, 95% CI 1.3–3.5), and bipolar disorder (OR 3.0, 95% CI 1.5–6.0). Significant differences were also observed when the results were stratified by age.
Subsequent psychiatric admissions are more common among low-income women who have an induced abortion than among those who carry a pregnancy to term, both in the short and longer term.
PMCID: PMC154179  PMID: 12743066
15.  The long-term effects of Medicaid managed care on obstetrics care in three California counties. 
Health Services Research  2001;36(4):751-771.
OBJECTIVE: To evaluate the long-term effects of Medicaid managed care (MMC) on obstetric service use and program costs in California. DATA SOURCES/STUDY SETTING: Longitudinal administrative data on Medi-Cal enrollment and claims and encounters related to pregnancy and delivery services were gathered from three counties--two long-standing MMC counties and one traditional fee-for-service Medicaid county--in California between 1987 and 1992. STUDY DESIGN: We studied Aid to Families with Dependent Children (AFDC) beneficiaries with live singleton vaginal deliveries with associated hospital stays of 14 days or less. Effects of managed care were examined with respect to prenatal visits, length of stay for delivery, maternal postpartum readmission rates, and total program expenditures. Multivariate analyses examined how the relative effect of managed care on service use and program expenditures in each MMC county evolves over time in comparison to fee-for-service. We controlled for length of Medi-Cal enrollment prior to delivery, data censoring, and individual characteristics such as race and age. PRINCIPAL FINDINGS: Prenatal care use is consistently lower in the MMC counties, although all three counties' prenatal care provision is well below the national standard. Drastic increases in one-day-stay deliveries were found: up to almost 50 percent of deliveries in MMC counties were one-day stays. Program cost savings associated with MMC enrollment are unambiguous. CONCLUSIONS: MMC cost savings might have come at the expense of reduced provision of prenatal care and shorter delivery length of stay. Future studies should verify any possible causal link and the effects on maternal and infant health outcomes.
PMCID: PMC1089255  PMID: 11508638
16.  A comparison of capitated and fee-for-service Medicaid reimbursement methods on pregnancy outcomes. 
Health Services Research  1998;33(1):55-73.
OBJECTIVE: To determine if the payment method influenced the likelihood of selected obstetrical process measures and pregnancy outcome indicators among Medicaid women. DATA SOURCE/STUDY SETTING: Data from the live birth certificates computer file for 1993 from the State of California. The computer files contain information about the demographic characteristics of the mother, her medical conditions prior to delivery, medical problems during labor and delivery, delivery method, newborn and maternal outcomes, and expected principal source of payment for prenatal care and for hospital delivery. STUDY DESIGN: The study sample consisted of singleton live births to women in the California Medi-Cal program residing in one of two counties in which a mixed-model managed care plan was the method of reimbursement or in one of three counties in which fee-for-service was the payment method. The study and control counties were matched in terms of geographic proximity and sociodemographics. PRINCIPAL FINDINGS: Among Medi-Cal women, the likelihood of low birth weight (LBW) was lower in the capitated payment group than in the fee-for-service payment group even when controlling for maternal and newborn characteristics and adequacy of prenatal care. There was no difference in either the adequacy of prenatal care, the cesarean birth rate, or the likelihood of adverse pregnancy outcomes other than LBW between the two payer groups. CONCLUSIONS: Results of this "natural experiment" suggest that enrollment of pregnant Medi-Cal beneficiaries in capitated healthcare services through a primary care case management system in a county-organized health system/health insuring organization can have a beneficial effect on low birth weight and provide care comparable to a fee-for-service system.
PMCID: PMC1070246  PMID: 9566177
17.  Progress in Pediatric Asthma Surveillance I: The Application of Health Care Use Data in Alameda County, California 
Preventing Chronic Disease  2006;3(3):A91.
The ability to conduct community-level asthma surveillance is increasingly crucial for public health programming and child health advocacy. We explored the potential and limitations of health care use records from both public and private sources for asthma surveillance in a California county.
We combined administrative patient record data from Kaiser Permanente of Northern California and Medi-Cal (the California Medicaid program) for Alameda County residents during 2001. We assessed the resulting data set for completeness, population representation, consistency with external data, and internal indicator consistency.
Our resulting data set included records for 226,383 children younger than 18 years. Completeness of Medicaid data was affected by managed care market share, reducing our usable data set size to 176,789, approximately equal to one of every two children in the county or one of every 3 person-months. External data documenting hospitalization rates due to asthma were poorly correlated with hospitalization rates (r = 0.2120, P = .20) but highly correlated with emergency department visits (r = 0.8607, P <.001) in the resulting data set. High internal consistency of indicators suggested that the data set represented a broad spectrum of health care access and quality of care congruent with clinical aspects of the disease.
The utility of these data is affected by logistical and administrative factors, including the health care payment structure and the market shares of care providers. These factors can be expected to similarly affect the utility of this approach in other counties. Our ability to generate county-level health statistics for comparison with other locations was limited, although the data set appeared well suited for within-county geographic analysis. In light of these findings, these data have the potential to expand the local health surveillance capacity of communities.
PMCID: PMC1637799  PMID: 16776892
18.  A community-based collaboration to assess and improve medical insurance status and access to health care of Latino children. 
Public Health Reports  2001;116(6):575-584.
OBJECTIVES: Despite eligibility for subsidized insurance, low-income Latino children are at high risk of being medically uninsured. The authors sought to understand and improve access to medical insurance for Latino children living in a California community of predominantly low-income immigrant families. METHODS: During the summer of 1999, trained women from the community conducted interviews in Spanish with 252 randomly selected mothers of 464 children younger than age 19. Mothers provided information about family demographics, children's medical insurance, health care access, and experiences obtaining and maintaining children's insurance. RESULTS: Most children (83.3%) were eligible for subsidized medical insurance (48.4% Medi-Cal eligible; 35.0% Healthy Families eligible). Twenty-eight percent of eligible children were not enrolled. Non-enrolled eligible children were older (median age 7) than enrolled children (median age 4) and more likely to be born outside the U.S. (22.2%) than enrolled children (4.8%). Among children ages 3-18, those not enrolled were less likely to have visited a doctor in the past 12 months (58% compared to 78.7%) and less likely to have a usual source of care (96.3% compared to 99.5%). Mothers of non-enrolled children were more likely than mothers of enrolled children to have less than seven years of education (47.8% compared to 36.4%). Families with non-enrolled children were more likely to report out-of-pocket medical expenses (84.1% compared to 53%). Families with non-enrolled children were more likely to report barriers to the enrollment process, such as problems providing required documents (39.7% compared to 15.1%), problems understanding Spanish forms (19.4% compared to 8.9%), and confusing paperwork (39.7% compared to 24.7%). Most mothers (75.9%) reported that community organizations provided very useful help with children's insurance enrollment. Almost half (48.6%) preferred to receive enrollment assistance from community organizations. Only 43.3% of mothers had heard of the Healthy Families program. CONCLUSIONS: To reach the majority of uninsured Latino children, community-based outreach and insurance application assistance are crucial. Most important, the process of applying for and maintaining coverage in Medi-Cal or Healthy Families must be simplified.
PMCID: PMC1497393  PMID: 12196617
19.  Predictors of California nursing facilities' acceptance of people with HIV/AIDS. 
Health Services Research  1998;32(6):867-880.
OBJECTIVE: To examine factors that might predict the provision of HIV/AIDS care among California nursing facilities (NFs) in 1990. STUDY DESIGN: Logistic regression to examine the probability that a NF had admitted a person with AIDS/HIV (PWA/H). Independent variables of key interest included whether the facility was hospital-based; whether it sustained a financial loss in FY 1990; whether it had a hospice; the percentage of its residents on Medicare; the percentage of its residents on MediCal; the number of PWA/Hs per elderly in the county where the facility was located; the ratio of home-based hospices to elderly in the county; and the ratio of NF beds to elderly in the county. DATA COLLECTION METHODS: Data on all California NFs, obtained from the Office of Statewide Health Planning and Development (OSHPD), were merged with state data on the cumulative incidence of AIDS cases by county; U.S. census data on the number of elderly by county; and home-based hospice data from the 1990 Case Management Resource Guide for California. PRINCIPAL FINDINGS: Of the 902 facilities examined, 7.65 percent served AIDS residents. The financial loss variable was not significant. The community-based hospice variable was significant and negative. All other key variables were significant and positive. CONCLUSIONS: This study (1) suggests that NFs respond to external pressures to provide AIDS care even in the absence of financial incentives or a positive financial margin; (2) supports concerns that competition may exist between the elderly and PWA/H for NF beds; (3) shows that NFs are less likely to provide care if substitute services are available; and (4) demonstrates that facilities capable of providing a higher level of clinical and psychosocial care may be particularly willing, perhaps able, to provide AIDS care.
PMCID: PMC1070238  PMID: 9460491
20.  Adherence to antipsychotics among Latinos and Asians with schizophrenia and limited English proficiency 
We examined the relationship between preferred English, Spanish, or an Asian language for mental health services and adherence to treatment with antipsychotic medication and Medi-Cal beneficiaries with schizophrenia in San Diego, California.
Data included 31,560 person-years from 1999–2004. Pharmacy records were analyzed to assess adherence to antipsychotic medication, based on the medication possession ratio (MPR). Clients were defined as nonadherent (MPR<0.5), partially adherent (0.5<=MPR<0.8), adherent (0.8<=MPR<=1.1), or as an excess filler (MPR>1.1). Regression models were used to examine adherence, hospitalization, and costs by race/ethnicity and language status.
Limited English proficient Latinos were more likely to be adherent to antipsychotic medications than English proficient Latinos (40.8% vs. 35.9%, P<0.001). Limited English proficient Latinos were less likely to be excess fillers than English proficient Latinos (15.1% vs. 20.4%, P<0.001). Limited English proficient Asians were less likely to be adherent than English proficient Asians (40.1% vs. 45.1%, P=0.034). Compared to English proficient Asians, limited English proficient Asians were more likely to be nonadherent (28.7% vs. 22.0%, P<0.001) and less likely to be excess fillers (12.5% vs. 17.4%, P=0.004). Controlling for adherence and comorbidities, limited English proficient clients had lower rates of hospitalization and health care costs than English proficient and white clients.
Adherence to antipsychotic medications varies among and within ethnic groups by English proficiency. Policies supporting the training of bilingual and multicultural ethnic minority providers, and interventions that capitalize on existing social support networks, may improve adherence to treatment among linguistically diverse populations.
PMCID: PMC3235435  PMID: 19176410
21.  Reforming the NHS reforms. 
BMJ : British Medical Journal  1994;308(6932):848-849.
Rather than improving efficiency, the reforms imposed on the NHS have increased bureaucracy, reduced patient choice, limited the range of core services, and led to inequity of treatment. In this paper I examine how the medical profession might help to solve these problems. Priorities must be set for health care since no government can afford all the possibilities offered by medical science. It is essential to forge a consensus of patients, carers, professionals, the public, and government if a system of priorities is to be equitable and just. We also need to be able to measure quality of outcome in health care. This requires consensus on what is the desired outcome and the development of appropriate guidelines, audit, and performance review. This is primarily a task for the health professions supported by management and by adequate investment. Basically, the government must reinstate the three traditional values of the NHS--equity, consensus, and regard for representative professional advice.
PMCID: PMC2540039  PMID: 8167497
22.  Working on reform. How workers' compensation medical care is affected by health care reform. 
Public Health Reports  1996;111(1):12-25.
The medical component of workers' compensation programs-now costing over $24 billion annually-and the rest of the nation's medical care system are linked. They share the same patients and providers. They provide similar benefits and services. And they struggle over who should pay for what. Clearly, health care reform and restructuring will have a major impact on the operation and expenditures of the workers' compensation system. For a brief period, during the 1994 national health care reform debate, these two systems were part of the same federal policy development and legislative process. With comprehensive health care reform no longer on the horizon, states now are tackling both workers' compensation and medical system reforms on their own. This paper reviews the major issues federal and state policy makers face as they consider reforms affecting the relationship between workers' compensation and traditional health insurance. What is the relationship of the workers' compensation cost crisis to that in general health care? What strategies are being considered by states involved in reforming the medical component of workers compensation? What are the major policy implications of these strategies?
PMCID: PMC1381735  PMID: 8610187
23.  Urban health insurance reform and coverage in China using data from National Health Services Surveys in 1998 and 2003 
In 1997 there was a major reform of the government run urban health insurance system in China. The principal aims of the reform were to widen coverage of health insurance for the urban employed and contain medical costs. Following this reform there has been a transition from the dual system of the Government Insurance Scheme (GIS) and Labour Insurance Scheme (LIS) to the new Urban Employee Basic Health Insurance Scheme (BHIS).
This paper uses data from the National Health Services Surveys of 1998 and 2003 to examine the impact of the reform on population coverage. Particular attention is paid to coverage in terms of gender, age, employment status, and income levels. Following a description of the data between the two years, the paper will discuss the relationship between the insurance reform and the growing inequities in population coverage.
An examination of the data reveals a number of key points:
a) The overall coverage of the newly established scheme has decreased from 1998 to 2003.
b) The proportion of the urban population without any type of health insurance arrangement remained almost the same between 1998 and 2003 in spite of the aim of the 1997 reform to increase the population coverage.
c) Higher levels of participation in mainstream insurance schemes (i.e. GIS-LIS and BHIS) were identified among older age groups, males and high income groups. In some cases, the inequities in the system are increasing.
d) There has been an increase in coverage of the urban population by non-mainstream health insurance schemes, including non-commercial and commercial ones.
The paper discusses three important issues in relation to urban insurance coverage: institutional diversity in the forms of insurance, labour force policy and the non-mainstream forms of commercial and non-commercial forms of insurance.
The paper concludes that the huge economic development and expansion has not resulted in a reduced disparity in health insurance coverage, and that limited cross-group subsidy and regional inequality is possible. Unless effective measures are taken, vulnerable groups such as women, low income groups, employees based on short-term contracts and rural-urban migrant workers may well be left out of sharing the social and economic development.
PMCID: PMC1828155  PMID: 17335584
24.  Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals? 
In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005.
Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices.
The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care.
PMCID: PMC2588611  PMID: 18990236
25.  Accelerated reforms in healthcare financing: the need to scale up private sector participation in Nigeria 
The health sector, a foremost service sector in Nigeria, faces a number of challenges; primarily, the persistent under-funding of the health sector by the Nigerian government as evidence reveals low allocations to the health sector and poor health system performance which are reflected in key health indices of the country.Notwithstanding, there is evidence that the private sector could be a key player in delivering health services and impacting health outcomes, including those related to healthcare financing. This underscores the need to optimize the role of private sector in complementing the government’s commitment to financing healthcare delivery and strengthening the health system in Nigeria. There are also concerns about uneven quality and affordability of private-driven health systems, which necessitates reforms aimed at regulation. Accordingly, the argument is that the benefits of leveraging the private sector in complementing the national government in healthcare financing outweigh the challenges, particularly in light of lean public resources and finite donor supports. This article, therefore, highlights the potential for the Nigerian government to scale up healthcare financing by leveraging private resources, innovations and expertise, while working to achieve the universal health coverage.
PMCID: PMC3937949  PMID: 24596895
Nigeria; Healthcare Financing; Health System; Private Sector

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