Canadian politicians, decision-makers, clinicians and researchers have come to agree that reforming primary care services is a key strategy for improving healthcare system performance. However, it is only more recently that real transformative initiatives have been undertaken in different Canadian provinces. One model that offers promise for improving primary care service delivery is the family medicine group (FMG) model developed in Quebec. A FMG is a group of physicians working closely with nurses in the provision of services to enrolled patients on a non-geographic basis. The objectives of this paper are to analyze the FMG's potential as a lever for improving healthcare system performance and to discuss how it could be improved. First, we briefly review the history of primary care in Quebec. Then we present the FMG model in relation to the four key healthcare system functions identified by the World Health Organization: (a) funding, (b) generating human and technological resources, (c) providing services to individuals and communities and (d) governance. Next, we discuss possible ways of advancing primary care reform, looking particularly at the family health team (FHT) model implemented in the province of Ontario. We conclude with recommendations to inspire other initiatives aimed at transforming primary care.
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.
In preparation for full Affordable Care Act implementation, California has instituted two healthcare initiatives that provide comprehensive coverage for previously uninsured or underinsured individuals. For many people living with HIV, this has required transition either from the HIV-specific coverage of the Ryan White program to the more comprehensive coverage provided by the county-run Low-Income Health Programs or from Medicaid fee-for-service to Medicaid managed care. Patient advocates have expressed concern that these transitions may present implementation challenges that will need to be addressed if ambitious HIV prevention and treatment goals are to be achieved.
30 semi-structured, in-depth interviews were conducted between October, 2012, and February, 2013, with policymakers and providers in 10 urban, suburban, and rural California counties. Interview topics included: continuity of patient care, capacity to handle payer source transitions, and preparations for healthcare reform implementation. Study team members reviewed interview transcripts to produce emergent themes, develop a codebook, build inter-rater reliability, and conduct analyses.
Respondents supported the goals of the ACA, but reported clinic and policy-level challenges to maintaining patient continuity of care during the payer source transitions. They also identified strategies for addressing these challenges. Areas of focus included: gaps in communication to reach patients and develop partnerships between providers and policymakers, perceived inadequacy in new provider networks for delivering quality HIV care, the potential for clinics to become financially insolvent due to lower reimbursement rates, and increased administrative burdens for clinic staff and patients.
California's new healthcare initiatives represent ambitious attempts to expand and improve health coverage for low-income individuals. The state's challenges in maintaining quality care and treatment for people living with HIV experiencing these transitions demonstrate the importance of setting effective policies in anticipation of full ACA implementation in 2014.
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.
Clinical quality program; Health care reform; Quality improvement
The authors describe an innovative academic health center (AHC)-led program of health care delivery and clinical education for the management of complex, common, and chronic diseases in underserved areas, using hepatitis C virus (HCV) as a model. The program, based at the University of New Mexico School of Medicine, represents a paradigm shift in thinking and funding for the threefold mission of AHCs, moving from traditional fee-for-service models to public health funding of knowledge networks. This program, Project Extension for Community Healthcare Outcomes (ECHO), involves a partnership of academic medicine, public health offices, corrections departments, and rural community clinics dedicated to providing best practices and protocol-driven health care in rural areas. Telemedicine and Internet connections enable specialists in the program to comanage patients with complex diseases, using case-based knowledge networks and learning loops. Project ECHO partners (nurse practitioners, primary care physicians, physician assistants, and pharmacists) present HCV-positive patients during weekly two-hour telemedicine clinics using a standardized, case-based format that includes discussion of history, physical examination, test results, treatment complications, and psychiatric, medical, and substance abuse issues. In these case-based learning clinics, partners rapidly gain deep domain expertise in HCV as they collaborate with university specialists in hepatology, infectious disease, psychiatry, and substance abuse in comanaging their patients. Systematic monitoring of treatment outcomes is an integral aspect of the project. The authors believe this methodology will be generalizable to other complex and chronic conditions in a wide variety of underserved areas to improve disease outcomes, and it offers an opportunity for AHCs to enhance and expand their traditional mission of teaching, patient care, and research.
Complementary and alternative medicine services in the United States are an approximately $9 billion market each year, equal to 3 percent of national ambulatory health care expenditures. Unlike conventional allopathic health care, complementary and alternative medicine is primarily paid for out of pocket, although some services are covered by most health insurance. Examining trends in demand for complementary and alternative medicine services in the United States reported in the Medical Expenditure Panel Survey during 2002–08, we found that use of and spending on these services, previously on the rise, have largely plateaued. The higher proportion of out-of-pocket responsibility for payment for services may explain the lack of growth. Our findings suggest that any attempt to reduce national health care spending by eliminating coverage for complementary and alternative medicine would have little impact at best. Should some forms of complementary and alternative medicine—for example, chiropractic care for back pain—be proven more efficient than allopathic and specialty medicine, the inclusion of complementary and alternative medicine providers in new delivery systems such as accountable care organizations could help slow growth in national health care spending.
Research into health and social services in Britain is largely funded by the Department of Health. Regional NHS research and development has recently been reformed and a new report now proposes replacement of the 13 research units funded by the department with three or four large multidisciplinary centres. Evidence to support such a step is lacking, and many criticisms of the existing units arise from poor departmental planning rather than deficiencies of the units themselves. Large units may make research less responsive to the department's needs, and it is essential that the proposed new structure is thoroughly evaluated before it is introduced.
Because of shrinking resources and the resulting threat to its academic vitality the Department of Paediatrics, Hospital for Sick Children, University of Toronto, entered into an agreement on alternative funding with the Ontario Ministry of Health in 1990. The department developed a set of principles that guided the negotiations, which ultimately led to a budget that formed the basis of the agreement. The contract with the ministry provides a global budget to the department; this budget funds faculty members, administrative staff and the educational and research programs formerly supported by fee-for-service billing to the Ontario Health Insurance Plan. The alternative funding plan has provided financial stability to the department and affords an opportunity to develop innovative and cost-effective models of pediatric care.
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.
California's drastic Medi-Cal reforms have created great difficulties in health care for the poor. Patients' clinical problems seldom are apparent in descriptions of changes in public insurance programs. Rapidly escalating costs of Medi-Cal led to irresistible pressures for reform, especially from the business community. The new Medi-Cal regulations provide for prospective contracts with hospitals for inpatient services, the transfer of “Medically Indigent Adults” to the responsibility of county governments and various other straightforward funding cutbacks. Confusion, disruption of services and adverse health outcomes have accompanied the Medi-Cal reforms.
While the Chronic Care Model (CCM) has been shown to improve the care of patients with chronic illnesses, primary care physicians have been unprepared in its use, and residencies have encountered challenges in introducing it into the academic environment.
Our residency program has implemented a diabetes management program modeled on the CCM to evaluate its impact on health outcomes of diabetic patients and educational outcomes of residents.
University-affiliated, community-based family medicine residency program.
Six residents, two faculty clinicians, and clinic staff formed a diabetes management team. We redesigned the outpatient experience for diabetic patients by incorporating elements of the CCM: multidisciplinary team care through planned and group visits; creation of a diabetes registry; use of guidelines-based flow sheets; and incorporation of self-management goal-setting. Residents received extensive instruction in diabetes management, quality improvement, and patient self-management.
We achieved overall improvement in all metabolic and process measures for patients, with the percentage achieving HbA1c, LDL, and BP goals simultaneously increasing from 5.7% to 17.1%. Educational outcomes for residents, as measured by compliance with review of provider performance reports and self-management goal-setting with patients, also significantly improved.
Through a learning collaborative experience, residency programs can successfully incorporate chronic care training for residents while addressing gaps in care for patients with diabetes.
chronic care model; learning collaborative; diabetes; residency education
Governments in Ontario have promised family physicians (FPs) that participation in primary care reform would be financially as well as professionally rewarding. We compared work satisfaction, incomes and work patterns of FPs practising in different models to determine whether the predicted benefits to physicians really materialized. Study participants included 332 FPs in Ontario practising in five models of care. The study combined self-reported survey data with administrative data from ICES and income data from the Canada Revenue Agency. FPs working in non–fee-for-service (FFS) models had higher levels of work satisfaction than those in FFS models. Incomes were similar across groups prior to the advent of primary care reform. Incomes of family health network FPs rose by about 30%, while family health group FPs saw increases of about 10% and those in FFS experienced minimal changes or decreases. Self-reported change in income was not reliable, with only 47% of physicians correctly identifying whether their income remained stable, increased or decreased. The availability of a variety of FFS- and non–FFS-based payment options, each designed to accommodate physicians with different types or styles of practice, may be a useful tool for governments as they grapple with issues of physician recruitment and retention.
Over the last three decades significant efforts have been made in many European countries to move away from a mental health system dominated by institutional care towards one whereby the main emphasis is on providing care and support within the community. Although the time of starting the reforms, their pace, the political context, and the exact objectives varies substantially across Europe, practically all countries have been undergoing such major reforms aimed at establishing services in the community to replace institutional based care. Each country makes its own decisions about the necessary mental health services taking into account a range of factors including population needs, level of resources, flexibility and coordination of organizational structures, as well as local culture. These factors become an integral element of a national mental health policy and action plan, closely linked with national public health strategies.
Greece has been modernizing an outdated mental health system, which was based on institutional care, over the last 20 years, by developing community-based mental health care. This article describes the methodology used for the evaluation of the Psychargos programme of the mental health reforms in Greece. Various forms of community-based mental health services have been developed including supported living facilities, community mental health centres and employment opportunities.
Evaluation; Mental health reforms; Community mental health services; Greece
The Medicare program, the largest health insurance program in the United States, is clearly at a crossroads as it enters its third decade. Historical increases in health care expenditures, plus a changing political and economic landscape, have set the groundwork for policy reform. Two basic reform strategies--reimbursement arrangements and program funding mechanisms--are discussed. In 1983, Congress enacted the Prospective Payment System (PPS) which initiated a fundamental change in the way hospitals are paid for care delivered to Medicare beneficiaries. But the PPS is only a stepping-stone to broader reforms such as capitation and vouchers. In addition, new methods of program funding may be necessary, especially in light of policymakers' considerations of coverage of services such as long term care and organ transplants.
In Finland, dental services are provided by a public (PDS) and a private sector. In the past, children, young adults and special needs groups were entitled to care and treatment from the public dental services (PDS). A major reform in 2001 – 2002 opened the PDS and extended subsidies for private dental services to all adults. It aimed to increase equity by improving adults' access to oral health care and reducing cost barriers. The aim of this study was to assess the impacts of the reform on the utilization of publicly funded and private dental services, numbers and distribution of personnel and costs in 2000 and in 2004, before and after the oral health care reform. An evaluation was made of how the health political goals of the reform: integrating oral health care into general health care, improving adults' access to care and lowering cost barriers had been fulfilled during the study period.
National registers were used as data sources for the study. Use of dental services, personnel resources and costs in 2000 (before the reform) and in 2004 (after the reform) were compared.
In 2000, when access to publicly subsidised dental services was restricted to those born in 1956 or later, every third adult used the PDS or subsidised private services. By 2004, when subsidies had been extended to the whole adult population, this increased to almost every second adult. The PDS reported having seen 118 076 more adult patients in 2004 than in 2000. The private sector had the same number of patients but 542 656 of them had not previously been entitled to partial reimbursement of fees.
The use of both public and subsidised private services increased most in big cities and urban municipalities where access to the PDS had been poor and the number of private practitioners was high. The PDS employed more dentists (6.5%) and the number of private practitioners fell by 6.9%. The total dental care expenditure (PDS plus private) increased by 21% during the study period. Private patients who had previously not been entitled to reimbursements seemed to gain most from the reform.
The results of this study indicate that implementation of a substantial reform, that changes the traditionally defined tasks of the public and private sectors in an established oral health care provision system, proceeds slowly, is expensive and probably requires more stringent steering than was the case in Finland 2001 – 2004. However, the equity and fairness of the oral health care provision system improved and access to services and cost-sharing improved slightly.
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.
With launching of Sputnik by the Soviet Union in the late 1950s, science and technology became a high priority in the United States. During the two decades since, health sciences libraries have experienced changes in almost all aspects of their operations. Additionally, recent developments in medical care and in medical education have had major influences on the mission of health science libraries. In the unending struggle to keep up with new technologies and services, libraries have had to support increasing demands while they receive a decreasing share of the health care dollar. This paper explores the economic challenges faced by academic health sciences libraries and suggests measures for augmenting traditional sources of funding. The development of marketing efforts, institutional memberships, and fee-based services by the Louis Calder Memorial Library, University of Miami School of Medicine, is presented as a case study.
BACKGROUND: Although several studies have outlined the need for and benefits of diversity in academia, the number of underrepresented minority (URM) faculty in academic health centers remains low, and minority faculty are primarily concentrated at the rank of assistant professor. In order to increase the diversity of the faculty of the University of California, San Diego (UCSD) School of Medicine, the UCSD National Center for Leadership in Academic Medicine, in collaboration with the UCSD Hispanic Center of Excellence, implemented a junior faculty development program designed in part to overcome the differential disadvantage of minority faculty and to increase the academic success rate of all faculty. METHODS: Junior faculty received counseling in career and research objectives; assistance with academic file preparation, introduction to the institutional culture; workshops on pedagogy and grant writing; and instrumental, proactive mentoring by senior faculty. RESULTS: After implementation of the program, the retention rate of URM junior faculty in the school of medicine increased from 58% to 80% and retention in academic medicine increased from 75% to 90%. CONCLUSION: A junior faculty development program that integrates professional skill development and focused academic career advising with instrumental mentoring is associated with an increase in the retention of URM faculty in a school of medicine.
The authors describe the evolution of a novel national training program to develop minority faculty for mental health services research careers. Recruiting, training, and sustaining minority health professionals for academic research careers in mental health services research have proven challenging.
Over the past 8 years the authors developed NIMH-funded programs to educate, train, and mentor minority psychiatrists and other junior faculty and graduate and post-graduate students. Their areas of academic interest focus primarily on minority mental health issues in primary care and community settings.
The authors began with a program that targeted local trainees from the University of New Mexico and expanded to regional and national programs offering weeklong institutes, onsite and distance mentoring by experts, and supportive peer interactions that addressed the considerable challenges affecting trainee career decisions and paths.
Early outcomes support the value of these programs.
To examine the effect of premiums and benefits on the health plan choices of older enrollees who choose Federal Employees Health Benefits Program (FEHBP) health plans as their primary payer.
Administrative enrollment data from the Office of Personnel Management (OPM) and plan premiums and benefits data taken from the Checkbook Guide to health plans.
We estimate individual plan choice models where the choice of health plan is a function of out-of-pocket premium, actuarial value, plan attributes, and individual characteristics. Plan attributes include plan structure (fee-for-service/preferred provider organization, point-of-service, or health maintenance organization), drug benefit structure, and whether or not the plan covers other types of spending such as dental services and diabetic supplies. The models are estimated by conditional logit. Our study focuses on three populations that currently choose FEHBP as their primary health care coverage and are similar to the Medicare population: current employees and retirees who are approaching the age of Medicare eligibility (ages 60–64) and current federal employees age 65+. Current employees age 65+ are eligible for Medicare, but their FEHBP plan is their primary payer. Retirees and employees 60–64 are not yet eligible for Medicare but are similar in many respects to recently age-eligible Medicare beneficiaries. We also estimate our model for current employees age 55 and younger as a comparison group.
Data Collection Methods
We select a random sample of retirees and employees age 60–64, as well as all current employees age 65+, from the OPM administrative database for the calendar year 2001. The plan choices available to each person are determined by the plans participating in their metropolitan statistical area. We match plan premium and attribute information from the Checkbook Guide to each plan in the enrollee's list of choices.
We find that current workers 65+, 60–64, and non-Medicare eligible retirees are sensitive to variation in plan premiums. The premium elasticities for these groups are similar in magnitude to those of the age 55 and under employee group. Older workers and retirees not yet eligible for Medicare are willing to pay a substantial amount for plans with open provider networks. The willingness to pay for open networks is significantly greater for these groups than for younger employees. Willingness to pay for open network plans varies significantly by income, but varies little by age within group.
Our finding that older workers and non-Medicare eligible retirees are sensitive to plan premiums suggests that choice-based reform of Medicare would lead to cost-conscious choices by Medicare beneficiaries. However, our finding that these groups are willing to pay more for open network plans than younger employees suggest that higher risk individuals may migrate toward higher benefit, higher cost plans. Our findings on the relationship between income and willingness to pay for open network plans suggest that means testing is a viable reform for lowering Medicare program costs.
Medicare; health insurance; health plan choice
The World Health Report 2000 stated that increased public financing for healthcare was an integral part of the efforts to achieve equity of access. In 2009, the Chinese government launched a three-year health reform program to achieve equity of access. Through this reform program, the government intended to increase its investment in primary healthcare institutions (PHIs). However, reports about the outcome and the improvement of the equity of access have yet to be presented.
Stratified sampling was employed in this research. The samples used for the study comprised 34 community health service centers (CHSCs) and 92 township hospitals (THs) from six provinces of China. Collected data, which were publicly available, consisted of the total revenue, financial revenue, and the number of people for the periods covering January 2010 to September 2010 and January 2011 to September 2011. Revenue information for 2009 and 2010 was obtained from China’s Health Statistics Yearbook.
By using indicators such as government investment, government finance proportion and per capita revenue, t-tests for paired and independent samples were used to analyze the changes in government investment.
Government invest large amount of money to the primary healthcare institutions. Government finance proportion in 2008 was 18.2%. This percentage increased to 38.84% in 2011, indicating statistical significance (p = 0.000) between 2010 and 2011. The per capita financial input was 20.92 yuan in 2010 and 31.10 yuan in 2011. Compared with the figures from 2008 to 2010, the gap in different health sectors narrowed in 2011, and differences emerged. The government finance proportion in CHSCs revenue was 6.9% higher than that of THs, while the per capita revenue of CHSCs was higher. In 2011, the highest and lowest government finance proportions were 48.80% (Shaanxi) and 19.36% (Shandong), respectively. In that same year, the per capita revenue of Shaanxi (40.69 Yuan) was higher than that of Liaoning (28.79 Yuan). Comparing the 2011 figures with those from 2008 to 2010, the gap in 2011 clearly narrowed.
In the three-year health reform program, the Chinese government increased its investment to PHIs gradually and significantly. Thus promote equity to access and universal coverage. However, the increase in government investment stemmed from political desire and from the lack of institutionalization of practice and experience. Hence, a mode of financial allocation must be formulated to promote consistency in government input after the three-year health reform program.
To determine the relationship and impact of student-faculty ratio on scholarship of pharmacy faculty members.
The number and rank of faculty members, pharmacy program characteristics, and faculty productivity data were collected to determine the impact of student-faculty ratio on faculty scholarship.
Faculty scholarship was not predicted by student-faculty ratio. Factors impacting positively on faculty productivity included National Institutes of Health funding; presence of clinical associate professors, instructors, and lecturers; and programs located in public universities.
Faculty productivity is not related to the student-faculty ratio, wherein more faculty members and fewer students equates to increased scholarship. However, public universities may have different infrastructures which are associated with greater academic productivity compared to private institutions. Additionally, utilizing instructors and clinical or nontenure-track faculty members can significantly increase scholarship among faculty members.
pharmacy faculty; scholarship; student-faculty ratio; productivity
Over the past three decades, a limited range of market like mechanisms have been introduced into the hierarchically structured English National Health Service (‘NHS’), which is a nationally tax funded, budget limited healthcare system, with access to care for all, producing structures known as a quasi market. Recently, the Health and Social Care Act 2012 (‘HSCA’) has been enacted, introducing further market elements. The paper examines the theory and effects of these market mechanisms.
Using neo-classical economics as a primary theoretical framework, as well as new institutional economics and socio-legal theory, the paper first examines the fundamental elements of markets, comparing these with the operation of authority and resource allocation employed in hierarchical structures. Second, the paper examines the application of market concepts to the delivery of healthcare, drawing out the problems which economic and socio-legal theories predict are likely to be encountered. Third, the paper discusses the research evidence concerning the operation of the quasi market in the English NHS. This evidence is provided by research conducted in the UK which uses economic and socio-legal logic to investigate the operation of the economic aspects of the NHS quasi market. Fourth, the paper provides an analysis of the salient elements of the quasi market regime amended by the HSCA 2012.
It is not possible to construct a market conforming to classical economic principles in respect of healthcare. Moreover, it is not desirable to do so, as goals which markets cannot deliver (such as fairness of access) are crucial in England. Most of the evidence shows that the quasi market mechanisms used in the English NHS do not appear to be effective either. This finding should be seen in the light of the fact that the operation of these mechanisms has been significantly affected by the national political (i.e. continuingly hierarchical) and budgetary context in which they are operating.
The organisational structures of a hierarchy are more appropriate for the delivery of healthcare in the English NHS.
The current proliferation of proposals for health care reform makes it difficult to sort out the differences among plans and the likely outcome of different approaches to reform. The current health care system has two basic features. The first, enrollment and eligibility functions, includes how people get into the system and gain coverage for health care services. We describe 4 models, ranging from an individual, voluntary approach to a universal, tax-based model. The second, the provision of health care, includes how physician services are organized, how they are paid for, what mechanisms are in place for quality assurance, and the degree of organization and oversight of the health care system. We describe 7 models of the organization component, including the current fee-for-service system with no national health budget, managed care, salaried providers under a budget, and managed competition with and without a national health budget. These 2 components provide the building blocks for health care plans, presented as a matrix. We also evaluate several reform proposals by how they combine these 2 elements.
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?