RESUMO
OBJECTIVE: To examine the effect of providing the Medicare & You handbook on consumers' attitudes and behavior regarding health plan decision making. DATA SOURCE: A national sample of 3,738 Medicare beneficiaries who were surveyed in late 1999 and early 2000 was employed. Data were collected using a mail survey with telephone follow-up; the response rate was 76 percent. STUDY DESIGN: Medicare beneficiaries were randomly assigned to a control group that received no Medicare-related in formation as part of the study, or to a treatment group that received a copy of the 2000 version of the Medicare & You handbook as part of a national mailing. Half of the treat men t group (the "re-mail" group) received a second copy of the handbook along wit h their mail survey instrument. PRINCIPAL FINDINGS: The control and treatment groups did not differ regarding their level of satisfaction with or confidence in their current choice of health plan according to predicted mean values. Treatment group beneficiaries had a significantly higher propensity to either change or consider changing health plans relative to beneficiaries in the control group. Controlling for other factors, 5 percent of treatment group members switched health insurance plans during the prior month compared to 3 percent of control group members. there were no significant differences in predicted values between the re-mail and no re-mail groups in any of the models. Type of supplemental insurance was also highly related to all three outcomes. CONCLUSIONS: Findings from this and a prior parallel study suggest th at messages contained in the Medicare & You handbook can have an influence on beneficiaries and the Medicare market . Thus, careful attention should be given to the wording and intent of these messages. This is particularly relevant given the current administration's emphasis on increasing enrollment in Medicare+Choice plans and findings from earlier research reporting that beneficiaries felt the handbook was pressuring them to enroll in managed care.
Assuntos
Comportamento do Consumidor/estatística & dados numéricos , Tomada de Decisões , Conhecimentos, Atitudes e Prática em Saúde , Serviços de Informação/provisão & distribuição , Seguro de Saúde (Situações Limítrofes)/estatística & dados numéricos , Manuais como Assunto , Medicare Part A/estatística & dados numéricos , Medicare Part B/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Feminino , Geografia , Pesquisas sobre Atenção à Saúde , Sistemas Pré-Pagos de Saúde/estatística & dados numéricos , Humanos , Seguro de Saúde (Situações Limítrofes)/classificação , Masculino , Medicare Part B/classificação , Indicadores de Qualidade em Assistência à Saúde , Inquéritos e Questionários , Estados UnidosRESUMO
People enrolled in Medicare often turn to family members and friends for help in making health decisions, including Medicare health plan choices. To learn how family members and friends participate in decisionmaking, what information they currently use, and what information they would like, we held eight focus groups in San Diego and Baltimore. Although responses were different in the two markets, participants in both cities reported receiving inadequate information and indicated they were largely unaware of available CMS-supported information. Beneficiaries want easy-to-use print materials targeted to their needs and opportunities to participate in seminars and receive personal counseling.
Assuntos
Comportamento do Consumidor , Tomada de Decisões , Família , Amigos , Serviços de Informação/estatística & dados numéricos , Medicare Part B/organização & administração , Idoso , Baltimore , California , Centers for Medicare and Medicaid Services, U.S. , Planos de Pagamento por Serviço Prestado , Feminino , Grupos Focais , Pesquisas sobre Atenção à Saúde , Humanos , Cobertura do Seguro , Masculino , Programas de Assistência Gerenciada , Pessoa de Meia-Idade , Estados UnidosRESUMO
Our objectives were to explore health insurance status and insurance type, adjusted for self-reported and perceived health variables, as determinants of having and using a usual care provider in the Women's Health Initiative (WHI) Observational Study (OS). This analysis describes insurance status in a large, diverse group of older women and tests the hypothesis that insurance was a key predictor of their access to healthcare in the mid-1990s. Multiple logistic regression analysis was used to evaluate determinants of having visited a usual healthcare provider within the proceeding 12 months, using cross-sectional information provided by a population-based cohort of 55,278 postmenopausal women. Five percent of women younger than 65 years and 0.2% of women 65 or older in the OS cohort lacked health insurance. Among the 31,684 women, aged 50-64 years, Hispanic women and those with fewer years of education and lower household income and who were current smokers were less likely, and those lacking insurance were the least likely, to have seen their healthcare provider within the preceding year. Among 23,594 women, aged 65-79 years, African American and Hispanic women and those with lower household income, and Medicare only and those who were current smokers, were less likely to have seen their healthcare provider within the preceding year. In both age groups, women with chronic medical conditions and poorer perceived health scores and those with prepaid insurance were more likely to have seen their healthcare provider. In the WHI OS, both health (self-reported and perceived) and type of health insurance remained independently associated with having visited a usual healthcare provider after multivariate adjustment for one another as well as for pertinent sociodemographic characteristics.
Assuntos
Acessibilidade aos Serviços de Saúde , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Idoso , Distribuição de Qui-Quadrado , Estudos Transversais , Feminino , Nível de Saúde , Humanos , Modelos Logísticos , Medicaid , Medicare , Pessoa de Meia-Idade , Pós-Menopausa , Estados Unidos , Saúde da MulherRESUMO
BACKGROUND: Amid current changes in health care access across the United States, the importance of health insurance status and insurance type relative to demographic, actual, and perceived health variables as determinants of screening for breast, colorectal, and cervical cancer is uncertain. This analysis evaluates the hypothesis that health insurance independently predicts cancer screening in the Women's Health Initia tive Observational Study cohort. METHODS: Questionnaire data from 55,278 women en rolled in the Women's Health Initiative Observational Study between September 1994 and February 1997 were analyzed by multiple logistic regression to identify predictors of self-reported mammography within 2 years, Pap smear within 3 years, and stool guaiac or flexible sigmoidoscopy within 5 years. RESULTS: Positive determinants of reporting cancer screening were age, ethnic origin, household income, educational level, family history of cancer, having a usual care provider, time since last provider visit, and insurance status and type. Smoking, diabetes, and, among older women, prior cardiovascular events were negative determinants of cancer screening. Among women younger than 65, lacking health insurance or having fee-for-service insurance was strongly associated with failure to report cancer screening, independently of having or using a usual care provider and of demographics, self-perceived health, and health characteristics. Among women 65 and older, those with Medicare alone were less likely, whereas those with Medicare + prepaid insurance were more likely, to report cancer screening. CONCLUSIONS: In the Women's Health Initiative Obser vational Study, a large, diverse group of older women, health insurance type and status were among the most important determinants of cancer screening indepen dent of demographics, chronic health conditions, and self-perceived health characteristics.
Assuntos
Neoplasias da Mama/diagnóstico , Neoplasias Colorretais/diagnóstico , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Programas de Rastreamento/economia , Neoplasias do Colo do Útero/diagnóstico , Saúde da Mulher , Fatores Etários , Idoso , Estudos Transversais , Feminino , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Humanos , Cobertura do Seguro/classificação , Seguro Saúde/classificação , Modelos Logísticos , Programas de Rastreamento/estatística & dados numéricos , Medicare/economia , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fatores Socioeconômicos , Inquéritos e Questionários , Estados UnidosRESUMO
BACKGROUND: The increasing presence of managed health care in the United States has been accompanied by the widespread use of performance indicators to assess health plans along various dimensions of quality. Current performance indicator sets virtually ignore psychosocial and behavioral factors in the prevention and management of illness, especially chronic illness, in spite of documented evidence in the medical literature of the importance of these factors. Instead, current indicator sets focus primarily on biomedical interventions to prevent, treat, and manage illness. METHODOLOGY: In a novel method for developing performance indicators--the use of a storytelling methodology--eight interdisciplinary panels, composed of health care experts at the community, state, and national levels, each completed two stories about patients with chronic illnesses. The first story described experiences a patient might have in the health care system as it is today; the second story retold the events that might transpire if attention to psychosocial and behavioral factors were integrated into the health care system. FINDINGS: Differences between the two sets of stories developed by the panels revealed common themes and specific areas where indicator development might prove fruitful. Performance indicators were identified from these themes, and work is underway to operationalize them; to identify barriers and opportunities for their inclusion in indicator sets; and to further document their potential health and cost-effectiveness. DISCUSSION: Although not scientifically rigorous, the storytelling method was found to provide consistent results and may be applied to many aspects of the health care planning process, health education, and quality improvement efforts.
Assuntos
Atenção à Saúde/métodos , Inovação Organizacional , Indicadores de Qualidade em Assistência à Saúde/organização & administração , Redes Comunitárias , Continuidade da Assistência ao Paciente , Características Culturais , Atenção à Saúde/organização & administração , Atenção à Saúde/normas , Processos Grupais , Acessibilidade aos Serviços de Saúde , Sistemas de Informação , Motivação , Assistência ao Paciente , Relações Médico-Paciente , Competência ProfissionalRESUMO
OBJECTIVE: To provide an overview of reasons why qualitative methods have been used and can be used in health services and health policy research, to describe a range of specific methods, and to give examples of their application. DATA SOURCES: Classic and contemporary descriptions of the underpinnings and applications of qualitative research methods and studies that have used such methods to examine important health services and health policy issues. PRINCIPAL FINDINGS: Qualitative research methods are valuable in providing rich descriptions of complex phenomena; tracking unique or unexpected events; illuminating the experience and interpretation of events by actors with widely differing stakes and roles; giving voice to those whose views are rarely heard; conducting initial explorations to develop theories and to generate and even test hypotheses; and moving toward explanations. Qualitative and quantitative methods can be complementary, used in sequence or in tandem. The best qualitative research is systematic and rigorous, and it seeks to reduce bias and error and to identify evidence that disconfirms initial or emergent hypotheses. CONCLUSIONS: Qualitative methods have much to contribute to health services and health policy research, especially as such research deals with rapid change and develops a more fully integrated theory base and research agenda. However, the field must build on the best traditions and techniques of qualitative methods and must recognize that special training and experience are essential to the application of these methods.
Assuntos
Pesquisa sobre Serviços de Saúde/métodos , Formulação de Políticas , Projetos de Pesquisa , Grupos Focais/métodos , Pesquisa sobre Serviços de Saúde/estatística & dados numéricos , Humanos , Entrevistas como Assunto/métodos , Observação/métodos , Estudos de Casos Organizacionais/estatística & dados numéricos , Garantia da Qualidade dos Cuidados de Saúde/métodosRESUMO
OBJECTIVES: CAHPS is designed to report information about health care quality from the consumer perspective. Enrollees are surveyed about their experiences with their health plan and medical care, and results are reported to other consumers choosing among health plans. Based on survey instruments designed to elicit reliable and valid information about health plan experiences from plan enrollees, the aim of the CAHPS team was to design a series of reporting products that present survey results so that consumers find the information understandable, meaningful, and useful in choosing among health plans. METHODS: Design of the survey instruments and reporting products were closely linked. The approach to reporting was based on previous research on consumers' information interests and needs in evaluating and choosing among plans. Cognitive tests were conducted with consumers to get their reactions to mock-ups of various approaches to reporting CAHPS survey results. RESULTS: Findings from previous research and cognitive testing, together with feedback from various experts and the public, were used to modify the survey questions, response options, and reporting formats to make it easier for consumers to understand and use reports. Changes included dropping topics of less interest to consumers, changing question wordings that were hard to understand, minimizing the number of different response categories, and revising questions to make them easier to group together for purposes of reporting. CONCLUSIONS: The CAHPS focus on reporting results to consumers presented an unusual challenge for survey design, requiring close coordination between instrument design and report development to produce a survey and reporting kit that serves consumers' information needs.
Assuntos
Comportamento do Consumidor , Coleta de Dados/métodos , Pesquisas sobre Atenção à Saúde/métodos , Serviços de Informação/organização & administração , Seguro Saúde/normas , Qualidade da Assistência à Saúde , Adulto , Cognição , Tomada de Decisões , Feminino , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Projetos de Pesquisa , Inquéritos e Questionários , Estados Unidos , United States Agency for Healthcare Research and QualityRESUMO
This paper addresses the challenges and opportunities that face the public in negotiating the health care system (both medicine and public health) in the 21st century. It addresses three issues: how consumers exercise choice, with special attention to the choice of health care coverage; how patients and communities interact with clinicians and public health professionals; and whether and how the public's "voice" is heard as health policy decisions, at the societal and institutional levels, are made. With respect to each of these issues, the paper describes the current status of public influence and articulates a vision for the future. These three related visions are (1) that empowered, informed, supported consumers make decisions about health plans, clinicians, treatments, and their own behavior; (2) that clinicians and public health professionals, working as partners with patients and communities, are in a position to "standardize the customization of care" so that all aspects of care are tailored to the needs of the individual, family, or community in question and social, economic, and cultural factors are taken into account in the day-to-day practice of medicine and public health; and (3) that the ability and willingness of the public to negotiate and shape the health care environment is supported by an independent infrastructure that permits enhanced public involvement in health policy making and governance. The paper identifies key elements of this vision, discusses challenges to pursuing and achieving each vision, and identifies opportunities that may support the pursuit of the vision.
Assuntos
Participação da Comunidade , Atenção à Saúde/organização & administração , Saúde Pública , Comportamento de Escolha , Aceitação pelo Paciente de Cuidados de Saúde , Relações Médico-Paciente , Formulação de Políticas , Estados UnidosRESUMO
An overview of (1) key trends shaping the healthcare environment and market; (2) ways in which these environmental trends are reflected in changes in the organization and delivery of healthcare; (3) the implications of environmental and organizational changes for older Americans; and (4) the research issues that can be addressed using organizational and behavioral theories. This introductory article sets the healthcare scene for the articles that follow.
Assuntos
Atenção à Saúde/tendências , Serviços de Saúde para Idosos/organização & administração , Atenção Primária à Saúde/organização & administração , Idoso , Setor de Assistência à Saúde/tendências , Pesquisa sobre Serviços de Saúde/organização & administração , Humanos , Estados UnidosRESUMO
BACKGROUND: Initiatives on the part of many groups to provide American consumers with information about the quality of health care may have several goals. Symbolic aims include recognizing consumers, increasing the sense of accountability, providing reassurance about health care quality, and emphasizing quality. Instrumental aims include improving system performance, increasing satisfaction with care and/or plans, and reducing random plan switching. These efforts may have both good effects and bad effects. BENEFITS AND RISKS: The possible positive byproducts of consumer information initiatives are learning about consumer preferences and variations, learning how to help consumers use health plans and providers, changing consumer-provider relationships, and building an infrastructure of consumer-centered intermediaries. Possible bad effects are generating demands that cannot be met, skewing the system to certain consumers' preferences, discouraging consumers from using information, adding another new program that will die, contributing to biased plan selection, and decreasing trust in providers. DISCUSSION: Before health care professionals can gather evidence about outcomes signaling success, they must address several major issues. How should high-quality performance be defined and by whom? Whose vision will be embedded in these definitions? Will it be the consumer's vision or the patient's vision that will be maximized? How long will it take before expected consequences occur? A strategy to measure success calls for beginning immediately to develop consensus on outcomes and a "theory of action" specifying the pathways and timing for different players.
Assuntos
Participação da Comunidade , Educação em Saúde , Serviços de Informação , Qualidade da Assistência à Saúde , Comportamento do Consumidor , Objetivos , Necessidades e Demandas de Serviços de Saúde , Humanos , Planos de Pré-Pagamento em Saúde , Estados UnidosAssuntos
Redes Comunitárias/organização & administração , Afiliação Institucional/estatística & dados numéricos , Setor Privado/organização & administração , Setor Público/organização & administração , Redes Comunitárias/estatística & dados numéricos , Continuidade da Assistência ao Paciente , Comportamento Cooperativo , Pesquisa sobre Serviços de Saúde , Nível de Saúde , Humanos , Modelos Organizacionais , Análise Multivariada , Setor Privado/estatística & dados numéricos , Setor Público/estatística & dados numéricos , Responsabilidade Social , Estados UnidosAssuntos
Participação da Comunidade , Planos de Assistência de Saúde para Empregados/normas , Programas de Assistência Gerenciada/normas , Defesa do Consumidor , Tomada de Decisões , Eficiência Organizacional , Planos de Assistência de Saúde para Empregados/economia , Reforma dos Serviços de Saúde , Programas de Assistência Gerenciada/economia , Qualidade da Assistência à Saúde , Estados UnidosRESUMO
This study assesses how consumers view condition-specific performance measures and builds on an earlier study to test an approach for communicating quality information. The study uses three separate designs: a small experiment, a cross-sectional analysis of survey data, and focus groups. We test whether providing information on the health care context affects consumer understanding of indicators. Focus groups were used to explore how consumers view performance measures. The cross-sectional survey analysis used survey data from the experiment and the focus groups to look at comprehension and the salience of condition-specific performance measures. Findings show that a general consumer population does view condition-specific performance measures as salient. Further, the findings provide evidence that information on the health care context makes a difference in how consumers understand performance measures.
Assuntos
Participação da Comunidade , Serviços de Informação/normas , Qualidade da Assistência à Saúde/classificação , Neoplasias da Mama/psicologia , Neoplasias da Mama/terapia , Comunicação , Estudos Transversais , Feminino , Grupos Focais , Pesquisa sobre Serviços de Saúde/métodos , Humanos , Satisfação do Paciente , Estados UnidosRESUMO
A system of analysis addressing predictors of management outcomes in Cranial Base Surgery has yet to be published. We therefore report data on seventy-nine consecutive patients undergoing surgery for tumors involving the cranial base, excluding patients with the diagnosis of pituitary microadenoma. Outcomes were defined prospectively in terms of completeness of tumor resection, complications of treatment with emphasis on neurological morbidity, and return to work or independent living. Also, preoperative features are analyzed as influencing cost of treatment, estimated in terms of the number of surgical procedures required, duration of hospital and Intensive Care Unit stay, and time taken to return to work. Preliminary analysis of data reveals that severe brainstem compression, large tumor size (average diameter > 3 cm), high cavernous sinus grade, and tumor encasement of major cerebral arteries are associated with incomplete tumor resection (p < 0.05). Patient age greater than 65, preoperative Karnofsky Performance Score (KPS) less than 80, and severe brainstem compression are associated with increased risk of stroke (p < 0.05). Age greater than 65 and preoperative KPS less than 80 are associated with an increased length of stay (p < 0.05). Other untoward events did not occur with sufficient frequency to reach statistical significance. A model of outcomes analysis in Cranial Base Surgery is proposed utilizing a database to incorporate a group of non-operated patients and include quality of life measurements in long-term patient follow-up.
Assuntos
Neoplasias Encefálicas/cirurgia , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Neoplasias Hipofisárias/cirurgia , Neoplasias Encefálicas/fisiopatologia , Seguimentos , Humanos , Neoplasias Meníngeas/fisiopatologia , Meningioma/fisiopatologia , Neoplasias Hipofisárias/fisiopatologia , PrognósticoRESUMO
BACKGROUND: A variety of financing mechanisms and managerial innovations have been developed in the past decade to control hospital costs. Some evidence suggests that those changes have not produced substantial improvements in labor efficiency among employees in the hospital's technical level, such as in the blood bank laboratories. STUDY DESIGN AND METHODS: This study measured labor efficiency in 40 hospital-based blood bank laboratories in Southern California during the year from July 1989 to June 1990 and explored the impact of financial, managerial, and operational factors on labor efficiency. RESULTS: With standardized output measures used in all blood bank laboratories, a wide variation of labor efficiency was found. Multivariate analyses indicate that the labor efficiency of blood bank employees was not influenced by organizational financial incentives, but was affected by the managerial styles of blood bank managers. CONCLUSION: Interpretation of the findings suggests that labor efficiency is affected by operational designs intended to improve responses to variable workloads and reduce slack time.
Assuntos
Bancos de Sangue/organização & administração , Eficiência , Hospitais , Laboratórios Hospitalares , Gestão de Recursos Humanos , Salários e BenefíciosRESUMO
Medicare beneficiaries who enroll in "risk contract" Health Maintenance Organizations (HMOs) are covered for services only if they are provided or approved by the HMO. Thus, their enrollment decisions involve selecting a health care delivery system and may be influenced by whether the HMO has contracts with particular providers. Disenrollment decisions, in turn, may be influenced by breaks in contracts between the HMO and its medical groups. This study examines decisions made by Medicare HMO enrollees when their HMO terminated its relationship with a major medical group; the group then signed a contract with a competing HMO. Beneficiaries were forced to choose between remaining with their HMO and switching to another provider, and switching to the competing HMO where they could keep their provider. Beneficiaries demonstrated considerable loyalty to their providers; nearly 60% switched to the competing HMO. Previous research on health care coverage decisions has been based on models which did not address consumers' knowledge, options, and information sources. In this decision context, we found that knowledge and information sources were the most important determinants of beneficiary decisions.
Assuntos
Comportamento de Escolha , Comportamento do Consumidor/estatística & dados numéricos , Sistemas Pré-Pagos de Saúde/estatística & dados numéricos , Medicare/organização & administração , Idoso , Distribuição de Qui-Quadrado , Continuidade da Assistência ao Paciente , Serviços Contratados , Demografia , District of Columbia , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Sistemas Pré-Pagos de Saúde/organização & administração , Humanos , Masculino , Modelos Psicológicos , Fatores Socioeconômicos , Estados UnidosRESUMO
Under a reformed health care system, what information will help consumers evaluate health care providers and plans? A member of the White House health care task force provides her perspective.
Assuntos
Participação da Comunidade , Serviços de Informação , Programas de Assistência Gerenciada , Reforma dos Serviços de Saúde , Estados UnidosRESUMO
Previous studies have demonstrated that functional status is a significant predictor of resource utilization for rehabilitation patients. Before implementing a prospective payment system (PPS) for rehabilitation, it is important to first: 1) develop an underlying conceptual framework of rehabilitation resource use; and 2) understand how the role of functional status may vary by rehabilitation condition. In this study, a theoretical model of rehabilitation is presented that proposes relationships between patient and provider characteristics, rehabilitation treatment, costs, and clinical outcomes of rehabilitation. Also presented are regression analyses based on this model for a key outcome of rehabilitation, change in functional status, for nine rehabilitation conditions using variables that minimize adverse incentives by providers in selecting patients for admission to rehabilitation. The change-in-functional-status model explained the most variance for back injury, cardiopulmonary, and arthritis, and less variance for stroke, spinal cord injury, and neurologic impairment. The significant predictors of change in functional status varied by condition. Results support the use of functional status measurements in a PPS for rehabilitation services, the need to refine the measurement of functional status, and the use of condition-specific activities of daily living (ADL) items to include in summary indices.