What makes health services usable?: Insights from a qualitative study of caregivers of children with disabilities.

BACKGROUND: The concept of usability from the field of user-centered design addresses the extent to which a system is easy to use, including under extreme conditions. Apart from applications to technologies, however, little attention has been given to understanding what shapes usability of health services more generally. Health service usability may impact the extent to which patients avail themselves of and benefit from those services. PURPOSE: The aim of the study was to develop the concept of usability as it applies to health services, particularly for a high-need, complex patient population. APPROACH: We conducted interviews and focus groups with 66 caregivers of children with disabilities and analyzed data through inductive coding and constant comparison. RESULTS: We find that before health services can be rendered usable for patients with complex health conditions, work is often required to develop trusting relationships with individual providers and to manage time demands and attendant challenges of physical access. In addition, our findings show that actions crucial to receiving benefits from one service often entail difficult tradeoffs either with other services or with other important features in the patient's life-world. Finally, we propose the concept of configuration to capture the complex interdependent arrangement of connections to multiple health services, often for multiple household members, and other life-world factors (e.g., employment, transportation, living conditions). These configurations are dynamic, fragile, and vulnerable to shocks-events that destabilize them, often negatively impacting the relative usability of services and of the entire configuration. Collectively, these findings illustrate health service usability as a relational, situated, emergent property rather than an inherent feature of the service itself. PRACTICE IMPLICATIONS: System-centered design perspectives produce services that are usable for the mythical "ideal" user. To be truly "patient centered," designs must "decenter" the health service and recognize it as one component of the patient's life-world configuration.

Why Do Some Caregivers of Children with Disabilities Participate in Care Management While Others Do Not? Lessons from a Population in a Pediatric Accountable Care Organization.

Accountable care organizations (ACOs) offer care coordination services in an attempt to lower costs while improving the quality of care; however, not all families participate. We conducted focus groups and individual interviews with caregivers of children who recently joined a pediatric ACO and evaluated why some caregivers of children with disabilities engage in care coordination while others do not. Four common themes emerged as factors influencing the degree of caregiver engagement in care coordination services. These themes include: (1) availability, (2) alignment of services with family need, (3) ease or difficulty of engagement, and (4) timing of services. These findings suggest that considering caregiver perspectives across stages of program development and implementation could encourage more caregivers to engage in care coordination programs.

Can Payment Reform Be Social Reform? The Lure and Liabilities of the "Triple Aim".

The formulation of the triple aim responds to three problems facing the US health care system: high cost, low quality, and poor health status. The purpose of this article is to analyze the potential of the health care system to achieve the triple aim and, specifically, the attempt to improve population health by rewarding providers who contain costs. The first section of the article will consider the task of improving population health through the health care system. The second section of the article will discuss CMS's efforts to pay providers to achieve the triple aim, that is, to improve health care and population health while containing cost. These include Maryland's Global Revenue Budget model, bundled payments, and ACOs, and they highlight the extent to which this version of integration is underwritten by savings achieved by providers for the Medicare program. The conclusion section of the article will consider the politics of payment reform as social reform. It will address proposals that health care payers and providers lead in addressing the social contributors to ill health and urge payment reformers to appreciate more fully the politics and policies of other sectors and the dynamics of their inclusion in population health improvement.

What Is the Value of Value-Based Purchasing?

Value-based purchasing (VBP) is a widely favored strategy for improving the US health care system. The meaning of value that predominates in VBP schemes is (1) conformance to selected process and/or outcome metrics, and sometimes (2) such conformance at the lowest possible cost. In other words, VBP schemes choose some number of "quality indicators" and financially incent providers to meet them (and not others). Process measures are usually based on clinical science that cannot determine the effects of a process on individual patients or patients with comorbidities, and do not necessarily measure effects that patients value; additionally, there is no provision for different patients valuing different things. Proximate outcome measures may or may not predict distal ones, and the more distal the outcome, the less reliably it can be attributed to health care. Outcome measures may be quite rudimentary, such as mortality rates, or highly contestable: survival or function after prostate surgery? When cost is an element of value-based purchasing, it is the cost to the value-based payer and not to other payers or patients' families. The greatest value of value-based purchasing may not be to patients or even payers, but to policy makers seeking a morally justifiable alternative to politically contested regulatory policies.

Instrumentality in health care: a response to Adam Oliver.

In his paper, 'Incentivizing improvements in health care delivery', Adam Oliver discusses recent efforts to manage the performance of health care workers in the United States and United Kingdom. Overall, the results of performance management seem to be mixed, but Oliver's discussion hints at a more fundamental question about this approach, specifically: what are the limits of a focused instrumentality in a context as rich, fluid and collaborative as the delivery of health care? Might performance management schemes actually frustrate the efforts of conscientious health care workers? Indicators make few allowances for the heterogeneity of treatment effects or patient values or preferences. Health care workers may also face pressure to appear to satisfy indicators that are actually impossible to satisfy.

Reducing variation in health care: the rhetorical politics of a policy idea.

For decades, geographic variation in the use and cost of health care has captured the imagination of researchers and policy makers. As a policy problem, variation suggests its own solution--reducing variation--but the substantive weaknesses of this policy idea invite a second look at its success. This article considers the politics of policy ideas to analyze the potential rhetorical strengths of reducing variation. It finds that this idea appeals to multiple health care audiences, remains practically and politically ambiguous as to problem and solution, and resonates with long-held aspirations of policy elites, including being hopeful about solving the seemingly intractable problems of the US health care system.

Consumer-operated service organizations: organizational characteristics, community relationships, and the potential for citizenship.

Consumer-operated service organizations (COSOs) are independent organizations whose administrative and financial control resides with consumers. Based on a 2008 mail survey and followup interviews conducted in 2009, this study depicts the internal characteristics and external relationships, as well as some relationships between the two, of COSOs in one state. Profiles include on the one hand, governance structures, services provided, sources and levels of funding, etc. and on the other, relationships between COSOs and other actors in the mental health system and the local community. COSOs emerge as more self-governing and community-based than required by certification requirements and as developing internally and externally in tandem. COSOs are not only adjunct or alternative service providers, but also civic associations and loci for the expression of citizenship by mentally ill people.

Characteristics associated with organizational independence in consumer-operated service organizations.

OBJECTIVE: This research compares two types of consumer organizations in one state in order to explore the significance of organizational independence for internal structure/operations and external relationships. The first type, consumeroperated service organizations (COSOs), are independent and fully self-governing; the second are peer-support service organizations (PSSOs), which are part of larger non-consumer entities. METHODS: Mail surveys were completed by COSO and PSSO directors of a geographically representative sample of organizations; telephone interviews were conducted with a sub-sample. Owing to small sample size, matched COSO-PSSO pairs were analyzed using non-parametric statistics. RESULTS: COSOs and PSSOs are similar in some ways, e.g., types of services provided, but significantly different on internal variables, such as budget size, and external variables, such as number of relationships with community groups. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Organizational independence appears to be a significant characteristic for consumer service organizations and should be encouraged by funders and among participants. Funders might establish administrative and/or programmatic measures to support consumer organizations that are independent or moving toward independence; their participants would also benefit from the provision, by authorities or advocates, of materials to guide organizations toward, for example, 501(c)3 status.

Mental health consumer-operated services organizations in the US: citizenship as a core function and strategy for growth.

Consumer-operated services organizations (COSOs) are independent, non-profit organizations that provide peer support and other non-clinical services to seriously mentally ill people. Mental health consumers provide many of these services and make up at least a majority of the organization's leadership. Although the dominant conception of the COSO is as an adjunct to clinical care in the public mental health system, this paper reconcieves the organization as a civic association and thereby a locus of citizenship. Drawing on empirical research on COSOs in one state and the citizenship and civic democracy literatures, COSOs are analyzed here as membership organizations with democratic norms and strong ties to local communities. The suggestion is made that by embracing and enhancing their status as civic associations, COSOs may advance the goals of the social movement that spawned them and avoid predictable obstacles to further growth and development.

Pay for performance in Medicare: evidentiary irony and the politics of value.

Pay for performance (P4P) is of growing importance in the Medicare program. Pay-for-performance policy has the support of political actors in both parties and in the legislative and executive branches; of experts, business, and consumer interests; and in a qualified way, of health care providers. The evidence that P4P improves quality or reduces cost, however, is scant, although P4P proponents claim that the program is evidence based. This article reviews the history of Medicare P4P, documents its widespread support, and evaluates both the evidence of its effectiveness and the expert discourse about that evidence. The article analyzes the political reasons for Medicare P4P's popularity despite its evidentiary deficiencies and emphasizes its role in the politics of value. Pay for performance allows Medicare policy makers to (1) reformulate intractable cost and quality problems as more malleable value problems; (2) offer an acceptable quid pro quo for payment negotiations with providers; and (3) reach a rare, if shallow, consensus based on the ideological ambiguity of P4P.

Who treats limited English proficient patients? Implications for linguistic access initiatives.

BACKGROUND: Growing linguistic diversity in the United States brings serious challenges for healthcare providers. Federal civil rights policy requires that physicians participating in Medicaid and State Children's Health Insurance Program (SCHIP) provide meaningful access for their limited English proficient (LEP) patients. Key to compliance is the criterion that the provider's responsibility is proportional to the number of LEP patients likely to be served. OBJECTIVES: This article identifies which physicians are most likely to treat LEP patients and the source of payment for these visits in a traditionally low immigration state. PROCEDURES: The study utilizes 2006-2007 survey data from a random sample of 202 South Carolina physicians' practices. Descriptive statistics establish a profile for practitioners who most frequently treat LEP patients, and ordinary least squares models determine the salient characteristics for providers treating LEP patients. MAIN FINDINGS: This study finds that public and community clinics and, to a lesser degree, OB/GYN practices, in counties with over 6% Hispanic population provide a disproportionate share of care to LEP patients. Furthermore, 54.7% of LEP visits were uninsured or self-pay, with the result that LEP patients concentrate in practices that serve the uninsured. CONCLUSIONS: Proposals seeking to increase linguistic access by requiring insurers to cover interpretation services are unlikely to achieve more than a limited impact due to the low insurance coverage rates among LEP patients. The burden of compliance with current linguistic access regulations is heaviest for practices that treat the highest proportion of uninsured and that have the fewest resources to meet regulatory requirements.

Evidence-based practice as mental health policy: three controversies and a caveat.

Evidence-based practice (EBP) is the subject of vigorous controversy in the field of mental health. In this paper I discuss three distinct but interrelated controversies: how inclusive the mental health evidence base should be; whether mental health practice is a variety of applied science; and when and how the effectiveness goal in mental health is defined. I provide examples of evidence-based policy in mental health. These controversies pertain as well to general medicine. To the extent that they remain unresolved, evidence-based policy making may lead to ineffective and limited care.