Changing Consumers and Changing Technology in Health Care and Health Care Delivery: Volume 19

“Managed care is the health law issue of 1999” (Leibold, 1999, p. 5). This chapter addresses changes in the health care system initiated by the managed care paradigm — which, in turn, has prompted many legal changes and challenges. Specifically, this chapter will describe the following: (a) an overview of the managed care system versus the traditional fee-for-service system; (b) a selected review of research literature on the strengths and limitations of the managed care system; and (c) a projection of the future trends of the managed care system for patients, consumers, health providers and society. The second area, the review of research literature, will include the impact of managed care on patients, consumers, physicians and nurses. In this chapter, the word patient, means someone who is ill; the word consumer, means someone who has health insurance and may become ill in the future and needs to utilize the health delivery system.

This chapter focuses on the proactive adaptations that patients can undertake to successfully navigate today's increasingly complex health care system. Our report urges a paradigm shift in patient and family expectations, moving from expectations of “patiently” awaiting good care to taking responsibility for finding and getting optimal health care services. We consider the role that key informal health care partners (caregivers) can play in facilitating these proactive adaptations. Based on extensive participant observations by the authors during recent illness episodes, we present a framework for planning and implementing proactive adaptations which can improve the health care that consumers receive.

This paper presents the construct of “medicalism” — a widespread mind set for defining and dealing with troubles — as a theory of how health service provision interacts with the desires of consumers. Medicalism has three components: individuation, externalization, and just pain. In concert this sets up a situation where explanation may be sought more fervently than cure. Thus, failure, rather than success, assures escalating demand for health services. This suggests thinking about how health care fits into the full array of defining and dealing with troubles. Medicine and war can be seen as two sides of the same coin, processes that individuate, and externalize troubles while justifying pain or expense. Escalating health care costs can then be seen as related to the refusal or inability to deal with problems in other spheres. Health care becomes a dumping ground for a vast range of social problems ranging from poverty to sexual assault. In so doing, health care is forced to do less of what it does well and more of what it does badly.

This paper uses social network principles to explain the sources of and variations in relationships among health care providers and patients. General principles of social networks applied are global structure, structural equivalence, structural conduciveness, and the duality of network linkages. Specific principles employed to understand structural variability in provider interrelationships are structural encapsulation and structural excludability, centrality and integration, subgroups and structural holes, close ties versus weak ties, and the virtual ties created by computersupported social networks (CSSNs). Various ways that social network principles help explain the evolving complexities of interconnectedness among health care providers and patients are demonstrated. Practical advantages of using social network principles to organize and to manage interrelationships among health care providers and patients are discussed.

This study examines healthcare from an environmental point of view using the ecology theory of organizations as the underlying framework. This research attempts to understand how hospital services and their technology affect the community. The focus is on community characteristics, hospital services and technology available within the community and their influence on community mortality rates. The community is defined as a Healthcare Service Area (HCSA) which is determined by the hospital utilization pattern of individuals. Data from the 1995 Area Resource Files are utilized in this analysis. Lisrel, structural equation modeling, was utilized for data analysis. The results indicate that socioeconomic status, presence of teaching hospitals and the age of the population will have a greater influence on crude mortality rates than the actual services and technology that hospitals provide. In summary, the findings suggest that the discussion of healthcare needs to look beyond the hospitals and their high tech services and diagnostics to determine what services will actually benefit the community.

In the past decade, national nursing home utilization rates for African Americans have risen above those of White elders suggesting improved access to care. This study examines the effect of Medicaid upon the supply of long-term care facilities in Chicago communities by tracing the construction and placement of homes at three points in the development of federal long-term care policy compared to the settlement and segregation of the city's neighborhoods by ethnoracial groups. Spatial analysis of nursing home distribution shows why facilities built after 1965 are more likely to serve African Americans. The policy implications of changing long-term care utilization patterns are discussed.

Two parallel developments in health care have begun to converge: (1) the demand for greater patient participation in health care, and (2) the evolution of computer tools designed to inform patients of health care options so they might decide among them. Little is known about how patients see these tools and how these perceptions affect participation in care. This study examines patients' responses to the routine use of “knowledge coupling” computer tools in primary care, and their influence on “shared decision making”. Three hundred fifty seven (357) patients responded to a survey that asked about various aspects of the knowledge coupling system used in a primary care practice. The results indicate that how patients see the knowledge coupling tools used in the practice affects perceptions of their involvement in care and decisions. Perceptions of involvement also positively relate to age, but remain unrelated to gender, education, income, and home computer use. Trends toward using computer tools to assist in health decisions will likely continue. This study suggests that as these tools become integrated into the routine care of patients they will have important implications for patient participation in care and decision making.

Proponents of telemedicine believe this technology will resolve many of the problems associated with the lack of access to specialty care by isolated populations. However, in order for telemedicine to be successful, health care professionals and patients must be willing to use it. Few studies exist that identify those characteristics that differentiate adopters from non-adopters of this technology. Furthermore, little is known about the kinds of health care professionals and patients who are willing to make continued use of telemedicine after initial adoption. Prior studies of the adoption of medical technology have identified personal characteristics such as age and gender among patients and age, gender, years since graduation from medical school, and medical specialty among providers as predictors of the adoption of medical technolgy. Using data collected from the first 483 teleconsultations performed by a West Texas medical system, we developed prediction models of the continued use of telemedicine using the personal characteristics of patients, primary care professionals, and medical specialists as predictors. We included the number of primary care professionals and specialists involved in prior teleconsultations in these prediction models. Patient characteristics contributed little to the prediction of continued use of telemedicine; however, characteristics of the health care professionals such as age, gender, and years since graduation as well as the number of health care personnel involved in previous consultations were significant predictors of the continued use of telemedicine.

Medical sociologists have documented psychiatry's tendency to define psychological and behavioral problems as mental disorders. But we know little about how other medical specialties view mental disorders and their treatment. We explore trends in mental health CME (continuing medical education) by analyzing twenty years of data on the quantity and content of articles on mental illness in family practice journals (1977–1996). Pooled time series analyses indicate that drug innovations had the strongest influence on the number of mental illness articles published. New drugs sharply increased attention to all types of mental disorders, not just those with pharmaceutical treatment indications. DSM modifications influenced publications in a complex way: The expanding number of medicalized illnesses in the DSM had a positive impact, while the paradigm shift to the medical model with DSM-III actually decreased the number of articles. Similarly, the supply of patients generated by deinstitutionalization increased coverage of mental illness in this literature, while the growth of managed care was associated with a decrease therein. Content analysis of articles on serious mental illnesses (n = 202) shows that drug innovations only increased the number of articles but did not affect drug treatment recommendations. These trends reflect how the medical model and drug treatments have become firmly established in the management of mental illness.

The purposes of this study were to: (a) measure and compare the subjective health status of persons with spinal cord injuries (SCIs); traumatic brain injuries (TBIs), burns, and intra-articular fractures of the lower extremities (IAFx); (b) identify factors that explain variation in the health assessments of persons with each injury type; and (c) determine whether the effects of study factors and variables are consistent across injury types. These tasks were accomplished by employing the Sickness Impact Profile (SIP), a generic, overall health status indicator, as the outcome measure in three separate sets of hierarchical regression analyses. The variable subsets useful in explaining overall SIP scores for the four injury types were defined and questions concerning similarities among the different injury types were addressed. Findings indicate that: (a) the overall, physical, and psychosocial health assessments of persons with TBIs, IAFx, and burns do not differ significantly; and (b) persons with SCIs, TBIs, IAFx, and burns should be considered distinct groupings with respect to the individual determinants of overall health status and the variable domains explaining the greatest amounts of variance in health status assessments.

A large epidemiological survey evaluating the extent of arthritis in the population aged 55+ uncovered a discrepancy between medically assessed need for and patient willingness to consider treatment involving total joint arthroplasty. In an attempt to understand this discrepancy, we conducted a qualitative study to assess patients' experiences of the disease. This paper is focused on how the quality of the marital relationship influences the everyday functioning of arthritis sufferers. Our results suggest that in addition to the individual's functional capacity, the couple's relational and functional behaviours influence the meaning of the disease and an individual's health care decision making.