Physical health decision making and decision aid preferences of individuals with severe mental illness

Individuals with severe mental illness (SMI) often suffer from comorbid physical health conditions that reduce quality of life and longevity. The integrated care movement has improved access to primary care services, but system change does not necessarily impact health behaviors. In an effort to better understand health behaviors of persons with SMI in integrated care, we explored physical health decision making and decision aid preferences. We conducted three focus groups, including two consumer groups and one mental health staff group. Data were analyzed using a grounded theory approach, employing independent coding, thematic analysis, and meaning-making processes. Data suggest that overall, the consumer groups preferred a shared decision making process, with the doctor making the final treatment decision. Staff indicated that decision making depended on a consumer’s functioning level. Consumers liked the idea of using a decision aid, and reported preferring the computerized aid. Staff felt that decision aids were dependent on consumer level of functioning. Consumers generally view primary care doctors as experts, but like the idea of using decision aids to assist in making medical decisions. Staff feel that consumers may need help in both decision making and decision aid use in primary care.     

Gendered uncertainty and variation in physicians' decisions for coronary heart disease: the double-edged sword of "atypical symptoms"

Nonmedical factors and diagnostic certainty contribute to variation in clinical decision making, but the process by which this occurs remains unclear. We examine how physicians' interpretations of patient sex-gender affect diagnostic certainty and, in turn, decision making for coronary heart disease. Data are from a factorial experiment of 256 physicians who viewed 1 of 16 video vignettes with different patient-actors presenting the same symptoms of coronary heart disease. Physician participants completed a structured interview and provided a narrative about their decision-making processes. Quantitative analysis showed that diagnostic uncertainty reduces the likelihood that physicians will order tests and medications appropriate for an urgent cardiac condition in particular. Qualitative analysis revealed that a subset of physicians applied knowledge that women have "atypical symptoms" as a generalization, which engendered uncertainty for some. Findings are discussed in relation to social-psychological processes that underlie clinical decision making and the social framing of medical knowledge.     

Modern health services and health care behavior: a survey in Kathmandu, Nepal

The most important problem regarding health service utilization in Third World countries is that established indigenous forms of health care are readily available and compete with modern health care. Thus, in addition to understanding the components of the decision to seek medical help, we must understand the conditions that affect the choice of a specific health care system. This study examines the impact of medical pluralism on the use of modern forms of health care in Nepal. The findings show that the presence of medical pluralism is a significant factor which delays use of modern health services. Policy implications are discussed, and the need for more research in this area is stressed.     

The effectiveness of health care cost management strategies: a review of the evidence

This Issue Brief discusses the evolution of the health care delivery and financing systems and its effects on health care cost management and describes the changes in the health care delivery system as they pertain to managed care. It presents empirical evidence on the effectiveness of managed care and concludes with an analysis of the potential of future health care reform to influence the evolution of the health care delivery system and affect health care costs. Between 1987 and 1993, total enrollment in health maintenance organizations (HMOs) increased from 28.6 million to 39.8 million, representing an additional 11.2 million individuals, or 4 percent of the U.S. population. At the same time, new forms of managed care organizations emerged. Enrollment in preferred provider organizations increased from 12.2 million individuals in 1987 to 58 million in 1992, and enrollment in point-of-service plans increased from virtually none in 1987 to 2.3 million individuals in 1992. In addition, the percentage of traditional fee-for-service plans with some form of utilization review increased to 95 percent in 1990 from 41 percent in 1987. Measuring the effects of the changing delivery system on the costs and quality of health care services has been a difficult task, resulting in considerable disagreement as to whether or not costs have been affected. In a recent report, the Congressional Budget Office recognizes two new major findings. First, managed care can provide cost-effective health care at a level of quality comparable with the care typically provided by a fee-for-service plan. Second, independent practice associations can be as effective as group- or staff-model HMOs under certain conditions. In the future, we are likely to see a continued movement of Americans into managed care arrangements, an increase in the number of physicians forming networks, a reduction in the number of insurers, an increase in the number of employers joining coalitions to purchase health care services for their employees, and a health care system that is generally more concentrated and vertically integrated.     

Maternal and child health and family planning services in the Sudan

Given the high rates of infant and maternal mortalty, the prevalence of infectious diseases, poor nutritional status among women and children, and numerous endemic diseases such as malaria and bilharzia, maternal-child health serivces have been given a high priority in the Sudan. In reality, however, this area has not received adequate attention within the primary health care system in terms of management, service provision, and training. Major obstacles to effective maternal-child health services include: 1) the lack of involvement of community health workers, the main providers of other primary health care services in the Sudan, in the area; 2) the clinical orientation of physicians, which mitigates against attention to the promotive and preventive components of health care; 3) a lack of standardization of medical records or data collection routines, which hinders program monitoring; and 4) the failure to integrate related national programs such as immunization into a comprehensive maternal-child health program. In addition, there are administrative and organizational obstacles, such as the lack of institutionalization of maternal-child health services within the Ministry of Health, inadequate managerial capabilities, an absence of guidelines for service delivery at the regional and provincial levels, delays in the procurement of equipment and supplies, a widely dispersed population, and transportation difficulties. Family planning, too, is supposed to be the responsibility of all primary health care workers in the Sudan. However, current training programs for physicians, nurses, village midwives, and community health workers do not prepare them to fulfill this role. Development of an official population policy in the Sudan is recommended to ameliorate some of these problems.     

Reforming the health care delivery system

The health care delivery system is evolving rapidly. There have been changes in the way health care is financed, the types of treatments available, the sites of care, and the physician patient relationship. These changes have resulted primarily from reactions to health care cost inflation. Health care reform is likely to accelerate some of these changes. The threat/promise of health care reform has already accelerated the consolidation of the health care services market. Health care reform is likely to reduce the number of insurers, increase the number of Americans in managed health care plans, increase the number of physicians in group practice, change provider income, and in general make the health care delivery system more concentrated and vertically integrated.     

Physician Resistance to Innovations: The Case of Contract Medicine

Abstract

Physicians' assessments of contract medicine arrangements such as health maintenance organizations (HMOs) are considered in light of innovation diffusion theory and changing professional relations in medical care. Data from a national sample of physicians reveal that physicians practicing in HMOs differed from others in that they were more likely to be primary-care practitioners and politically liberal; they were also more likely to have thought that a physician surplus was emerging and that HMOs offered better working conditions. They did not differ from other physicians in job satisfaction. After considering differences between the two groups, the research examines how physicians, who did not practice in HMOs, viewed such contract medicine arrangements. Findings indicate that physicians in fee-for-service (FFS) practices felt that working conditions and service quality in HMOs are highly related and are better in FFS practices than in HMOs. In addition, physicians who anticipated heightened competition from HMO development were more likely to favorably evaluate HMO service delivery. The findings suggest accommodation to an organizational innovation if it is seen as preserving practice autonomy, but limited acceptance otherwise.     

Ärztliche Resilienz durch Achtsamkeit

This article in the journal Gruppe. Interaktion. Organisation (GIO) examines the reforms in the German public health care system, which lead to increased pressure on physicians due to the new economic incentive structures. Therefore burnout and depression was explored as a serious problem among this profession. In research mindfulness is seen as an important factor to enhance the medical resilience and thus increase the quality of care. The available empirical evidence suggests that individual mindfulness training should be combined with organizational interventions in order to achieve the greatest impact. The integration of the spiritual, social, juridical and ethical dimensions within an interdisciplinary research area “Medical Spirituality” may take into account transpersonal experiences which have a healing transforming influence on the physicians as well as the whole health care system.     

Mexican immigration and health care: a political economy perspective.

This paper examines the case of Mexican immigrants in the United States and their access to medical services within a political economy of health framework. Such an approach stresses that the provision of health care is independent of health factors per se and that access to health care is not equally distributed throughout a population. The first section reviews the three major concepts influencing medical anthropologists working within a political economy framework: the social origins of illness; the allocation of health resources; and fieldwork in Third World countries. The analysis then focuses upon the reasons for limiting immigrants' access to health care, followed by an examination of the socioeconomic characteristics of Mexican immigrants, including an undocumented immigration status, which limit their access to health care. Finally, the consequences of limited access to health services are suggested, including a low utilization of preventive health services resulting from the high cost of care combined with the immigrants' generally low income, lack of medical insurance and fear of using U.S. health services.     

Access to health care in urban areas of developing societies

Emphasis on rural health problems has led to a relative neglect of urban health issues in developing societies. Yet the fact that a large proportion of the limited financial and human resources is allocated to urban health care makes it imperative for researchers and health planners to evaluate the effectiveness of the urban health care system. This paper examines data on health care utilization from a sample survey of 1500 households conducted in three areas of Accra, Ghana in 1982. The factors that influence the use of three types of health care services (clinics, drug vendors, and traditional healers) are examined. Suggestions are made for increasing the effectiveness of the health care system in Accra, with the aim of making medical care more accessible to all families.     

Variables Affecting Patient Satisfaction with Health Care Services in the College Health Setting

Abstract

Patient satisfaction with health care services is an important factor in health care delivery. It will significantly influence whether or not a patient seeks medical care, complies with prescribed treatment, and/or maintains a continuing relationship with a medical practitioner.

A survey questionnaire, relating patient satisfaction with a number of variables identified through a literature review, was mailed to a random sample of 500 students utilizing Student Health Service (SHS) at Kent State University (KSU) during the five week study period. The data obtained would be utilized to help with planning future health care services and staff inservice education programs.

The findings of this survey indicate that patient satisfaction has a statistically significant correlation with perceived technical competence of the practitioner and perceived adequacy of the interpersonal aspects of the practitioner-patient relationship. A significant relationship did not exist between satisfaction and expectations the patient holds of the practitioner's role performance. A statistically significant relationship was found to exist between receiving health information/education related to diagnosis, prognosis, and treatment plan and satisfaction with health care services. This relationship did not hold for health information/education related to activity restrictions or preventive measures. The study also revealed that time waited during the medical care encounter was inversely related to satisfaction. Last, stepwise regression found that perceived technical competence of the practitioner was the most important variable influencing patient satisfaction with health care services.

This study provides data about factors important to personal satisfaction with health care services for a selected group of college students.     

Managed care and the rationalization of mental health services

Managed care represents a response to the wider institutional demand for technical rationality and efficiency, and it may be in conflict with professionally generated logics of mental health care which emphasize the delivery of quality care, as well as providing services to all who need care. The organizational and policy conundrum is to balance conflicting institutional demands for efficiency (cost savings) and effectiveness (access and quality). This paper examines managed care in one public sector mental health care system that has attempted to incorporate the principles of managed care into a community based system of care and to overcome the potential contradictions between demands for efficiency and professional logics of care. Both qualitative and quantitative data are used to examine changes in organizational structure and service offerings; providers' experience of managed care, and the effect of managed care on working conditions and work experiences, and changes in the goals of the organization as measured by the specification of client outcomes. I find that, while increased performance accountability and outcome assessment (in keeping with demands for efficiency) have the potential to improve mental health care services, in fact, providers report that the primary effect of managed care has been an emphasis on cost containment, and there has been a corresponding de-emphasis on the provision of community based services for clients with long term care needs. However, there is potential for professional logics to be maintained by larger institutional forces demanding quality care.     

The contribution of a cultural perspective in understanding and evaluating client satisfaction

Increasing attention is being given to including measures of client satisfaction as a component in the evaluation of health care services. An understanding of cultural factors that may influence attitudes and behaviors in the health care situation can contribute to the theory and measurement of client satisfaction. Through an examination of some of the cross-cultural literature, this paper delineates dimensions of the health care situation in which clients have been shown to have distinctive preferences, behavioral patterns, attitudes, and treatment expectations. A knowledge of the beliefs and attitudes concerning health and illness that are espoused by a particular cultural group can be a valuable asset in understanding how members of that group will evaluate the delivery of health care services. The examination of how cultural and ethnic differences may affect client satisfaction outcomes points to the necessity of avoiding a global measure of client satisfaction without first examining those particular aspects of health care delivery and of the measurement context that may have a predictable influence on client satisfaction ratings.     

Power and change: primary health care at the crossroads in Sweden.

This paper is based on in-depth interviews with members of Sweden's medical interest groups involved in a national effort to control health care costs. Sweden is faced with escalating costs due primarily to a growing high technology hospital sector. Simultaneously, consumer demand for primary care services and for gerontological care is rising rapidly. The Swedish way of changing the health care system is described and an analysis of the power struggle between physicians, health care bureaucrats and politicians is presented.     

Free enterprise, professional ideology, and self-interest: an analysis of resistance by Canadian physicians to universal health insurance

Under Canada's universal health care system, physicians are remunerated through government-run health insurance plans; a private market for physicians' services is virtually nonexistent. A proposal to ban the practice of extra-billing, whereby some physicians billed patients for amounts over and above insured rates, met with physicians' opposition. The particular constellation of legislative, social, and political events that followed the proposed ban presented a unique opportunity to explore the nature of the medical profession's resistance to encroachment on professional autonomy. The results of this survey of physicians in four specialties (N = 313) in metropolitan Toronto suggest that resistance to universal health insurance is complex; it involves a prevailing social ideology among physicians, which happens to be antiwelfare and conservative generally, entangled with economic self-interest and a specific set of beliefs about medical practice and physicians' rights and privileges.     

NEW TRENDS IN THE DOCTOR-PATIENT RELATIONSHIP: IMPACTS OF MANAGED CARE ON THE GROWTH OF A CONSUMER PROTECTIONS MODEL

Managed care is prompting a large revision not only in the ways doctors are employed and paid but also in the essence of the relationship between doctors and patients. In medical sociology, a discipline with a long-standing focus on scrutinizing the role of both the physician and the patient, there has already been discussion of a shift from the doctor as more all knowing to a less dominant position vis-a-vis both the patient and delivery of care. Patients are aware of shifts that place physicians in an environment characterized by new roles and responsibilities, such as acting as a gatekeeper. Limitations on health care coverage and the rethinking of roles have led to a depiction of the patient as the consumer of care and the managed care plan's becoming the commercial enterprise from which a service is obtained. The model of the patient as consumer of medically related goods and services appears to be growing, as does a model of the physician as one who contracts for a specified range of services for specific patients. In this article, trends in and problems with contemporary managed care are raised. Calls for patients' rights legislation may be among the health trends of the new millennium.     

Patient Rights: An Advocate's Perspective

Abstract

The current growing concern about patients' rights and the delivery of student health care precipitates an environment of fear, distrust, and uneasiness within university health services. This paper addresses several selected clinical, ethical, and legal issues which have come into conflict during recent years. Our examination surveys ethical and legal principles of confidentiality, defines areas in which breaches are most likely to occur, and suggests ways of preventing breaches of confidence between students and health services.

While the fundamental ethical principle underlying confidentiality is the individual's right of privacy, many issues of confidentiality are extremely difficult to resolve. University health services have expanded the concept of health care to encompass all the conditions — medical, emotional, social, economic and environmental — which affect the health of students. As a result, health service administrators should be fully aware of the laws and associated legal complexities in their own state which affect confidentiality. Furthermore, student health physicians, and particularly mental health therapists must be sensitive to needs for protecting the privacy of students.

Legal principles of confidentiality discussed in this paper with respect to specific problem situations which might arise in a student health center include: 1) right to privacy; 2) privileged communications; 3) releasing information from the medical record; 4) releasing information to the student; and 5) treating minors without parental consent. Finally, in addition to the responsibilities which must be assumed by the health professional, certain student responsibilities in the selection and utilization of health professionals are recommended.     

Pediatricians and foster children

The poor state of health and health care of foster children is well documented. The cure lies in the hands of the agencies that administer the foster care system and pay for medical services, and in those of the physicians who provide that care. This study suggests that much of the problem may be solvable. Adequate numbers of pediatricians in Connecticut seem to be committed to caring for foster children, but major impediments remain, including inadequate reimbursement for both primary and specialty health services. The institution of a medical passport can make needed information available and help to establish and promote standards of care. Pediatricians appear willing to take a leadership role in assisting other agencies in developing programs to improve the care of these children; despite the problems in providing medical care to foster children, most pediatricians view it as part of their responsibility to the community and to all children.     

Some implications of the emergence and diffusion of medical expert systems

This paper has two sections. The first introduces the area of medical decision making and the use of artificial intelligence techniques for developing medical expert systems. It also briefly discusses how a physician and an expert system interact, using the INTERNIST-I system as an example. An elaboration of several technical problems which expert systems must overcome for them to be accepted and used by physicians ends this discussion. The second section considers the implications medical expert systems for physicians and patient care. It suggests that medical expert systems regulate and routinize physicians' work. Moreover, the encoding of expert knowledge in a computer program will likely demystify the practice of medicine, nullifying much of the art of medicine. Alternatively, medical expert systems may improve the physician's decision making, extend the practitioner's capabilities, and hence increase the physician's prestige. Moreover, computer aided decision making could speed diagnosis, especially for difficult cases, thus providing the doctor with time for other pursuits. However, medical expert systems will be a mixed blessing for patient care. On the one hand, they could provide expert advice in medically underserved areas, decrease the number of referrals patients and physicians must contend with, while offering expert advice to a greater number of patients. On the other hand, expert systems could further alienate patients from practitioners and from the health system in general. Even more than other medical technologies, computers in the doctor's office could increase the separation between the doctor and patient, while lowering the physician's confidence in her or his own decision making. The conclusion discusses the importance of control over work in determining the use of technology and the influence of the changing medical power structure on the use of expert systems.I thank J. Zvi Namenwirth for his careful review and thoughtful comments on this and previous drafts of this paper. I also appreciate the useful suggestions offered by anonymous reviewers of an earlier draft.