Health Reform Initiatives Research Articles

Treatment biases in traumatic neurosurgical care: a retrospective study of the Nationwide Inpatient Sample from 1998 to 2009.

This study was designed to assess the relationship between insurance status and likelihood of receiving a neurosurgical procedure following admission for either extraaxial intracranial hemorrhage or spinal vertebral fracture. A retrospective analysis of the Nationwide Inpatient Sample (NIS; 1998-2009) was performed. Cases of traumatic extraaxial intracranial hematoma and spinal vertebral fracture were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Within this cohort, those patients receiving a craniotomy or spinal fusion and/or decompression in the context of an admission for traumatic brain or spine injury, respectively, were identified using the appropriate ICD-9 procedure codes. A total of 190,412 patients with extraaxial intracranial hematoma were identified between 1998 and 2009. Within this cohort, 37,434 patients (19.7%) received a craniotomy. A total of 477,110 patients with spinal vertebral fracture were identified. Of these, 37,302 (7.8%) received a spinal decompression and/or fusion. On multivariate analysis controlling for patient demographics, severity of injuries, comorbidities, hospital volume, and hospital characteristics, uninsured patients had a reduced likelihood of receiving a craniotomy (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.71-0.82) and spinal fusion (OR 0.67, 95% CI 0.64-0.71) relative to insured patients. This statistically significant trend persisted when uninsured and insured patients were matched on the basis of mortality propensity score. Uninsured patients demonstrated an elevated risk-adjusted mortality rate relative to insured patients in cases of extraaxial intracranial hematoma. Among patients with spinal injury, mortality rates were similar between patients with and without insurance. In this study, uninsured patients were consistently less likely to receive a craniotomy or spinal fusion for traumatic intracranial extraaxial hemorrhage and spinal vertebral fracture, respectively. This difference persisted after accounting for overall injury severity and patient access to high- or low-volume treatment centers, and potentially reflects a resource allocation bias against uninsured patients within the hospital setting. This information adds to the growing literature detailing the benefits of health reform initiatives seeking to expand access for the uninsured.

Enabling patient-centered communication and care through health information technology

Advances in communication science and developments in health information technology coupled with recent health reform initiatives have created unique opportunities for progressing toward a patient-centered healthcare system in the US. We propose a conceptual framework to describe ways in which patient-centered communication may serve as a critical link in translating health information technology functionality into delivery of patient-centered care. In this context, health information technology may provide the infrastructure for patient-centered communication to enable delivery of patient-centered care. Key aspects of patient-centered communication and health information technology are reviewed and patient-centered care is described as emerging through health information technology-enabled patient-centered communication.

Students’ Perceptions of School Counselors: An Investigation of Two High Schools in Beijing, China

This study sought to examine students' perceptions of their school counselors in two high schools in Beijing, China. Independent t tests found that female students rated school counselors' availability significantly higher than male students did. Also, students who had received prior counseling services rated counselors significantly higher in the following areas than did students who had never received counseling services: knowledge of achievement tests, friendliness and approachability, understanding students' point of view, advocating for students, promptness in responding to requests, ability to explain things clearly, reliability to keep promises, availability, and overall effectiveness. A 2 × 2 between-subjects ANOVA found an interaction effect between gender and use or nonuse of counseling services. In general, students gave positive evaluations of school counselors and were satisfied with counseling services.Keywords: school counselors; counseling services; students' perceptions; high schools; Beijing, ChinaChina has been experiencing dramatic economic and social changes in the past 3 decades (Guthrie, 2012). During this time there has been increased attention to both mental health problems and student development (Cyranoski, 2010; Lim, Lim, Michael, Cai, & Schock, 2010; Xin & Zhang, 2009). It has been estimated that at least 17.5% of the Chinese population has some form of mental illness, one of the highest rates in the world (Phillips et al., 2009), accounting for about 20% of hospitalizations in the country (Fei, 2006). Facing significant mental health challenges, several authors have noted the need for more counseling professionals and mental health service providers (Cook, Lei, & Chiang, 2010; Davey & Zhao, 2012). In rural areas with fewer resources, the demand for mental health care is even greater (Ji, 2000).Given such great needs for mental health services, China has been making tremendous efforts in reforming its mental health service system (Tse, Ran, Huang, & Zhu, 2013). In 2004, China launched the 686 Project, a mental health reform initiative modeled on the World Health Organization's recommended framework for integrating hospital-based services with a community mental health service system (Ma, 2012). By the end of 2011, 1.83 million Chinese people with severe mental illness had been treated as a result of the project.While China has witnessed growth in the counseling profession, at the same time it has struggled to build national certification and licensing standards, and create comprehensive counselor training (Chang & Kleinman, 2002; Cook et al., 2010; Davey & Zhao, 2012; Ding, Kuo, & Van Dyke, 2008; Hou & Zhang, 2007). In 2002, China's National Counseling Licensing Board was formed, and there is currently a three-tier national licensing program. More than 30 locations throughout China offer the qualification exams for counselors, and recently a national exam to license school counselors was instituted (Lim et al, 2010). Results from a nationwide survey of professional training of mental health practitioners in China showed that quality of training and supervision were among common concerns (Gao et al., 2010). Also, more accredited professional training programs at the university or college level must be designed and established. Beijing Normal University, in collaboration with Rowan University in the United States, was reported to be the first university in China to offer a school counseling training program (Lim et al., 2010).Mental Health of Students in ChinaIncreased attention to student well-being has shown high prevalence of mental health problems among Chinese students (Cook et al, 2010; Wang & Miao, 2001). Common psychological problems among students included test anxiety, academic pressure, loneliness, social discomfort, video game addiction (Thomason & Qiong, 2008), Internet addiction, child obesity, self-centeredness and reclusion (Worrell, 2008). …

Integrated Care Book Offers ‘How-To’ Advice for Psychiatrists

Integrated Care Book Offers ‘How-To’ Advice for Psychiatrists

Best-practice integrated health care governance - applying evidence to Australia's health reform agenda.

Internationally, health reform initiatives have identifi ed improved integration between community and acute care delivery as key to sustainability.1,2 Australian reform initiatives have been no exception. In 2009, Australia’s National Health and Hospitals Reform Commission laid the “blueprint” for Australia’s health care future.3 It stressed the importance of “connecting and integrating health and aged care services for people over their lives”. However, it also observed that “each level of government formulates policy in relation to its own responsibilities, not necessarily taking account of the health system as a whole”, and that “current governance arrangements are contributing directly to weaknesses in the quality, effectiveness and effi ciency of the Australian health system”.3 Three years later, the National Healthcare Agreement 2012 committed all federal, state and territory governments to support an integrated approach to the promotion of healthy lifestyle, and prevention, diagnosis and treatment of illness across the continuum of care.4 Despite the critical nature of joint community and acute care cooperation in delivering on the plethora of mutually agreed objectives, there was no mention of any commitment to the integrated governance arrangements pivotal to such success. Concurrently, Australia’s fi rst National Primary Health Care Strategy established a network of 61 primary health care organisations, Medicare Locals (MLs), across Australia.5 While the Strategy stated that MLs “will be an integral component of the National Health and Hospitals Network” and “have some common governance membership with the Local Hospital Networks [LHNs] in their region”, an integrated governance model was never developed.5 Given the priority placed on effective governance frameworks to deliver clear roles and responsibilities to both funders and providers of health care, what is the governance vehicle best suited to achieving our national reform outcomes, and how is it best crafted in the current Australian health care reality? In 2013, we conducted a systematic review to explore international peer-reviewed articles and relevant websites for effective and sustainable integrated primary–secondary health governance models. Ten key elements were identifi ed, many interdependent, from 21 articles that met the inclusion criteria.6 The evidence suggests the following specifi c governance elements are important to support integrated care across the primary–secondary care continuum: • Joint planning was identifi ed as key in 18 of the 21 articles. Governance arrangements included formal agreements such as memoranda of understanding (MOUs), joint board memberships and multilevel partnerships in the planning process. • Integrated information communication technologies were noted in 17 articles, particularly, a shared electronic health record, and systems that link clinical and fi nancial measures. • Effective change management was noted in 17 articles, requiring a shared vision, leadership, time and committed resources to support implementation. • Sixteen studies agreed on the importance of shared clinical priorities, including the use of multidisciplinary clinician networks, a team-based approach and pathways across the continuum to optimise care. • Aligning incentives to support the clinical integration strategy, noted in 15 studies, includes pooling multiple funding streams and creating equitable incentive structures. • Providing care across organisations for a geographical population, noted in 13 articles, required a form of enrolment, maximised patient accessibility and minimised duplication. • Use of data as a measurement tool across the continuum for quality improvement and redesign, found in 12 studies, requires agreement to share relevant data. • Professional development supporting joint working, supported by 11 articles, allowed alignment of differing cultures and agreement on clinical guidelines. • An identifi ed need for consumer/patient engagement, noted in eight studies, is achieved by encouraging community participation at multiple governance levels. • One-third of articles acknowledged the need for adequate resources to support innovation to allow adaptation of evidence into care delivery.6

Radiation oncology: a perspective on health reform and value-based initiatives.

The American Society for Radiation Oncology Payment Reform Action Plan is a three-phased proactive plan to ensure predictable and fair reimbursement for radiation oncology treatment.

The Demand for Alternative Forms of Financing Universal Health Care in Canada: A Literature Review

<div class="page" title="Page 32"><div class="layoutArea"><div class="column"><p><span>The discourse surrounding the unsustainability of financing universal health care in Canada has led many stakeholders to evaluate the current system in or- der to consider alternative forms of funding. Several health care financing mod- els have been suggested and include Medical Savings Accounts (MSAs), in- creased taxation and targeting policy to control specific cost drivers such as price inflation of physician and hospital services. This paper targets health care pro- fessionals, researchers and policy makers and calls for more awareness in evalu- ating public health reform initiatives for alternative measures of financing Uni- versal Health Care. Public reform must be critically considered in order to im- prove the cost and delivery of health care services since private methods ulti- mately impede on individual and population determinants of health. Discussed here are alternative financing strategies with an evaluation of benefits, limita- </span><span>tions, and future recommendations for Canada’s health care system. </span></p></div></div></div>

The need to maintain quality and build capacity for emergency medicine training

The need to maintain quality and build capacity for emergency medicine training

Prevention and management of chronic disease in Aboriginal and Islander Community Controlled Health Services in Queensland: a quality improvement study assessing change in selected clinical performance indicators over time in a cohort of services

ObjectiveTo evaluate clinical healthcare performance in Aboriginal Medical Services in Queensland and to consider future directions in supporting improvement through measurement, target setting and standards development.DesignLongitudinal study assessing baseline performance...

Improving Value in Healthcare

Despite having the highest per capita spending on healthcare in the world, seriously ill patients in the United States often do not receive the highest quality care. Improving the value of healthcare by increasing quality while reducing escalating costs is at the heart of US health reform. With the passage of the Patient Protection and Affordable Care Act of 2010, new healthcare delivery and payment models are being implemented to achieve these goals. This article reviews areas of health reform that have specific relevance for hospice and palliative care, highlights palliative care’s positive outcomes, and reflects on current challenges within the healthcare system as well as within the field itself. Considerations regarding the language we use are explored, and recommendations are provided to ensure hospice and palliative care is represented in the planning and implementation of health reform initiatives.

Improving reproductive health in rural China through participatory planning

China's new health reform initiative aims to provide quality accessible health care to all, including remote rural populations, by 2020. Public health insurance coverage for the rural poor has increased, but rural women have fared worse because of lower status and lack of voice in shaping the services they need. Use of prenatal care, safe delivery and reproductive tract infections (RTIs) services is inadequate and service seeking for health problems remains lower for men. We present findings from a study of gender and health equity in rural China from 2002 to 2008 and offer recommendations from over a decade of applied research on reproductive health in rural China. Three studies, conducted in poor counties between 1994 and 2008, identified problems in access and pilot tested interventions and mechanisms to increase women's participation in health planning. They were done in conjunction with a World Bank programme and the global Gender and Health Equity Network (GHEN). Reproductive health service-seeking improved and the study interventions increased local government commitment to providing such services through new health insurance mechanisms. Findings from the studies were summarised into recommendations on gender and health for inclusion in new health reform efforts.

Decision-Making Criteria among National Policymakers in Five Countries: A Discrete Choice Experiment Eliciting Relative Preferences for Equity and Efficiency

BackgroundWorldwide, there is a need for formalization of the priority setting processes in health. Recent research has used the term multicriteria decision analysis for methods that systematically include preferences for both equity and efficiency. The present study compares decision-makers' preferences at the country level for a set of equity and efficiency criteria according to a multicriteria decision analysis framework. MethodsDiscrete choice experiments were conducted for Brazil, Cuba, Nepal, Norway, and Uganda. By using standardized methods, we elicited preferences for intervention attributes using a individual choice questionnaire. A multinomial logistic regression was applied to estimate the coefficients for all single-policy criteria, per country. Attributes were assigned to an equity group or to an efficiency group. After testing for scale variance, predicted probabilities for interventions with both types of attributes were compared across countries. ResultsThe Norway and Nepal groups showed considerable preferences for efficiency criteria over equity criteria with percent change in respective predicted sum probabilities of [10%, −84%] and [6%, −79%]. Brazil and Uganda also showed preference for the efficiency criteria though less convincingly ([−34%, −93%], [−18%, −63%], respectively). The Cuban group showed the strongest preferences with equity attributes dominating efficiency ([−52%, 213%]). ConclusionsGroup preferences of policymakers show explicit but varying trade-offs of efficiency and equity in these diverse settings. This multicriteria decision analysis approach, using discrete choice experiments, indicates that systematic setting of health priorities is possible across a variety of countries. It may be a valuable tool to guide health reform initiatives.

Massachusetts Health Reforms: Uninsurance Remains Low, Self-Reported Health Status Improves As State Prepares To Tackle Costs

The Massachusetts health reform initiative enacted into law in 2006 continued to fare well in 2010, with uninsurance rates remaining quite low and employer-sponsored insurance still strong. Access to health care also remained strong, and first-time reductions in emergency department visits and hospital inpatient stays suggested improvements in the effectiveness of health care delivery in the state. There were also improvements in self-reported health status. The affordability of health care, however, remains an issue for many people, as the state, like the nation, continues to struggle with the problem of rising health care costs. And although nearly two-thirds of adults continue to support reform, among nonsupporters there has been a marked shift from a neutral position toward opposition (17.0 percent opposed to reform in 2006 compared with 26.9 percent in 2010). Taken together, Massachusetts's experience under the 2006 reform initiative, which became the template for the structure of the Affordable Care Act, highlights the potential gains and the challenges the nation now faces under federal health reform.

History for the Future (of Nursing)

On October 5, 2010, the Institute of Medicine (IOM)1 released the report The Future of Nursing: Leading Change, Advancing Health.2 Based on the two yearlong deliberations of a stellar committee chaired by former Health and Human Services Secretary Donna Shalala and vice chair Linda Burnes Bolton, CNO of Cedars Sinai Medical Center in Los Angeles, the report is positioned to serve as a blueprint for transforming the nursing profession. The report's main message directly addressed nursing and patient care: Health care reform could not be accomplished without better educated nurses who had the skills and knowledge to lead improvements in the quality of care and patient access. As the Nurse Scholar in Residence at the IOM3 in 2010, I proposed to work with the Future of Nursing committee as part of my residence commitment. When I first interviewed with a committee senior staff member, she was hesitant and questioned what I could contribute as a historian. My response was and context. Because all deliberations are confidential, I cannot relate specific contributions, but as you read the report, the historical perspective and the use of context as an explanatory framework is clear. As an historian I knew that numerous studies about the nursing profession had been conducted by many different groups, and that the reasons for and findings of each study reflected the politics (both local and national) of the time period and the participants. The Future of Nursing study followed this tradition. This does not mean that the members sought individual political gain, but that each had their own sense (and perhaps that of the groups they represented) of the nursing profession and its place in the health care system. Economists, political scientists, insurance executives, physicians and nurses themselves each came from their particular standpoint and place in terms of how they valued nurses' work and what they thought could and should be accomplished by the report. Each understood nursing's history from their own political, personal, and historical vantage point. The IOM conducted its last major study on nursing in 1983, which was situated in a different political and social context.4 Yet, some of the recommendations from the 1983 report seemed familiar-the need for better educated nurses, better workforce data, a more diverse workforce, and the need to remove practice barriers. But, context and contingency are time and place dependent and shape the work we do and the meaning that work holds for patients. We also know there is, indeed, historical continuity that gives shape to our values and our responsibilities as the largest group of caregivers in the health care arena. These perspectives implicitly shaped how the report and the recommendations were developed as historical evidence grounded modern data. But history also provides examples of opportunities and possibilities. We know that nurse leaders such as Dorothy Smith (University of Florida Gainesville) and Mary Elizabeth Carnegie (Florida A&M) changed how and where nurses were educated and how African American nurses negotiated their space in the professional association structures in the post War decades. And we know that nurses have been innovators in public and community health- types of care that will be the backbone of new delivery systems such as medical homes and accountable care organizations. We also see the worth and work of pioneer advanced practice nurses as they practiced in medically underserved areas or in collaboration with physician colleagues. As historians we can learn from these historical examples and use them to explain and to critique larger policy issues. For example, better quality, value, and access to health care services can be achieved only with the participation of nurses as leaders and as valued clinicians. This is as true today as it was with the passage of Medicare and Medicaid in 1965, but unlike previous health reform initiatives we now have the opportunity provided by explicit recognition of this relationship in the text of the legislation. …

Health reform and Healthy People initiative.

The passage of the Affordable Care Act builds on and strengthens the foundation for prevention and wellness that Healthy People--the nation's health promotion and disease prevention aspirations for a healthier nation--established. The Affordable Care Act reaffirms the themes of Healthy People by promoting population-based prevention and sets the stage for Healthy People 2020. The heart of Healthy People 2010 lies in its leading health indicators, reflecting high-priority health issues for the nation. National progress requires broad application of the ecological health model. We reviewed the status of each Healthy People 2010 indicator and noted how the Affordable Care Act drives future positive health outcomes using the ecological model of health as a prism for viewing health improvement.

Obamacare: an ethical analysis of his leadership and the health reform initiative

PurposeThis paper aims to explore President Obama's leadership style during passage of this major and controversial piece of legislation. Specifically it addresses the historical development of healthcare reform in the USA, and provides an ethical analysis of President Obama's leadership in pursuing the health reform initiative.Design/methodology/approachBased on a review of the literature, speeches, and application of leadership and ethical theory, an analysis was done of President Obama's leadership and ethical approach to healthcare reform.FindingsThis analysis revealed that Obama's behavior was consistent with the full‐range leadership model articulated by Bass and Avolio. Moreover, his personal and strategic ethical approach to promulgating healthcare reform incorporated both deontological and teleological ethical principles.Originality/valueThis paper provides a current look at President Obama's leadership style and demonstrates how incorporating different ethical theories can result in the same outcome.

Foundation’s Consumer Advocacy Health Reform Initiative Strengthened Groups’ Effectiveness

Private foundations may hesitate to fund consumer advocacy for enacting and implementing health reform because the effects are hard to measure, and because they are concerned that funds will be used for lobbying activities that are prohibited by federal tax rules governing private philanthropy. Mathematica Policy Research evaluated a Robert Wood Johnson Foundation initiative supporting state consumer health advocacy networks. During the three-year grant period, most networks coalesced and improved their ability to advocate effectively. A majority of state policy makers reported that consumers became more involved and effective in shaping health policy, and many wanted consumer advocates to remain involved in public debates on implementing federal health reform. The evaluation shows that targeted investments by foundations to strengthen consumer groups' ability to advocate effectively can help ensure that their voice is heard in critical policy debates.

Comment on de Brantes, Rastogi, and Painter: Reducing Avoidable Complications in Patients with Chronic Diseases: ThePrometheusApproach

Since the Institute of Medicine's publications (1999, 2001) that highlighted major deficiencies in the quality of health care in the United States, extensive efforts have been made to improve patient care. Legislation was passed that requires reporting of compliance with national performance measures (Public Law 109–171, 2006), guidelines were developed by specialty societies to provide clinical direction (Agency for Healthcare Research and Quality 2011) and pay-for-performance programs were underwritten by hospitals and insurers (Lindenauer et al. 2007). There is little evidence to suggest that these initiatives substantially improved the overall quality of patient care. Meanwhile, health care costs continue to spiral out of control, threatening the stability and welfare of our entire economy. HSR's December Theme Issue on Payment Reform addresses “an area that will undoubtedly be of critical importance as the nation gears up to implement one of the largest American health reform initiatives in history” (Fraser, Encinosa, and Baker 2010). In this issue, de Brantes, Rastogi, and Painter (2010) attempt to demonstrate that the recently developed Prometheus payment system can make a substantial, relatively painless contribution to quality improvement and cost containment by creating strong financial incentives for health care providers to reduce costly potentially avoidable complications (PACs). Although implementation of the Prometheus payment system in several pilot sites was funded by the Robert Wood Johnson Foundation in February 2008 (Robert Wood Johnson Foundation 2011), analyses presented in this paper utilized only historical data from a large claims data set and projections by other investigators. Based on the assumption that a prototypical practice achieved target complication rates, the authors projected a net gain of “close to U.S.$20,000” for this practice if the Prometheus payment system were employed. While not a clinically achievable end-point, the authors identify that the elimination of all PACs from this prototypical practice would have a “total calculated margin opportunity for the practice [that] is close to U.S.$600,000.” From their analysis of this single prototypical practice, the authors concluded that “the incentives in the Prometheus Payment appear to create the impetus for reduction in PACs.” In their abstract, they extended their findings to suggest that “total costs associated to the six chronic conditions studied could decrease by 3.8 percent” as a result of nationwide adoption of Prometheus payment reform. A careful examination of this paper calls all of these conclusions into question. It also exposes several unintended consequences that are likely to undermine efforts to address the current health care crisis in the United States. These unintended consequences arise from an acceptance of three fallacies: the fallacy of the prototypical practice, the fallacy of arbitrary standards, and the fallacy of something for nothing.

Meeting US Health Reform Mandates with Computerized Health Services Utilization Matching and Optimization

Recent US health reform initiatives now require extensive consumer involvement through healthcare purchasing exchanges. The opportunity exists to monitor and plan for peak service needs in such an environment. The use of computational systems and methods for health services planning and utilization review have traditionally been employed in post-facto or financial analysis settings. In this technology review we propose one innovative model and attribute-based method that collects and analyzes indicators of consumers or patients within a defined network, accepts sensor data about individuals, and presents a set of health care service options at least partially based on the acceptance of indications of member attributes as well as sensor data about network actors.

The Impacts of State Health Reform Initiatives on Adults in New York and Massachusetts

To analyze the effects of health reform efforts in two large states--New York and Massachusetts. National Health Interview Survey (NHIS) data from 1999 to 2008. We take advantage of the "natural experiments" that occurred in New York and Massachusetts to compare health insurance coverage and health care access and use for adults before and after the implementation of the health policy changes. To control for underlying trends not related to the reform initiatives, we subtract changes in the outcomes over the same time period for comparison groups of adults who were not affected by the policy changes using a differences-in-differences framework. The analyses are conducted using multiple comparison groups and different time periods as a check on the robustness of the findings. Nonelderly adults ages 19-64 in the NHIS. We find evidence of the success of the initiatives in New York and Massachusetts at expanding insurance coverage, with the greatest gains reported by the initiative that was broadest in scope--the Massachusetts push toward universal coverage. There is no evidence of improvements in access to care in New York, reflecting the small gains in coverage under that state's reform effort and the narrow focus of the initiative. In contrast, there were significant gains in access to care in Massachusetts, where the impact on insurance coverage was greater and a more comprehensive set of reforms were implemented to improve access to a full array of health care services. The estimated gains in coverage and access to care reported here for Massachusetts were achieved in the early period under health reform, before the state's reform initiative was fully implemented. Comprehensive reform initiatives are more successful at addressing gaps in coverage and access to care than are narrower efforts, highlighting the potential gains under national health reform. Tracking the implications of national health reform will be challenging, as sample sizes and content in existing national surveys are not currently sufficient for in-depth evaluations of the impacts of reform within many states.