The effects of family physician-contracted service on health-related quality of life and equity in health in China.

BACKGROUND: Family physician-contracted service (FPCs) has been recently implemented in Chinese primary care settings. This study was aimed at measuring the effects of FPCs on residents' health-related quality of life (HRQoL) and equity in health among the Chinese population. METHODS: The study data was drawn from the 2018 household health survey (Shaanxi Province, China) using multistage, stratified cluster random sampling. We measured HRQoL using EQ-5D-3L based on the Chinese-specific time trade-off values set. Coarsened exact matching (CEM) technique was used to control for confounding factors between residents with and without a contracted family physician. The concentration index (C) was calculated to measure equity in health. RESULTS: Individuals with a contracted family physician had significantly higher HRQoL than those without, after data matching (0.9355 vs. 0.8995; P <  0.001). Additionally, the inequity in HRQoL among respondents with a contracted family physician was significantly lower than those without a contracted family physician (Cs of EQ-5D utility score: 0.0084 vs. 0.0263; p <  0.001). CONCLUSIONS: This study highlights the positive effects of FPCs on HRQoL and socioeconomic-related equity in HRQoL. Future efforts should prioritize the economically and educationally disadvantaged groups, the expansion of service coverage, and the competency of family physician teams to further enhance health outcome and equity in health.

Association of Use of Contract Nurses With Hospitalized Patient Pressure Injuries and Falls.

BACKGROUND: Hospital-acquired pressure injuries (HAPIs) and falls are outcomes sensitive to quality of nursing care. Use of contract (traveler) nurses varies among organizations, but there is little research on the effect of contract nurses on nurse-sensitive outcomes. OBJECTIVES: To explore the relationship between use of contract nurses and two key nurse-sensitive outcomes, HAPIs and falls. RESEARCH DESIGN: This was a cross-sectional study of unit-level nursing, patient, and hospital factors versus HAPIs and falls from a national nursing data consortium from 2015 to 2016. We used cluster analysis to identify similar units, and compared outcomes between clusters. SUBJECTS: 605 nursing units in 166 hospitals, 3.2 patients per nurse, and 5.3% contract nurses. MEASURES: Prevalence and incidence of HAPIs and number of falls, adjusted by patient days. RESULTS: For both prevalence and incidence of HAPIs, there was a statistically significant difference between the five independent cluster groups (p = .012 and p = .001, respectively). The cluster with the highest percentage of nurse travelers (>7%) had the highest HAPI prevalence (0.84%) and incidence (0.055 per 1,000 patient days) despite higher nurse staffing, compared to HAPI prevalence of 0.32% and incidence of 0.017 per 1,000 patient days in the cluster with the lowest percentage of nurse travelers (<2%). We did not identify a consistent relationship between use of contract nurses and falls. CONCLUSIONS: Use of contract nurses was associated with higher HAPI prevalence and incidence, independent of staffing levels. CLINICAL RELEVANCE: Our results suggest that institutions should either minimize the use of contract nurses, or engage in extensive training to confirm that contract nurses have understanding of the institutional practices around HAPIs.

Factors associated with contracted services of Chinese family doctors from the perspective of medical staff and consumers: a cross-sectional study.

BACKGROUND: The family doctor system has developed rapidly all over the world, and in the past few years, China has actively explored family doctor-type contracted services. This study aimed to explore the related factors of Contracted Family Doctors Services (CFDS) from the perspectives of medical staff and consumers, and to provide a stronger basis for the development and promotion of CFDS. METHODS: A combination of quantitative and qualitative methods were used in this study. A self-reported questionnaire was designed through a literature analysis, group discussions, expert consultations and a pre-investigation, and conducted among community health service providers in 12 community health service centres across four provinces of China. A total of 389 participants participated, and 320 valid questionnaires were obtained, with an effective response rate of 82.3%. A total of 36 consumers participated in in-depth interviews, and the effective rate was 100.0%. An exploratory factor analysis, a confirmatory factor analysis, inductive methods, and expert consultations were used to analyse the related factors of CFDS. RESULTS: The related factors of CFDS from the perspectives of medical staff were divided into four dimensions, with the following weighting coefficients: national government factors (31.9%), community health service agency factors (24.7%), consumer-related factors (22.6%), and contracted doctor-related factors (20.8%). The related factors of CFDS from the perspectives of consumers were divided into four dimensions, with the following frequency sequence: national government factors, contract doctor-related factors, community health service agency factors, and consumers-related factors. National government factors played an important role in CFDS from the perspectives of medical staff and consumers. CONCLUSIONS: The related factors of CFDS were the same from the perspective of medical staff and consumers, but the weight of each factor was different. The development of CFDS is inseparable from the support of policies. It is suggested that the government should strengthen the publicity of CFDS, expand the coverage, introduce personalised contract programs that meet the needs of different groups, and promote the rapid development of CFDS.

The effect of family doctor-contracted services on noncommunicable disease self-management in Shanghai, China.

BACKGROUND: Noncommunicable diseases (NCDs) are a major threat to population health worldwide. In Shanghai, China, a new pattern of NCD management-self-management-has been developed in community health service centres (CHSCs). OBJECTIVE: To clarify how contracting with CHSC-based family doctors (FDs) influences the engagement in and effectiveness of self-management behaviour among NCD patients. METHOD: We conducted two waves of a questionnaire survey (in 2013 and 2016) to collect data on patients with NCDs. Separate logistic regression models and longitudinal analysis were performed to examine the effect of contracting with an FD on NCD self-management and the effectiveness of this self-management. RESULTS: Nearly all contracted patients (80.79%) had implemented NCD self-management, while only 55.57% of non-contracted patients did so. The self-management effectiveness rate was also higher among contracted patients than among non-contracted ones (86.66% vs. 54.79%). In the population-averaged models, contracted patients had 2.25 and 2.91 times greater odds of implementing self-management and reporting that the self-management was effective, respectively, after controlling for all related variables. Additionally, awareness of FD-contracted services, satisfaction with CHSCs, and experiencing first contact at CHSCs had positive impacts on the implementation and effectiveness of self-management. CONCLUSIONS: FDs were important for ensuring that NCD patients engaged in self-management behaviour, the most common form of which was focus group. Participation in NCD focus groups may be key for attaining the effects of self-management, including improved health knowledge, greater health awareness, more frequent engagement in health behaviour, and, most importantly, greater practice of self-monitoring. Self-management might help to achieve greater NCD control.

Content analysis of locum tenens recruitment emails for anesthesiologists.

BACKGROUND: Locum tenens continues to be an increasingly utilized employment option among healthcare organizations to cope with short-term provider vacancies. There exist no studies that explore the job characteristics of such assignments. The purpose of this study was to characterize the clinical responsibilities and compensation of anesthesiology locum tenens positions through content analysis of recruitment emails. Through this data, anesthesiologists interested in locum tenens will be better equipped to evaluate the merit of potential opportunities. METHODS: The study was conducted using a compiled database of unsolicited emails received by one of the authors. A total of 241 emails containing 794 assignments were included during the period of 1/09/17 to 1/26/18 (383 days in total). The information was extracted using a standardized template and was entered into a database. Additional validation of the content was done using a data mining tool. RESULTS: Most of the job opportunities originated from five staffing agencies. A total of 37, 25, and 17% of the assignments were allocated to hospitals, ambulatory surgical centers, and trauma centers respectively. The mean caseload for the assignments was between 8.5 and 11.1 cases per day. The mean daily work shift was 9.1 hours, and the average duration of the assignment was one week. The most frequently requested cases included general (74%), orthopedics (54%), and OB/GYN (51%). However, information regarding training qualifications and licensing was not routinely provided. Only 13.1% of assignments specified a system of medical documentation with paper charting being the most common. The mean hourly rate for locum anesthesiologists in our sample was $186.19, significantly higher than the national average of $127.88. Around 28% of staffing agencies covered the licensing expenses of specialists while 23% covered the expense of travels and 20% covered accommodation costs. CONCLUSIONS: Descriptions for locum tenens positions follow common anesthesiology practices and feature superior compensation to national estimates. However, vital information is often omitted from recruitment emails, and practice settings are highly variable. Anesthesiologists are urged to fully investigate opportunities before accepting based on recruitment emails. Managers should require more details to be provided in job offers.

Attitude towards working in rural areas: a cross-sectional survey of rural-oriented tuition-waived medical students in Shaanxi, China.

BACKGROUND: Attracting and recruiting health workers to work in rural areas is still a great challenge in China. The rural-oriented tuition-waived medical education (RTME) programme has been initiated and implemented in China since 2010. This study aimed to examine the attitudes of rural-oriented tuition-waived medical students (RTMSs) in Shaanxi towards working in rural areas and the related influencing factors. METHODS: A cross-sectional survey was conducted in 2015 among 232 RTMSs in two medical universities from the first group of students enrolled in the RTME programme in Shaanxi. Descriptive and analytical statistics were used for the data analyses. RESULTS: Of the 230 valid responses, 92.6% expressed their intentions of breaking the contract for working in rural township hospitals for 6 years after their graduation under the RTME programme. After the contract expired, only 1.3% intended to remain in the rural areas, 66.5% had no intention of remaining, and 32.2% were unsure. The factors related to a positive attitude among the RTMSs towards working in rural areas (no intention of breaking the contract) included being female, having a mother educated at the level of primary school or below, having a good understanding of the policy, having a good cognition of the value of rural medical work, and being satisfied with the policy. The factors related to a positive attitude of the RTMSs towards remaining in rural areas included being female, having a rural origin, having no regular family monthly income, having a father whose occupation was farmer, having a mother educated at the level of postsecondary or above, having the RTMSs be the final arbiter of the policy choice, having a good understanding of the policy, having a good cognition of the value of rural medical work, and being satisfied with the educational scheme. CONCLUSIONS: Related policy makers and health workforce managers may benefit from the findings of this study. Appropriate strategies should be implemented to stimulate the RTMSs' intrinsic motivation and improve their willingness to work in rural areas and to better achieve the objectives of RTME policy. Meanwhile, measures to increase the retention of RTMSs should also be advanced.

Factors in the drop in the migration of Spanish-trained nurses: 1999-2007.

AIM: To reveal correlates of the decrease of Spanish nurse migration (1999-2007). BACKGROUND: Nursing outmigration is a concern for countries. Nurse migration from Spain began in the 1990s. INTRODUCTION: From 1999 to 2007, the yearly number of migrations dropped significantly. We ask what social, economic and policy factors could be related to this drop. METHODS: We used publicly available statistics to confirm hypothesis (1) The drop in nursing migration coincided with a drop in nursing unemployment. Then we hypothesized that this coincided with (1a) a decrease in the number of graduates, (1b) an increase in the number of hospitals and/or beds functioning, and/or (1c) an increase in the ratio of part-time contracts. RESULTS: Our analysis confirms hypotheses (1) and (1c) and disconfirms (1a) and (1b). CONCLUSION: The greater availability of part-time contracts seems to have encouraged nurses to remain in Spain. IMPLICATIONS FOR NURSING MANAGEMENT: The strategy to reduce nursing unemployment with more part-time contracts, while temporarily successful in Spain, brings with it major challenges for patient care and the working life of nurses. We suggest that nurse leaders and health policymakers consider proactive policies to adjust the balance between supply and demand without decreasing the quality of available positions.

[Treatment by panel physicians of patients in protective institutions and homes : Analysis based on secondary data]. / Vertragsärztliche Versorgung von Patienten in beschützenden Einrichtungen und Heimen : Analyse auf Basis von Sekundärdaten.

BACKGROUND: According to the nursing statistics from 2014 a total of 2.6 million patients in Germany required nursing care of which 1.86 million received care at home and approximately 29 % (764,000 patients) received inpatient treatment exclusively in a nursing home. Reports on the number of long-term nursing care patients usually only include patients with a need of long-term care (according to § 14 German Social Code XI) confirmed by the statutory healthcare insurance. Currently, in Germany there is no nationwide report based on routine (billing) data estimating the number of patients in protective residential homes or institutions, nursing homes or homes for the elderly with nursing personnel (private institutions) based on routine data. This needs to be clarified. MATERIAL AND METHODS: The present analysis was based on the nationwide ambulatory statutory healthcare insurance physician (ASHIP) authorized billing data from 2014. An estimation of the number of patients in nursing and retirement homes was made based on the medical services data. Morbidity and outpatient medical healthcare details were analyzed using methods for descriptive analyses. RESULTS: In 2014 a total of 525,863 patients in private nursing homes received ASHIP-authorized treatment, of which 173,233 were treated exclusively in nursing homes by ASHIP-authorized physicians and 352,630 patients were treated in nursing homes as well as in ASHIP-authorized practices. In the year under investigation approximately two thirds of the patients in nursing homes consulted ambulatory practices in addition to care in the nursing home. CONCLUSION: Nationwide ambulatory ASHIP billing data can substantially contribute to assessment of multimorbidities and provision of long-term healthcare by panel physicians for patients in nursing homes.

[Travel times of patients to ambulatory care physicians in Germany]. / Zurückgelegte Wegzeiten in der ambulanten ärztlichen Versorgung in Deutschland.

BACKGROUND: The time needed by patients to get to a doctor's office represents an important indicator of realised access to care. In Germany, findings on travel times are only available from surveys or for some regions. OBJECTIVE: For the first time, this study examines nationwide and physician group-specific travel times in the ambulatory care sector in Germany and describes demographic, supply-side and spatial determinants of variations. METHODS: Using a full review of patient consultations in the statutory health insurance system from 2009/2010 for 14 physician groups (approximately 518 million cases), case-related travel times by car between patients' places of residence and physician's practices were estimated at the municipal level. RESULTS: Physicians were reached in less than 30 min in 90.8% of cases for primary care physicians and up to 63% of cases for radiologists. Patients between 18 and under 30 years of age travel longer to get to the doctor than other age groups. The average travel time at the county level systematically differs between urban and rural planning areas. In the case of gynecologists, dermatologists and ophthalmologists, the average journey time decreases with increasing physician density at the county level, but remains approximately constant from a recognisable point of inflection. There is no association between primary care physician density and travel time at the district level. Spatial analyses show physician group-specific patterns of regional concentrations with an increased proportion of cases with very long travel times. CONCLUSION: Patients' travel times are influenced by supply- and demand-side determinants. Interactions between influential determinants should be analysed in depth to examine the extent to which the time travelled is an expression of regional under- or over-supply rather than an expression of patient preferences.

[Patient-sharing networks : New approaches in the analysis and transformation of geographic variation in healthcare]. / Virtuelle Behandlernetzwerke : Neue Ansätze zur Analyse und Veränderung räumlicher Versorgungsunterschiede.

The analysis of geographic variations has spurred arguments that area of residence determines access to and quality of healthcare. In this paper we argue that unwarranted geographic variations can be traced back to actions of individual patients and their healthcare providers (doctors, hospitals). These actors interact in a complicated web of shared responsibilities. Designing effective interventions to reduce unwarranted geographic variations may therefore depend on methods to identify these interactions and communities of providers with a shared accountability. In the US, Canada, and Germany, routine data have been used to identify self-organized informal or virtual networks of physicians and hospitals, so-called patient-sharing networks (PSNs). This is an emerging field of analysis. We attempt to provide a brief report on the state of work in progress. It can be shown that variation between PSNs in a given area is effectively greater than variation between regions. While this suggests that reducing unwarranted variation needs to start at the level of PSN, methods to identify PSNs still vary widely. We compare epidemiological approaches and approaches based on graph theory and social network analysis. We also present some preliminary findings of exploratory analyses based on comprehensive claims data of physician practices in Germany. Defining PSNs based on usual provider relationships helps to create distinctive patient populations while PSNs may not be mutually exclusive. Social network analysis, on the other hand, appears better equipped to differentiate between provider communities with stronger and weaker ties; it does not yield distinctive patient populations. To achieve accountability and to support change management, analytic methods to describe PSNs still need refinement. There are first projects in Germany which use PSNs as an intervention platform in order to achieve improved cooperation and reduce unwarranted variation in their care processes.

Maximize Marketing with a Deeper Dive into Data and Metrics.

In the current business environment for contract radiology services, a more stra- tegic approach to marketing can strengthen the ability of an organization to retain existing contracts and win new ones. Although over 70% of surveyed AHRA members believe that marketing is valued within their organizations, only a quarter rated their current marketing programs as highly effective. Survey responses indicate recognition of an unmet need for-marketing programs that are data driven and designed to be evaluated based on meas6rable outcomes. Starting with an understanding of a few key essentials of marketing data and basic categories of marketing metrics can form the foundation of a demonstra- bly effective marketing program for a contract-based radiology organization.

Mais Médicos program: provision of medical doctors in rural, remote and socially vulnerable areas of Brazil, 2013-2014.

INTRODUCTION: The Mais Médicos program was introduced in 2013 with the aim of reducing the shortage of doctors in priority regions and diminishing regional inequalities in health. One of the strategies has been to offer 3-year contracts for doctors to work in primary healthcare services in small towns, inland, rural, remote, and socially vulnerable areas. This report describes the program's implementation and the allocation of doctors to these target areas in 2014. METHODS: To describe the provision of doctors in the first year of implementation, we compared the doctor-to-population ratio in the 5570 municipalities of Brazil before and after the program, based on the Federal Board of Medicine database (2013), and the official dataset provided by the Ministry of Health (2014). RESULTS: In its first public call (July 2013) 3511 municipalities joined the Mais Médicos program, requesting a total of 15 460 doctors; although the program prioritizes the recruitment of Brazilians, only 1096 nationals enrolled and were hired, together with 522 foreign doctors. As a consequence, an international cooperation agreement was set in place to recruit Cuban doctors. In 12 months the program recruited 14 462 doctors: 79.0% Cubans, 15.9% Brazilians and 5.1% of other nationalities, covering 93.5% of the doctors demanded; they were assigned to all the 3785 municipalities enrolled. The study reveals a major decrease in the number of municipalities with fewer than 0.1 doctors per thousand inhabitants, which dropped from 374 in 2013 to 95 in 2014 (75% reduction). Of the total, 294 doctors were sent to work in the country's 34 Indigenous Health Districts (100% coverage) and 3390 doctors were deployed in municipalities containing certified rural maroon communities (formed centuries ago by runaway slaves). After 1 year of implementation, the municipalities with maroon communities with less than 0.1 doctors per thousand inhabitants were reduced by 87% in the poorest north region. More than 30% of municipalities with maroon communities in the richest regions had more than 1.0 doctors per thousand inhabitants, whereas in the poorest regions fewer than 7% of municipalities reached that level. CONCLUSIONS: The Mais Médicos program has granted medical assistance to these historically overlooked populations. However, it is important to evaluate the mid- and long-term sustainability of this initiative.

Challenges in promoting joint use agreements: experiences from Community Transformation Grant awardees in North Carolina, Illinois, and Wisconsin, 2011-2014.

Community Transformation Grant awardees in North Carolina, Illinois, and Wisconsin promoted joint use agreements (formal agreements between 2 parties for the shared use of land or facilities) as a strategy to increase access to physical activity in their states. However, awardees experienced significant barriers to establishing joint use agreements, including 1) confusion about terminology and an aversion to complex legal contracts, 2) lack of applicability to single organizations with open use policies, and 3) questionable value in nonurban areas where open lands for physical activity are often available and where the need is instead for physical activity programs and infrastructure. Furthermore, promotion of formal agreements may unintentionally reduce access by raising concerns regarding legal risks and costs associated with existing shared use of land. Thus, joint use agreements have practical limitations that should be considered when selecting among strategies to promote physical activity participation.

Characteristics of joint use agreements in school districts in the United States: findings from the School Health Policies and Practices Study, 2012.

INTRODUCTION: Joint use or shared use of public school facilities provides community access to facilities for varied purposes. We examined a nationally representative sample of school districts in the United States to identify characteristics associated with having a formal joint use agreement (JUA) and with the kinds of uses to which JUAs apply. METHODS: We analyzed data from the 2012 School Health Policies and Practices Study. The response rate for the module containing questions about formal JUAs was 60.1% (N = 630). We used multivariate logistic regression models to examine the adjusted odds of having a formal JUA and χ(2) analyses to examine differences in district characteristics associated with the uses of the JUA. RESULTS: Among the 61.6% of school districts with a formal JUA, more than 80% had an agreement for the use of indoor and outdoor recreation facilities; other uses also were identified. JUAs were more common in urban than rural areas, in large than small school districts, and in the West compared with the Midwest, South, and Northeast. CONCLUSION: In many districts, school facilities appear to be an untapped resource for community members. Formal JUAs provide an opportunity for shared use while addressing issues of liability, cost, and logistics.

Study on the evaluation and influencing factors of contracted residents on the coordination of primary medical institutions.

Background: The implementation of family doctor contract service is a pivotal measure to enhance primary medical services and execute the hierarchical diagnosis and treatment system. Achieving service coordination among various institutions is both a fundamental objective and a central element of contract services. Objective: The study aims to assess residents' evaluations and determining factors related to the coordination of health services within primary medical institutions across different regions of Shandong Province. The findings intend to serve as a reference for enhancing the coordination services offered by these institutions. Methods: The study employed a multi-stage stratified random sampling method to select three prefecture-level cities in Shandong Province with different economic levels. Within each city, three counties (districts) were randomly sampled using the same method. Within each county (district), three community health service centers and township health centers implementing family doctor contract services were selected randomly. Face-to-face questionnaire surveys were conducted with contracted residents using the coordination dimension of the revised Primary Care Assessment Tools Scale (PCAT) developed by the research team. Data analysis was conducted using such methods as one-way analysis of variance and multiple linear regression. Results: The sample included 3,859 contracted residents. The coordination dimension score of primary medical institutions averaged 3.41 ± 0.18, with the referral service sub-dimension scoring 3.60 ± 0.58 and the information system sub-dimension scoring 3.34 ± 0.65. The overall score of the referral service sub-dimension surpassed that of the information system sub-dimension. Regression results indicated that the city's economic status, the type of contracted institutions, gender, education, marital status, income, occupation, health status, and endowment insurance payment status significantly influenced the coordinated service score of primary medical institutions (p < 0.05). Conclusion: The coordination of primary medical institutions in Shandong Province warrants further optimization. Continued efforts should focus on refining the referral system, expediting information infrastructure development, enhancing the service standards of primary medical institutions, and fostering resident trust. These measures aim to advance the implementation of the hierarchical diagnosis and treatment and two-way referral system.

Contracting in specialists for emergency obstetric care- does it work in rural India?

BACKGROUND: Contracting in private sector is promoted in developing countries facing human resources shortages as a challenge to reduce maternal mortality. This study explored provision, practice, performance, barriers to execution and views about contracting in specialists for emergency obstetric care (EmOC) in rural India. METHODS: Facility survey was conducted in all secondary and tertiary public health facilities (44) in three heterogeneous districts in Maharashtra state of India. Interviews (42) were conducted with programme managers and district and block level officials and with public and private EmOC specialists. Locations of private obstetricians in the study districts were identified and mapped. RESULTS: Two schemes, namely Janani Suraksha Yojana and Indian Public Health standards (IPHS) provided for contracting in EmOC specialists. The IPHS provision was chosen for use mainly due to greater sum for contracting in (US $ 30/service episode vs.300 US$/month). The positions of EmOC specialists were vacant in 83% of all facilities that hence had a potential for contracting in EmOC specialists. Private specialists were contracted in at 20% such facilities. The contracting in of specialists did not greatly increase EmOC service outputs at facilities, except in facilities with determined leadership. Contracting in specialists was useful for non emergency conditions, but not for obstetric emergencies. The contracts were more of a relational nature with poor monitoring structures. Inadequate infrastructure, longer distance to private specialists, insufficient financial provision for contracting in, and poor management capacities were barriers to effective implementation of contracting in. Dependency on the private sector was a concern among public partners while the private partners viewed contracting in as an opportunity to gain experience and credibility. CONCLUSIONS: Density and geographic distribution of private specialists are important influencing factors in determining feasibility and use of contracting in for EmOC. Local circumstances dictate balance between introduction or expansion of contracts with private sector and strengthening public provisions and that neither of these disregard the need to strengthen public systems. Sustainability of contracting in arrangements, their effect on increasing coverage of EmOC services in rural areas and overlapping provisions for contracting in EmOC specialists are issues for future consideration.

Framing the decision to contract out elderly care and primary health care services - perspectives of local level politicians and civil servants in Finland.

BACKGROUND: In the literature there are only few empirical studies that analyse the decision makers' reasoning to contract out health care and social services to private sector. However, the decisions on the delivery patterns of health care and social services are considered to be of great importance as they have a potential to influence citizens' access to services and even affect their health. This study contributes to filling this cap by exploring the frames used by Finnish local authorities as they talk about contracting out of primary health care and elderly care services. Contracting with the private sector has gained increasing popularity, in Finland, during the past decade, as a practise of organising health care and social services. METHODS: Interview data drawn from six municipalities through thematic group interviews were used. The data were analysed applying frame analysis in order to reveal the underlying reasoning for the decisions. RESULTS: Five argumentation frames were found: Rational reasoning; Pragmatic realism; Promoting diversity among providers; Good for the municipality; Good for the local people. The interviewees saw contracting with the private sector mostly as a means to improve the performance of public providers, to improve service quality and efficiency and to boost the local economy. The decisions to contract out were mainly argued through the good for the municipal administration, political and ideological commitments, available resources and existing institutions. CONCLUSIONS: This study suggests that the policy makers use a number of grounds to justify their decisions on contracting out. Most of the arguments were related to the benefits of the municipality rather than on what is best for the local people. The citizens were offered the role of active consumers who are willing to purchase services also out-of-pocket. This development has a potential to endanger the affordability of the services and lead to undermining some of the traditional principles of the Nordic welfare state.

[Is the needs-based planning mechanism effectively needs-based? An analysis of the regional distribution of outpatient care providers]. / Wie "bedarfsgerecht" ist die Bedarfsplanung? Eine Analyse der regionalen Verteilung der vertragsärztlichen Versorgung.

AIMS: Since the 1990s licenses for opening a medical practice in Germany are granted based on a needs-based planning system which regulates the regional allocation of physicians in primary care. This study aims at an analysis of the distribution of physicians (and hence the effects of the planning system) with regard to the overarching objective of primary care supply: the safeguarding of "needs-based and evenly distributed health care provision" (Section 70 para 1 German Social Code V). METHODS: The need for health care provision of each German district (or region) and the actual number of physicians in the respective area are compared using a concentration analysis. For this purpose, the local health-care need was approximated in a model based on the morbidity predictors age and sex and by combining data on the local population structure with the age- and sex-specific frequency of physician consultations (according to data of the GEK sickness fund). The concentration index then measures the degree of regional inequity in the distribution of outpatient care. RESULTS: The results of the analysis demonstrate an inequitable regional distribution between medical needs of the local population and the existing outpatient health care provider capacities. These regional disparities in needs-adjusted supply densities are particularly large for -outpatient secondary care physicians and psychotherapists, even when taking into account the care provision of urban physicians for peri-urban areas as well as the adequacy of longer travel times to specialists. One major reason for these inequities is the design of today's physician planning mechanism which mainly conserves a suboptimal status quo of the past. CONCLUSION: The initiated reforms of the planning mechanism should progress and be further deepened. Especially today's quota-based allocation of practice licenses requires fundamental changes taking into account the relevant factors approximating local health care needs, re-assessing the adequate spatial planning level and expanding opportunities for introducing innovative and more flexible health care services models.

Assessing the level of public health partner spending using the funding formula analysis tool.

Public health services are delivered through a variety of organizations. Traditional accounting of public health expenditures typically captures only spending by government agencies. New Hampshire collected information from public health partners, such as community centers that host smoking cessation classes or health education done by Girls, Inc. This study compares the new data to spending by government agencies, focusing on breakdowns by fund source and service categories. Expanded funds secured by these partners account for a 42% of all local public health spending, and they spent 4 times more than government agencies on promoting healthy behavior. The funding formula analysis tool revealed that these partners spent in ways that would be politically difficult to achieve. In an era of declining budgets, an understanding of public health's partners is increasingly vital.