Health Care Fraud and Industry Structure in the United States

The cost of health care fraud and abuse is enormous. Not only is it costing us a lot of money but one wonders how many more people could afford and receive medical insurance if fraud and abuse were significantly lower. This paper will show that the problem is embedded in the way America does health business. The problem needs to be better addressed by both the criminal justice community and the health care industry. Most importantly, those making the health care industry policy decisions need to make a paradigm shift. The system is out of balance because of past policies and decisions that have given excessive power and liberty to the medical services community and insurance providers. Using O’Toole's Compass Card of the four major ideas that have influenced political decision‐making as a guide, this paper recommends that current decision‐making needs to strengthen the equality and community poles and restrict the liberty and efficiency poles so that more balance might exist within the American health care system. Talcott Parsons saw the dangers of commercializing health care over half a century ago. The health care scene of today shows that he was correct in his appraisal.     

Community participation in primary health care

The medical profession lacks an analysis of society and medical care is individualistic rather than societal, curative rather than preventive. This paper, which reports on experience in the field, shows how community health should help people to reflect and discover the causes of their poverty and ill health so that they may be able to tackle effectively the issues of social injustice such as low wages and other forms of exploitation. Community health, then, becomes a way of motivating the people to mobilize themselves to resist the domination of the traditionally powerful. If this is not done, community health may remain only a social service that keeps the people dependent and not participants in the process of their own development.     

A Functional Classification of Services for Older People

A deductively derived classification scheme is proposed which categorizes the health and social services of a community according to the levels of competence (behavioral functioningj and the levels of independence of the older people they address. Five levels of individual behavioral functioning ranging from simple to complex are specified: life-maintenance and health; perception-cognition: self-maintenance; effectance: and sociol role performance. Three levels of independence (of living arrangements) are specified ranging from the independent to the dependent subgroups of older people: the comparatively well elderly; elderly who require alternatives to prevent premature institutionalization; and elderly whose needs may confer institutional care or its equivalents. The services of a sample community are classified within this two dimensional scheme. The applications of the classification scheme to both community planning and individual treatment plan formulation are discussed.     

Palliative healthcare: cost reduction and quality enhancement using end-of-life survey methodology

American medical institutions throughout the 20th century prescribed high customer satisfaction, but when it came to death, largely ignored it. An accelerated accumulation of esoteric medical information and the application of this knowledge to affect new cures and longer lives instilled an unquestioning reverence for the medical community among the patient population. Diminishing marginal gains in life expectancy, escalating costs related to life sustaining technologies, and a psychographic shift in the dominant consumer base have challenged this traditional reverence. Armed with unprecedented access to medical information, a more knowledgeable and assertive patient population has emerged in the 21st century to institute its own standards of what constitutes quality health care. In terms of end of life care, this has meant recognition that the emotional needs of the dying have been largely underserved by the current American medical model. Patients and their families are no longer willing to accept the traditional medical perspective of death as failure and have numerous international palliative care models that serve as benchmarks of success when it comes to quality of dying. When cure is a possibility, Americans will pursue it at all costs, but when it is not a possibility, they want honest communication and the opportunity to say good-bye to their loved ones. In the context of these emergent needs, life review is offered as a solution. The value proposition targets not only dying patients and their families, but also society as a whole.     

Palliative Healthcare: Cost Reduction and Quality Enhancement Using End-of-Life Survey Methodology

ABSTRACT

American medical institutions throughout the 20th century prescribed high customer satisfaction, but when it came to death, largely ignored it. An accelerated accumulation of esoteric medical information and the application of this knowledge to affect new cures and longer lives instilled an unquestioning reverence for the medical community among the patient population. Diminishing marginal gains in life expectancy, escalating costs related to life sustaining technologies, and a psychographic shift in the dominant consumer base have challenged this traditional reverence. Armed with unprecedented access to medical information, a more knowledgeable and assertive patient population has emerged in the 21st century to institute its own standards of what constitutes quality health care. In terms of end of life care, this has meant recognition that the emotional needs of the dying have been largely underserved by the current American medical model. Patients and their families are no longer willing to accept the traditional medical perspective of death as failure and have numerous international palliative care models that serve as benchmarks of success when it comes to quality of dying. When cure is a possibility, Americans will pursue it at all costs, but when it is not a possibility, they want honest communication and the opportunity to say good-bye to their loved ones. In the context of these emergent needs, life review is offered as a solution. The value proposition targets not only dying patients and their families, but also society as a whole.     

Partnerships, Power and the "New" Politics of Community Participation in British Health Care

Multi–sectoral approaches to health improvement in its broadest sense have entailed an emphasis by the British government upon partnership working in and around community involvement in planning processes. New service planning and delivery organizations in the health service—primary care groups and primary care trusts—thus have to ensure that public and patient involvement strategies reflect a coordinated, if not integrated, multi–sectoral approach to such involvement. But how are these enforced partnership arrangements shaping the approach taken by primary care groups and trusts to the issue of public and patient involvement? More particularly, is the traditional dominance of health service managers and the medical profession in decision–making processes under challenge? This article draws on a study of primary care groups and trusts in three districts in order to gauge perceptions and calculations with regard to partnerships for involvement. Results appear to suggest that health service managers and practitioners continue to exercise considerable influence in comparison to that of patients and citizens. But, if the findings are viewed in the broader contexts of government managerialist strategies of surveillance and accountability and the growth of service–user and advocacy organizations, partnerships may offer significant scope for “lay” challenges to managerial and medical power.     

Challenging Professional Roles: Lay Carers' Involvement in Health Care in the Community

The bulk of care in the community is carried out by lay carers. Recent policy initiatives to support them in the United Kingdom are outlined. There remains evidence of significant gaps in support from professional health and social‐care workers including community nurses. This paper reports three studies of lay carers: those caring for older people, carers of technology‐dependent children, and home‐care workers involved in the “direct payments” scheme. Findings are reported in the areas of decisions about appropriate caring roles, the lay–professional boundary, training and respite opportunities and the expertise of lay carers. Recommendations for policy and practices are made.     

The aging of the Chinese population and the cost of health care

It is projected that by 2050 China could have a staggering 115 million elderly citizens over 80 years old. Serious planning is needed to cope with this demand. This is the direct and inevitable result of the one-child policy that came into effect in 1979, as an independent policy to the Comprehensive Economic Reform; but the complementary nature is unmistakable.In accordance with the objective of this special issue of the Social Science Journal, the modest objective of this paper presents a brief history of the health care reform which really only began in 2002. We borrow from a major pilot study (the CHARLS data set) to provide quantitative measures of the cost of medical insurance. CHARLS samples two provinces, the inland poorer Gangsu and the coastal prosperous Zhejiang. The premium was 13 and 27 Yuan for the rural populations Gansu and Zhejiang. For the urban population, the premium was 289 versus 337 for men versus women in urban Gansu. But for the urban areas of Zhejiang, the pattern is radically different; 324.3 Yuan for women and a much higher 608 Yuan for men.Urban residents have always enjoyed better health care. With the support of the central government, 90% of rural population now received some form of basic health coverage. The issue is the reimbursement rate. For outpatient care, the reimbursement rates max out at under 40% and 32% for the urban and rural patients, respectively. This is certainly not enough to cover catastrophic illness, and that is why many Chinese feel they are just one major illness away from utter poverty. Outpatient care is even worse. The reimbursement rates average around only 10%. As Chinese statistics on full medical cost (especially for the elderly) is lacking, we utilize statistics from Taiwan and try to estimate the health care cost of the aging population.We discuss potential issues observed in the Taiwan experience, and proposed an incentive scheme, Self-Motivated Health Maintenance (SMHM), to deal with moral hazards and to reduce the overall health care cost. We believe the SMHM is a win–win–win solution. China has the possibility of building this into their health insurance.     

Beliefs, death, anxiety, denial, and treatment preferences in end-of-life care: a comparison of social work students, community residents, and medical students

This study examined cultural and religious beliefs, death anxiety, denial, and medical treatment preferences in end-of-life care in a sample of social work students, community residents, and medical students in a mid-western city of 49,000. Results indicated that most social work students, community residents, and medical students preferred palliative as opposed to life-prolonging care during terminal illness. The three groups differed in cultural and religious beliefs and all three reported a moderate amount of death anxiety. Students reported less denial of terminality than community residents. Implications for personal and professional preparation to provide end-of-life care are discussed.     

The impact of ethnicity on attitudes toward health care reform in New Mexico

Latinos tend to have significantly lower levels of access to general and top quality medical care than do non-Latino whites, and although disparities in access to health care have diminished for all other minority groups over time, they have widened for Latinos. Given these trends, current attempts to provide universal health care at both the national and state levels across the United States have large implications for the health status of Latinos. The objective of this analysis is to determine whether Latinos have different attitudes regarding health reform than non-Latino whites. Our data are from a statewide random digit dialing telephone survey of New Mexico residents, age 18 and older, conducted in the Fall of 2007. With a Latino population of 44% and ongoing health care reform efforts by the state legislature, New Mexico is an ideal location for this analysis. After controlling for a host of individual level factors, our findings suggest that while Latinos are less likely to identify health care as a salient state issue relative to the economy and crime, they are more likely than non-Latino whites to believe affordable health care programs are important. Finally, Latinos view employers, more than government or individuals, to be responsible for expanding health care coverage.     

Beliefs,Death Anxiety,Denial, and Treatment Preferences in End-of-Life Care

Abstract

This study examined cultural and religious beliefs, death anxiety, denial, and medical treatment preferences in end-of-life care in a sample of social work students, community residents, and medical students in a mid-western city of 49,000. Results indicated that most social work students, community residents, and medical students preferred palliative as opposed to life-prolonging care during terminal illness. The three groups differed in cultural and religious beliefs and all three reported a moderate amount of death anxiety. Students reported less denial of terminality than community residents. Implications for personal and professional preparation to provide end-of-life care are discussed.     

Links between social environment and health care utilization and costs

The social environment influences health outcomes for older adults and could be an important target for interventions to reduce costly medical care. We sought to understand which elements of the social environment distinguish communities that achieve lower health care utilization and costs from communities that experience higher health care utilization and costs for older adults with complex needs. We used a sequential explanatory mixed methods approach. We classified community performance based on three outcomes: rate of hospitalizations for ambulatory care sensitive conditions, all-cause risk-standardized hospital readmission rates, and Medicare spending per beneficiary. We conducted in-depth interviews with key informants (N = 245) from organizations providing health or social services. Higher performing communities were distinguished by several aspects of social environment, and these features were lacking in lower performing communities: 1) strong informal support networks; 2) partnerships between faith-based organizations and health care and social service organizations; and 3) grassroots organizing and advocacy efforts. Higher performing communities share similar social environmental features that complement the work of health care and social service organizations. Many of the supportive features and programs identified in the higher performing communities were developed locally and with limited governmental funding, providing opportunities for improvement.     

The role of "Theatre for Development" in mobilising rural communities for primary health care: the case of Liwonde PHC Unit in southern Malawi

The improved health conditions that are essential for development may depend more upon the self-help motivation of local people than upon the provision of Western-style health facilities. Such motivation can be created by the culturally-appropriate dissemination of health education at the community level. This article describes an effective health improvement strategy implemented in three villages in southern Malawi during the late 1980s. After an introduction, the paper presents an overview of current strategies used in Malawi for the dissemination of primary health care information and notes that these strategies have failed to reach the rural population. Next, the paper describes the health status of two of the villages, Mbela and Mwima, before the introduction of the Liwonde Agricultural Development Division Primary Health Care Program. None of the three village involved had access to modern health care facilities. This program involved the joint efforts of the community, a primary health care team, and the Chancellor College Theatre for Development. The paper continues by presenting a conceptual model of the process. Community involvement was assured by the election of the members of village health committees and the delivery of health training to two members of each committee. The Theatre for Development used interactive dramatic techniques and participatory research activities in Mwima and Mbela to help the communities assess their health needs and possible solutions in conjunction with the introduction of primary health care activities. The article also contrasts the Theatre for Development technique with the focus group approach and notes that the latter may not be successful in motivating self-help efforts. Finally, the relative success of the Theatre for Development methodology used in the two villages is described by comparing health indicators with those before the intervention and with those in the third village where this approach was not used in conjunction with introduction of primary health care services.     

An Ecological Understanding of Caregiver Experiences in Palliative Care

Palliative care is specialized health care to improve quality of life for patients with serious illness and their families through prevention and relief of suffering. A Palliative Care Institute was held in western Washington to capture community voices about diverse needs, strengths, and opportunities for improvement of palliative care. Researchers employed qualitative methods to obtain thematic data, provide real-time analysis, and engage in a multivoting technique to reflect stakeholder interest in individual themes and prioritize larger group interests. Bronfenbrenner’s ecological systems framework was used to explore caregiver experiences. Within the microsystem, caregivers reported difficulties in interactions with medical providers as a key challenge. Within the mesosysytem, interactions between patients and medical providers and the impact on caregivers were explored. Within the exosystem, caregivers reported lack of control over the schedules of personal care staff. Macrosystem influences included impact of local culture on the development of palliative care services. Chronosystem influences include de-medicalization of childbirth and its impact on perceptions of palliative care. Implications include the need for social workers to be proactive in fostering trust and effective communication between care providers and caregivers, and the demand for health care provider training in communication with patients and families.     

Professional Perspectives on Decision Making about the Long-term Care of Older People

With the increasing pressure on social and health care resources,professionals have to be more explicit in their decision makingregarding the long-term care of older people. This groundedtheory study used 19 focus groups and nine semi-structured interviews(99 staff in total) to explore professional perspectives onthis decision making. Focus group participants and intervieweescomprised care managers, social workers, consultant geriatricians,general medical practitioners, community nurses, home care managers,occupational therapists and hospital discharge support staff.The emerging themes spanned context, clients, families and services.Decisions were often prompted by a crisis, hindering professionalsseeking to make a measured assessment. Fear of burglary andassault, and the willingness and availability of family to helpwere major factors in decisions about living at home. Serviceavailability in terms of public funding for community care,the availability of home care workers and workload pressureson primary care services influenced decision ‘thresholds’regarding admission to institutional care. Assessment toolsdesigned to assist decision making about the long-term careof older people need to take into account the critical aspectsof individual fears and motivation, family support and the availabilityof publicly funded services as well as functional and medicalneeds.     

Barriers Associated with the Implementation of an Advance Care Planning Program in a Prison Setting

Advance care planning is considered a best practice within health care. However, the extent to which planning occurs within prison settings is unknown. Through the course of implementing an advance care planning (ACP) program for aging and dying offenders at a medical classification center, multiple barriers were identified that need to be addressed systemically to ensure the medical wishes of offenders were known and honored. This article will outline the barriers and the steps that were taken to create systems change to promote and sustain advance care planning.     

关于新医疗制度改革的研究综述

在经济发展的基础上,保证人民群众公平享有公共卫生和基本医疗服务,是实现人民共享改革发展成果的重要体现。中国医药卫生体制经过多次改革和发展,取得了很多成就,但也存在一些问题,尤其是国家的经济发展进入新阶段,原有医疗体制有很多制度与经济发展阶段不符。公民的医疗卫生保障需求日益增加,如何在新形势下解决公民的医疗问题,2009年的新医改方案就是一次重要的制度再设计。     

Assessing an Adult Mental Health Clinic for Age-Related Issues

A community mental health clinic in an urban setting is the subject of an exploratory assessment to determine whether its 55 + patients are being treated according to the special diagnostic and treatment issues that tend to affect older people. Depression is found to be high on the list of diagnoses in this age group. As many as 40% of the group are considered to be at risk for suicide. The interrelationship of medical and psychological factors is emphasized. Sixty-two percent of those studied are determined to be socially isolated. Treatment techniques recommended in the literature for older patients are summarized, and it is determined that, while therapists at the clinic.have not been trained in geriatric psychology, many are instinctively utilizing these techniques. Recommendations are made for increased use of groupwork with older patients, inservice education for staff, attention to medical complications, improved outreach, and involvement of family.     

医疗卫生制度和谐发展的理论模式初探

医疗卫生制度的理想状态应是各利益主体协调发展,实现良性循环,但其现状并不令人满意。目前医疗卫生制度遇到的问题使整个医疗卫生体系的发展陷入政策性困境之中,解决之道在于重塑各利益主体间良性互动的相互关系,建立起医疗卫生制度和谐发展的理想模式。     

The end of the asylum (town): community responses to the depopulation and closure of the Saskatchewan Hospital, Weyburn

Never is the fraught relationship between the state-run custodial mental hospital and its host community clearer than during the period of rapid deinstitutionalization, when communities, facing the closure of their mental health facilities, inserted themselves into debates about the proper configuration of the mental health care system. Using the case of Weyburn, Saskatchewan, site in the 1960s of one of Canada's earliest and most radical experiments in rapid institutional depopulation, this article explores the government of Saskatchewan's management of the conflict between the latent functions of the old-line mental hospital as a community institution, an employer, and a generator of economic activity with its manifest function as a site of care made obsolete by the shift to community models of care.