Reorganizing Health Care Delivery Systems: Problems of Managed: Volume 21

The theme of this volume is reorganizing health care delivery systems: problems of managed care and other models of health care delivery. The volume contains 11 papers, organized into four sections. The sections cover, in order, managed care issues and organizational features, special groups of patients and health issues, lessons from other countries, and broader policy concerns and health insurance reform. Issues of how to best organize a health care delivery system are not new, but the amount of interest in this topic in the U.S. (as well as in other countries) has grown in recent decades. Reorganizing health care delivery systems is a concern of many of the systems of the world, and this volume contains some papers from countries other than the U.S., although the majority of the papers do relate issues to the U.S. health care delivery system. While the majority of the papers in this volume relate to structural and organizational factors, the impact of individual patients is not neglected. One section focuses very much on more specialized groups of patients, and several other papers use surveys of patients or other individual level data as part of their discussion of these issues. Before discussing the specific papers briefly, it is useful to review some material about the organization of the health care delivery system, especially within the U.S. This includes some discussion of how issues of organization of care and special forms of delivering care such as managed care have become major issues in the U.S. health care system at this point in time.

Health care insurance companies often conduct sample surveys of health plan members. Survey purposes include: consumer satisfaction with the plan and members’ health status, functional status, health literacy and/or health services utilization outside of the plan. Vendors or contractors typically conduct these surveys for insurers. Survey results may be used for plans’ accreditation, evaluation, quality improvement and/or marketing. This article describes typical sampling plans and data analysis strategies used in these surveys, showing how these methods may result in biased estimators of population parameters (e.g. percentage of plan members who are satisfied). Practical suggestions are given to improve these surveys: alternate sampling plans, increasing the response rate, component calculation for the survey response rate, weighted analyses, and adjustments for unit non-response. Since policy, regulation, accreditation, management and marketing decisions are based, in part, on results from these member surveys, these important and numerous surveys need to be of higher quality.

Despite continuing debate about costs and benefits, managed care became an integral part of the health care sector during the 1990s. In this paper, we examine the organizational and practice variation in the managed care industry at two points in the 1990s using a national census of organizations operating in those years. We use a definition of managed care that captures the increased diversity within the industry while still distinguishing it from traditional indemnity, fee-for-service care. We draw on institutional theory to begin to formulate a framework for understanding why certain organizational forms and practices emerged when and where they did.

Community household survey data tested the intervening role (between education and reported health outcomes) of adaptations of Antonovsky’s (1987) tripartite sense of coherence (SOC). Comprehensibility was indexed by clarity and responsiveness of insurance representatives, manageability was measured by problems reported with physician office visits, and meaningfulness was assessed with household members’ community health activities. SOC measures did not link education to either impairments or to health lifestyle scores. Comprehensibility and manageability linked education with self-reported well-being. Education and manageability each reduced impairments, while education, manageability, and meaningfulness increased lifestyle totals. Results help elucidate the influence of education on health.

This study uses ethnographic data from two diabetes clinics to examine how some organizational features of medical settings are connected to the daily cognitive and interactional work of medical providers – specifically, the process of assessing patient adherence and using such assessments to make treatment decisions. I address continuity of care, scheduling and time constraints, team management, provider interaction, and medical recordkeeping as organizational-level issues that impact individual-level providers’ work. More than a top-down model of how “macro” influences “micro,” this study highlights how organizational influences are accounted for in terms of variation in patients’ behavior.

The purpose of this paper is to contribute to the understanding of women’s experiences of living with and surviving HIV/AIDS. We argue that strong conceptualization of this experience will lead to more efficient health care delivery for this growing population, within the general framework of managed care. Our analytical strategy is to integrate the nursing concept of inner strength with ideas from the sociological concept of the existential self. There are numerous definitions of the increasingly popular concept of inner strength in the health care literature, largely developed through the experiences of women living with breast cancer. In general, this concept is useful because it focuses research attention on patients’ experiences and perceptions of illness. Nevertheless, current definitions can be critiqued for their tendency: (1) view inner strength as a thing-like phenomenon, as if it were like a disease, to be measured, treated and supplemented; (2) describe inner strength in overly metaphoric and romanticized terms that do not reflect the everyday life of living with a serious illness; and (3) assume that inner strength is equivalent to doing well. We argue that this concept can be of greater scholarly and clinical use if it is defined as follows: Inner strength refers to the different ways women with serious illnesses experience and, subsequently, talk about the deepest, existential resources available to and used by them to manage severe threats to body and self. We developed this concept through a series of 19 biographical and conversational interviews with women living with HIV/AIDS. Our interviews found that these women describe their experiences in terms of three types of narratives or stories. Faith stories recount the ways reliance upon a higher power (spiritual or religious) provides a sense of inner strength. Character stories recount the ways women experience inner strength as a resource available to them before as well as during their illness. Uncertainty stories recount the ways women perceive their inner strength as problematic. We conclude with specific suggestions for the application of our revised concept of Inner strength to the role of nursing in the delivery of managed care to women living with HIV/AIDS.

Health promotion and rehabilitation models of care are valuable for persons with chronic health conditions, but when these individuals are dependent on a life-maintaining technology, such as kidney dialysis, a cure-oriented model may dominate the system within which they receive care. Providers can preserve their monopoly over expert treatment knowledge by defining the key care issues, by limiting patients’ access to expert knowledge, and by discrediting the patient as a responsible actor. Multiple care paradigms can benefit patients with chronic conditions, however, empowering the patient-actor to collaborate with the clinician to maximize functioning and well-being as well as patient survival.

Long-term care has increasingly been subject to mechanisms to manage care in order to control costs and meet institutional demands for cost containment and efficiency. Fundamentally, managed care seeks to limit access to services that are deemed costly, intensive and/or long-term. However, long-term care by definition requires continuity of care across diverse service sectors. In order for managed long-term care to work, these sectors must be well integrated and able to share information about client needs. In this paper we examine the growth of managed care in the long-term care sector. We have collected data from long-term care agencies in adjoining counties (one urban, the other suburban) at three points in time (1997, 1999, and 2001) and are in a position to describe changes in the types of agencies providing long-term care, and the degree of managed care penetration in our sample. We also collected data on administrators’ evaluations of managed care, and their perceptions of the effect of managed care on services and service system integration. We conclude by discussing the future of long-term care.

The National Health Service is key to Britain’s welfare state, and has been subject to repeated reform initiatives. Such reforms rarely “fix” the problems for which they are introduced, but evaluations have neglected the significance of local action. Reform implementation involves local translation of politically contextualized ideas into workable practice. I focus on implementation processes and the role of professions. Ethnographic data reveal local actors engaging with policy objectives to protect existing structures within the boundaries of official reform rhetoric. Actors employ multiple strategies to maintain existing systems. Rather than “failing,” policy is made through localized collaboration.

Understanding the determinants of health services use is essential for planning for effective services, particularly health care policies in a newly independent state, the Republic of Kazakhstan. The main purpose of this study is to examine the relative importance of social capital factors in affecting the variation in health status and use of health services, using structural equation modeling. The results show that health status is a strong predictor of health services use when the effect of social capital is held constant; and that social capital is directly linked with health status.

Health care systems are evaluated by the triad of access, quality, and cost. This article presents evidence-based outcomes of multiple measures of concern with the United States (U.S.) health care system and proposes a universal health care system as the solution of choice. One third of the U.S. population is either non-insured or underinsured. Lack of quality care is shown by several indicators. Cost concerns are noted in cross-national studies which emphasize that the U.S. spends twice as much for health care but with less access for its citizens to health care. The presidential election of Fall 2004 provides a “window of opportunity” for this policy to be enacted.

This research explores how families coming off of Temporary Assistance to Needy Families (TANF), the national cash welfare program, plan for their health insurance after their automatic benefits expire. Data were collected in focus groups in rural communities and small towns in Oregon. Respondents reported that topics related to health insurance or planning for health insurance are not components of any welfare-to work curriculum, nor are they part of routine conversations with caseworkers. Many respondents reported that we were the first ones to raise these issues with them. Consequently, they had done virtually no planning for when their transitional Medicaid expires despite their serious concerns about access to health care and their previous negative experiences with being uninsured.