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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.

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.

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.

ABSTRACT

INTRODUCTION

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.

AIM

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.

SETTING

University-affiliated, community-based family medicine residency program.

PROGRAM DESCRIPTION

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.

PROGRAM EVALUATION

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.

DISCUSSION

Through a learning collaborative experience, residency programs can successfully incorporate chronic care training for residents while addressing gaps in care for patients with diabetes.

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.

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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.

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.

Chiropractic fee negotiations in Saskatchewan utilize the Chiropractic Compensation Review Committee with recourse to the Chiropractic Consultation Committee. Health care professionals who practise on a fee for service basis provide the government with a budgetary problem. Although the fees are set, the health care provider can determine his own income by deciding how many visit services he/she wishes to provide. In the fiscal years 1981-82 to 1990-91, chiropractors earned $699.00 per year more than one would expect given the increases in fee schedules. Each chiropractor earned $2,329.00 per year more than was necessary to make up for losses due to inflation. The allegation that unnecessary treatments were performed on patients is countered by analysis of the services per discrete patient values by mode of practice. The increased earnings of chiropractors was accomplished by treating an increasing percentage of the population who sought health care. Comparative information was obtained from the four western provinces.

Study objective

The impact of isolated gatekeeping on health care costs remains unclear. The aim of this study was to assess to what extent lower costs in a gatekeeping plan compared with a fee for service plan were attributable to more efficient resource management, or explained by risk selection.

Design

Year 2000 costs to the Swiss statutory sick funds and potentially relevant covariates were assessed retrospectively from beneficiaries participating in an observational study, their primary care physicians, and insurance companies. To adjust for case mix, two‐part regression models of health care costs were fitted, consisting of logistic models of any costs occurring, and of generalised linear models of the amount of costs in persons with non‐zero costs. Complementary data sources were used to identify selection effects.

Setting

A gatekeeping plan introduced in 1997 and a fee for service plan, in Aarau, Switzerland.

Participants

Of each plan, 905 randomly selected adult beneficiaries were invited. The overall participation rate was 39%, but was unevenly distributed between plans.

Main results

The characteristics of gatekeeping and fee for service beneficiaries were largely similar. Unadjusted total costs per person were Sw fr231 (8%) lower in the gatekeeping group. After multivariate adjustment, the estimated cost savings achieved by replacing fee for service based health insurance with gatekeeping in the source population amounted to Sw fr403–517 (15%–19%) per person. Some selection effects were detected but did not substantially influence this result. An impact of non‐detected selection effects cannot be ruled out.

Conclusions

This study hints at substantial cost savings through gatekeeping that are not attributable to mere risk selection.

We interviewed health care providers representing 23 fee-for-service (FFS) practices, 19 health service organizations (HSOs) and 11 community health centres (CHCs) in Ontario to compare self-reported approaches to disease prevention and health promotion. Few significant differences were found across practice types in the presence of recall systems for screening or in knowledge of, compliance with or estimated coverage for selected preventive maneuvers recommended by the Canadian Task Force on the Periodic Health Examination. CHCs reported a significantly greater variety of formal health promotion programs and a greater tendency to use nonphysician health care personnel to carry out both prevention and health promotion activities. The results must be interpreted with caution because of the use of self-reported data, the low response rate for FFS practices and the use of a restrictive definition of disease prevention tied to evidence from the reports of the task force. Thus, the results cast some doubt on the common assumption that increasing the population served by alternative modes of delivery such as HSOs and CHCs necessarily increases the level of disease prevention and health promotion activity.

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.

Chiropractic physicians are seeking a higher level of cultural authority within their communities and the United States health care system. This commentary suggests an innovative strategy that might expedite the attainment of professional authority while improving the training of chiropractic students and faculty. The authors propose the founding of integrative medicine centers of excellence by colleges of chiropractic that will employ clinical faculties comprised of allopathic, chiropractic, osteopathic, and naturopathic physicians. Initially, the health care facilities should offer primary care through an integrative medicine model. It is anticipated that these centers of excellence will require both government and private funding in order to develop research programs, provide high-quality patient care, and improve the medical training for students with residents programs

Background

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.

Results

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.

Conclusion

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.

International studies suggest that cognitive-behavioural therapy (CBT) for the treatment of mental disorders results in improved clinical and economic outcomes. In Canada, however, publicly funded CBT is scarce, representing an inequity in service delivery. A research framework to evaluate the Canadian health economic impact of increasing access to CBT is proposed. Canadian data related to the epidemiology of mental disorders, patterns of usual care, CBT effectiveness, resource allocation and costs of care will be required and methodologies should be transparent and outcomes meaningful to Canadian decision-makers. Findings should be delivered by multidisciplinary teams of researchers and health professionals. Barriers to funding reform must be identified and knowledge translation strategies delineated and implemented. Canadian clinical and economic outcomes data are essential for those seeking to provide decision-makers with the evidence they need to evaluate whether CBT represents value for mental health dollars spent.

Approximately one-quarter of all Canadian children will seek emergency care in any given year, with the two most common medical problems affecting children in the emergency department (ED) being acute respiratory illness and injury. Treatment for some medical conditions in the ED remains controversial due to a lack of strong supporting evidence.

The purpose of this paper is to describe a multi-centre team grant in pediatric emergency medicine (PEM) that has been recently funded by the Canadian Institutes of Health Research (CIHR). This program of research integrates clinical research (in the areas of acute respiratory illness and injury) and knowledge translation (KT). This initiative includes seven distinct projects that address the objective to generate new evidence for clinical care and KT in the pediatric ED. Five of the seven research projects in this team grant make significant contributions to knowledge development in KT science, and these contributions are the focus of this paper.

The research designs employed in this program include: cross-sectional surveys, randomized controlled trials (RCTs), quasi-experimental designs with interrupted time-series analysis and staggered implementation strategies, and qualitative designs.

This team grant provides unique opportunities for making important KT methodological developments, with a particular focus on developing a better theoretical understanding of the causal mechanisms and effect modifiers of different KT interventions.

Objective

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.

Method

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.

Results

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.

Conclusions

Early outcomes support the value of these programs.

OBJECTIVE

We compare preventive services utilization among privately insured African Americans and Hispanics in managed care organizations (MCOs) versus fee-for-service (FFS) plans. We also examine racial/ethnic disparities in the receipt of preventive services among enrollees in FFS or MCO plans.

DESIGN

Analysis of the nationally representative 1996 Medical Expenditure Panel Survey.

PARTICIPANTS

Participants included 1,120 Hispanic, 929 African-American, and 6,383 non-Hispanic white (NHW) adults age 18 to 64 years with private health insurance.

MEASUREMENTS AND MAIN RESULTS

We examined self-reported receipt of physical examination, blood pressure measurement, cholesterol assessment, Papanicolau testing, screening mammography, and breast and prostate examinations. Multivariate modeling was used to adjust for age, gender, education, household income, and health status. Hispanics in MCOs were more likely than their FFS counterparts to report having preventive services, with adjusted differences ranging from 5 to 19 percentage points (P < .05 for physical examination, blood pressure measurement, breast examination and Pap smear). Among African Americans, such patterns were of a smaller magnitude. In both MCOs and FFS plans the proportion of African Americans reporting preventive services was equal to or greater than NHWs. In contrast, among Hispanic women in FFS, a non–statistically significant trend of fewer cancer screening tests than NHW's was observed (Pap smears 75% vs 80%; mammograms 66% vs 74%, respectively). In both MCO and FFS plans, Hispanics were less likely than NHWs to report having blood pressure and cholesterol measurement (P < .05).

CONCLUSIONS

With the demise of traditional MCOs, reform efforts should incorporate those aspects of MCOs that were associated with greater preventive service utilization, particularly among Hispanics. Existing ethnic disparities warrant further attention.

Improving education in health promotion and prevention has been identified as a priority for all accredited professional health care training programs, an issue recently addressed by a collaboration of stakeholders in chiropractic education who developed a model course outline for public health education. Using a course evaluation questionnaire, the authors surveyed students in the public health course at the Canadian Memorial Chiropractic College (CMCC) before and after the implementation of new course content based on the model course outline. Following the new course, there were significant improvements in perceived relevance to chiropractic practice and motivation to learn the material as a foundation for clinical practice. Changes made to the content and delivery of the course based on the model course outline were well received in the short term.

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.

Background

In the transition from a planned economy to a market-oriented economy, China’s state funding for health care declined and traditional coverage plans collapsed, leaving China’s poor exposed to potentially ruinous health care costs. In reforming health care for the 21st century, equity in health care financing has become a major policy goal. To assess progress towards this goal, this paper examines the equity characteristics of health care financing in a province of northwestern China, comparing the equity performance between urban and rural areas at two different points in time.

Methods

Analysis of whether health care financing contributions were progressive according to income were made using the Kakwani index for each of the four health care financing channels of general taxes, public and private health insurance, and out-of-pocket payments. Two rounds of surveys were conducted, the first in 2003 (13,619 individuals in 3946 households) and the second in 2008 (12,973 individuals in 3958 households). Household socio-economic, health care payment, and utilization information were recorded in household interviews.

Results

Low-income households have undertaken a larger share of the health care financing burden in recent years, reflected by negative Kakwani indices, which indicate a regressive system. We found that the indices for general taxation were −0.0024 (urban) and −0.0281 (rural) in 2002, and −0.0177 (urban) and −0.0097 (rural) in 2007. Public health insurance presented different financing distributions in urban and rural areas (urban: 0.0742 in 2002, 0.0661 in 2007; rural: –0.0615 in 2002,–0.1436 in 2007.). Out-of-pocket payments were progressive but not equitable. Public health insurance coverage has expanded but financing equity has decreased.

Conclusions

Health care financing policies in China need ongoing reform. Given the inequity of general consumption taxes, elimination of these would improve financing equity considerably. Optimizing benefit packages in public health insurance is as important as expanding coverage, both for health care financing and for utilization management as well. Although they are progressive, out-of-pocket payments are not equitable in China and have the effect of excluding the poor from health care as they cannot afford to pay for medical care and so withdraw from treatment.

Adoption of the new perspective of public health as a comprehensive and multidisciplinary mixture of objectives and activities requires a novel approach to the planning and the evaluation of health programs and to the training of health personnel.

The implication of this process for the Israeli health arena suggests the establishment of a national center for public health. The cornerstones of the Israel National Center for Public Health (INCPH) consist of the classic triad: health care providers, leaders of regulatory agencies, and representatives of the academic institutions.

The INCPH basic units would be structured by a top executive board of directors, by steering or professional committees whose main objectives are to develop criteria and guidelines and the evaluation of projects, and by a permanent staff group to maintain primary responsibility for the implementation of the center's programs.

A number of practical steps have been taken in respect to the establishment of the center. The suggested mode of operation encompasses a variety of mechanisms to promote research in and planning or evaluation of health services and a nationwide effort to coordinate health manpower education by combining expertise and knowledge of all the nation's teaching institutions. International activity consisting of the education of health professionals from developing countries is also envisaged.

Does a prepaid group practice (PGP) deliver less outpatient mental health care than the fee-for-service (FFS) sector when they serve comparable populations with comparable benefits? To examine this issue, we used data from the Rand Health Insurance Study, which randomized families into a prepaid group practice or FFS insurance plans. Participants in a FFS plan with no cost sharing (i.e., free care) are equally likely to visit a mental health specialist in a year, but incur 2.8 times the costs of prepaid participants (p less than .05). This difference is due to fewer visits per user, substitution of psychiatric social workers for psychiatrists and psychologists, and reliance on group rather than individual therapies in the prepaid plan. Because of the experimental design, these differences are due to institutional and incentive differences rather than adverse selection. We found no evidence of appreciable or significant adverse selection into or out of the prepaid group practice. A full evaluation of the desirability of prepaid or fee-for-service care requires data on health outcomes, which are not presented here.

The project was directed toward planning, developing, and implementing a subregional biomedical information network among the forty-three health care facilities (hospitals) of the four-county area served by Loma Linda University's health sciences library. The project coordinator contacted administrators and health care professionals in the forty-three institutions to present a plan for the network. The health care facilities were encouraged to support the continuation of the network through contract fees. The availability of specific information services was assured through contractual agreements. It was anticipated that the subregional network would be self-supporting after the twelve-month project period (December 1, 1976-November 30, 1977). The working territory (40,429 square miles) encompassed Mono, Inyo, Riverside, and San Bernardino counties. The project resulted in nine of the forty-three hospitals signing annual contracts for library services. It is recommended that projects of this kind extend beyond a year's duration in order to educate health professionals concerning the value of access to biomedical literature in improving patient care.

Background

Primary care reform in Ontario, Canada, included the initiation of a blended capitation model in 2001–2002 and an enhanced fee-for-service model in 2003. Both models involve patient rostering, incentives for preventive care and requirements for after-hours care. We evaluated practice characteristics and patterns of care under both models.

Methods

Using administrative data, we identified physicians belonging to either the capitation or the enhanced fee-for-service group throughout the period from Sept. 1, 2005, to Aug. 31, 2006, and their enrolled patients. Practices were stratified by location (urban v. rural). We compared the groups in terms of practice characteristics and patterns of care, including comprehensiveness of care, continuity of care, after-hours care, visits to the emergency department and uptake of new patients.

Results

Patients in the capitation and enhanced fee-for-service practices had similar demographic characteristics. Patients in capitation practices had lower morbidity and comorbidity indices. Comprehensiveness and continuity of care were similar between the 2 groups. Compared with patients in enhanced fee-for-service practices, those in capitation practices had less after-hours care (adjusted rate ratio [RR] 0.68, 95% confidence interval [CI] 0.61–0.75) and more visits to emergency departments (adjusted RR 1.20, 95% CI 1.15–1.25). Overall, physicians in the capitation group enrolled fewer new patients than did physicians in the enhanced fee-for-service group (37.0 v. 52.0 per physician); the same was true of new graduates (60.3 v. 72.1 per physician).

Interpretation

Physicians enrolled in the capitation model had different practice characteristics than those in the enhanced fee-for-service model. These characteristics appeared to be pre-existing and not due to enrolment in a new model. Although the capitation model provides an alternative to fee-for-service practice, its characteristics should be the focus of future policy development and research.

Background

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.

Methods

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.

Results

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.

Conclusion

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.