The Affordable Care Act (ACA) dramatically expands health insurance for addiction treatment and provides unprecedented opportunities for service growth and delivery model reform. Yet most addiction ...treatment programs lack the staffing and technological capabilities to respond successfully to ACA-driven system change. In light of these challenges, we conducted a national survey to examine how Single State Agencies for addiction treatment--the state governmental organizations charged with overseeing addiction treatment programs--are helping programs respond to new requirements under the ACA. We found that most Single State Agencies provide little assistance to addiction treatment programs. Most agencies are helping programs develop collaborations with other health service programs. However, fewer than half reported providing help in modernizing systems to support insurance participation, and only one in three provided assistance with enrollment outreach. In the absence of technical assistance, it is unlikely that addiction treatment programs will fully realize the ACA's promise to improve access to and quality of addiction treatment.
The health system of Mexico Gómez Dantés, Octavio; Sesma, Sergio; Becerril, Victor M ...
Salud pública de México,
2011, Letnik:
53 Suppl 2
Journal Article
Recenzirano
This paper describes the Mexican health system. In part one, the health conditions of the Mexican population are discussed, with emphasis in those emerging diseases that are now the main causes of ...death, both in men and women: diabetes, ischaemic heart disease, cerebrovascular diseases and cancer. Part two is devoted to the description of the basic structure of the system: its main institutions, the population coverage, the health benefits of those affiliated to the different heath institutions, its financial sources, the levels of financial protection in health, the availability of physical, material and human resources for health, and the stewardship functions displayed by the Ministry of Health and other actors. This part also discusses the role of citizens in the monitorization and evaluation of the health system, as well as the levels of satisfaction with the rendered health services. In part three the most recent innovations and its impact on the performance of the health system are discussed. Salient among them are the System of Social Protection in Health and the Popular Health Insurance. The paper concludes with a brief analysis of the short- and middle-term challenges faced by the Mexican health system.
Teledermatology (TD) enables remote triage and management of dermatology patients. Previous analyses of TD systems have demonstrated improved access to care but an inconsistent fiscal impact.
To ...compare the organizationwide cost of managing newly referred dermatology patients within a TD triage system vs a conventional dermatology care model at the Zuckerberg San Francisco General Hospital and Trauma Center (hereafter referred to as the ZSFG) in California.
A retrospective cost minimization analysis was conducted of 2098 patients referred to the dermatology department at the ZSFG between June 1 and December 31, 2017.
Implementation of the TD triage system in January 2015.
The main outcome was mean cost to the health care organization to manage newly referred dermatology patients with or without TD triage. To estimate costs, decision-tree models were constructed to characterize possible care paths with TD triage and within a conventional dermatology care model. Costs associated with primary care visits, dermatology visits, and TD visits were then applied to the decision-tree models to estimate the mean cost of managing patients following each care path for 6 months. The mean cost for each visit type incorporated personnel costs, with the mean cost per TD consultation also incorporating software implementation and maintenance costs. Finally, ZSFG patient data were applied within the models to evaluate branch probabilities, enabling calculation of mean cost per patient within each model.
The analysis captured 2098 patients (1154 men 55.0%; mean SD age, 53.4 16.8 years), with 1099 (52.4%) having Medi-Cal insurance and 879 (41.9%) identifying as non-White. In the decision-tree model with TD triage, the mean (SD) cost per patient to the health care organization was $559.84 ($319.29). In the decision-tree model for conventional dermatology care, the mean (SD) cost per patient was $699.96 ($390.24). Therefore, the TD model demonstrated a statistically significant mean (SE) cost savings of $140.12 ($11.01) per patient. Given an annual dermatology referral volume of 3150 patients, the analysis estimates an annual savings of $441 378.
Implementation of a TD triage system within the dermatology department at the ZSFG was associated with cost savings, suggesting that managed health care settings may experience significant cost savings from using TD to triage and manage patients.
Objectives: To identify elements that are integral to high‐quality practice and determine considerations relating to high‐quality practice organisation in primary care.
Study design: A narrative ...systematic review of published and grey literature.
Data sources: Electronic databases (PubMed, CINAHL, the Cochrane Library, Embase, Emerald Insight, PsycInfo, the Primary Health Care Research and Information Service website, Google Scholar) were searched in November 2013 and used to identify articles published in English from 2002 to 2013. Reference lists of included articles were searched for relevant unpublished articles and reports.
Data synthesis: Data were configured at the study level to allow for the inclusion of findings from a broad range of study types. Ten elements were most often included in the existing organisational assessment tools. A further three elements were identified from an inductive thematic analysis of descriptive articles, and were noted as important considerations in effective quality improvement in primary care settings.
Conclusion: Although there are some validated tools available to primary care that identify and build quality, most are single‐strategy approaches developed outside health care settings. There are currently no validated organisational improvement tools, designed specifically for primary health care, which combine all elements of practice improvement and whose use does not require extensive external facilitation.
The year 2017 marked the first year women comprised a majority of U.S. medical school matriculants. While more women are pursuing surgical training, within plastic surgery, there is a steady ...attrition of women advancing in leadership roles. The authors report the current status of women in academic plastic surgery, from trainees to chairwomen and national leadership positions.
The Electronic Residency Applications Service, San Francisco Match, National Resident Matching Program, Association of American Medical Colleges, American Council of Academic Plastic Surgeons, Plastic Surgery Education Network, and professional websites for journals and national societies were accessed for demographic information from 2007 to 2017.
The number of female integrated pathway applicants remained stable (30 percent), with an increased proportion of female residents from 30 percent to 40 percent. There was an increase in female faculty members from 14.6 percent to 22.0 percent, an increase of less than 1 percent per year. Twelve percent of program directors and 8.7 percent of department heads were women. Nationally, major professional societies and administrative boards demonstrated a proportion of female members ranging from 19 percent to 55 percent (average, 27.7 percent). The proportion of female committee leaders ranged from 0 percent to 50 percent (average, 21.5 percent). Only six societies have had female presidents. No major journal had had a female editor-in-chief. The proportion of female editorial board members ranged from 1 percent to 33 percent (average, 16.1 percent).
The authors' study shows a leak in the pipeline at all levels, from trainees to faculty to leadership on the national stage. This report serves as a starting point for investigating reasons for the underrepresentation of talented women in plastic surgery leadership.
This is a defining moment for health and health care in the United States, and medical schools and teaching hospitals have a critical role to play. The combined forces of health care reform, ...demographic shifts, continued economic woes, and the projected worsening of physician shortages portend major challenges for the health care enterprise in the near future. In this commentary, the author employs a diversity framework implemented by IBM and argues that this framework should be adapted to an academic medicine setting to meet the challenges to the health care enterprise. Using IBM's diversity framework, the author explores three distinct phases in the evolution of diversity thinking within the academic medicine community. The first phase included isolated efforts aimed at removing social and legal barriers to access and equality, with institutional excellence and diversity as competing ends. The second phase kept diversity on the periphery but raised awareness about how increasing diversity benefits everyone, allowing excellence and diversity to exist as parallel ends. In the third phase, which is emerging today and reflects a growing understanding of diversity's broader relevance to institutions and systems, diversity and inclusion are integrated into the core workings of the institution and framed as integral for achieving excellence. The Association of American Medical Colleges, a leading voice and advocate for increased student and faculty diversity, is set to play a more active role in building the capacity of the nation's medical schools and teaching hospitals to move diversity from a periphery to a core strategy.
Context: A small proportion of patients with serious illness or multiple chronic conditions account for the majority of health care spending. Despite the high cost, evidence demonstrates that these ...patients receive health care of inadequate quality, characterized by fragmentation, overuse, medical errors, and poor quality of life. Methods: This article examines data demonstrating the impact of the U.S. health care system on clinical care outcomes and costs for the sickest and most vulnerable patients. It also defines palliative care and hospice, synthesizes studies of the outcomes of palliative care and hospice services, reviews variables predicting access to palliative care and hospice services, and identifies those policy priorities necessary to strengthen access to high-quality palliative care. Findings: Palliative care and hospice services improve patient-centered outcomes such as pain, depression, and other symptoms; patient and family satisfaction; and the receipt of care in the place that the patient chooses. Some data suggest that, compared with the usual care, palliative care prolongs life. By helping patients get the care they need to avoid unnecessary emergency department and hospital stays and shifting the locus of care to the home or community, palliative care and hospice reduce health care spending for America's sickest and most costly patient populations. Conclusions: Policies focused on enhancing the palliative care workforce, investing in the field's science base, and increasing the availability of services in U.S. hospitals and nursing homes are needed to ensure equitable access to optimal care for seriously ill patients and those with multiple chronic conditions.
Background
Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity ...and mortality, effectiveness and psychosocial outcomes between midwife‐led continuity models and other models of care.
Objectives
To compare midwife‐led continuity models of care with other models of care for childbearing women and their infants.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (25 January 2016) and reference lists of retrieved studies.
Selection criteria
All published and unpublished trials in which pregnant women are randomly allocated to midwife‐led continuity models of care or other models of care during pregnancy and birth.
Data collection and analysis
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.
Main results
We included 15 trials involving 17,674 women. We assessed the quality of the trial evidence for all primary outcomes (i.e. regional analgesia (epidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum, preterm birth (less than 37 weeks) and all fetal loss before and after 24 weeks plus neonatal death using the GRADE methodology: all primary outcomes were graded as of high quality.
For the primary outcomes, women who had midwife‐led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37 weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = eight; high quality) and less all fetal loss before and after 24 weeks plus neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence). Women who had midwife‐led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.07; participants = 16,687; studies = 12; high quality). There were no differences between groups for caesarean births or intact perineum.
For the secondary outcomes, women who had midwife‐led continuity models of care were less likely to experience amniotomy (average RR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = four), episiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants = 17,674; studies = 14) and fetal loss less than 24 weeks and neonatal death (average RR 0.81, 95% CI 0.67 to 0.98; participants = 15,645; studies = 11). Women who had midwife‐led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = seven), have a longer mean length of labour (hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = three) and more likely to be attended at birth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = seven). There were no differences between groups for fetal loss equal to/after 24 weeks and neonatal death, induction of labour, antenatal hospitalisation, antepartum haemorrhage, augmentation/artificial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartum haemorrhage, breastfeeding initiation, low birthweight infant, five‐minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).
Due to a lack of consistency in measuring women's satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in midwife‐led continuity models of care. Similarly, there was a trend towards a cost‐saving effect for midwife‐led continuity care compared to other care models.
Authors' conclusions
This review suggests that women who received midwife‐led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care.
Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and all fetal loss/neonatal death associated with midwife‐led continuity models of care.
Because of severe and protracted shortages of pediatric behavioral health (BH) specialists, collaboration between pediatric primary care practitioners (PCPs) and BH specialists has the potential to ...increase access to BH services by expanding the BH workforce. In a previous study, we demonstrated that phase 1 of a behavioral health integration program (BHIP) enrolling 13 independently owned, community-based pediatric practices was associated with increased access to BH services while averting substantial cost increases and achieving high provider self-efficacy and professional satisfaction. The current study was undertaken to assess whether the initial access findings were replicated over 4 subsequent implementation phases and to explore the practicality of broad dissemination of the BHIP model.
After phase 1, BHIP was extended over 4 subsequent phases in a stepped-wedge design to 46 additional pediatric practices, for a total cohort of 59 practices (354 PCPs serving >300 000 patients). Program components comprised BH education and consultation and support for integrated practice transformation; these components facilitated on-site BH services by an interprofessional BH team. Outcomes were assessed quarterly, preprogram and postprogram launch.
Across combined phases 1 to 5, BHIP was associated with increased primary care access to BH services (screening, psychotherapy, PCP BH visits, psychotropic prescribing) and performed well across 7 standard implementation outcome domains (acceptability, appropriateness, feasibility, fidelity, adoption, penetration, and sustainability). Emergency BH visits and attention-deficit/hyperactivity disorder prescribing were unchanged.
These findings provide further support for the potential of integrated care to increase access to BH services in pediatric primary care.
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