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1.  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
2.  The quest for equity in Latin America: a comparative analysis of the health care reforms in Brazil and Colombia 
Introduction
Brazil and Colombia have pursued extensive reforms of their health care systems in the last couple of decades. The purported goals of such reforms were to improve access, increase efficiency and reduce health inequities. Notwithstanding their common goals, each country sought a very different pathway to achieve them. While Brazil attempted to reestablish a greater level of State control through a public national health system, Colombia embraced market competition under an employer-based social insurance scheme. This work thus aims to shed some light onto why they pursued divergent strategies and what that has meant in terms of health outcomes.
Methods
A critical review of the literature concerning equity frameworks, as well as the health care reforms in Brazil and Colombia was conducted. Then, the shortfall inequality values of crude mortality rate, infant mortality rate, under-five mortality rate, and life expectancy for the period 1960-2005 were calculated for both countries. Subsequently, bivariate and multivariate linear regression analyses were performed and controlled for possibly confounding factors.
Results
When controlling for the underlying historical time trend, both countries appear to have experienced a deceleration of the pace of improvements in the years following the reforms, for all the variables analyzed. In the case of Colombia, some of the previous gains in under-five mortality rate and crude mortality rate were, in fact, reversed.
Conclusions
Neither reform seems to have had a decisive positive impact on the health outcomes analyzed for the defined time period of this research. This, in turn, may be a consequence of both internal characteristics of the respective reforms and external factors beyond the direct control of health reformers. Among the internal characteristics: underfunding, unbridled decentralization and inequitable access to care seem to have been the main constraints. Conversely, international economic adversities, high levels of rural and urban violence, along with entrenched income inequalities seem to have accounted for the highest burden among external factors.
doi:10.1186/1475-9276-11-6
PMCID: PMC3317827  PMID: 22296659
Brazil; Colombia; health care reform; health care system; equity; health inequities; comparative analysis; health policy
3.  The establishment of a primary spine care practitioner and its benefits to health care reform in the United States 
It is widely recognized that the dramatic increase in health care costs in the United States has not led to a corresponding improvement in the health care experience of patients or the clinical outcomes of medical care. In no area of medicine is this more true than in the area of spine related disorders (SRDs). Costs of medical care for SRDs have skyrocketed in recent years. Despite this, there is no evidence of improvement in the quality of this care. In fact, disability related to SRDs is on the rise. We argue that one of the key solutions to this is for the health care system to have a group of practitioners who are trained to function as primary care practitioners for the spine. We explain the reasons we think a primary spine care practitioner would be beneficial to patients, the health care system and society, some of the obstacles that will need to be overcome in establishing a primary spine care specialty and the ways in which these obstacles can be overcome.
doi:10.1186/2045-709X-19-17
PMCID: PMC3154851  PMID: 21777444
Low Back Pain; Neck Pain; Health Care Reform; Primary Care; Health Policy
4.  Lost in the Rush to National Reform: Recommendations to Improve Impact on Behavioral Health Providers in Rural Areas 
As the United States embarks on the most ambitious national health reform since the 1960s, this article highlights the challenges faced by behavioral health agencies, providers, and clients in rural areas and presents recommendations to improve access to and quality of services. Lessons learned from five years of research on a major systems-change initiative in New Mexico illuminate potential problem areas for rural agencies under national health reform, including insufficient financial resources, shortages of trained staff, particularly clinicians with advanced credentials, and delays in adopting the latest information technology. We recommend that rural states: (1) undertake careful planning for smooth transitions; (2) provide financial resources and technical assistance to expand rural safety-net services and capacity; (3) modify the health home model for the rural context; and (4) engage in ongoing evaluation, which can help ensure the early identification and rectification of unanticipated implementation issues.
doi:10.1353/hpu.2012.0059
PMCID: PMC3415203  PMID: 22643628
Medicaid; rural health services; mental health; health reform; United States
5.  Health Reforms as Examples of Multilevel Interventions in Cancer Care 
To increase access and improve system quality and efficiency, President Obama signed the Patient Protection and Affordable Care Act with sweeping changes to the nation’s health-care system. Although not intended to be specific to cancer, the act's implementation will profoundly impact cancer care. Its components will influence multiple levels of the health-care environment including states, communities, health-care organizations, and individuals seeking care. To illustrate these influences, two reforms are considered: 1) accountable care organizations and 2) insurance-based reforms to gather evidence about effectiveness. We discuss these reforms using three facets of multilevel interventions: 1) their intended and unintended consequences, 2) the importance of timing, and 3) their implications for cancer. The success of complex health reforms requires understanding the scientific basis and evidence for carrying out such multilevel interventions. Conversely and equally important, successful implementation of multilevel interventions depends on understanding the political setting and goals of health-care reform.
doi:10.1093/jncimonographs/lgs012
PMCID: PMC3482967  PMID: 22623600
6.  Healthcare reform from the inside: A neurosurgical clinical quality program 
During the past decade, the U.S. health care system has faced increasing challenges in delivering high quality of care, ensuring patient safety, providing access to care, and maintaining manageable costs. While reform progresses at a national level, health care providers have a responsibility and obligation to advance quality and safety. In 2009, the authors implemented a department-wide Clinical Quality Program. This Program comprised of an inter-disciplinary group of providers and staff working together to ensure the highest quality of patient care. The following methodology was followed to establish the Program: (1) Identifying the Department's quality improvement (QI) and patient safety priorities based on reviewing prior performance data; (2) Aligning the Department's priorities with institutional goals to select mutually significant initiatives; (3) Finalizing the goals for improvement based on departmental priorities, existing expertise and resources; (4) Launching the Program through an inter-disciplinary retreat that emphasizes open dialogue, innovative solutions, and fostering leadership in frontline providers; (5) Sustaining the QI initiatives through proactive performance review and management of barriers; and (6) Celebrating success to empower providers to remain engaged. Several challenges are inherent to the implementation of a clinical quality program, including lack of time and expertise, and the hierarchical nature of medicine, which can create a barrier to teamwork. This Program illustrates that improvement can lead to a sustainable clinical quality program and culture change.
doi:10.4103/2152-7806.102943
PMCID: PMC3513849  PMID: 23227433
Clinical quality program; Health care reform; Quality improvement
7.  Dutch healthcare reform: did it result in performance improvement of health plans? A comparison of consumer experiences over time 
Background
Many countries have introduced elements of managed competition in their healthcare system with the aim to accomplish more efficient and demand-driven health care. Simultaneously, generating and reporting of comparative healthcare information has become an important quality-improvement instrument. We examined whether the introduction of managed competition in the Dutch healthcare system along with public reporting of quality information was associated with performance improvement in health plans.
Methods
Experiences of consumers with their health plan were measured in four consecutive years (2005-2008) using the CQI® health plan instrument 'Experiences with Healthcare and Health Insurer'. Data were available of 13,819 respondents (response = 45%) of 30 health plans in 2005, of 8,266 respondents (response = 39%) of 32 health plans in 2006, of 8,088 respondents (response = 34%) of 32 health plans in 2007, and of 7,183 respondents (response = 31%) of 32 health plans in 2008. We performed multilevel regression analyses with three levels: respondent, health plan and year of measurement. Per year and per quality aspect, we estimated health plan means while adjusting for consumers' age, education and self-reported health status. We tested for linear and quadratic time effects using chi-squares.
Results
The overall performance of health plans increased significantly from 2005 to 2008 on four quality aspects. For three other aspects, we found that the overall performance first declined and then increased from 2006 to 2008, but the performance in 2008 was not better than in 2005. The overall performance of health plans did not improve more often for quality aspects that were identified as important areas of improvement in the first year of measurement. On six out of seven aspects, the performance of health plans that scored below average in 2005 increased more than the performance of health plans that scored average and/or above average in that year.
Conclusion
We found mixed results concerning the effects of managed competition on the performance of health plans. To determine whether managed competition in the healthcare system leads to quality improvement in health plans, it is important to examine whether and for what reasons health plans initiate improvement efforts.
doi:10.1186/1472-6963-9-167
PMCID: PMC2761896  PMID: 19761580
8.  The effect of health care reform on academic medicine in Canada. Editorial Committee of the Canadian Institute for Academic Medicine. 
Although Canadian health care reform has constrained costs and improved efficiency, it has had a profound and mixed effect on Canadian academic medicine. Teaching hospitals have been reduced in number and size, and in patient programs have shifted to ambulatory and community settings. Specialized care programs are now multi-institutional and multidisciplinary. Furthermore, the influence of regional planning bodies has grown markedly. Although these changes have likely improved clinical service, their impact on the quality of clinical education is uncertain. Within the academic clinical department, recruitment of young faculty has been greatly complicated by constraints on licensing, billing numbers, fee-for-service income and research funding. The departmental practice plan based on university funds and fee-for-service income is being replaced by less favourable funding arrangements. However, emphasis on multidisciplinary programs has rendered these departments more flexible in structure. The future of Canadian academic medicine depends on an effective alliance with government. Academia and government must agree, particularly on human-resource requirements, research objectives and the delivery of clinical and academic programs in regional and community settings. The establishment of focal points for academic health sciences planning within academic health sciences centres and within governments would assist in these developments. Finally, government and the academic health sciences sector must work together to remove the current impediments to the recruitment of highly qualified young faculty.
PMCID: PMC1487837  PMID: 8624998
9.  Costs and coverage. Pressures toward health care reform. 
Western Journal of Medicine  1992;157(5):576-583.
Signs of discontent with the health care system are growing. Calls for health care reform are largely motivated by the continued increase in health care costs and the large number of people without adequate health insurance. For the past 20 years, health care spending has risen at rates higher than the gross national product. As many as 35 million people are without health insurance. As proposals for health care reform are developed, it is useful to understand the roots of the cost problem. Causes of spiraling health care costs include "market failure" in the health care market, expansion in technology, excessive administrative costs, unnecessary care and defensive medicine, increased patient complexity, excess capacity within the health care system, and low productivity. Attempts to control costs, by the federal government for the Medicare program and then by the private sector, have to date been mostly unsuccessful. New proposals for health care reform are proliferating, and important changes in the health care system are likely.
PMCID: PMC1022049  PMID: 1441510
10.  Health-care reform and its impact on African-American surgical specialists. 
Since 1960, numerous concepts of health-care reform have been submitted to the US Congress and the American public with different viewpoints and objectives. The priority for the US Congress to pass a bipartisan health-reform plan has been circumvented by the newly elected majority Republican Congress. Nevertheless, health-care cost containment, quality control, and health-care delivery concepts have been implemented gradually into the concept of competitive managerial health care. A few of the serious problems in the African-American community are the efficiency and quality of the health-care delivery system and the effects of managed care on African-American primary physicians and surgical specialists. The critical shortages of this group, especially the latter, may create a dilemma in the implementation of a quality surgical care delivery system. The Association of American Medical Colleges, the American College of Surgeons, and other affiliating organizations should become sensitized to the African-American community's health needs, deficiencies, and the rational institution of an equitable, efficient, comprehensive, and quality health-care plan coupled with a sustained and increasing supply of certified, diversified, and experienced African-American surgical manpower in company with family practice physicians and primary care physicians.
PMCID: PMC2608027  PMID: 8839031
11.  Does the Accountable Care Act aim to promote quality, health, and control costs or has it missed the mark? Comment on “Health system reform in the United States” 
McDonough’s perspective on healthcare reform in the US provides a clear, coherent analysis of the mix of access and delivery reforms in the Affordable Care Act (ACA) aka Obamacare. As noted by McDonough, this major reform bill is designed to expand access for health coverage that includes both prevention and treatment benefits among uninsured Americans. Additionally, this legislation includes several financial strategies (e.g. incentives and penalties) to improve care coordination and quality in the hospital and outpatient settings while also reducing healthcare spending and costs. This commentary is intended to discuss this mix of access and delivery reform in terms of its potential to achieve the Triple Aim: population health, quality, and costs. Final remarks will include the role of the US federal government to reform the American private health industry together with that of an informed consume
doi:10.15171/ijhpm.2014.23
PMCID: PMC3952545  PMID: 24639986
US Healthcare Reform; Obamacare; Affordable Care Act (ACA); Healthcare Exchanges; Triple Aim
12.  Behavioral Health and Health Care Reform Models: Patient-Centered Medical Home, Health Home, and Accountable Care Organization 
Discussions of health care delivery and payment reforms have largely been silent about how behavioral health could be incorporated into reform initiatives. This paper draws attention to four patient populations defined by the severity of their behavioral health conditions and insurance status. It discusses the potentials and limitations of three prominent models promoted by the Affordable Care Act to serve populations with behavioral health conditions: the Patient Centered Medical Home, the Health Home initiative within Medicaid, and the Accountable Care Organization. To incorporate behavioral health into health reform, policymakers and practitioners may consider embedding in the reform efforts explicit tools – accountability measures and payment designs – to improve access to and quality of care for patients with behavioral health needs.
doi:10.1007/s11414-012-9306-y
PMCID: PMC3568195  PMID: 23188486
behavioral health; health care reform; patient-centered medical home; health home; accountable care organization
13.  Evaluation of Health Care System Reform in Hubei Province, China 
This study established a set of indicators for and evaluated the effects of health care system reform in Hubei Province (China) from 2009 to 2011 with the purpose of providing guidance to policy-makers regarding health care system reform. The resulting indicators are based on the “Result Chain” logic model and include the following four domains: Inputs and Processes, Outputs, Outcomes and Impact. Health care system reform was evaluated using the weighted TOPSIS and weighted Rank Sum Ratio methods. Ultimately, the study established a set of indicators including four grade-1 indicators, 16 grade-2 indicators and 76 grade-3 indicators. The effects of the reforms increased year by year from 2009 to 2011 in Hubei Province. The health status of urban and rural populations and the accessibility, equity and quality of health services in Hubei Province were improved after the reforms. This sub-national case can be considered an example of a useful approach to the evaluation of the effects of health care system reform, one that could potentially be applied in other provinces or nationally.
doi:10.3390/ijerph110202262
PMCID: PMC3945597  PMID: 24566052
health care system reform; evaluation; indicators; China
14.  Primary Care Shortages: Strengthening This Sector Is Urgently Needed, Now and in Preparation for Healthcare Reform 
Background
The United States currently faces great challenges in primary care, particularly when the Patient Protection and Affordable Care Act (ACA) greatly expands the health insurance market.
Objectives
To (1) discuss key areas where primary care needs to be strengthened, including advanced models of physician reimbursement, chronic disease management, and improved patient adherence to medications, and (2) to review initiatives applying evidence-based medicine (EBM) where positive changes have in fact occurred.
Discussion
This article discusses initiatives that have implemented EBM as their model for change and presents interviews with primary care experts to support the growing need for change in primary care. To improve the quality of care and reduce costs, more needs to be done, particularly by fostering the number of primary care physicians (PCPs) and other healthcare professionals in PCP offices, as well as adjusting payment methods that much more strongly support and reward the primary care and the patient-centered medical home (PCMH) models. An additional area where substantial improvements are needed involves inner-city, rural, and other underserved populations. Provider- and managed care–driven changes are taking place, but much more needs to be done, particularly as a result of the ACA-associated health insurance enrollment expansion. Innovation in payment for PCPs and PCMHs (and corresponding changes in care delivery and improvements in clinically significant outcomes) will be key factors toward the successful implementation of ACA changes. In addition, several examples are discussed, in which the flexibility of managed care and its results-driven orientation are crucial factors for success. Future initiatives that will likely be more challenging and will require significant government funding include the US underserved populations and incentives to encourage medical school students and residents to choose primary care as a specialty.
Conclusion
More innovation, particularly related to realignment of financial incentives to strengthen primary care, is needed to meet America's growing healthcare quality and cost challenges.
PMCID: PMC4046463
15.  The UK's dysfunctional relationship with medical migrants: the Daniel Ubani case and reform of out-of-hours services 
In 2008, a patient died in the UK after being given an excessive dose of diamorphine by an overseas-trained doctor working in out-of-hours (OOH) primary care. This incident led to a debate on the recourse to international medical graduates and on the shortcomings of the OOH system. It is argued here that a historical reflection on the ways in which the NHS uses migrant labour can serve to reframe these discussions. The British Medical Association, the General Medical Council, and the House of Commons Health Committee have emphasised the need for more regulation of overseas graduates. Such arguments fit into a well-established pattern of dependency on and denigration of overseas graduates. They give insufficient weight to the multiple systemic failings identified in reports on OOH provision by the Department of Health and the Care Quality Commission. Medical migrants are often found in under-resourced and unpopular parts of healthcare systems, in the UK and elsewhere. Their presence provides an additional dimension to Julian Tudor Hart's inverse care law: the resources are fewer where the need is greatest, and the practitioner dealing with the consequences is more likely to be a migrant. The failings of the UK OOH system need to be understood in this context. Efforts to improve OOH care should be focused on controlling quality rather than the movement of doctors. A wider reflection on the nature of the roles that international medical graduates are asked to play in healthcare systems is also required.
doi:10.3399/bjgp11X561230
PMCID: PMC3047316  PMID: 21375907
medical history 20th cent; medical history 21st cent; medical staff; migrants; out-of-hours medical care; primary health care
16.  Human resources: the Cinderella of health sector reform in Latin America 
Human resources are the most important assets of any health system, and health workforce problems have for decades limited the efficiency and quality of Latin America health systems. World Bank-led reforms aimed at increasing equity, efficiency, quality of care and user satisfaction did not attempt to resolve the human resources problems that had been identified in multiple health sector assessments. However, the two most important reform policies – decentralization and privatization – have had a negative impact on the conditions of employment and prompted opposition from organized professionals and unions. In several countries of the region, the workforce became the most important obstacle to successful reform.
This article is based on fieldwork and a review of the literature. It discusses the reasons that led health workers to oppose reform; the institutional and legal constraints to implementing reform as originally designed; the mismatch between the types of personnel needed for reform and the availability of professionals; the deficiencies of the reform implementation process; and the regulatory weaknesses of the region.
The discussion presents workforce strategies that the reforms could have included to achieve the intended goals, and the need to take into account the values and political realities of the countries. The authors suggest that autochthonous solutions are more likely to succeed than solutions imported from the outside.
doi:10.1186/1478-4491-3-1
PMCID: PMC548503  PMID: 15659241
17.  Turkish health system reform from the people’s perspective: a cross sectional study 
Background
Since 2003, Turkey has implemented major health care reforms to develop easily accessible, high-quality, efficient, and effective healthcare services for the population. The purpose of this study was to bring out opinions of the Turkish people on health system reform process, focusing on several aspects of health system and assessing whether the public prefer the current health system or that provided a decade ago.
Methods
A cross sectional survey study was carried out in Turkey to collect data on people’s opinions on the healthcare reforms. Data was collected via self administered household’s structured questionnaire. A five-point Likert-type scale was used to score the closed comparative statements. Each statement had response categories ranging from (1) “strongly agree” to (5) “strongly disagree.” A total of 482 heads of households (response rate: 71.7%) with the mean age of (46.60 years) were selected using a multi stage sampling technique from seven geographical regions in Turkey from October 2011 to January 2012. Multiple logistic regressions were performed to identify significant contributing factors in this study.
Results
Employing descriptive statistics it is observed that among the respondents, more than two third of the population believes that the changes have had positive effects on the health system. A vast majority of respondents (82.0%) believed that there was an increase in accessibility, 73.7% thought more availability of health resources, 72.6% alleged improved quality of care, and 72.6% believed better attitude of politician/mass media due to the changes in the last 10 years. Indeed, the majority of respondents (77.6%) prefer the current health care system than the past. In multivariate analysis, there was a statistically significant relationship between characteristics and opinions of the respondents. The elderly, married females, perceived themselves healthy and those who believe that people are happier now than 10 years ago have a more positive opinion of the changes. While, the single unemployed from rural region who perceived themselves as unhealthy and believe that people are unhappy now compare to ten years ago showed less positive opinions.
Conclusions
Hence, we conclude that from the people’s perspective overall the health system reforms were most likely successful.
doi:10.1186/1472-6963-14-30
PMCID: PMC3932508  PMID: 24447374
Perspectives; Health reform; Turkey
18.  Palliative care by family physicians in the 1990s. Resilience amid reform. 
Canadian Family Physician  2001;47:1989-1995.
OBJECTIVE: To explore issues family physicians face in providing community-based palliative care to their patients in the context of a changing health care system. DESIGN: Focus groups. SETTING: Small (< 10,000 population), medium-sized (10,000 to 50,000), and large (> 50,000) communities in Nova Scotia. PARTICIPANTS: Twenty-five men and women physicians with varying years of practice experience in both solo and group practices. METHOD: A semistructured approach was used, asking physicians to reflect on recent palliative care experiences in order to explore issues of care. MAIN FINDINGS: Five themes emerged from the discussions: resources needed, availability of family support, time and money supporting physicians' activities, symptom control for patients, and physicians' emotional reactions to caring for dying patients. CONCLUSION: With downsizing of hospitals and greater emphasis on community-based care, the issues identified in this study will need attention, particularly in designing an integrated service delivery model for palliative care.
PMCID: PMC2018440  PMID: 11723593
19.  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?
Images
PMCID: PMC1381735  PMID: 8610187
20.  Use of a Policy Debate to Teach Residents About Health Care Reform 
Background
Resident education involves didactics and pedagogic strategies using a variety of tools and technologies in order to improve critical thinking skills. Debating is used in educational settings to improve critical thinking skills, but there have been no reports of its use in residency education. The present paper describes the use of debate to teach resident physicians about health care reform.
Objective
We aimed to describe the method of using a debate in graduate medical education.
Methods
Second-year through fourth-year physical medicine and rehabilitation residents participated in a moderated policy debate in which they deliberated whether the United States has one of the “best health care system(s) in the world.” Following the debate, the participants completed an unvalidated open-ended questionnaire about health care reform.
Results
Although residents expressed initial concerns about participating in a public debate on health care reform, all faculty and residents expressed that the debate was robust, animated, and enjoyed by all. Components of holding a successful debate on health care reform were noted to be: (1) getting “buy-in” from the resident physicians; (2) preparing the debate; and (3) follow-up.
Conclusion
The debate facilitated the study of a large, complex topic like health care reform. It created an active learning process. It encouraged learners to keenly attend to an opposing perspective while enthusiastically defending their position. We conclude that the use of debates as a teaching tool in resident education is valuable and should be explored further.
doi:10.4300/JGME-03-03-32
PMCID: PMC3179223  PMID: 22942966
21.  Getting the Foundations Right: Alberta's Approach to Healthcare Reform 
Healthcare Policy  2011;6(3):22-27.
Alberta's abolition of its health regions and the creation of Alberta Health Services in 2008 has integrated previously disparate providers of healthcare services. The long-term benefits of this “second-wave” approach to health systems structuring include lower administrative costs, greater equity of access, improved intraprovincial learning and economies of scale. Some benefits have begun to be realized but, as with any merger, performance should be judged over a multi-year time frame.
PMCID: PMC3082384  PMID: 22294988
22.  School-Based Health Centers in an Era of Health Care Reform: Building on History 
School-based health centers (SBHCs) provide a variety of health care services to youth in a convenient and accessible environment. Over the past 40 years, the growth of SBHCs evolved from various public health needs to the development of a specific collaborative model of care that is sensitive to the unique needs of children and youth, as well as to vulnerable populations facing significant barriers to access. The SBHC model of health care comprises of on-school site health care delivery by an interdisciplinary team of health professionals, which can include primary care and mental health clinicians. Research has demonstrated the SBHCs’ impacts on delivering preventive care, such as immunizations; managing chronic illnesses, such as asthma, obesity, and mental health conditions; providing reproductive health services for adolescents; and even improving youths’ academic performance. Although evaluation of the SBHC model of care has been complicated, results have thus far demonstrated increased access to care, improved health and education outcomes, and high levels of satisfaction. Despite their proven success, SBHCs have consistently faced challenges in securing adequate funding for operations and developing effective financial systems for billing and reimbursement. Implementation of health care reform (The Patient Protection and Affordable Care Act [P.L. 111-148]) will profoundly affect the health care access and outcomes of children and youth, particularly vulnerable populations. The inclusion of funding for SBHCs in this legislation is momentous, as there continues to be increased demand and limited funding for affordable services. To better understand how this model of care has and could further help promote the health of our nation’s youth, a review is presented of the history and growth of SBHCs and the literature demonstrating their impacts. It may not be feasible for SBHCs to be established in every school campus in the country. However, the lessons learned from the synergy of the health and school settings have major implications for the delivery of care for all providers concerned with improving the health and well-being of children and adolescents.
doi:10.1016/j.cppeds.2012.03.002
PMCID: PMC3770486  PMID: 22677513
23.  Health in China. From Mao to market reform. 
BMJ : British Medical Journal  1997;314(7093):1543-1545.
After the Liberation by Mao Ze Dong's Communist army in 1949, China experienced massive social and economic change. The dramatic reductions in mortality and morbidity of the next two decades were brought about through improvements in socioeconomic conditions, an emphasis on prevention, and almost universal access to basic health care. The economic mismanagement of the Great Leap Forward brought about a temporary reversal in these positive trends. During the Cultural Revolution there was a sustained attack on the privileged position of the medical profession. Most city doctors were sent to work in the countryside, where they trained over a million barefoot doctors. Deng Xiao Ping's radical economic reforms of the late 1970s replaced the socialist system with a market economy. Although average incomes have increased, the gap between rich and poor has widened.
PMCID: PMC2126766  PMID: 9183206
24.  Primary and managed care. Ingredients for health care reform. 
Western Journal of Medicine  1994;161(1):78-82.
The use of primary and managed care is likely to increase under proposed federal health care reform. I review the definition of primary care and primary care physicians and show that this delivery model can affect access to medical care, the cost of treatment, and the quality of services. Because the use of primary care is often greater in managed care than in fee-for-service, I compare the two insurance systems to further understand the delivery of primary care. Research suggests that primary care can help meet the goal of providing accessible, cost-effective, and high-quality care, but that changes in medical education and marketplace incentives will be needed to encourage students and trained physicians to enter this field.
PMCID: PMC1011384  PMID: 7941522
25.  Health Reform: A Community Experience Using Design Research as a Guide 
Mayo Clinic Proceedings  2011;86(10):973-980.
Meaningful health reform in the United States must improve the health of the population while lowering costs. In an effort to provide a framework for doing so, the Institute of Health Care Improvement created the triple aim, which encompasses the goals of (1) improving individual health and experience with the health care system, (2) improving population health, and (3) decreasing the rate of per capita health care costs. Current reform efforts have focused on the development of Patient-Centered Medical Homes (an innovative team-based model of care that facilitates a partnership between the patient’s personal physician coordinating care throughout a patient’s lifetime to maximize health outcomes), but these relatively narrow efforts are focused on office practice and payment methods and are not generally oriented toward community needs. We sought to apply design research in assessing a community opportunity to apply the triple aim as a strategy to transform health care delivery. Mixed methodology provides greater insight into the unexpressed health needs of individuals and into the creation of delivery systems more likely to achieve the triple aim. In a small, midwestern town, a mixed methods approach was used to assess community health needs to facilitate design and implementation of care delivery systems. The research findings suggest that health system design concepts should focus on the creation of health, not health care; foster simplicity; create nurturing relationships; eliminate user fear; and contain costs. These observations can be helpful to health care professionals who are developing new methods of care delivery and policymakers and payers contemplating new payment systems to achieve the goals of the triple aim.
doi:10.4065/mcp.2011.0225
PMCID: PMC3184026  PMID: 21964174

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