Meaningful Health Care Reform Research Articles

Relationship-centered health care as a Lean intervention.

Continuous improvement efforts, recognized in much literature as Lean management techniques have been used in efforts to improve efficiency in democratic health care contexts for some time to varying degrees of success. The complexity of the health care system is magnified by the sheer number of processes and sub processes required to deliver value within a bureaucratic environment, while maintaining some level of compassionate and personalized care. There is inherent tension between what is required to be efficient and what is required to be caring and this conflict presses against Lean practice at the level of delivery.Administration and care intersect at the point of the patient's experience. In order to achieve the dual goals of improved value and lower costs, the application of Lean thinking for meaningful health care reform must acknowledge the fundamental dichotomy between the impersonal tasks required to provide health services, and human interactions. Meaningful health care reform requires an acknowledgement of this distinction, currently not recognized in literature. While administrative process improvements are necessary, they are insufficient to achieve a sustainable and caring health care system. Lean thinking must be applied differently for administrative processes and patient care encounters, because these are fundamentally different processes. In this way, Lean principles will effectively contribute to sustainable health system improvements.

Primary health care, a concept to be fully understood and implemented in current China’s health care reform

The English concept “primary health care” (PHC) has been misunderstood and wrongly interpreted in Chinese as “entry-level health care” (初級卫生保健) for more than a half century. On the other hand, specialty care was considered “advanced health care.” This misconception of PHC permeated the government and the health care field with many negative consequences for China’s vision of its health care and development strategy, in areas such as government policy-making, health care financing, infrastructure planning, and health care workforce training. This article elucidates how PHC has been misconstrued and translated into “entry-level health care” in China and why it is a wrong interpretation of the PHC concept from various angles, including the basic English meaning of “primary” and “health care,” the concept of comprehensive PHC, the global PHC experience, and the harmful consequences of the misconception in China’s PHC development and in society at large. China’s current new health care reform toward a PHC-centered health system has made significant early achievements, but also faces huge challenges, including the widespread and ingrained misconception of PHC. It is hoped that academic scholars in the health care field, medical professionals, and officials in the government will gain clearer insight into the PHC concept and rectify its harmful effects on PHC development in various sectors, and promote advancement of meaningful health care reform applicable to the masses.

Editor’s Note

Editor’s Note David Granger Greetings and welcome to the latest edition of Education & Culture. You will find in this issue a healthy portion of instantly recognizable Deweyan themes, but in many instances with a new, sometimes surprising twist. Below I will highlight a few elements of these creative variations on the familiar. Some of you might recall that our lead article, Jim Garrison’s “Making Meaning Together Beyond Theory and Practice,” had its first life as the 2012 Dewey Lecture. In this piece, Garrison examines the popular Deweyan theme of the relationship between theory and practice. Yet unlike many authors, who look to Dewey in arguing for the necessity somehow to bridge theory and practice, Garrison points out that Dewey in fact prompts us to see theory and practice (like many other seemingly ubiquitous dichotomies) as “subfunctions within the larger function of making meaning, knowledge, and value in our lives.” Thus the emphasis here is really on creation rather than construction, especially as the latter term is currently used in education to denote the process of artificially making engaging and useful something that is otherwise uninteresting and not useful. Our next piece is Gary Bullert’s “The Committee for Cultural Freedom and the Roots of McCarthyism.” In this offering, Bullert situates the Committee for Cultural Freedom (CCF), of which Dewey was a founding member, within its historical-geographical milieu so as to revisit and scrutinize popular allegations that Dewey and his cohorts (namely, Sidney Hook) contributed to the red-scare hysteria and repressive anti-communism of the 1940s and 1950s, in part through efforts to expel communist party members from the teaching profession. After examining the issue in its many and complicated facets, Bullert concludes, among other things, that the CCF in fact “offered a responsible alternative to the excesses” of McCarthyism. Traversing some allied ground, Cherilyn Keall, in “The Paradox of Freedom: John Dewey on Human Nature, Culture, and Education,” explores the meaning of Dewey’s provocative (and to many confusing) claim that human nature both does and does not change. Here we are provided with an opportunity to revisit another popular dichotomy and see what it looks like through a Deweyan lens. In doing so, Keall argues, we find that Dewey understands human nature to have two interrelated facets, one that changes, due to our embeddedness in diverse, ever-evolving cultures, and one that does not, resulting from the innate needs that we all share through our similar constitution as human beings. As a result, human freedom, an issue fundamental to the work of all manner of educators, must be conceived with an eye to the inexpugnable stability and precariousness of human nature. This is followed by Victor Rodriguez’s intriguing look at what he calls “Radical Dewey: Deweyan Pedagogy in Mexico, 1915–1923.” Rodriguez chooses this particular time period because it predates the appropriation of Dewey’s ideas by Mexico’s revolutionary government, prior to which his writings were popular among [End Page 1] socialists, radical pedagogues and progressive-minded teachers. Yet little scholarship to date has looked closely at or taken seriously this earlier, and at times very creative, application of Dewey’s work, focusing instead on the better known subsequent state project experiment with Deweyan schools in the mid-1920s. Rodriguez attempts to amend the record on this important topic. The pressing issue of healthcare is then taken up in Danielle Lakes’ very topical piece “Engaging Deweyan Ethics in Healthcare: Leonard Fleck’s Rational Democratic Deliberation.” Here, Lake makes the case that a form of ”open dialogue between citizens,” developed and utilized by author Leonard Fleck, a close reader of Dewey and former member of the Hillary Rodham Clinton Task Force on Health Reform (1993), deserves serious attention as a vehicle for making possible meaningful healthcare reform. As Lake explains, “It is my hope that Fleck’s rational democratic deliberation could begin to build a foundation for further cooperation, for greater education about the various and complicated bioethical situations we must confront and, finally, for establishing working solutions that are amenable to adjustment.” “Reconstructing Deweyan Growth: The Significance of James Baldwin’s Moral Psychology” is Jeff Frank’s thoughtful attempt to make Dewey’s...

The Truth About Torts: Defensive Medicine and the Unsupported Case for Medical Malpractice 'Reform'

In the debate about health care reform, “defensive medicine” has become a convenient culprit for rising costs and especially rising physician malpractice premiums. Vaguely defined, the phrase, “defensive medicine,” is used to suggest that physicians make medical decisions to avoid potential litigation, instead of with their patients’ health and safety in mind. On the strength of this assertion alone, some policymakers argue for restricting Americans’ right to bring suit to recover damages for medical malpractice. This report demonstrates, however, that the proponents of medical malpractice “reform” lack persuasive evidence that tort litigation against physicians encourages them to make medical decisions that they would not have made otherwise.Powerful business interests have compelling reasons to perpetuate the “defensive medicine” myth. Because the national health care debate has been framed around costs – not patient health and safety or access to care – the “defensive medicine” message has been successfully deployed to restrict Americans’ access to the courts in many states. Meanwhile, “defensive medicine” also serves as a politically expedient straw man, allowing policymakers and the insurance industry to ignore or obscure the real drivers of rising medical costs, including the high costs of prescription drugs; the high demand for, and increasing use of, state-of-the-art technology; the growing incidence of chronic diseases; and an aging population that lives longer and consumes more medical care.This report first establishes that an intact and robust civil justice system is necessary to the health of society and exposes how rarely doctors are actually being sued. Next, it examines why doctors order tests and procedures. It then surveys available empirical evidence showing that a supposed “defensive medicine” mindset has little impact on medical decisions or on medical practice costs. The report also exposes extraordinary shortcomings in the methodology and academic rigor of the evidence most frequently cited by civil justice opponents.The evidence reveals that “defensive medicine” is largely a myth, proffered by interests intent on limiting citizen access to the courts for deserving cases, leaving severely injured patients with no other recourse for obtaining the corrective justice they deserve. These changes would limit the deterrent effect of civil litigation and diminish the regulatory backstop that the civil justice system provides to the professional licensing system, leading to more medical errors. Restricting lawsuits might save doctors a negligible amount on malpractice premiums but the vast majority of any savings will most certainly line the pockets of the insurance companies demanding these restrictions. On the other hand, buying into this myth has very real and dangerous consequences. Allowing civil justice opponents to pretend that constraining the civil justice system equates to meaningful health care reform distracts us from doing the things that must be done to fix the system, including avoiding the 98,000 deaths caused by preventable medical errors every year and reducing the unacceptable number of uninsured Americans.

Health care reform in the USA: Recommendations from USA and non-USA radiologists

To compare the opinions and recommendations of imaging specialists from United States (USA) and non-USA developed nations for USA health care reform. A survey was emailed out to 18 imaging specialists from 17 non-USA developed nation countries and 14 radiologists within the USA regarding health care reform. The questionnaire contained the following questions: what are the strengths of your health care system, what problems are present in your nation's health care system, and what recommendations do you have for health care reform in the USA. USA and non-USA radiologists received the same questionnaire. Strengths of the USA health care system include high quality care, autonomy, and access to timely care. Twelve of 14 (86%) USA radiologists identified medicolegal action as a major problem in their health care system and felt that medicolegal reform was a critical aspect of health care reform. None of the non-USA radiologists identified medicolegal aspects as a problem in their own country nor identified it as a subject for USA health care reform. Eleven of 14 (79%) USA radiologists and 16/18 (89%) non-USA radiologists identified universal health care coverage as an important recommendation for reform. Without full universal coverage, meaningful health care reform will likely require medicolegal reform as an early and important aspect of improved and efficient health care.

A Good Coalition

A Good Coalition

Progress in Cancer Care: A Rational Call To Do Better

Progress in Cancer Care: A Rational Call To Do Better

To Have Meaningful and Sustainable Health Care Reform, It Has to Be Complete

Journal of Craniofacial Surgery: November 2009 - Volume 20 - Issue 6 - p 1957-1958 doi: 10.1097/SCS.0b013e3181c2a856

Creating meaningful health care reform

Creating meaningful health care reform

Health care reform: the differential diagnosis

Economic and political experts appear to agree that the US health care system is a horrible mess, and there is no consensus as to how to fix it. The differential diagnosis is that our health care system: (a) is dying because of hopelessly opposed political parties and greedy insurance companies or (b) has a treatable illness. I believe that the illness is treatable, if we adhere to several guiding principles. These include (a) universal access to compassionate health care, (b) improved health care through scientific advances, and (c) reduced administrative and legal costs. Establishing these three goals, and introducing a series of changes designed to achieve them, can result in meaningful health care reform. Goal number one: universal, compassionate coverage. The first goal should be the easiest to achieve. Initially, through a combination of private and public options, everybody should have some form of health insurance. I believe that the ultimate goal should be a single-payer system, but that need not be the first step toward universal coverage. Achieving universal health insurance today would require the government to provide coverage for that portion of the 15% in the United States who are currently uninsured and cannot afford health insurance and to make health insurance a requirement for those who can afford it. The reality is that everybody now has access to health care, but the uninsured primarily use the most expensive forms of health care (e.g., the emergency room), boosting the costs. Cost savings from regulating physician income and from administrative and tort reform could be used to pay for universal coverage. A bigger challenge is training the primary care providers who will be required in a new, more efficient health care system. This will require increased efforts by US medical schools to recruit and train primary care providers. To promote preventive care, all insurers should be required to refund a portion of insurance costs to patients who undergo their annual physical examinations. The discussion about health care has to refocus on how to provide access for all to a physician who is well trained and cares about patients and who works in a system that is humane and no longer treats patients and physicians like commodities. Goal number two: scientific advances in medical knowledge. America has the best biomedical research infrastructure in the world. However, this great national treasure is fragile and must be continually supported in order to develop new, more effective and affordable diagnostics and therapies. Sustained increases in support for biomedical research are an essential component of health care reform. Goal number three: reducing costs. Any discussion of meaningful health care reform has to include improvements in diagnosis and effectiveness of health care delivery achieved using electronic medical records. The costs of implementing electronic patient records should be shared among the medical schools, as a single format would meet the needs of all. Similarly, as a first step toward a single-payer plan, all insurance providers should be required to use the same form, which would largely be filled out automatically using the electronic record. This would drastically reduce administrative costs associated with insurance and billing. Additional cost savings could be achieved by meaningful tort reform that protects the legal rights of patients but reduces frivolous lawsuits. This could be facilitated by an enhanced system of case review by experts, prior to initiating costly legal proceedings. Further cost regulation should include compensating all physicians with salaries, which would remove incentives for unnecessary procedures. The diagnosis is clear: our health care system is in critical condition. However, its strengths include the world’s best systems for training health care providers and biomedical researchers. The quality and effectiveness of the administrative components of our health care system must be improved so that they enhance the health of the patient, rather than destroy it.

Agreement Could Shrink Part D 'Donut Hole'

Back to table of contents Previous article Next article Government NewsFull AccessAgreement Could Shrink Part D 'Donut Hole'Rich DalyRich DalySearch for more papers by this authorPublished Online:7 Aug 2009https://doi.org/10.1176/pn.44.15.0006APA has hailed an agreement by drug companies and the Obama administration to discount by 50 percent the cost of pharmaceuticals that fall within Medicare's drug coverage gap.The voluntary agreement by pharmaceutical companies, announced in June, will cut the cost of name-brand prescription medications by up to 50 percent when they fall into the so-called donut hole of Medicare's Part D prescription drug program that excludes coverage of drugs when their annual costs rise to between $2,700 and $6,154. Drug costs are reimbursed at 75 percent when they are less than $2,700 annually, and Medicare covers 100 percent of the cost of drugs once their accumulated cost rises above $6,154 annually.The agreement is predicted to provide up to $30 billion in discounts to seniors and save the federal government an additional $50 billion over 10 years in health care costs. Obama administration officials have not specified how these savings will occur.APA President Alan Schatzberg, M.D., hailed the development, calling the coverage gap “an excessive burden to those over 65 and those who are chronically disabled, including those suffering from mental illnesses.”“Although this is a first step, it is a step in the direction of providing high-quality, affordable health care to all Americans,” Schatzberg said. “APA recognizes that full prescription coverage is an integral part of any meaningful health care reform and applauds the effort to eliminate one of the most glaring deficiencies in Medicare.”The Obama administration described the agreement as part of the effort to enact major health care reform under consideration in Congress, because the details of the $50 billion projected savings in the agreement will be negotiated as part of final health care reform legislation. The deal is the latest high-profile voluntary agreement that the administration has announced with entities involved in the health care sector. The White House also has reached agreements for health care providers and hospitals to provide billions in savings to Medicare over the next 10 years, according to administration announcements. However, few details have been released on how those savings will be achieved, and some congressional leaders have said they will not honor the agreements in formulating health care reform measures.“The agreement by pharmaceutical companies to contribute to the health reform effort comes on the heels of the landmark pledge many health-industry leaders made to me last month, when they offered to do their part to reduce health spending $2 trillion over the next decade,” Obama said in a written statement issued in June.Those deals are important because the high cost of expanding insurance coverage to the nation's 47 million uninsured—estimated between $1 trillion and $2 trillion over 10 years—has slowed the pace of legislation in Congress to overhaul health care. Public-opinion polls also have consistently found that although most people support health reform, support is weak for any specific funding proposal.The impact of the latest agreement on people with serious mental illness could be significant.Roughly 3.5 million Medicare beneficiaries are projected to fall into the donut hole this year, according to congressional health reform advocates. According to a 2008 Kaiser Foundation study, about 500,000 Medicare beneficiaries—or 15 percent—stopped using their prescription drugs when they fell into the prescription costs range that comprises the donut hole. The study examined some beneficiaries with chronic illnesses, including people receiving treatment for depression, and found that 15 percent who were prescribed antidepressants stopped taking the medication when they reached the coverage gap in 2007. Another 8 percent stopped taking Alzheimer's medications when they reached the gap.Anita Everett, M.D., chair of APA's Council on Healthcare Systems and Financing, said the planned assistance would have a “tremendous impact” on fixed-income Medicare patients with mental illness.“Many individuals with mental illness depend on Medicare for access to psychiatric and other medications; the donut hole payment makes medications unaffordable to many who choose to go without rather than to pay hundreds of dollars each month for medications,” said Everett, in comments to Psychiatric News.Meanwhile, the pharmaceutical drug discount agreement drew some criticism from consumer advocates and liberal politicians, who said the total $80 billion in drug company price cuts are a tiny fraction of the $3.3 trillion in prescription drug spending that the Department of Health and Human Services estimates will occur over the next 10 years.The Kaiser Foundation report “The Medicare Part D Coverage Gap: Costs and Consequences in 2007” is posted at<http://www.kff.org/medicare/upload/7811.pdf>.▪ ISSUES NewArchived

Policy coherence in US tobacco control: beyond FDA regulation.

As the Obama administration moves to enact meaningful and comprehensive health care reform in the United States, tobacco control must be elevated as a public health priority [1]. Though tobacco control efforts have been recognized as a top public health achievement of the 20th century [2], tobacco use continues to be the leading preventable cause of death in the US [3]. As Box 1 shows, the US bears a heavy burden from the health and fiscal effects of smoking. Thus, continued progress in preventing tobacco use and promoting smoking cessation must be a leading priority for health care reform under the new administration. This policy paper gives the current status of tobacco control policies, initiatives, and legislative action at the time of going to press. Box 1. Health and Economic Burdens of Smoking, United States Tobacco use… …is the leading preventable cause of death. At least 443,000 annual premature deaths in the United States from 2000–2004 were attributable to smoking [33]. …leads to premature death. During 2000–2004, 5.1 million years of productive life were lost due to cigarette smoking and exposure to passive smoking per year [33]. …contributes to health disparities. African Americans, Native Americans/Alaska Natives, the poor, and people with lower educational attainment suffer from a higher burden of disease and disability from smoking. …is a major cause of cancer in the lung, larynx, pharynx, mouth, and bladder. It also causes cancer in the pancreas, cervix, kidney, and stomach. …causes deaths from heart disease, stroke, and chronic obstructive pulmonary disease. …is a fiscal burden. Cigarette smoking and exposure to tobacco smoke results in productivity losses of $96.8 billion annually [33] and over $75 billion in annual US medical expenditures [6].

Health Care Reform: Postelection Possibilities

Previously we examined health care system reform proposals of major candidates in 2008 Presidential Primaries (Flint & Gorin, 2008). Whatever outcome of 2008 election, pressure for reform is not likely dissipate. In this article we assess current climate for and possibility of reform. We also identify and discuss four current approaches--conservative reform, a single-payer system; private--public models; and state reform. BACKGROUND Readers of this journal are well aware of problems facing our health care system, particularly in areas of access and cost. More than 47 million Americans are completely uninsured, and number of underinsured people (that is, individuals with inadequate coverage) has reached 25 million, having grown 60 percent between 2003 and 2007 (Schoen, Collins, & Kriss, & Doty, 2008). According Urban Institute, 22,000 adults (ages 25 64) a year die because of a lack of health insurance (Dorn, 2008). Although health care inflation has slowed in recent years, this modest respite is likely temporary (Ginsburg, 2008). Despite recent moderation in medical care inflation, nearly a fifth of population went without or delayed receiving needed care (Cunningham & Felland, 2008). Although problems with access were particularly intense for individuals without coverage and those in poorer health, insured people also faced large increases in unmet need (Cunningham & Felland, 2008, p. 1). The central reason cited for problems with access was concern about cost. Health care costs are spreading beyond impeded access care. The Government Accountability Office recently warned that health care inflation poses a serious threat long-term fiscal stability of nation (Long-Term Fiscal Outlook, 2008). Given these circumstances, pressure for health reform is not likely any time soon. Prospects for Reform Prognosticating is fraught with risk, particularly because at time of this writing we do not know which party will win White House or control Congress. Nonetheless, basis of information we have, this is our best estimate of current climate and prospects for reform. Wyden and Bennett (2008) argued that we have entered a period during which it may be possible break 60 years of gridlock and enact meaningful health care reform. They point bipartisan support for Senate Bill 334, Healthy Americans Act (2007), which guarantees universal coverage though market-driven health care choices like those that members of Congress have (Wyden & Bennett, 2008, p. 690). They cite ideological truce between Republicans and Democrats, and recognition by business and labor groups that they must work together modernize our employer-based system meet needs of both workers and employers (Wyden & Bennett, 2008, p. 690). Democratic pollsters assert that fundamental reform may be possible, but warn that the opportunity could easily dissipate (Lake, Crittenden, & Mermin, 2008).Voters believe that health care should be a right and recognize reform as an investment in future. They also want security and peace of mind universal coverage would bring. Despite this, opponents will actively work to sow confusion, doubt, and fear about major change (Lake et al., 2008, p. 698). Immigration is a particular wild card. Opponents of reform are likely attack any universal proposal as benefiting illegal immigrants, a charge that is potentially a greater liability than any of usual attacks taxes, government control, and so on (Lake et al., 2008, p. 697). Although reform is a real possibility, advocates cannot take it for granted but must work strategically as well as passionately for changes they seek (Lake et al., 2008, p. 698). McInturff and Weigel (2008), prominent Republican pollsters, argue that situation we face today is similar that in early 1990s. …

Inclusion of Immigrant Families in U.S. Health Coverage Expansions

This paper examines federal and state restrictions on immigrants and the negative impact of these restrictions on local efforts to serve the uninsured. It examines a health coverage program offered to low-income residents in Alameda County, California from 2000 to 2005, illustrating local efforts to expand health coverage to both adults and children, regardless of immigration status. After five years of operating the pilot program, leaders of Alameda County's health care safety net conclude that local health coverage programs are unsustainable over a long period of time without significant federal and state support. The financial resources that federal, state, and local governments are patching together for health coverage could be used more efficiently if consolidated. Stabilizing the federal tax base and recognizing the phenomenal amount of federal, state, and local funding that is already spent on medical care for the uninsured are the first steps towards achieving meaningful health care reform.

Inclusion of Immigrant Families in U.S. Health Coverage Expansions

This paper examines federal and state restrictions on immigrants and the negative impact of these restrictions on local efforts to serve the uninsured. It examines a health coverage program offered to low-income residents in Alameda County, California from 2000 to 2005, illustrating local efforts to expand health coverage to both adults and children, regardless of immigration status. After five years of operating the pilot program, leaders of Alameda County's health care safety net conclude that local health coverage programs are unsustainable over a long period of time without significant federal and state support. The financial resources that federal, state, and local governments are patching together for health coverage could be used more efficiently if consolidated. Stabilizing the federal tax base and recognizing the phenomenal amount of federal, state, and local funding that is already spent on medical care for the uninsured are the first steps towards achieving meaningful health care reform.

The Long Arm of Health Care Disparity

There is no greater embarrassment to the world's wealthiest nation than the fact that over 44 million of its own citizens are uninsured and, at least, another 60 million are “under-insured.” Therefore, over one-third of Americans are ill prepared for the financial hardships resulting from mounting medical problems. For many, emergency departments—often cramped and understaffed—are the only access to health care. With inordinate waiting periods and some patients only presenting when the disease is intolerable (which is oftentimes a reliable marker for an advanced state of the disease), the current state of health care in the United States is not sustainable or ethical. Equal access to health care is one of the inherent responsibilities of this great nation. This country spends over a trillion dollars per year for health care, which no other nation can even approach. The health care industry is the only trillion-dollar industry in the United States. With $1.7 trillion being spent for health care last year, it is unlikely that more dollars would effectively address the disparity issue. In fact, this is, perhaps, one of the few times when “how” money is used rather than “how much” is at the crux of a better and more equitable system. Based on the premise that universal access to basic medical care is a right, meaningful health care reform—a critical element in combating racial disparity—cannot be based on a person's socioeconomic status. With the first national health care disparities report demonstrating racial disparity in surgical complications, the authors explored possible causes using New York State Hospital data. The purpose of the study was to investigate possible racial disparity (African American versus Caucasian) with regard to surgical complications in the state of New York. Hospital discharge data obtained from 1998–2000 in New York was used in the analysis. The data included information on 145,833 African Americans and 865,293 Caucasian patients. The authors highlight that previous studies have shown that African Americans have had higher complication rates than Caucasians. The present study, unlike the earlier ones, controls for patient comorbidity. It also controls for such hospital characteristics as hospital size, academic affiliation, hospital specialization (using the Herfindahl index) and other hospital demographics. Also, hospital ecological characteristics were controlled for such factors as percent of African American patients discharged in the past year, percent of Medicaid patients discharged, and Metropolitan Statistical Area sizes. The primary statistical method used in the data analysis was the hierarchical logistic regression, which controlled sequentially for patient and hospital characteristics. The first logistic regression model included race and gender and age, with the second adding the presence or absence of comorbidities and length of stay. The third added patient social and economic factors, including insurance, HMO status, and admission type (elective nor not). The fourth and fifth added hospital characteristics from the AHA file and hospital ecological characteristics, respectively. Tables 1 and 21 contain the main results. However, it should be noted that for Table 1, which has African Americans and Caucasians compared on outcome variables, patient demographics, patient morbidity indicators, patient social factors, hospital characteristics, and hospital ecology, there is no mention as to the statistical methodology used to produce the P values. Therefore, no determination can be made regarding the appropriateness of the analysis. Also, due to the extremely large sample sizes, virtually any difference between the 2 study groups (African Americans and Caucasians) will be statistically significant. Whether these differences are important in any practical sense remains to be answered. For example, the authors noted that the unadjusted complication rate for African Americans is 1.8% and 1.4% for Caucasians. This difference is 0.4% or 4 people out of a 1000. Although statistically significant, this difference cannot be considered “large” by any reasonable definition. The major portion of this paper addressed whether this 0.4% difference could be eliminated after controlling for several independent variables. The authors ultimately conclude that the higher rates of surgical complications among African Americans, as compared with Caucasians, are primarily explained by patient comorbidities and secondarily by hospital characteristics. Unfortunately, with comorbidities in African Americans so closely linked with health care disparity, particularly with respect to suboptimal access to medical management, the authors cannot readily uncouple the surgical complications from a more systematic racial and socioeconomic bias.

Third World medicine in First World cities: capital accumulation, uneven development and public health

This paper addresses issues of public health and access to care for the urban poor in the context of current U.S. urban, economic and industrial policy. The pathologies that threaten “inner city” neighborhoods are the result of decades of political neglect, economic exploitation and resource withdrawal, which themselves stem directly from public and corporate sector strategies to facilitate capital accumulation and consolidation. The resulting conditions of uneven development between wealthy and impoverished local sectors mirror similar relationships between First and Third World countries. These same patterns are reflected and reproduced in the health care “industry” itself, where growing corporate dominance has developed alongside a concomitant reduction in support for public sector and community-based care. These trends create and exacerbate conditions that place poor and minority populations at risk. Community development and political empowerment, as well as the overall corporate hegemony that increasingly characterizes the political economy of the U.S.A., are essential public health considerations that must be included in any meaningful health policy or health care reform proposals.

Measuring the quality of care: reforming the health care system.

Elements of meaningful health care reform must include the ability of patients, providers, and payers to select services offering quality care at an affordable price. To achieve this goal, an appropriate definition of quality needs to be articulated and adopted; data capturing the definition needs to be collected; and appropriate measures need to be selected to analyze that data. Results need to be publically available to assist in making informed choices. The health professions need to fulfill their social contract. And, government needs to ensure that public safety and accountability are maintained and preserved. While the goals and strategies of the different players in the health care arena may be different, there is one thing in common--the needs of citizens must be met through the provision of available, accessible, quality, equitable, and cost-effective health care. These values need to be incorporated into a reform plan. Currently, our ability to comprehensively, consistently, and uniformly perform these tasks is severely limited. While many diverse factors, such as the limitation of financial support and the lack of uniform information systems, contribute to this situation, we believe it is possible through the implementation of a series of recommendations to achieve these goals. This paper outlines the current situation, reviews insights derived from the literature and past and current experiences. Recommendations are made that apply equally to health reform efforts at the state and/or federal levels.

Access to health care. A conceptual framework and its relevance to health care planning.

Despite some serious past efforts to clarify its multiple dimensions and meanings, access to health care has remained a rather elusive concept, hampering the work of health care policymakers and professionals as they endeavor to effect meaningful health care reform. This article provides perhaps the most detailed clarification of the access concept, especially the crucial linkages among the various access dimensions, and presents a comprehensive conceptual framework for evaluation and planning activities as they relate to people's access to health care services. The proposed conceptual model recognizes access as the outcome of a process involving the interplay between the characteristics of the health care service system and of potential users in a specified area, and moderated by health care related public policy and planning efforts. An elaborate typology of access, incorporating four pairs of access dimensions, is also derived. This atomization of the concept allows us to focus on specific aspects of the access to health care problem, and to develop precise outcome indicators of health system performance for evaluative purposes. Further, it enables the access concept and its pertinent dimensions to be put into proper perspective when assessing the health care access situation in a specific national or regional context. The relevance of the proposed access model and the typology to health care planning in general, and to spatial planning of health care service systems in particular, is also discussed.