Variations in appointment delays for physicians' services: Theory and empirical evidence

Waiting times for physician appointments have been used in past studies as a measure of access to, or excess demand pressure on, local ambulatory care systems. This paper offers an alternative view—that short appointment delays are one of several types of amenities produced by physicians in combination with health services. Empirical evidence is presented that illuminates some previously unknown relationships between appointment delays, patient diagnosis, site of care, and family income. A model is developed with the capability of predicting short-run responses to changes in demand for physicians' services. The model and empirical evidence are used as the basis for interpreting recent experience in Canada with its system of national health insurance (NHI) and for predicting potential consequences regarding the production of amenities of NHI in the US.This research has been supported in part by a grant (HS—00825) from the Center for Health Services Research, US Department of Health, Education, and Welfare, to the University of Florida. We are indebted to John B. Wayne and to Paula Sloan for their assistance and to University of Florida colleague Gary Shannon for comments on an earlier draft.     

Quality of care assessment: policy relevant issues

This paper reviews the quality assessment literature, presents a study which compares five different methods of assessing quality of care, and proposes policy recommendations. Results are: (1) Most quality assessment issues are a century old. (2) The results of assessment of quality of care are dependent on the method used; therefore, more methodologic research is needed. (3) The use of lists of criteria, concerning what a physician does, to assess quality of care could result in decreased efficiency in the health system by requiring the performance of ineffective procedures. (4) It is not certain that examination of the level of care rendered will increase the health level of the population; therefore, any national program which assesses quality of care must be prospectively evaluated. (5) A quality assessment system must be concerned with both the population who received services at the institution, and the population who did not but for whom the institution is responsible.From the Carnegie-Commonwealth Clinical Scholar Program of the Johns Hopkins University.Supported in part by grants 5R01HS00110 and 5T01HS00112 from the National Center for Health Services Research and Development and by the Carnegie Corporation and Commonwealth Fund. Dr. Brook was a Carnegie-Commonwealth Clinical Scholar and is now a Commissioned Officer in the U.S. Public Health Service stationed at the National Center for Health Services Research and Development. This paper does not represent the official position of this agency.     

Public policy and health resource distribution

Despite federal health programs of the thirties, the Great Society programs and the establishment of health planning agencies in the sixties, health resources continue to accumulate in wealthier areas. According to a rational decision-making model public resources would be expected therefore to be directed toward those poorer areas with perceived needs. This paper explores the distribution of public and private health resources among towns of Connecticut. Using a rational decision-making model, the distribution of these resources is tested in a series of stepwise regression equations against the socioeconomic and health characteristics of the population. Private allocations of health resources (such as physician distribution) respond to socioeconomic factors while public resources do not show a clear pattern of overcoming the maldistribution effected by private actions. We find little evidence to support the hypothesis that Connecticut's town and state decision makers in health were following a rational model such as is the basis for health planning. Some other more complex model, such as a bureaucratic politics model, would explain better public policy decisions in health resource allocation.Research for this paper was carried out under Department of Health, Education, and Welfare Grant #5-R01-HS-00900. We wish to thank Berton Freedman for assistance with computer programming, and our former Yale Health Policy Project colleagues, George A. Silver, James Warner Bjorkman, and Christa Altenstetter for comments on an earlier draft. This earlier paper entitled Socio-Economic Indicators, Health Resources and Health Status: A Statistical Analysis and its Policy Implications was presented to the Statistics Section, American Public Health Association Meetings, November 16–20, 1975, Chicago, Illinois.     

More on health care paradoxes

Federal and state government efforts to improve the nation's health focus particular attention on the necessity of increasing the numbers of physicians. Yet, evidence from several studies suggest weak linkages between health and the number of physicians. The present study surveys civilian health and the number of physicians during the period of national mobilization in the U.S. in the 1940's. This period, where low physician/population ratios prevailed for several years, is unique in recent history and provides a useful reference for current health policy. Reduced numbers of physicians are shown to have had a measurable negative impact on civilian health over the period.The author would like to express gratitude to the Brookings Institution for support and to a referee for helpful suggestions.     

SCIENTIFIC‐BUREAUCRATIC MEDICINE AND UK HEALTH POLICY1

One prominent method for controlling health costs is to find measures for the management of demand. Various options exist for this; and many of them have been tried during the fifty years of the UK's National Health Service. Current policy now focuses on what may be called “scientific‐bureaucratic medicine.” This policy is based on the assumptions that valid medical knowledge is derived from accumulated research evidence and that such knowledge should be implemented through clinical guidelines which are enforced to some extent. This UK development has parallels with the US Agency for Health Care Policy and Research whose experience, therefore, raises some policy issues for the UK.     

Political stability and the science of comparative politics

Abstract. The utility of comparative politics has been questioned from time to time in two ways. Doubts have been cast upon its ability to offer genuine and useful generalisations, and these doubts have been reinforced by the appearance of studies which, while statistically adventurous, are not grounded upon a sufficiently sound theoretical base. In this paper we consider Alasdair MacIntyre's objections to the idea of a science of comparative politics, and discuss the nature of law-like generalisations. We explore the extent to which MacIntyre's objections may be overcome, and indicate the form that generalisations about political stability could take. We also argue that studies of stability need a clear explanatory linkage between the empirical data they utilise and the hypotheses of a theory about political stability. This is often lacking in such studies, which seem to substitute a sophisticated statistical technique for genuine political theory.     

Can ministries of health support primary health care? Some suggestions for structural reorganization and planning

Patrick Vaughan is Reader in health care epidemiology, Gill Walt is Lecturer in health policy and Anne Mills is Lecturer in health economics, at the Evaluation and Planning Centre for Health Care, London School of Hygiene and Tropical Medicine, Gower Street, London WC1, United Kingdom. A previous version of this paper was prepared for the Commonwealth Secretariat, London, for the Conference of Commonwealth Health Ministers held in Ottawa, Canada, in October 1983.     

Stewardship of health security: The challenges of applying the One Health approach

Experience with the control of epidemics, notably the 2004 outbreaks of avian influenza, has demonstrated that a “One Health approach,” that recognizes that human, animal, and environmental health are interdependent, is the most effective way of dealing with threats from emerging infectious diseases (EID). However, introducing and applying a One Health approach is challenging for many countries. One of the key challenges relates to stewardship. The evolution of the strategies and policies used to introduce and adopt the One Health approach in the detection and response to EID over the period 2005 to 2017 is described at global level and in country case studies of Thailand and Indonesia. Both countries experienced significant outbreaks of H5N1 avian influenza from 2004 and have sought to adopt the One Health approach in their response strategies. The challenges for stewardship of health systems in introducing a One Health approach are described, and key lessons identified in regard to national level agency coordination, engagement of the broader civil society outside government, and developing a reliable, credible, and impartial decision‐making process. The concept of stewardship provides valuable insights for policymakers on how to incorporate a One Health approach into their EID response systems.     

Book reviews

Research on the impact of parties on public policy, and on immigration policy in particular, often finds limited evidence of partisan influence. In this paper, we examine immigration policy-making in the UK coalition government. Our case provides evidence that parties in government can have more of an impact on policy than previous studies acknowledge, but this only becomes apparent when we open up the ‘black box’ between election outcomes and policy outputs. By examining how, when and why election pledges are turned into government policies, we show that partisan influence depends not only on dynamics between the coalition partners, but how these dynamics interact with interdepartmental conflicts and lobbying by organised interests. In-depth process tracing allows us to see these complex dynamics, which easily get lost in large-n comparisons of pledges and outputs, let alone outcomes.     

Does sex education affect adolescent sexual behaviors and health?

This study examines whether offering sex education to young teenagers affects several measures of adolescent sexual behavior and health: virginity status, contraceptive use, frequency of intercourse, likelihood of pregnancy, and probability of contracting a sexually transmitted disease. Using data from the National Longitudinal Study of Adolescent Health, I find that while sex education is associated with adverse health outcomes, there is little evidence of a causal link after controlling for unobserved heterogeneity via fixed effects and instrumental variables. These findings suggest that those on each side of the ideological debate over sex education are, in a sense, both correct and mistaken. Opponents are correct in observing that sex education is associated with adverse health outcomes, but are generally incorrect in interpreting this relationship causally. Proponents are generally correct in claiming that sex education does not encourage risky sexual activity, but are incorrect in asserting that investments in typical school-based sex education programs produce measurable health benefits.     

'Designing Better Health Care in the South': A Case Study of Unsuccessful Transformational Change in Public Sector Health Service Reform

This article presents a case study of a project known as 'Designing Better Health Care in the South' that attempted to transform four separately incorporated health services in southern Adelaide into a single regional health service. The project's efforts are examined using Kotter's (1996) model of the preconditions for transformational change in organisations and the areas in which it met or failed to meet these preconditions are analysed, using results from an evaluation that was commenced during the course of the attempted reform. The article provides valuable insights into an attempted major change by four public sector health organisations and the facilitators and barriers to such change. It also examines the way in which forces beyond the control of individual public sector agencies can significantly impact on attempts to implement organisational change in response to an identified need. This case study offers a rare glimpse into the micro detail of health care reform processes that are so widespread in contemporary health services but which are rarely systematically evaluated.     

关于加强基层医疗卫生服务建设的建议——兼论推进疫情防控关口前移

加强基层卫生服务,推进疫情关口前移,是落实习近平总书记关于疫情防控重要指示精神的重要举措。本文在总结当前基层疫情防控现状的基础上,分析国外家庭医生制度特点及对我国的借鉴意义,探讨我国基层卫生服务建设的重点、难点与不足以及在重大疫情防控中的作用,并在此基础上提出建议:加强基层卫生服务体系建设,培养全科医生公共卫生应急技能,强化基层疫情应急服务,加强医防融合和全民健康教育,推进疫情防控关口前移,构建重大传染病的社会屏障。     

Immigrant Health Care Access and the Affordable Care Act

In spite of major coverage expansions under the Patient Protection and Affordable Care Act (ACA), a large proportion of immigrants will continue to remain outside the scope of coverage. Because various provisions of the ACA seek to enhance access, advancing knowledge about immigrant access to health care is necessary. The authors apply the well‐known Andersen model on health care access to two measures—one focusing on perceptions of unmet health care needs and the other on physician visits during the last year. Using data from the New Jersey Family Health Survey, the authors find that prior to implementation of the ACA coverage expansions, immigrants in New Jersey reported lower levels of unmet health care needs despite poorer self‐rated health compared with U.S.‐born residents. The article concludes with a discussion of the use of Andersen model for studying immigrant health care access and the broader implications of the findings.     

Partnerships to Improve Rural and Remote Health Care

It is well known that rural communities do not have access to the same range of healthcare services as urban communities and that health status is poorer in rural areas. As models of health service delivery are changing from treatment and illness prevention to wellness models, health providers are under increasing pressure to re-engineer healthcare services to rural and remote areas in a climate of shrinking resources and community skepticism. The purpose of this article is to examine a developing model of partnership in rural Tasmaniain the context of these changes to health service delivery, changes to health professional training and the application of information and telecommunications technology. The partners are the Tasmanian Department of Health and Human Services and the University of Tasmania. The establishment of the university's Rural Health Teaching Sites in conjunction with the Tasmanian Telehealth Network provides a demonstration of this partnership in action.     

A Framework for Unifying Formal and Empirical Analysis

An important disconnect exists between the current use of formal modeling and applied statistical analysis. In general, a lack of linkage between the two can produce statistically significant parameters of ambiguous origin that, in turn, fail to assist in falsifying theories and hypotheses. To address this scientific challenge, a framework for unification is proposed. Methodological unification leverages the mutually reinforcing properties of formal and applied statistical analysis to produce greater transparency in relating theory to test. This framework for methodological unification, or what has been referred to as the empirical implications of theoretical models (EITM), includes (1) connecting behavioral (formal) and applied statistical concepts, (2) developing behavioral (formal) and applied statistical analogues of these concepts, and (3) linking and evaluating the behavioral (formal) and applied statistical analogues. The elements of this EITM framework are illustrated with examples from voting behavior, macroeconomic policy and outcomes, and political turnout.     

The need for centres of health research excellence in the developing world

Pervasive ill health and overpopulation impede progress in most developing countries but in recent years, programs providing aid to these regions have de-emphasized health as a priority. Furthermore, support for building the health research capacity, so essential to the success of efforts to promote improved health, has been lacking. This paper examines these policies as they relate to one developing country, one global h ealth program and a major Canadian development agency. Much has been achieved in the past decade in one of the world's poorest countries, Bangladesh, but major health problems persist, particularly in maternal and child health. With the will to build effective health programs, Bangladesh lacks the resources and the research base needed for their development. The World Health Organization, (WHO) Diarrhoeal Disease Control (CDD) program, which addresses a major cause of child mortality in Bangladesh, promotes effective treatment but it contributes little to a permanent research establishment in that country. The Canadian International Development Agency (CIDA) which directs only a small portion of its $2.2 billion annual budget to health, lacks an influential level of technical expertise in health. This agency has no mandate to support health research in the developing world; research is the responsibility of the International Development Research Centre (IDRC), the Health Sciences Division of which closed in July, 1995. To upgrade the place of health and health research in development, the attitudes and policies of major donors must change and models of success are needed. Of the existing institutions or programs involved in health and health research in the developing world, the internationally funded health research centre, strategically sited in the developing world could provide the excellence around which relevant programs should flourish. An existing example of this rare species, the International Centre for Diarrhoeal Disease Research, Bangladesh, merits particular consideration in this regard.     

Race,Medicine, and Social Justice: Pharmacogenetics,Diversity, and the Case of BiDil

In this article, I probe an example of high‐technology medicine as a case study in the problems of the regulation of advancing technology. Specifically, I address the implications of pharmacogenomics—an emerging form of population‐based health care intervention—for public policies designed to eliminate racial disparities in health. Using the case of BiDil, a historical precursor to pharmacogenetic technology, I offer a framework for further studies of high‐technology medicine in which policy analysis is part of a social review based on the justice standard of ex ante mutual advantage. It is the contention in this article that the most just and reasonable deployment of pharmacogenomics is as a compensatory tool to alleviate health disparities.     

Risk compensation and the effectiveness of safety belt use laws: a case study of New Jersey

This paper investigates the effectiveness of New Jersey's mandatory belt use law (MUL) by testing specifically for: (1) a safety effect, and (2) a risk-compensation effect that could offset (in part) any safety impact. The main findings are that injury severity declined significantly in the 22 months following implementation of the MUL; but that accident frequency increased significantly. The increase in accidents may be explained only partially by increased driving mileage. These findings suggest that the real safety effect of the law may have been diluted by risk-compensating behavior.This paper is based on a study conducted for the New Jersey Office of Highway Traffic Safety by the Rutgers University Bureau of Economic Research. We are grateful to William Ascher and two referees for useful comments.     

A profile of children with disabilities receiving SSI: highlights from the National Survey of SSI Children and Families

This article provides a nationally representative profile of noninstitutionalized children 0 to 17 years of age who were receiving support from the Supplemental Security Income (SSI) program because of a disability. To assess the role of the SSI program in providing assistance to low-income children with disabilities and their families, it is important to obtain detailed information on demographic characteristics, income and assets, health and disabilities, and health care utilization. Yet administrative records of the Social Security Administration do not contain many of the relevant data items, and the records provide only an incomplete picture of the family relationships affecting the lives of children with disabilities. The National Survey of SSI Children and Families fills this gap. This summary article is based on survey interviews conducted between July 2001 and June 2002 and provides some highlights characterizing children with disabilities who were receiving SSI and their families. Most children receiving SSI (hereafter referred to as "SSI children") lived in a family headed by a single mother, and less than one in three lived with both parents. A very high proportion, about half, were living in a household with at least one other individual reported to have had a disability. About 70 percent of children received some kind of special education. SSI support was the most important source of family income, with earnings a close second. On average, SSI payments accounted for nearly half of the income for the children's families, and earnings accounted for almost 40 percent. When all sources of family income were considered, slightly more than half (54 percent) of SSI children lived in families above the poverty threshold, a notable fact given that the federal SSI program guarantees only a subpoverty level of income. However, beyond these averages there was substantial variation, with some children living in families with income well below the poverty threshold and others having income well over 200 percent of the poverty threshold. About one-third of SSI children lived in families owning a home, two-thirds lived with parents or guardians with at least one car, and about 40 percent lived with parents or guardians with zero liquid assets. Less than 4 percent lived with adults who owned stocks, mutual funds, notes, certificates of deposit, or savings bonds. The Social Security Administration's administrative records contain only a limited amount of information about disability diagnoses. The National Survey of SSI Children and Families supplements those records with data from an array of questions on functional limitations, self-reported health, and the perceived severity of disabilities. The data suggest that a great degree of variation in severity exists within the childhood caseload, as reflected in reports of the presence or absence of six functional limitations, perceived overall health status, and perceived impact of disability on the child's ability to do things. Overall, 36 percent of the children were reported to have had disabilities that affected their abilities to do things "a great deal," and for 21 percent their difficulties had very little or no impact. Physical disabilities were most common among children aged 0 to 5, and mental disabilities dominated the picture for the other two age groups: 6 to 12 and 13 to 17. Virtually all SSI children are covered by some form of health insurance, with Medicaid being by far the most common source of health insurance coverage. Just as in the case of the severity of disabilities, substantial variation was reported in health care utilization among SSI children. Almost 30 percent of children had two or fewer doctor visits during the 12 months preceding the interview, and close to 50 percent had five or more doctor visits. About four-fifths of the children had no reported hospitalizations or surgeries during the previous year. More than 40 percent of the children visited an emergency room during the previous year, most of them more than once. Importantly, no out-of-pocket costs associated with medical care were reported for more than two-thirds of the children, and only about 3 percent had annual expenses exceeding $1,000 for physical and mental health care. This finding suggests that SSI payments are not used to cover medical expenses for the overwhelming majority of children. The use of supportive therapies varied widely among SSI children: more than half reported having used physical, occupational, or speech therapy; only 8 percent used respite care for the parents or other family members. An analysis of the perception of the survey respondents shows that more than one-third of children had unmet needs for mental health counseling services, and about three-quarters of families had unmet needs for respite care. In several service categories, the proportion perceived to have had unmet service needs was around 10 percent or less. In the dominant service category of physical, occupational, and speech therapy, only 11 percent perceived to have had unmet service needs.     

The impact of citizen influence on local government expenditure

This paper examines the impact of three measures of direct citizen influence — the initiative, referendum, and recall — on the level of local public expenditure for a national sample of communities with 10,000 persons or more. Two types of statistical tests are performed to analyze the role of the median voter model and to measure the effect of these governmental characteristics on the level of public spending. Like earlier literature, this paper finds only modest effects of these structural characteristics on local government expenditure. Alternative methodologies are needed to explore the ambiguities which exist in many of the previous studies.