Current Health Care Reform Research Articles

Care models for older people based on a case study-Geriatrics as an active discipline

Geriatrics can enable and monitor aholistic care of older people through acomprehensive geriatric assessment in a structured way. Therefore, it must be integrated much more closely with preventive, rehabilitative and acute care units. Geriatrics are not seen in any aspects as areplacement for general practitioners or in-hospital structures but much more as asupplement to them. With its function-oriented concept, geriatrics can best coordinate the demographically necessary triage between prevention, acute treatment, rehabilitation and palliative care, thus avoiding undertreatment and overtreatment. This can only succeed in collaboration with general practitioners and specialist colleagues. The article categorizes geriatric care structures, such as preventive home visits, acute complex medical treatment, delirium prevention, outpatient and inpatient rehabilitation services based on acase example and makes proposals for structural changes that urgently need to be considered in the current healthcare reform, such as outpatient geriatric centers (AGZ).

Evolving Challenges in the Implementation of China's "Four Frees and One Care" Policy for HIV/AIDS.

In response to the HIV/AIDS epidemic, China initiated the "Four Frees and One Care" policy in late 2003. This policy provided free counseling, testing, and antiretroviral treatment for people living with HIV, while also offering support to affected families. While instrumental in advancing HIV/AIDS prevention, the policy faces evolving challenges. This study aims to analyze this challenge from multiple dimensions and, based on this analysis, provide effective recommendations for the Chinese government to address it, promoting the sustainable development of the "Four Frees and One Care" policy. The research found that reduced government funding has led to the decline of grassroots organizations, creating a disconnect between administrative and treatment systems. Additionally, advancements in medical technology introduce new antiretroviral drugs, complicating their integration into the healthcare system. In the current healthcare reform, updating the list of free antiretroviral drugs proves challenging. Adapting the policy to contemporary HIV/AIDS prevention should be a priority for the Chinese government. Balancing financial constraints, organizational sustainability, and evolving medical technologies will be pivotal for the ongoing transformation of the "Four Frees and One Care" initiative.

Mapping barriers to midwives’ educational role in Cyprus guided by the Theoretical Domains Framework

Abstract Issue The high caesarean section (C/S) rate in Cyprus (>60%) led to the formation of a National Committee to address this Public Health priority. Among WHO recommendations for C/S reduction are midwifery-led educational interventions; yet, medicalization of birth in Cyprus is curtailing the autonomous role of midwives. Description of problem While midwives could “make every contact count” during routine appointments, antenatal education (AE) is reduced to a formal activity within the antenatal class space with documented low attendance. This formative research mapped barriers to the educational role of Cypriot midwives guided by behaviour theory. A context-specific understanding is needed to shape an appropriate intervention and promote a common understanding among stakeholders. Results One in three midwives islandwide (N = 119, response: 34%) rated 83 determinants (from 1=more to 6=less problematic), guided by the Theoretical Domains Framework (TDF). “Beliefs about AE importance” (M = 5.57, SD = 0.96) and “Professional role” (M = 5.58, SD = 0.57) received the highest scores. Lack of organizational resources (M = 3.39, SD = 0.97), institutional and inter-professional support (M = 3.77, SD = 1.4) and acceptance (M = 4.25, SD = 0.85) were identified as problematic. While perceived capabilities and intentions were rated favourably, achieving “Goals” was difficult, mainly due to competing priorities (M = 3.86, SD = 0.84). Self-efficacy and behavioural control were lower among less experienced midwives (p < 0.01) and in the private sector (p = 0.08), which accounts for >70% of births. Lessons Beyond the antenatal class, AE is a ‘bad fit’ with routine practice. The phenomenon pertains to organizational arrangements but also norms and perceptions of other providers and service users. While current Healthcare reforms present prospects in re-defining the role of midwives, the educational role is not adequately supported or promoted given the limited number of visits and reimbursement restrictions imposed. Key messages • Barriers to routine antenatal education originate from an unsupportive system and socio-cultural norms which alienate midwives in an already medicalized environment. • This theory-driven formative study described the issue in behaviour terms in the context of shaping an intervention to strengthen the health education role of midwives.

Effects of establishing a financing scheme for outpatient care on inpatient services: empirical evidence from a quasi-experiment in China

The relationship between outpatient and inpatient care is central to the current healthcare reform debate especially in developing countries. Despite the importance of this relationship to health policy makers, empirical evidence, particularly evidence that can be interpreted as causal is limited and inconclusive. This paper examines the effects of establishing a financing scheme for outpatient care on inpatient utilization and expenditure in China's Urban Employee Basic Medical Insurance scheme. Under a quasi-experimental design, we use a unique administrative insurance claim dataset and conduct a difference-in-differences analysis. Our results indicate that after the policy change, total number of admissions and total inpatient expenditure of the enrollees decreased by 0.47% and 6.05% respectively, which imply outpatient and inpatient care are substitutes, and the reduction in cost-sharing can release the underuse of the outpatient care, so as to reduce those excessive demands for inpatient care. Moreover, we present evidence that the effects on the admissions of Ambulatory Care Sensitive Conditions which should be sensitive to outpatient care intervention are relatively limited because of the lower reimbursement cap, inadequate capacity of the local primary care providers and stickiness in patients' healthcare-seeking behaviors. While the enrollees aged over 55 and retirees are more vulnerable to the medical prices, and the enrollees living in the central districts are more responsive because of the better and more accessible primary care.

The hospital management practices in Chinese county hospitals and its association with quality of care, efficiency and finance

BackgroundCounty hospitals as the backbone of the China’s healthcare system are providing services for over 70% of the total population. However, the hospital management practice (HMP) and its links with quality of care, efficiency and finance in these hospitals are unknown.MethodsWe did two cross-sectional surveys of HMP in 2013 and 2015 among 101 county hospitals across rural China. Three managing roles (hospital director, director of medical affairs office and director of cardiology) and a cardiologist were invited to the surveys. A novel HMP rating scale, with 100 as full score, was used to measure the HMP in 17 indicators under four dimensions (target, operation, performance, and talent management) for each hospital. We analyzed the association of HMP score with variables on quality of care, efficiency and finance using linear mixed models with and without adjustment for potential confounders.FindingsA total of 95 hospitals participated in at least one survey and were included in the analysis. The overall mean HMP score varied dramatically across the hospitals and 84% of them scored less than 60. The dimension mean HMP score was 38.6 (target), 56.4 (operation), 53.2 (performance) and 55.7 (talent), respectively. The pattern of indicator mean HMP score, however, was almost identical between hospitals with high and low overall HMP score, showing the same ‘strength’ (staff satisfaction, staff performance appraisal, ‘hard wares’, patient-centered services, etc.) and ‘weakness’ (target balance, target setting, continuous quality improvement, penalties on staff with dissatisfied performance, etc.). The associations of overall mean HMP score with quality of care and efficiency variables and cost per hospitalization was not statistically significant. The statistical significance in the association with hospital annual total income disappeared after adjusting for region, teaching status, number of competitors, number of staff and number of beds in use.ConclusionThe HMP in Chinese county hospitals scores low in general and was not significantly associated with hospital care quality, efficiency and finance. The current healthcare reform in China should address the micro level issues in hospital management practices.

Dissatisfaction with Local Medical Services for Middle-Aged and Elderly in China: What Is Relevant?

As violent clashes between doctors and patients in China intensify, patient dissatisfaction has been identified as a major concern in the current healthcare reform in China. This study aims to investigate the main determinants of dissatisfaction with local medical services attributable to middle-aged and elderly characteristics and identify areas for improvement. A total of 14,263 rural participants and 4898 urban participants were drawn from the China Health and Retirement Longitudinal Study in 2018. Dissatisfaction was measured by two methods: binary outcome (1 = Dissatisfaction; 0 = No) demonstrated the risk of occurring dissatisfaction among various characteristics, and continuous outcome (ranges from score 1 to 5) showed the degree. The mean score of dissatisfaction was 2.73 ± 1.08. Sixteen percent of rural participants and 19% of urban participants reported dissatisfaction with local medical services, respectively. The multilevel analyses demonstrated that participants’ utilization of paid family doctor services decreased the risk of occurring dissatisfaction; dissatisfaction was less focused on females; having chronic diseases increased the risk of dissatisfaction. This study suggests promotion of family doctor services can effectively reduce middle-aged and elderly dissatisfaction with the local medical services. In addition, more attention should be focused on males and middle-aged and elderly with chronic diseases in order to decrease dissatisfaction.

Policy Effect of the Public Health Clinic Closure and Consolidation Policies on All the Preventative Practices Following the Affordable Care Implementation in Louisiana

The purpose of this study is to examine the policy effect of the public health clinic closure and consolidation policies on public health preventive practices in Louisiana. It is observed in the literature that many governments’ efforts towards the healthcare market has being failing across different political administrations. This is because the current health care reform, public health clinics closures and policy consolidations following the implementation of the affordable care act seems to be disappointing in the state of Louisiana. Currently, many parishes, are battling with low health care professional’s availability, and high prevalence of poor health outcomes (i.e. high spread of STDs, high cancer spread, low accessibility to healthcare, and several communicable diseases) making all the public health interventions programs or initiatives look bad in the face of the policy reforms. However, it is not clear whether the policy consolidation and public health clinics closures are the causal factors to the high spread of diseases and health disparities across the parishes. As a result, this particular study used paired t-test and secondary source of data from the Department of Health and Hospitals and Integrated Public Use Microdata Series USA (IPUMS-USA) spanning from 2008 to 2019 to examine the problem. The study finds that the average Gonorrhea infection rate, and P&S Syphilis infection rate between 2014 and 2019 is greater than the average infection rate before the closure of the public health clinics (2008 and 2013). Above all, the study establishes that there is a strong evidence of significant difference in the following: (a) access to healthcare, (b) Sexually-Transmitted Disease (STD) Screening preventative practices, and (c) the participation of Breast Cancer Screening preventative practices resulting from the different periods of policy implementation in relation to public health clinic closures. Therefore, the study recommends that all the closures of the public health clinics needs to be reopen to ensure a greater access to healthcare and healthy population. Keywords: Healthcare, ACA, Clinic, Policy, healthcare, Preventive, Screening, and STDs. DOI: 10.7176/PPAR/10-11-05 Publication date: November 30 th 2020

An Examination of Health Disparities in Louisiana Parishes Resulting from Clinic Closures and Policy Consolidation

It has been observed in the healthcare and public policy literature that the healthcare market seems to be failing despite the tremendous efforts by policymakers, lawmakers, and different political leaders. In relation to the existing public health data, it is further observed in the literature that the current health care reforms, public health clinics closures and policy consolidations following the implementation of the affordable care act appear to be disappointing in the state of Louisiana—in relation to the high spread of STDs, breast-cancer, and low preventive screening participation across the parishes in Louisiana. As a result, this current study has utilized secondary data source to examine the health disparities in Louisiana state parishes resulting from the public health clinic closure and consolidation policies on all the preventative practices by utilizing data from Louisiana Department of Health. As part of the study design, the researcher utilizes descriptive design, bar chart and pie-chart to analyze the health disparities data following the clinic closures. The study suggested that the federal governments, state governors and local governments should reconsider the reopening of all the closures of the public health clinics in order to ensure a greater access to healthcare and healthy population among the Louisiana residents among the different parishes. Keywords: Health, Clinic, Parishes, Policy, Healthcare, Screening, and STDs. DOI: 10.7176/JLPG/103-07 Publication date: November 30 th 2020

Evaluating the effect of hierarchical medical system on health seeking behavior: A difference-in-differences analysis in China.

The unbalanced allocation of healthcare resources and the underutilization of primary care facilities are the core problems that restrict the current healthcare reforms in China. In order to encourage residents to go to primary care facilities, China implemented the Hierarchical Medical System (HMS) in 2015. This study aims to evaluate the effect of HMS on health seeking behavior in China using panel data. Statistics for the study were derived from China Family Panel Studies (CFPS) 2012, 2014, 2016 and 2018, and China health and family planning statistical yearbook 2012, 2014, 2016 and 2018. We employed the difference-in-differences (DID) model with multiple periods. In total, 61,932 residents were incorporated for a final sample covered 25 provinces. The results indicated that the implementation of HMS had a significantly positive effect on the probability of urban residents going to primary care facilities for contact. However, the effect of HMS was not significant for rural residents. Basic health insurance was a significant factor for directing residents to primary care facilities. Self-assessed health, chronic disease, economic level and educational status were also found to be focal factors of health seeking behavior. In conclusion, the introduction of HMS has led to improved health seeking behavior and is worth putting more effort into. For policy makers, basic medical insurance is still an important health policy that enables systematic health seeking behavior. Initiatives to continue to expand the adjustment range of economic incentives should be adopted to promote the implementation of HMS. However, the effect of HMS in chronic disease is poor and efforts to formulate chronic disease as a breakthrough to HMS should be carried out. Moreover, the government should increase the publicity of HMS.

The Hospital Management Practices in Chinese County Hospitals and Its Association with Quality of Care, Efficiency and Finance

Background: County hospitals as the backbone of the China’s healthcare system are providing services for over 70% of the total population. However, the hospital management practice (HMP) and its links with quality of care, efficiency and finance of these hospitals are unknown. Methods: We did two cross-sectional surveys of HMP in 2013 and 2015 among 101 county hospitals participated in the Third Phase of the Clinical Pathways for Acute Coronary Syndromes in China (CPACS-3) Study. A novel HMP rating scale, with 100 as full score, was used to measure the hospital management practice in 17 indicators under four dimensions (target, operation, performance, and talent management) for each hospital. We analyzed the association of HMP score with quality of care, efficiency and finance using general linear models with adjustment for potential confounders. Findings: A total of 83 hospitals responded in both surveys. The overall mean HMP score varied dramatically across the hospitals (from 31.1 to 71.1) and 86% of hospitals scored less than 60 out of 100. The dimension mean HMP score was 38.8 (target), 56.1 (operation), 52.9 (performance) and 55.6 (talent), respectively. The pattern of indicator mean HMP score, however, was almost identical between hospitals with high and low overall HMP score, showing the same ‘strength’ (staff satisfaction, staff performance appraisal, ‘hard wares’, patient-centered services, etc.) and ‘weakness’ indicators (target balance, target setting, continuous quality improvement, penalties on staff with dissatisfied performance, etc.). The overall mean HMP score was not associated with hospital care quality and efficiency but associated significantly with hospital annual revenue. Interpretation: The HMP in Chinese county hospitals scores low in general and was not associated with hospital care quality and efficiency but associated with the total revenue. The current healthcare reform in China should address the issues in hospital management practices. Trial Registration: This study is part of the ancillary study of the Third Phase of the Clinical Pathways for Acute Coronary Syndromes in China (CPACS-3) Program (NCT02195193). Funding Statement: Sanofi (China). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The study was approved by the Peking University Institutional Review Board.

Healthcare Reform in the U.S. Must Be Driven by Policy and Data, Not Politics and Ideology

Background U.S. healthcare spending will reach 20% of GDP by 2026. Despite this spending, almost 14% of our under-65 population still lacks health insurance and out-of-pocket healthcare spending is high. To date, much of the healthcare reform debate has focused on who pays—the government, employers or individuals. Objective To review current healthcare reform issues and evidence. Method We address the questions of how much we pay, how we pay and what we receive for the money as a potential foundation for constructive dialogue. Results U.S. healthcare spending continues to exceed that of other countries, without offering universal coverage. Notwithstanding coverage expansions implemented under the Affordable Care Act, uninsurance rates have been rising. Rapid growth of high deductible plans has also significantly increased rates of underinsurance. There is very little evidence that specific policies or interventions employed to date will significantly reduce cost, especially under a fee for service system, where volume makes up for cuts. Global risk payments hold the greatest promise for real cost containment because they can drive true delivery system reform. Conclusion Meaningful, long-term healthcare reform cannot be successful until comprehensive, evidence-based policies that address healthcare costs are fully embraced and implemented.

Influence of patient and hospital characteristics on inpatient satisfaction in China's tertiary hospitals: A cross-sectional study.

BackgroundPatient satisfaction has been seen as a key criterion when evaluating hospitals and is one of the main focuses of the current health‐care reform in China. This paper aimed to explore patient‐ and hospital‐level factors associated with inpatient satisfaction, which can provide policy implications for the evaluation and development of a patient‐oriented health‐care system.MethodsThe paper analyses data from the 2017 China National Patient Survey which includes 20 300 inpatients from 131 tertiary hospitals across 31 provinces. Descriptive analysis and multivariable logistic regressions are conducted to identify key factors related to satisfaction.ResultsPatient sociodemographic characteristics, including gender, age, income and insurance type, are found to be strongly associated with their satisfaction of inpatient experience. In terms of institutional characteristics, hospital type, size, staffing and financial performance are also significantly correlated with inpatient satisfaction. Patients are more satisfied with specialist hospitals and large hospitals measured by the number of beds and surgeries. Hospitals with higher nurse‐to‐bed ratio also receive more satisfaction. The financial performance of hospitals, however, is negatively associated with satisfaction.ConclusionPatient satisfaction contains unique information on service quality and thus should be incorporated into the matrix of hospital evaluation. Meanwhile, differences in patient composition must be adjusted to make fair comparisons across hospitals. Moreover, future reform needs to put greater efforts in the design of comprehensive public insurance scheme, efficient hospital structure and an overall well‐functioning health‐care delivery system in order to better serve patients in China.

833 The Impact of Trainee Physician Experience on Costs and Treatment Outcomes Among Patients Hospitalized With Ulcerative Colitis

INTRODUCTION/AIM: The efficiency and the delivery of care have been at the center of the current healthcare debate and reform. We sought to investigate the “July effect” on resource utilization among patients admitted to teaching hospitals with ulcerative colitis. METHODS: This was a retrospective cohort study using the 2016 Nationwide Inpatient Sample (NIS), the largest public inpatient database in the US. Patients with a principal diagnosis of Ulcerative colitis (UC) were included. Patients were excluded if they were younger than 18 years or treated at non-teaching hospital. The primary outcome was total hospitalization charges associated with the hospital admission for UC. Secondary outcomes were 1) length of stay 2) in-hospital mortality and 3) surgical intervention. Patient outcomes at the start of the academic year (July- September) were compared with those at the end of the academic year (April -June). Proportions were compared using fisher’s exact test and continuous variables using student t- test. Multivariate analysis was used to adjust for gender, age, Charlson Comorbidity Index, income in patient zip code, hospital region, location, size and teaching status. RESULTS: 24,650 patients were included in the study. The mean age was 46 years and 54% were females. Compared with patients admitted in July/August/September, those admitted in April/May/June had an adjusted mean difference in total hospitalization charges of 7,380$, (95% Confidence Interval (CI: $14,160 - $599, P = -0.03). Similar results were obtained for Length of Stay: Compared with patients admitted in July/August/September, those admitted in April/May/June, had an adjusted mean difference in length of stay of 0.7 days, CI: 1.3 -0.1, P = 0.02. There was no statistically significant difference in in-hospital mortality rate (adjusted odds ratio (aOR): 0.60, CI: 0.13-2.80, P = 0.51) or surgery rate (aOR: 0.91, CI: 0.59- 1.40, P = 0.68) among the two patient groups. CONCLUSION: The experience of the physician in training affects efficiency of care among patients admitted to the hospital with ulcerative colitis, but does not seem to impact treatment outcomes including in-hospital mortality and colectomy rate.

Feasibility study for implementation of the AI-powered Internet+ Primary Care Model (AiPCM) across hospitals and clinics in Gongcheng county, Guangxi, China

BackgroundThe sustainability of the rural health-care system is under pressure in Gongcheng county, Guangxi, China, mainly owing to disparities between rural and urban medical resources, and preference of local patients to seek health care in urban tertiary hospitals. Our aim is to reform the county's primary care model to improve rural health-care services and increase its use, a critical component of the current national health-care reform plan. In this study, we primarily test the feasibility of implementing artificial intelligence (AI) powered bidirectional referral between rural clinics and the county hospitals on a new internet-based platform. We focused on developing the new web platform and primary care model and implementing it throughout the whole county health system, which serves over 300 000 residents. MethodsOur reform adopts the University of California, San Francisco primary care model augmented with AI on a cloud platform. The main county hospital of Gongcheng county, Guangxi, China, and its associated rural clinics used the AI-powered Internet+ Primary Care Model (AiPCM) platform to provide patient education, patient engagement, bidirectional referral, panel management, and health coaching. The aim was for the three-level county health-care system to operate seamlessly and cost-effectively. In conjunction, the second key innovation required to make AiPCM work in rural China was deployed; an online health-care team from Guilin Medical University provided support to rural doctors in the form of professional training, online support, and a chatbot to assist village doctors in making referrals and managing the health care of rural residents. FindingsWe developed a new web platform to smoothly integrate AiPCM into existing clinical workflows at county, town and village levels. The main county people's hospital, two town health centres, and 17 village clinics joined the web platform in the first phase of the pilot study. The internet-based hub and spokes model allows the main county hospital (hub), and town health centres and village clinics (spokes) to care collaboratively for patients through bidirectional referral mechanisms. County hospital teams focus on diagnosis and treatment of patients referred from town health centres. Town health centre teams provide panel management for patients at risk and refer patients to county hospitals when needed. Village clinic doctors engage villagers and refer patients to town health centres when needed. County hospital specialists provide feedback to the referring doctors for them to continue caring for the patient locally. As care data are collected, a chatbot can be trained to further assist village and town doctors to make referrals and provide initial primary care. The AiPCM cloud platform can allow Guilin Medical University teams to add more capabilities to the county health system, including doctor training, patient coaching, referral assistance, chatbot training, and patient education. Thus, it is feasible to use AiPCM on a web platform to effectively implement bidirectional referrals, which should encourage more patients to see local doctors. InterpretationWith AiPCM and technical support from academic institutions, the new primary care model can be implemented in rural China. Next, we will evaluate the effectiveness of AiPCM, its effect on the number of rural residents receiving the health care that they require, and patient clinical outcomes. FundingNone.

219 Impact of Hospital Size and Teaching Status on Patients With Clostridium difficile Colitis Treatment Outcomes

INTRODUCTION: The efficiency and delivery of care has been at the center of the current healthcare debate and reform. Clostridium Difficile Infection (CDI) is the leading cause of hospital acquired infectious diarrhea. This study sought to investigate the effect of hospital size, urban location and teaching status on in-hospital mortality and resource utilization among patients admitted to hospital with CDI. METHODS: This is a retrospective cohort study using the National Inpatient Sample (NIS) 2016. NIS is the largest publicly available all-payer inpatient care database in the United States. Patients were included if they had a principal diagnosis of CDI, and were excluded if they were younger than 18 years. The primary outcome was in-hospital mortality. The secondary outcome was resource utilization as measured by hospital length of stay (LOS) and total hospitalization charges. The exposure of interest was hospital size, urban location and teaching status. Multivariate regression analysis was utilized to account for confounders. RESULTS: 19,580 patients were included in this study. The mean age was 64 years and 64% of patients were females. Adjusted odds ratios (aOR) and mean differences (aMD) are presented in Table 1. After adjusting for confounders, the odds of in-hospital mortality were similar for patients at rural, urban teaching and urban non-teaching hospitals as well as at small, medium and large hospitals. However, patients treated at urban teaching and non-teaching hospitals had significantly longer LOS compared with those treated at rural hospitals. Similarly, patients treated at large and medium hospitals had significantly longer mean LOS compared with those treated at small hospitals. Patients treated at urban teaching and non-teaching hospitals had significantly higher mean total hospitalization charges compared with those treated at rural hospitals, and patients treated at large and medium hospitals had significantly higher mean total hospitalization charges compared with those treated at small hospitals. CONCLUSION: Despite significantly higher resource utilization (LOS and total hospitalization charges) at larger urban teaching hospitals, CDI in-hospital mortality was similar to those treated at small, rural non-teaching hospitals. One possible explanation lies in the complexity of CDI larger teaching referral centers. Another possibility is the variable adherence to C. difficile infection guidelines.

Impact of payer status on survival in parotid malignancy.

In the setting of current national healthcare reform, it becomes especially relevant to understand the current state of healthcare disparities with regards to insurance status. To determine the impact of payer status on survival in parotid malignancy, we utilized the National Cancer Database (NCDB). Retrospective database review. National Cancer Database (2004-2012). The NCDB was queried for cases of primary malignancy of the parotid gland between 2004 and 2012. The impact of payer status on overall survival was evaluated, as well as the relationship of insurance status with patient and tumor variables. 15,815 cases met inclusion criteria. A majority had private insurance (47.8%), followed by Medicare (40.9%), Medicaid (5.0%), uninsured (3.2%) and other government sources (1.3%). Medicare patients had the lowest 5 and 10-year survival rates (50.7% (95% CI [49.3-52.1]) and 27.8% (95% CI [25.0-30.9]), respectively). On multivariable analysis, uninsured, Medicare, and Medicaid patients had worse overall survival than the privately insured (HR 1.42, 95% CI [1.17-1.74]; HR 1.29, 95% CI [1.17-1.42]; HR 1.36, 95% CI [1.13-1.62], respectively). Uninsured and Medicaid patients were more likely than the privately insured to present with advanced stage disease, nodal metastasis and longer times to treatment following diagnosis. In parotid malignancy, uninsured, Medicaid, and Medicare patients have worse survival outcomes compared to those with private insurance. Uninsured and Medicaid patients also present with more advanced stage disease and have increased wait times before definitive treatment is initiated.

ERAS and patient reported outcomes in thoracic surgery: a review of current data.

Quality-focused, cost-effective, patient-centered care is at the forefront of current healthcare reform. Recent data show that enhanced recovery after surgery (ERAS) results in improved surgical outcomes and decreased hospital costs. As a result, ERAS has been widely accepted among multiple surgical subspecialties as a modality for increasing the value of healthcare delivered to our patients. While this objective data is convincing for practitioners and administrators alike, how ERAS directly impacts the patient experience is unclear. Patient reported outcomes (PRO) are starting to drive patterns of healthcare delivery and influence surgical decision-making. In order to improve surgical outcomes and deliver patient-centered care, it is imperative that clinicians start reviewing objective metrics contained within morbidity and mortality data alongside subjective data regarding patients' experience. This article reviews the current data surrounding both ERAS and PROs within thoracic surgery and investigates how the two concepts are ultimately related.

Establishing Appropriate Agency Relationships for Providers in China.

Physicians play multiple roles in a health system. They typically serve simultaneously as the agent for patients, for insurers, for their own medical practices, and for the hospital facilities where they practice. Theoretical and empirical results have demonstrated that financial relations among these different stakeholders can affect clinical outcomes as well as the efficiency and quality of care. What are the physicians’ roles as the agents of Chinese patients? The marketization approach of China’s economic reforms since 1978 has made hospitals and physicians profit-driven. Such profit-driven behavior and the financial tie between hospitals and physicians have in turn made physicians more the agents of hospitals rather than of their patients. While this commentary acknowledges physicians’ ethics and their dedication to their patients, it argues that the current physician agency relation in China has created barriers to achieving some of the central goals of current provider-side health care reform efforts. In addition to eliminating existing perverse financial incentives for both hospitals and physicians, the need for which is already agreed upon by numerous scholars, we argue that the success of the ongoing Chinese public hospital reform and of overall health care reform also relies on establishing appropriate physician-hospital agency relations. This commentary proposes 2 essential steps to establish such physician-hospital agency relations: (1) minimize financial ties between senior physicians and tertiary-level public hospitals by establishing a separate reimbursement system for senior physicians, and (2) establishing a comprehensive physician professionalism system underwritten by the Chinese government, professional physician associations, and major health care facilities as well as by physician leadership representatives. Neither of these suggestions is addressed adequately in current health care reform activities.

Retooling the Health Care Workforce in the Era of the Affordable Care Act: An Evaluation of an Advanced Certificate Program in Integrated Primary and Behavioral Health Care

ABSTRACTThe Affordable Care Act aims to increase affordable coverage, reduce overall costs, and improve health outcomes. To achieve these aims, new knowledge and skills must be built within the existing workforce. The purpose of this article is to examine the behavioral and organizational changes brought about by an educational program that aimed to retool the healthcare workforce for the implementation of integrated primary and behavioral healthcare models, with an added emphasis on prevention. Sixty-three participants of an Advanced Certificate Program completed 1 or more evidence-informed learning modules centered on integrated primary and behavioral health care. The vast majority of students who completed each of the 5 modules of the program reported acquiring new knowledge and skills. Student satisfaction of the program met or exceeded overall expectations. In addition, program participation has resulted in not only students’ intentions to change workplace practices but also actual implementation of workplace changes related to integrated care models. The Advanced Certificate Program appears to be a promising platform for service providers to align their knowledge and skills with the premises of current healthcare reform.

Facilitators and barriers to optimal preventive service use among providers and older patients

Preventive service use remains low among Medicare beneficiaries despite the Affordable Care Act's waiver of coinsurance. This study sought to understand barriers and facilitators to preventive service provision, access, and uptake. We used a mixed methods approach synthesizing quantitative survey and qualitative focus group data. Self-reported utilization of and factors related to preventive services were explored using quantitative data from the 2012 Medicare Current Beneficiary Survey. Qualitative data from 16 focus groups conducted in 2016 with a range of providers, health advocates, and Medicare beneficiaries explored perspectives on preventive service use. Providers indicated time and competing priorities as factors for not offering patients a full range of preventive services, while beneficiaries reported barriers related to knowledge, perception, and trust. Current healthcare reform efforts incorporating team-based care, nurses and other non-physician providers, and coordinated electronic health records could support enhanced use of preventive services if fully implemented and utilized.