The Legal Status of General Practitioners at the dawn of the New Primary Care in Italy.

Abstract: A debate is developing in Italy on the reform of the employment status of general practitioners. The dispute was prompted by the extraordinary resources the European Union has allocated to Italy on the condition of several structural reforms, among which lies the renewal of the primary care system. One of the most debated questions is whether general practitioners should become civil servants or remain autonomous workers. The issue is not only relevant to the quality and efficiency of primary care but is propitious for improving the legal certainty of this "hybrid figure" in Italian health law. The commentary suggests that, from a public law point of view, the employment status of civil servants better agrees with the foreseeable conditions of general practitioners working in Community Houses. In any case, national and regional policymakers must take into consideration possible controversies and litigation arising from an inappropriate qualification of the legal status of general practitioners in building the new system of Italian primary care.

Ten Years Later: Reflections on Critics' Worst-Case Scenarios for the Affordable Care Act.

The primary goals of the Affordable Care Act (ACA) were to increase the availability and affordability of health insurance coverage and thereby improve access to needed health care services. Numerous studies have overwhelmingly confirmed that the law has reduced uninsurance and improved affordability of coverage and care for millions of Americans. Not everyone believed that the ACA would lead to positive outcomes, however. Critics raised numerous concerns in the years leading up to the law's passage and full implementation, including about its consequences for national health spending, labor supply, employer health insurance markets, provider capacity, and overall population health. This article considers five frequently heard worst-case scenarios related to the ACA and provides research evidence that these fears did not come to pass.

The evolution of New Zealand's health workforce policy and planning system: a study of workforce governance and health reform.

INTRODUCTION: While considerable attention has been given to improving health workforce planning practice, few articles focus on the relationship between health workforce governance and health reform. By outlining a sequence of health reforms, we reveal how New Zealand's health workforce governance and practices came under pressure, leading to a rethink and the introduction of innovative approaches and initiatives. CASE DESCRIPTION: New Zealand's health system was quite stable up to the late 1980s, after which 30 years of structural and system reform was undertaken. This had the effect of replacing the centralised medically led health workforce policy and planning system with a market-driven and short-run employer-led planning approach. The increasing pressures and inconsistencies this approach produced ultimately led to the re-centralisation of some governance functions and brought with it a new vision of how to better prepare for future health needs. While significant gain has been made implementing this new vision, issues remain for achieving more effective innovation diffusion and improved integrated care orientations. DISCUSSION AND EVALUATION: The case reveals that there was a failure to consider the health workforce in almost all of the reforms. Health and workforce policy became increasingly disconnected at the central and regional levels, leading to fragmentation, duplication and widening gaps. New Zealand's more recent workforce policy and planning approach has adopted new tools and techniques to overcome these weaknesses that have implications for the workforce and service delivery, workforce governance and planning methodologies. However, further strengthening of workforce governance is required to embed the changes in policy and planning and to improve organisational capabilities to diffuse innovation and respond to evolving roles and team-based models of care. CONCLUSION: The case reveals that disconnecting the workforce from reform policy leads to a range of debilitating effects. By addressing how it approaches workforce planning and policy, New Zealand is now better placed to plan for a future of integrated and team-based health care. The case provides cues for other countries considering reform agendas, the most important being to include and consider the health workforce in health reform processes.

Too many and too few: The paradoxical case of physicians in the Russian Federation.

There is a paradox characterising the Russian health workforce. By international standards, Russia has a very high number of physicians per capita but at the same time is confronted by chronic real shortages of qualified physicians. This paper explores the reasons for this paradox by examining the structural characteristics of health workforce development in the context of the Soviet legacy and the comparative performance of other European countries. The paper uses data on comparative health workforce dynamics to argue that Russia is a European laggard, before then evaluating recent and current policies within that context. The health workforce challenges facing all low- and middle-income countries are acute, and this paper confirms this IS the case for Russia-Europe's largest country. The paper argues that the physician shortage is driven by the model of health workforce development inherited from the Soviet period, with its emphasis on quantitative rather than structural indicators. We find that, in contrast to most European Union countries, Russia's stalled reform process leaves it facing a chronic shortage of appropriately trained physicians. We document the costs of failed and slow reforms during the last 2 decades, while cautiously welcoming some recent policy initiatives.

Human resource for health reform in peri-urban areas: a cross-sectional study of the impact of policy interventions on healthcare workers in Epworth, Zimbabwe.

BACKGROUND: The need to understand how healthcare worker reform policy interventions impact health personnel in peri-urban areas is important as it also contributes towards setting of priorities in pursuing the universal health coverage goal of health sector reform. This study explored the impact of post 2008 human resource for health reform policy interventions on healthcare workers in Epworth, a peri-urban community in Harare, Zimbabwe, and the implications towards health sector reform policy in peri-urban areas. METHODS: The study design was exploratory and cross-sectional and involved the use of qualitative and quantitative methods in data collection, presentation, and analysis. A qualitative study in which data were collected through a documentary search, five key informant interviews, seven in-depth interviews, and five focus group discussions was carried out first. This was followed by a quantitative study in which data were collected through a documentary search and 87 semi-structured sample interviews with healthcare workers. Qualitative data were analyzed thematically whilst descriptive statistics were used to examine quantitative data. All data were integrated during analysis to ensure comprehensive, reliable, and valid analysis of the dataset. RESULTS: Three main factors were identified to help interpret findings. The first main factor consisted policy result areas that impacted most successfully on healthcare workers. These included the deployment of community health workers with the highest correlation of 0.83. Policy result areas in the second main factor included financial incentives with a correlation of 0.79, training and development (0.77), deployment (0.77), and non-financial incentives (0.75). The third factor consisted policy result areas that had the lowest satisfaction amongst healthcare workers in Epworth. These included safety (0.72), equipment and tools of trade (0.72), health welfare (0.65), and salaries (0.55). CONCLUSIONS: The deployment of community health volunteers impacted healthcare workers most successfully. This was followed by salary top-up allowances, training, deployment, and non-financial incentives. However, health personnel were least satisfied with their salaries. This had negative implications towards health sector reform interventions in Epworth peri-urban community between 2009 and 2014.

Coping and compromise: a qualitative study of how primary health care providers respond to health reform in China.

BACKGROUND: Health reform in China since 2009 has emphasized basic public health services to enhance the function of Community Health Services as a primary health care facility. A variety of studies have documented these efforts, and the challenges these have faced, yet up to now the experience of primary health care (PHC) providers in terms of how they have coped with these changes remains underdeveloped. Despite the abundant literature on psychological coping processes and mechanisms, the application of coping research within the context of human resources for health remains yet to be explored. This research aims to understand how PHC providers coped with the new primary health care model and the job characteristics brought about by these changes. METHODS: Semi-structured interviews with primary health care workers were conducted in Jinan city of Shandong province in China. A maximum variation sampling method selected 30 PHC providers from different specialties. Thematic analysis was used drawing on a synthesis of theories related to the Job Demands-Resources model, work adjustment, and the model of exit, voice, loyalty and neglect to understand PHC providers' coping strategies. RESULTS: Our interviews identified that the new model of primary health care significantly affected the nature of primary health work and triggered a range of PHC providers' coping processes. The results found that health workers perceived their job as less intensive than hospital medical work but often more trivial, characterized by heavy workload, blurred job description, unsatisfactory income, and a lack of professional development. However, close relationship with community and low work pressure were satisfactory. PHC providers' processing of job demands and resources displayed two ways of interaction: aggravation and alleviation. Processing of job demands and resources led to three coping strategies: exit, passive loyalty, and compromise with new roles and functions. CONCLUSIONS: Primary health care providers employed coping strategies of exit, passive loyalty, and compromise to deal with changes in primary health work. In light of these findings, our paper concludes that it is necessary for the policymakers to provide further job resources for CHS, and involve health workers in policy-making. The introduction of particular professional training opportunities to support job role orientation for PHC providers is advocated.

The ACA's Cost-Sharing Reduction Plans: A Key to Affordable Health Coverage for Millions of U.S. Workers.

Issue: Without the cost-sharing reductions (CSRs) made available by the Affordable Care Act, health plans sold in the marketplaces may be unaffordable for many low-income people. CSRs are available to households earning between 100 percent and 250 percent of the federal poverty level that choose a silver-level marketplace plan. In 2016, about 7 million people received cost-sharing reductions that substantially lowered their deductibles, copayments, coinsurance, and out-of-pocket limits. Goal: To examine variations in consumer cost-sharing reductions between silver-level plans with CSRs to traditional marketplace plans and to employer-based insurance. Methods: Data analysis of 1,209 CSR-eligible plans sold in individual marketplaces in all 50 states and Washington, D.C. Key findings and conclusions: Cost-sharing amounts in silver plans with CSRs are much less than those in non-CSR base silver plans; silver plans with CSRs generally offer far better financial protection than those without. General annual deductibles range from $246 for CSR silver plans with a platinum-level actuarial value (94%) to as much as $3,063 for non-CSR silver plans. Out-of-pocket limits vary from $6,223 in base silver plans to $1,102 in silver plans with CSRs and a platinum-level actuarial level.

Economic benefits of less restrictive regulation of advanced practice nurses in North Carolina.

BACKGROUND: With looming provider shortages and increased demand for health care, many states are looking for low-cost ways to alleviate the shortages. PURPOSE: The purpose of this study was to assess the economic impact of less restrictive regulations for advanced practice registered nurses (APRNs) in North Carolina. METHOD: We use economic impact analysis to demonstrate the economic impacts of making state scope-of-practice regulations on APRNs less restrictive in North Carolina. Outcomes include economic output, value-added, payroll compensation, employment, and tax revenue for North Carolina and for various subregions. DISCUSSION: If North Carolina adopted the same approach to APRN regulation as the least restrictive states, its economy will benefit from substantial increases in economic output and employment. The state will also see increases in tax revenue. CONCLUSIONS: In addition to substantially shrinking the size of projected physician shortages, allowing full scope-of-practice for APRNs will bring significant economic benefits to the state of North Carolina. Our analysis should be helpful to policy makers considering ways to deal with provider shortages.

A survey of nurses, midwives, and physicians attitudes in regard to health reform plan at Jahrom University of Medical Sciences in 2020.

BACKGROUND: The health reform plan (HRP) is a plan to improve Iran's health systems that began in 2014. The three main approaches of this plan include financial protection of the people, creating justice in access to health services, and improving the quality of services. It predicted that the level of health system responsiveness would increase. Achieving this goal is possible only with the correct implementation. The best people to measure the correct implementation are nurses, midwives, and physicians. Hence, this study was conducted to assess the attitude of nurses, midwives, and physicians about the implementation of the HRP. MATERIALS AND METHODS: This cross-sectional descriptive study was conducted in educational hospitals of Jahrom University of Medical Sciences in 2020. By convenience sampling method, 325 nurses, midwives, and physicians participated in this study. Sampling was done in all work shifts, and in all wards. A researcher-making questionnaire was used to collect data. The scoring did by the Likert scale from (completely agree = 4 to completely disagree = 1). Quantitative and qualitative face and content validity was calculated (IS: 0.84, CVI: 0.92, CVR: 0.87), and its reliability was calculated by Cronbach's alpha method (0.78). The data were analyzed by SPSS software version 16. Descriptive statistics, Mann-Whitney U-test, and Kruskal-Wallis test were used for the data analysis (P ≤ 0.05). RESULTS: In the study, 90.15% agreed with the implementation of the HRP. There was no significant difference between the male and female (P = 0.063). There was a significant difference between the educational degree (P = 0.006), married and the single participants' attitude (P = 0.003), the nurses, midwives, and physicians (P = 0.001). CONCLUSION: HRP is more successful in the field of financial protection, so policymakers should pay more attention to justice in access to health services and improving the quality of services fields.

Redesigning provider payment: Opportunities and challenges from the Hawaii experience.

OBJECTIVES: To describe the process of developing a new physician payment system based on value and transitioning away from a fee-for-service payment system STUDY DESIGN: Descriptive. This paper describes a recent initiative involving redesign of primary care provider payment in the State of Hawaii. While there has been extensive discussion about switching payment from volume to value in recent years, much of this change has happened at the organizational level and this initiative focused on changing the incentives for individual providers. METHODS: Descriptive paper. In this paper we discuss the approach taken to shift incentives from fee-for-service towards value using behavioral economics as a conceptual framework for program design. We summarize the new payment system, challenges in its design, and our approach to piloting of different behavioral economic strategies to improve performance. RESULTS: None. CONCLUSIONS: This paper will provide useful guidance to health plans or health delivery systems considering shifting primary care payment away from fee-for-service towards value highlighting some of the design challenges and necessary compromises in implementing such a system at scale.

Employer-Sponsored Insurance Stable For Low-Income Workers In Medicaid Expansion States.

We assessed rates of employer health insurance offer, take-up, and coverage in June 2013 and March 2017 among workers. Overall, offer rates remained stable, and take-up and coverage rates increased. In Medicaid expansion states, the share of workers with family incomes at or below 138 percent of the federal poverty level who had employer-based coverage held steady, while uninsurance rates declined.

Why Did Employer Coverage Fall In Massachusetts After The ACA? Potential Consequences Of A Changing Employer Mandate.

The Affordable Care Act (ACA) attempted to minimize disruptions to employer-sponsored insurance in part by implementing an employer mandate. Research has shown that employer coverage rates have been stable nationally under the ACA. Massachusetts enacted its own employer mandate in 2006 before eliminating it in 2014, in anticipation of the federal mandate. But the ACA's employer mandate was delayed until 2015 and exempted smaller firms that had been covered by the Massachusetts' mandate. In this unique policy environment, we found that the employer-sponsored insurance rate in Massachusetts fell by 2.3 percentage points after the ACA's coverage expansion took effect (2014-16), compared to the rest of the US. Coverage dropped more for middle-income workers than for lower-income workers, which suggests that crowd-out by Medicaid was not the primary factor. Employer surveys show that employer coverage offer rates declined significantly at small firms in Massachusetts beginning in 2014, but not at large firms. Our findings suggest that eliminating Massachusetts's employer mandate may have contributed to falling employer coverage rates in the state, although other policy and economic factors cannot be ruled out. These results may have implications for understanding the effects of the ACA's employer mandate and its potential repeal.

The Medicare Access And CHIP Reauthorization Act: Effects On Medicare Payment Policy And Spending.

In 2015, Congress repealed the Sustainable Growth Rate formula for Medicare physician payment, eliminating mandatory payment cuts when spending exceeded what was budgeted. In its place, Congress enacted the Medicare Access and CHIP Reauthorization Act (MACRA), which established a two-track performance-based payment system that encourages physicians to participate in alternative payment models. MACRA could have huge effects on health care delivery, but the nature of those effects is highly uncertain. Using the RAND Corporation's Health Care Payment and Delivery Simulation Model, we estimated the effects of MACRA on Medicare spending and utilization and examined how effects would differ under various scenarios. We estimate that MACRA will decrease Medicare spending on physician services by -$35 to -$106 billion (-2.3 percent to -7.1 percent) and change spending on hospital services by $32 to -$250 billion (0.7 percent to -5.1 percent) in 2015-30. The spending effects are critically dependent on the strength of incentives in the alternative payment models, particularly the incentives for physicians to reduce hospital spending and physician responses to MACRA payment rates.

Narrow Networks On The Health Insurance Marketplaces: Prevalence, Pricing, And The Cost Of Network Breadth.

Anecdotal reports and systematic research highlight the prevalence of narrow-network plans on the Affordable Care Act's health insurance Marketplaces. At the same time, Marketplace premiums in the period 2014-16 were much lower than projected by the Congressional Budget Office in 2009. Using detailed data on the breadth of both hospital and physician networks, we studied the prevalence of narrow networks and quantified the association between network breadth and premiums. Controlling for many potentially confounding factors, we found that a plan with narrow physician and hospital networks was 16 percent cheaper than a plan with broad networks for both, and that narrowing the breadth of just one type of network was associated with a 6-9 percent decrease in premiums. Narrow-network plans also have a sizable impact on federal outlays, as they depress the premium of the second-lowest-price silver plan, to which subsidy amounts are linked. Holding all else constant, we estimate that federal subsidies would have been 10.8 percent higher in 2014 had Marketplaces required all plans to offer broad provider networks. Narrow networks are a promising source of potential savings for other segments of the commercial insurance market.

Performance And Participation Of Physicians In Year One Of Medicare's Value-Based Payment Modifier Program.

In 2015 Medicare launched the Physician Value-Based Payment Modifier program, the largest US ambulatory care pay-for-performance program to date and a precursor to the forthcoming Merit-based Incentive Payment System. In its first year, the program included practices with a hundred or more clinicians. We found that 1,010 practices met this criterion, 899 of which had at least one attributed beneficiary. Of these latter practices, 263 (29.3 percent) failed to report performance data and received a 1 percent reporting-based penalty. Of the 636 practices that reported performance data, those that elected quality tiering-voluntarily receiving performance-based penalties or bonuses-and those with high use of electronic health records had better performance on quality and costs than other practices. Practices with a primary care focus had better quality than other practices but similar costs. These findings translated into differences in the receipt of penalties and bonuses and may have implications for performance patterns under the Merit-based Incentive Payment System.

Grandfathered, Grandmothered, And ACA-Compliant Health Plans Have Equivalent Premiums.

Many small employers offer employees health plans that are not fully compliant with Affordable Care Act (ACA) provisions such as covering preventive services without cost sharing. These "grandfathered" and "grandmothered" plans accounted for about 65 percent of enrollment in the small-group market in 2014. Premium costs for these and ACA-compliant plans were equivalent.

Wage Growth for the Health Care Workforce: Projecting the Affordable Care Act Impact.

OBJECTIVE: To predict changes in wage growth for health care workers based on projections of insurance enrollment from the Affordable Care Act (ACA). DATA SOURCES: Enrollment data came from three large employers and a sampling of premiums from ehealthinsurance.com. Information on state Medicaid eligibility rules and costs were from the Kaiser Family Foundation. National predictions were based on the MEPS and Medicare Current Beneficiary surveys. Bureau of Labor Statistics data were used to estimate employment. STUDY DESIGN: We projected health insurance enrollment by plan type using a health plan choice model. Using claims data, we measured the services demanded for each plan choice and year. Projections of labor demand were based on current output/input ratios. Changes in wages resulting from changes in labor demand from 2014 to 2021 were based on labor supply and demand elasticities. PRINCIPAL FINDINGS: Expenditures required to retain and grow the health care workforce will increase substantially. Wages will increase most for professions with the greatest training requirements (physicians and registered nurses). The largest impact will be felt in 2015. CONCLUSIONS: Projected wage increases for health care workers may drive substantial growth in insurance premiums and reduce the affordability of health insurance.

The Experience of Risk-Adjusted Capitation Payment for Family Physicians in Iran: A Qualitative Study.

BACKGROUND: When a country's health system is faced with fundamental flaws that require the redesign of financing and service delivery, primary healthcare payment systems are often reformed. OBJECTIVES: This study was conducted with the purpose of exploring the experiences of risk-adjusted capitation payment of urban family physicians in Iran when it comes to providing primary health care (PHC). MATERIALS AND METHODS: This is a qualitative study using the framework method. Data were collected via digitally audio-recorded semi-structured interviews with 24 family physicians and 5 executive directors in two provinces of Iran running the urban family physician pilot program. The participants were selected using purposive and snowball sampling. The codes were extracted using inductive and deductive methods. RESULTS: Regarding the effects of risk-adjusted capitation on the primary healthcare setting, five themes with 11 subthemes emerged, including service delivery, institutional structure, financing, people's behavior, and the challenges ahead. Our findings indicated that the health system is enjoying some major changes in the primary healthcare setting through the implementation of risk-adjusted capitation payment. CONCLUSIONS: With regard to the current challenges in Iran's health system, using risk-adjusted capitation as a primary healthcare payment system can lead to useful changes in the health system's features. However, future research should focus on the development of the risk-adjusted capitation model.

Are health workers motivated by income? Job motivation of Cambodian primary health workers implementing performance-based financing.

BACKGROUND: Financial incentives are widely used in performance-based financing (PBF) schemes, but their contribution to health workers' incomes and job motivation is poorly understood. Cambodia undertook health sector reform from the middle of 2009 and PBF was employed as a part of the reform process. OBJECTIVE: This study examines job motivation for primary health workers (PHWs) under PBF reform in Cambodia and assesses the relationship between job motivation and income. DESIGN: A cross-sectional self-administered survey was conducted on 266 PHWs, from 54 health centers in the 15 districts involved in the reform. The health workers were asked to report all sources of income from public sector jobs and provide answers to 20 items related to job motivation. Factor analysis was conducted to identify the latent variables of job motivation. Factors associated with motivation were identified through multivariable regression. RESULTS: PHWs reported multiple sources of income and an average total income of US$190 per month. Financial incentives under the PBF scheme account for 42% of the average total income. PHWs had an index motivation score of 4.9 (on a scale from one to six), suggesting they had generally high job motivation that was related to a sense of community service, respect, and job benefits. Regression analysis indicated that income and the perception of a fair distribution of incentives were both statistically significant in association with higher job motivation scores. CONCLUSIONS: Financial incentives used in the reform formed a significant part of health workers' income and influenced their job motivation. Improving job motivation requires fixing payment mechanisms and increasing the size of incentives. PBF is more likely to succeed when income, training needs, and the desire for a sense of community service are addressed and institutionalized within the health system.

The demand for health care workers post-ACA.

Concern abounds about whether the health care workforce is sufficient to meet changing demands spurred by the Affordable Care Act (ACA). We project that by 2022 the health care industry needs three to four million additional workers, forty percent of which is related to demand growth under the ACA. We project faster job growth in the ambulatory care sector, especially in home health care. Given the current profile, we expect that the future health care workforce will be increasingly female, young, racially/ethnically diverse, not US-born, at or below the poverty level and at a low level of educational attainment.