Health Care Reforms, Power Concentration, and Receding Citizen Participation.

The article highlights several outstanding features of French healthcare reforms in light of New Public Management (NPM). The paper exposes the economic, administrative, and social context of reforms. It investigates horizontal integration, as exemplified by the concentration of power within the Regional Health Organizations, the verticalization of the chain of command, and ensuing conflicts between the French welfare elite and the operating core (eg, the medical profession). Outcomes were below expectations in many areas. The NPM-endorsed fragmentation of public organizations has yet to take root in the French healthcare system. There was little consultation with the medical profession. Physicians' autonomy and patients' rights receded.

French Idiosyncratic Health-Care Reforms, Performance Management and Its Political Repercussions.

CONTEXT: France has undergone major changes in social policy that made an impact on the health-care sector. The paper reminds readers of the application and shortcomings of the concept of New Public Management (NPM) in the French health system. PROBLEM: The paper investigates NPM health reforms in France. Reforms aimed at containing costs. What administrative restructuring was implemented? What were reform idiosyncrasies? What were their limitations? Which critical public health emergencies remain? METHODS: We examine the political and economic context of health-care reforms, the rise of the regulatory state, and its core element: the diagnostic-related group (DRG) scale. We critically examine the recentralization of health policy decisions and its impact on care providers and provide an international perspective on reforms. RESULTS: Reforms put priority on the use of yardsticks and also emphasized regulation and competition but rejected public-private partnerships on the Anglo-Saxon model. Central health authorities regain their authority over health policy decisions, and decentralization was weakened. CONCLUSION: Restrictions in public service delivery triggered a general discontent among the population. The political repercussions of reforms eventually crystallized into the Yellow Vest movement.

How Multidimensional Is Emotional Intelligence? Bifactor Modeling of Global and Broad Emotional Abilities of the Geneva Emotional Competence Test.

Drawing upon multidimensional theories of intelligence, the current paper evaluates if the Geneva Emotional Competence Test (GECo) fits within a higher-order intelligence space and if emotional intelligence (EI) branches predict distinct criteria related to adjustment and motivation. Using a combination of classical and S-1 bifactor models, we find that (a) a first-order oblique and bifactor model provide excellent and comparably fitting representation of an EI structure with self-regulatory skills operating independent of general ability, (b) residualized EI abilities uniquely predict criteria over general cognitive ability as referenced by fluid intelligence, and (c) emotion recognition and regulation incrementally predict grade point average (GPA) and affective engagement in opposing directions, after controlling for fluid general ability and the Big Five personality traits. Results are qualified by psychometric analyses suggesting only emotion regulation has enough determinacy and reliable variance beyond a general ability factor to be treated as a manifest score in analyses and interpretation. Findings call for renewed, albeit tempered, research on EI as a multidimensional intelligence and highlight the need for refined assessment of emotional perception, understanding, and management to allow focused analyses of different EI abilities.

The Symbol Digit Modalities Test (SDMT) is sensitive but non-specific in MS: Lexical access speed, memory, and information processing speed independently contribute to SDMT performance.

BACKGROUND: The Symbol Digit Modalities Test (SDMT) is the most sensitive metric of neurocognitive function in multiple sclerosis (MS), and is consistently interpreted as a measure of information processing speed (IPS). OBJECTIVE: To evaluate the cognitive psychometric profile captured by the SDMT to identify whether different cognitive processes independently underlie performance. METHODS: Three samples of MS patients (total n=661; 185 research patients at MS center; 370 clinical patients at MS center; 106 persons with MS from the community) completed objective assessments of neuropsychological function across cognitive domains. Exploratory factor analysis (EFA) was used to derive latent cognitive factor scores, and operationalize cognitive domain composite scores, to understand the unique, shared and redundant contribution of different cognitive domains to SDMT performance using hierarchical multiple regression and commonality analysis. RESULTS: Across three independent samples we provide converging strong evidence that the cognitive domains of Memory, IPS and Rapid Automatized Naming (lexical access speed) jointly and uniquely contribute to SDMT performance. CONCLUSION: The SDMT measures multiple cognitive processes, which likely explains the high degree of sensitivity to cognitive change in MS. Researchers and clinicians should interpret the SDMT as a multifarious measure of general cognition rather than a specific test of IPS.

Technocratic recentralization in the French health care system: A critical evaluation.

The French health care system implemented several corporate management recipes such as diagnostic-related groups (DRGs), benchmarking, and activity-based management in a bid to restore fiscal discipline and to "reassert the center." The government also regrouped health policy decisions with the Regional Health Agencies and opted for a top-down line of command to ensure policy implementation. Though reforms emphasized evidenced-based policy and outputs measurement, outcomes were below expectations in many areas and led to a shift in values. Professional autonomy and patient engagement receded. This leads us to a critical evaluation of the French audit society.

A Social-Cognitive Moderated Mediated Model of Psychological Safety and Empowerment.

This study examines the indirect role of psychological safety in shaping the four cognitions of psychological empowerment (i.e., meaning, competence, self-determination, impact) through three social mechanisms: authentic interactions, spiritual development, and perceived organizational voice. Data were collected from 229 congregation members of a nondenominational church. Preliminary analyses reveal psychological safety is: (a) linked to all four empowerment cognitions, (b) associated with the three proximal social mechanisms, and (c) indirectly predicts three of the four empowerment cognitions through heightened level of authentic interactions, spiritual development, and perceived organizational voice. Moreover, extraversion moderated the relationship of psychological safety with authentic interactions which, in turn, strengthened the size of the indirect effect for the meaning subcomponent of empowerment. Overall, this study suggests empowerment research can draw upon the potential, but frequently untapped, benefits of cultivating a secure space to facilitate member motivation through sincerity, personal development, and perceived voice.

Assessment of new public management in health care: the French case.

The French health care system embraced New Public Management (NPM) selectively, and crafted their own version of NPM using Diagnostic-Related-Group accounting to re-centralize the health care system. Other organizational changes include the adoption of quasi-markets, public private partnerships, and pay-for-performance schemes for General Practitioners. There is little evidence that these improved the performance of the system. Misrepresentation has remained high. With the 2009 Hospital, Patients, Health and Territories Act physician participation in hospital governance receded. Decision-making powers and health units were re-concentrated to instill greater national coherence into the health system.

Adverse childhood experiences, posttraumatic stress disorder symptoms, and emotional intelligence in partner aggression.

Intimate partner violence (IPV) has been linked to childhood abuse, posttraumatic stress disorder (PTSD), and low emotional intelligence (EI). Relationships among adverse childhood experiences (ACE), PTSD symptoms, and partner aggression (i.e., generalized tendency to aggress toward one's partner) were assessed in 108 male IPV offenders. It was hypothesized that ACE is positively correlated with partner aggression, PTSD mediates the ACE-aggression relationship, and the ACE-PTSD-aggression mediation varies by selected EI facets. Results indicate that ACE has an indirect effect on partner aggression via PTSD and PTSD mediates the ACE-aggression link when emotional self-regulation is low and when intuition (vs. reason) is high. Trauma-exposed IPV offenders may benefit from comprehensive treatments focusing on PTSD symptoms, emotional control, and reasoning skills to reduce aggression.

Hypersensitive reactions to local dental anesthetics and patient information: critical review of a drug leaflet.

This paper discusses the case of a patient who experienced adverse reactions to a local anesthetic. It reviews symptoms of adverse reactions, possible causes, patient management, and alternative anesthesia modes. The second part of the paper discusses the product leaflet information and the associated legal issues.

Healthcare reforms and cost reduction strategies in Europe: the cases of Germany, UK, Switzerland, Italy and France.

PURPOSE: This paper aims to analyse health reforms carried out in a sample of European countries. DESIGN/METHODOLOGY/APPROACH: Using a country-specific approach, outstanding health reform features such as: greater competition between sickness funds in Germany; fund-holding practices in the UK; managed care models in Switzerland; health networks in France; and healthcare system decentralisation in Italy are analysed. FINDING: There have been different approaches to controlling healthcare costs. Some states relied on public sector competition by creating quasi-markets (UK), insurance sector competition, particularly in Switzerland and Germany, organisational reforms in France by creating health networks and decentralisation in Italy. RESEARCH LIMITATIONS/IMPLICATIONS: Societal and legal aspects are not discussed. ORIGINALITY/VALUE: The paper compares healthcare reform effectiveness in a number of western European countries.

Cost reduction strategies for emergency services: insurance role, practice changes and patients accountability.

Progress in medicine and the subsequent extension of health coverage has meant that health expenditure has increased sharply in Western countries. In the United States, this rise was precipitated in the 1980s, compounded by an increase in drug consumption which prompted the government to re-examine its financial support to care delivery, most notably in hospital care and emergencies services. In California for example, 50 emergency service providers were closed between 1990 and 2000, and nine in 1999-2000 alone. In that State, only 355 hospitals (out of 568) have maintained emergency services departments (Darves, WebMB, 2001). Reforming hospital Emergency Department (ED) operations requires caution not only because the media pay a lot of attention to ED operations, but also because it raises ethical issues: this became more apparent with the enactment of the EMTALA which stipulates that federally funded hospitals are required to give emergency aid in order to "stabilize" a patient suffering from an "emergency medical condition" before discharging or transferring that patient to another facility. While in essence the law aims to preserve patient access to care, physicians assert that the EMTALA leads to more patients seeking care for non-urgent conditions in EDs (GAO, Report to Congressional Committees, 2001), leading to overcrowding, delayed care for patients with true emergency needs, and forcing hospitals to divert ambulances to other facilities resulting in further delays in urgent care. Also, fewer physicians are willing to be on-call in emergency departments because the EMTALA law requires on-call physicians to provide uncompensated care. Thus there is a need to find a balance between appropriate care to be provided to ED patients, and low costs since uncompensated care is not covered by state or federal funds. This concerns, first and foremost, hospitals that provide a greater amount of uncompensated care (e.g. hospitals serving communities with a higher population of illegal immigrants). Looking at the intrinsic causes of high ED costs, the paper first explains why costs of care provided in EDs are high, and look at a major cause of high ED costs: overcrowding and ED users' characteristics. This is followed by a discussion on a much-debated factor: the use of EDs for non-emergency conditions, a practice which has often been accused of disproportionately raising costs. We look at various mechanisms used either to divert or prevent the patient from using ED: these include triage services; and the role of HMOs in the ED chain of care: though the US government has increasingly relied on Managed Care organizations to contain costs (e.g. Medicaid and Medicare Managed Care), do HMOs make a difference when it comes to ED costs? Of particular interest is the family physician acting as a gatekeeper, and the legislation that was enacted to protect those who bypass the referral system. We then look at the other end of the ED chain (i.e. the recipient): the financial responsibility of ED users has increased. Alternative providers such as walk-in clinics are increasingly common. EDs also attempt to reengineer their operations to curb costs. While the data are mostly applicable to a private health care system (e.g. the US), the article, using a critical assessment of the existing literature, has implications for other EDs generally, wherever they operate, since every ED faces similar funding problems.

Patient satisfaction under managed care.

PURPOSE: In the USA, health maintenance organizations (HMOs) have pledged to control health care costs. Many patients have complained about the quality of care under the HMO regime and limits imposed on them, particularly access to care. Has quality of care been degraded under the HMO regime, resulting in an impact on patient satisfaction? There have been many studies that have compared the satisfaction of HMO patients with that of patients in the traditional fee-for-service payment system. The aim of this paper is to review HMO patient satisfaction. DESIGN/METHODOLOGY/APPROACH: A review of patient satisfaction under managed care arrangements with a focus on HMOs. The article describes the US history of managed care and its effect on the satisfaction of several patient categories including the general population, vulnerable patients and the elderly. FINDINGS: There is much information available on patient satisfaction with their insurers and most surveys indicate the lack of choice of a provider--a major source of discontent. Therefore, patient protection laws are necessary to avoid abuse. ORIGINALITY/VALUE: Patients have little ability or are not willing to rely on the information available when selecting a provider. The paper discusses patient awareness regarding satisfaction surveys and how the latter can be used when patients are seeking care.

[Professional satisfaction of American physicians in the Managed Care context]. / Satisfaction professionnelle des praticiens américains sous régime Managed care.

The objective of this article is to shed a light on the satisfaction of physicians (both primary care physicians and specialists) in the Managed Care context. Most surveys have brought in negative results. The article also analyzes the resources and the means used by physicians to express their discontent in this new era.

[Managed care and the under-privileged in the United States]. / Le Managed Care et les populations demunies aux Etats-Unis.

It has been said that "vulnerable populations" (elderly people, chronic patients,...) were largely affected by the Managed Care. The following article shed a light on the quality of care delivered to Medicaid patients under Managed Care. After a short description of the US Managed care experience, the specificities and difficulties (quality, adverse selection, non-compliance...) of Medicaid patients under capitation plans will be described.