Changing the Health Care System Models from Here and Abroad (1994) / Chapter Skim
Currently Skimming:
European Health Care Reform and Primary Care
European Health Care Reform and Primary Care
Pages 31-51
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 31... ...
The U.S. Surgeon General's report of 1979,~ Healthy People, did, however, articulate a set of central health promotion and disease prevention goals for the nation.
|
From page 32... ...
The British government, on the other hand, under Margaret Thatcher, was not convinced that it was getting value for its money for health care expenditures that were slightly under 6 percent of the gross domestic product, and in December 1989 it launched a full-scale reform of the National Health Service (NHS) , with only marginal new resources added.
|
From page 33... ...
Patients paid taxes in exchange for universal financial entitlement to services. Figure 2 shows a postreform NHS in which the government has delegated its purchasing authority to 177 (and this number is decreasing)
|
From page 34... ...
i Contracts $$$ > ~ ~$$$ > EMPLOYERS Insurance/claims Blue Cross < processing 1 $$$ 1 1 Flexible servic as 1~ COMMERCIALS HMOs PPOs, EPOs, POSs, etc. $$$ Deductibles Copayments CLAIMS · CLAIMS ~ ~ -CLA MS PATIENTS C EMS t''t SUBSCRIBERS FIGURE 3 Health care financing in the United States.
|
From page 35... ...
They are crucial strengths of their system and crucial weaknesses in ours: universal financial access to health services and the general practice service as a primary care referral system. A final feature, and perhaps the most radical one, is described in a recent report called Health of the Nation,2 issued in fuly 1992, which calls for a renewal of the original goal of the NHS, which is to serve as an instrument for improving the health of the entire population, not just the provision of individual patient care.
|
From page 36... ...
This involves accountability to internal and external review criteria as well as to the patient. In revisiting this definition today, one might add the concept of "community-oriented" primary care, with primary care providers assuming some role, if not direct responsibility, for improving the health of the community they serve.5 When trying to develop health policy mechanisms to support primary care service delivery and education, it is important that definition be clear so you can test the models you are developing.
|
From page 37... ...
I arrived from Michigan as a pediatric resident in the Social Medicine Program at Montefiore Hospital in the Bronx in 1971. It was the end of the golden age of the federal community health center movement, in which interdisciplinary teams of doctors, nurses, and community health workers with legal aid, social, and mental health services worked out of a neighborhood health center to serve a geographically defined community.
|
From page 38... ...
Outpatient setting is a major focus; patients are seen intermittently over long periods of time Disease prevention; problem mangement; reduction of discomfort, dissatisfaction, and worry; health promotion Primary care physician in pediatrics, general internal medicine, family practice (not always on the faculty, therefore low prestige in medical school) Knowledge and skills in general medicine; psychosocial and problem management are central Ambulatory diagnosis relies on probability derived from clinical experience and epidemiology.
|
From page 39... ...
Ironically, this often meant rebuilding and expanding health care centers and programs that had existed in the 1970s but that had been dismantled during the city's fiscal crisis. It also meant that the city had to assume financial responsibility for investment in capital and staffing costs, because there was no other source of financial support due to the inadequacy of outpatient reimbursement and the number of uninsured patients.
|
From page 40... ...
Since the mid-1970s, graduates of primary care residency programs in general internal medicine and general pediatrics with significantly more primary care and ambulatory-care experience and often with significantly less inhospital experience than their traditional counterparts have performed well on their board exams and as clinicians and faculty in teaching hospitals, medical schools, and the community. Family practice residents are trained in excellent primary care "teaching health centers" and have been increasingly important primary care service providers all over the country.
|
From page 41... ...
All of these countries see a strong primary care system as the foundation on which to build reformed health care delivery systems. To achieve this in the United States we need mechanisms to ensure that the kind of ongoing financial support enjoyed by hospital-based secondary- and tertiary-care services and graduate medical education in past years is extended to community-based primary care.
|
From page 42... ...
As the size of the middle class increased and demand soared, surgeons and apothecaries also started seeing outpatients and keen competition led to an agreement. The Medical Practice Law of 1858 determined that the physician and surgeon consultant specialists "got the hospital" and the apothecaries, who later became GPs, "got the patient." With the 1915 National Insurance System, the GP list began, and shortly after that, hospital doctors became salaried.
|
From page 43... ...
In the United States, the simplest mechanism that could be used to start developing a primary care sector would be to designate recognized primary care providers, including nondoctors. They would be eligible for enhanced payment for primary care, and one would need to create financial disincentives for specialists who do the same work.
|
From page 44... ...
Persistent geographic maldistribution led to a recent Fortune magazine article describing "a national physician shortage" and blaming the protectionist attitudes of physicians for the maldistributions.~2 Although financial incentives for practice are obviously a problem (and one we have not been prepared to address) , we have tended to believe that an educational strategy might work: the proper experiences in primary care during medical school would increase the numbers of pri .
|
From page 45... ...
In Canada, with about 50 percent family practitioners, provincial governments fund the majority of GME positions and influence the mix of the numbers and types of GME positions offered. New York State recently began a policy of "up-weighting" primary care residencies under a state methodology for funding the indirect costs of GME.
|
From page 46... ...
The initial vision for the NHS was to guarantee universal financial access and distribute the available health care resources as equitably as possible. As such, and especially in the post-Thatcher era, the NHS has enormous symbolic value as one of the few, if not the only, remaining public service that is available to all citizens regardless of their income and that is publicly accountable to them for its performance.
|
From page 47... ...
If we provide only traditional clinical medical care, even if we ensure the effectiveness of each intervention, we limit our ability to significantly influence the health of the larger community, although we may save enormous amounts of resources. If we can begin to unlock the financing of primary care and the use of primary care practices as a base for health promotion and disease prevention as well as treatment, then we can reach out into the larger community and take better advantage of the power of the health care system as a broader instrument for improving community health.
|
From page 48... ...
for specialists without merit awards, although two-thirds of consultants eventually receive merit awards and this disparity is under negotiation in the new GP contract.~4 When the number of GPs was declining in the 1960s, a new Family Doctor Charter was written to change the basic financing of general practice and address premises costs, staffing costs, and targeting incentives for night calls and home care. The recent reforms have added incentives for prevention activities, and the GP fundholder initiative shifts even more power into the hands of certain GPs so that they can purchase an array of services for their patients.
|
From page 49... ...
The experiment with health care rationing in Oregon, with all of its flaws, has caught the imagination of health policy leaders throughout Europe because they understand financial limitations and see it as an effort to involve the public in an open debate about what the health care system should do. However, the real challenge for the future is the need to provide incentives for health service providers to use their institutional resources and influence to improve community health in its broadest sense and to help the community to think more carefully about issues related to the allocation of scarce resources.
|
From page 50... ...
citizens should have access to health care, then that would become a linchpin in a new vision for health care delivery systems of the future, and a key element in ensuring the appropriate use of services will be effective primary care development. Second, no matter how difficult the financial situation, the United States has enormous resources in its health care system that are unheard of in other countries.
|
From page 51... ...
1978. Medical Students, Medical Schools and Society During Five Eras: Factors Affecting Career Choices of Physicians 1958-1976.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.