RESUMEN
OBJECTIVE: This study examined the impact of an Integrated Care Delivery intervention on health care seeking and outcomes for chronically-ill patients in Henan province, China. METHODS: A case-control study was carried out in six health care organizations from two counties in Henan province, China. 371 patients aged 50 years or over with hypertension or diabetes who visited either community health centers or hospitals in the Intervention or Control Counties were systematically selected and surveyed on health care seeking behavior, quality of care, and pathway of care for their major chronic condition. Bivariate analyses were performed to compare quality and value of care indicators between patients from the Intervention and Control Counties. Multivariate analyses were used to confirm these associations after controlling for patients' demographic and health characteristics. RESULTS: Patients in both the Intervention and Control Counties chose their current health care providers primarily out of concern for quality of care (provider expertise and adequate medical equipment) and patient-centered care. Compared with the patients from the Control County, those from the Intervention County performed significantly better on almost all the quality and value of care indicators even after controlling for patients' demographic and health characteristics. Significant associations between types of health care facilities and quality as well as value of care were also observed. CONCLUSION: The study showed that the Integrated Care Delivery Model was critical in guiding patients' health care seeking behavior and associated with improved accessibility, continuity, coordination and comprehensiveness of care, as well as reducing health inequities and mitigating disparities for older patients with chronic conditions.
Asunto(s)
Enfermedad Crónica/terapia , Aceptación de la Atención de Salud/estadística & datos numéricos , Atención Dirigida al Paciente/métodos , Población Rural/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , China/epidemiología , Diabetes Mellitus/terapia , Femenino , Humanos , Hipertensión/terapia , Masculino , Persona de Mediana Edad , Atención Dirigida al Paciente/estadística & datos numéricos , Encuestas y CuestionariosRESUMEN
OBJECTIVE: Reform of the health care system in urban areas of China has prompted concerns about the utilization of Community Health Centers (CHC). This study examined which of the dominant primary care delivery models, i.e., the public CHC model, the 'gate-keeper' CHC model, or the hospital-owned CHC models, was most effective in enhancing access to and quality of care for patients with chronic illness. METHODS: The case-comparison design was used to study nine health care organizations in Guangzhou, Dongguan, and Shenzhen cities within Guangdong province, China. 560 patients aged 50 or over with hypertension or diabetes who visited either CHCs or hospitals in these three cities were surveyed by using face-to-face interviews. Bivariate analyses were performed to compare quality and value of care indicators among subjects from the three cities. Multivariate analyses were used to assess the association between type of primary care delivery and quality as well as value of chronic care after controlling for patients' demographic and health status characteristics. RESULTS: Patients from all three cities chose their current health care providers primarily out of concern for quality of care (both provider expertise and adequate medical equipment), patient-centered care, and insurance plan requirement. Compared with patients from Guangzhou, those from Dongguan performed significantly better on most quality and value of care indicators. Most of these indicators remained significantly better even after controlling for patients' demographic and health status characteristics. The Shenzhen model (hospital-owned and -managed CHC) was generally effective in enhancing accessibility and continuity. However, coordination suffered due to seemingly duplicating primary care outpatients at the hospital setting. Significant associations between types of health care facilities and quality of care were also observed such that patients from CHCs were more likely to be satisfied with traveling time and follow-up care by their providers. CONCLUSION: The study suggested that the Dongguan model (based on insurance mandate and using family practice physicians as 'gate-keepers') seemed to work best in terms of improving access and quality for patients with chronic conditions. The study suggested adequately funded and well-organized primary care system can play a gatekeeping role and has the potential to provide a reasonable level of care to patients.
Asunto(s)
Enfermedad Crónica/terapia , Centros Comunitarios de Salud/normas , Accesibilidad a los Servicios de Salud/normas , Atención Primaria de Salud/estadística & datos numéricos , Calidad de la Atención de Salud/estadística & datos numéricos , Población Urbana/estadística & datos numéricos , Adulto , Anciano , Estudios de Casos y Controles , China , Centros Comunitarios de Salud/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Atención Primaria de Salud/normas , Encuestas y CuestionariosRESUMEN
In May 2011, a year after the passage of the Affordable Care Act (ACA), Vermont became the first state to lay the groundwork for a single-payer health care system, known as Green Mountain Care. What can other states learn from the Vermont experience? This article summarizes the findings from interviews with nearly 120 stakeholders as part of a study to inform the design of the health reform legislation. Comparing Vermont's failed effort to adopt single-payer legislation in 1994 to present efforts, we find that Vermont faced similar challenges but greater opportunities in 2010 that enabled reform. A closely contested gubernatorial election and a progressive social movement opened a window of opportunity to advance legislation to design three comprehensive health reform options for legislative consideration. With a unified Democratic government under the leadership of a single-payer proponent, a high-profile policy proposal, and relatively weak opposition, a framework for a single-payer system was adopted by the legislature - though with many details and political battles to be fought in the future. Other states looking to reform their health systems more comprehensively than national reform can learn from Vermont's design and political strategy.
Asunto(s)
Reforma de la Atención de Salud/organización & administración , Política , Sistema de Pago Simple/organización & administración , Comités Consultivos , Reforma de la Atención de Salud/legislación & jurisprudencia , Instituciones de Salud , Personal de Salud , Política de Salud , Humanos , Liderazgo , Sistema de Pago Simple/economía , Sistema de Pago Simple/legislación & jurisprudencia , Cambio Social , VermontRESUMEN
BACKGROUND: In 2011 the state of Vermont adopted legislation that aims to create the nation's first state-level single-payer health care system, a system that would go well beyond national reform efforts. OBJECTIVES: To conduct a prospective, institutional stakeholder analysis to guide development of a politically viable, universal health care reform proposal, as commissioned by Vermont's legislature in July 2010. METHODS: A total of 64 semi-structured stakeholder interviews with nearly 120 individuals, representing 60 different groups/institutions, were conducted between July and December 2010. Interviews probed stakeholders regarding five major design components: financing options, decoupling insurance from employment, organization/governance, comprehensiveness of benefits, and payment reform. RESULTS: There was a range of opposition and support across stakeholder groups and components, and more remarkably a diversity of views within groups often believed to be unwavering supporters or detractors of comprehensive health reform. Given the balance of conflicting views, relative power, and acceptable trade-offs, the research team proposed a single-payer health care system financed through payroll taxes, decoupled from employment, with a generous benefit package, governed by a public-private intermediary. CONCLUSIONS: Prospective political analysis can assist in choosing among a range of technically sound policy options to create a more politically viable health reform package.