The relationship between medical education and trans health disparities: a call to research

According to the National Transgender Discrimination Survey, 28% of trans respondents reported postponing medical care due to discrimination, and 28% reported being harassed by providers when they did seek out care. Scholars have proposed that what is taught (or not) in medical schools might play a role in the unequal health care experienced by many trans people. As medical education becomes a site of intervention for reducing transgender health disparities, it presents opportunities for sociologists to study and explain the processes by which medical training creates, reinforces, and potentially challenges stigma‐related health disparities. In this paper, we propose three areas of inquiry that might help explain this situation: the hidden curriculum, patient health movements and consumerism, and medical competency. By employing these concepts, we argue that sociologists can develop more comprehensive explanations for the relationship between medical education and transgender health inequalities and offer solutions to address this disparity.     

Leading collective action to address wicked problems

The alleviation of wicked problems requires collective action because these issues are characterized by significant uncertainty and complexity. This research extends prior work by examining how conveners' use robust action to navigate wicked problems' defining characteristics in the mobilization process. It provides a longitudinal study of a health care nonprofit attempting to engage other stakeholders in addressing the high costs and inadequate quality of health care in a region of the United States. Specifically, the convener sought to address this wicked problem by developing a health information exchange. The findings relate five robust action tactics through which the convener advanced collective action.     

Health promotion and disease prevention: a look at demand management programs

This Issue Brief describes employers' efforts to contain health expenditures through demand management programs. These programs are designed to reduce utilization by focusing on disease prevention and health promotion. Demand management includes work site health promotion, wellness programs, and access management. Work site health promotion is a comprehensive approach to improving health and includes awareness, health education, behavioral change, and organizational health initiatives. Wellness programs usually include stress management, smoking cessation, weight management, back care, health screenings, nutrition education, work place safety, prenatal and well baby care, CPR and first aid classes, and employee assistance programs (EAPs). These programs are often viewed positively by workers and can have long-term benefits for employers above and beyond health care cost containment. Demand management can benefit employers by increasing productivity, employee retention, and employee morale and by reducing turnover, absenteeism, future medical claims, and ultimately expenditures on health care. Even though a growing number of employers are offering wellness programs, only 37 percent of full-time workers employed in medium and large private establishments were eligible for wellness programs by 1993. However, a recent survey found that 88 percent of major employers have introduced some form of health promotion, disease prevention, or early intervention initiative to encourage healthy lifestyles among their salaried employees. Distinctions must be drawn between short- and long-term strategies. Demand management can be thought of as a short-term strategy when the focus of the program is on creating more appropriate and efficient health care utilization. Disease prevention is characterized by longer-term health improvement objectives. Whether the purpose is to reduce utilization in the short term or in the long term, the ultimate goal remains the same: to reduce health care expenditures while improving overall health. This goal can be achieved through the use of health risk appraisals, organizational health risk appraisals, high risk programs, awareness programs, medical call centers, return to work programs, EAPs, and smoking cessation programs. Studies of a health program's cost effectiveness must disentangle the effects of many competing factors on cost effectiveness. For example, a health risk appraisal program may identify health problems of which the patient and the health care provider were unaware, resulting in the treatment of these health problems. At the same time, the employer may have switched from a nonmanaged pharmaceutical program to a managed program with incentives for participants to utilize generic and/or mail order drugs. As a result, when evaluating a health promotion program, the long-run impact on the program's cost effectiveness is most important.     

Paying for the health and social care of the elderly

The aging population of Japan is causing serious concern among social policymakers. The most urgent issue is to find a way to pay for the health and social care of the frail elderly. After universal coverage of pension and health insurance was achieved, but just before the economic growth rate was considerably slowed, in part, because of the oil crisis, the Japanese government more than doubled pension benefits and made medical care for the elderly free. Since the early 1980s, the government has tried hard to cut and control these benefits, only with moderate success. With a consumption tax rate of only 5%, rather than the proposed 7%, the government is now considering establishing a new health and social care insurance scheme for the elderly to finance the increasing cost of their care.     

Paying for the Health and Social Care of the Elderly

The aging population of Japan is causing serious concern among social policymakers. The most urgent issue is to find a way to pay for the health and social care of the frail elderly. After universal coverage of pension and health insurance was achieved, but just before the economic growth rate was considerably slowed, in part, because of the oil crisis, the Japanese government more than doubled pension benefits and made medical care for the elderly free. Since the early 1980s, the government has tried hard to cut and control these benefits, only with moderate success. With a consumption tax rate of only 5%, rather than the proposed 7%, the government is now considering establishing a new health and social care insurance scheme for the elderly to finance the increasing cost of their care.     

Measuring the quality of health care

This Issue Brief examines some of the issues involved in defining and measuring the quality of health care and in implementing quality measures. It discusses the importance of measures of health care quality in the evolving health care delivery system, examines some of the conceptual issues involved in defining quality of care, and discusses some of the measures of health care quality and how these measures have been implemented in the health care delivery system. The major impetus for quality assurance programs is cost management: it is an attempt to allocate scarce health care resources efficiently. This requires making choices among alternatives, which may mean that maximizing quality of care for whole populations may not maximize the quality of care for individuals. Quality, in terms of any single good or service, has a number of dimensions. Health care is a complex bundle of services, and each component service within an episode of care affects the other components and the patients differently. Moreover, patients differ in numerous ways, which means that similar symptoms may require different services if care is to be effective. Measuring quality of health care services requires accounting for all of these factors. In attempting to manage health care costs, employers and other private health plans have begun to employ process measures of quality, i.e., evaluating caregivers' activities, the decisions made at each step in an episode of illness, and the appropriateness of the care provided. Process is an important component of quality measures because it focuses directly on the uncertainty in the efficacy of treatment. Given this uncertainty, the logic of medical decision making is an important determinant of quality and cost effectiveness. Examining the process of care involves assembling a panel of physicians who review medical records to determine the appropriateness of the care received. Providers have increasingly found that their medical decision making and practice styles are being monitored by purchasers as new health care delivery systems are being formed. The American Medical Association found that 39 percent of surveyed physicians were subject to clinical profiling.     

Community,Family, and Race/Ethnic Differences in Health Status in Rural Areas1

Abstract Many race-specific differences in health outcomes that have been observed in previous research have been attributed to class and racebased group differences which either facilitate or constrain health opportunities and behaviors. These include such variables as different rates of poverty, health insurance coverage, and access to medical care. However, these relationships have been inadequately examined in rural communities where minority status may be even more detrimental to health than in urban areas, due to various constraints on access to health care. We present an analysis that assesses the effects of community, family structure, sociodemographic, and medical care variables on self-reported health status among Hispanics, Mrican Americans, and non-Hispanic whites in six rural communities in Florida. Community structural characteristics had a significant effect on self-reported health, as did some of the measures of how respondents “experience” community. These relationships held even when other sets of variables were added to the models. Family/household characteristics and sociodemographic and medical care variables were less important in explaining self-reported health status. These findings suggest that community continues to be important in explaining differences in health status in rural areas.     

Fuzzy modelling and efficiency in health care systems

American Medical Institute reports that each year, because of the medical error, minimum fifty thousand people are dead. For a safety and quality medical system, it is important that information systems are used in health care systems. Health information applications help us to reduce the human error and to support patient care systems. Recently, it is reported that medical information systems applications have also some negative effect on all medical integral elements. The cost of health care information systems is about 4.6% of the total cost. In this paper, it is tried a risk determination model according to principles of fuzzy logic. The improvement of health care systems has become a very popular topic in Turkey recent years. Using necessary information system; it became possible to care patients in a safer way. However, using the necessary HIS tools to manage of administrative and clinical processes at hospitals became more important than before. For example; clinical work flows and communication among pharmacists, nurses and physicians are still not enough investigated. We use fuzzy modeling as a research strategy and developed sum fuzzy membership functions to minimize human error. In application in Turkey the results are significantly related with each other. Besides, the sign differences in health care information systems strongly effects of risk magnitude. The obtained results are discussed and some comments are added.     

Factors contributing to eviction from permanent supportive housing: Lessons from HUD-VASH

IntroductionEviction from housing is associated with several negative outcomes, further exacerbated among high-need populations requiring financial and supportive services to maintain housing stability. This study investigated risk and protective factors—both characteristics and precipitating events of tenant eviction—informing permanent supportive housing (PSH) programs’ efforts to identify tenants at risk and intervene.MethodsUsing administrative data for a cohort of 20,146 Veterans participating in PSH, this study assessed differences in Veterans who exited the program due to eviction and Veterans who exited because they accomplished their goals. A series of logistic regressions identified patterns of health services use that may signal imminent eviction.ResultsVeterans with a drug use disorder and those who received inpatient, emergency, or outpatient care related to mental/behavioral health and substance use conditions proximal to program exit had greater risk for eviction. Receipt of outpatient primary medical care and supportive services was generally protective against eviction. The likelihood of eviction was greatest for Veterans with acute care use within 30 days of exit.DiscussionPSH providers may use these correlates of eviction to identify Veterans in need of an intervention to prevent eviction. Future work should focus on operationalizing these findings and identifying appropriate interventions.     

INDIVIDUAL WELFARE WHEN CONSUMERS CAN SHOP FOR HEALTH INSURANCE

The statewide system of health insurance exchanges established by the Affordable Care Act (ACA) of 2010 will allow millions of U.S. citizens to change their health care policies more easily than they can switch automobile or homeowner insurance coverages, because deniability based on prior claim history is illegal. Focusing on this consumer endogeneity of health insurance policy choice, we examine the individual moral hazard welfare implications of a reduction in the price of medical care, which is a potential consequence of the ACA. We show that endogenous policy choice plays a key role in determining the welfare outcome. While moral hazard welfare improvement is not precluded, a distinctly possible outcome is that the consumer revises his/her choice of insurance policy so as to retain some portion of the reduction in expenditure risk caused by the medical care price decrease. In this event, moral hazard welfare loss is higher than it was before the price decrease, although the increased loss is tempered by the endogenous contract choice effect. This result resuscitates an old conventional wisdom. (JEL I11, I13, I30)     

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.     

Marital trajectories and mental health

This study expands the marital status and mental health literature by examining several dimensions of marital trajectories, including the number and type of prior marital losses and duration in current status. Data are drawn from the Piedmont Health Survey of the National Institute of Mental Health Epidemiologic Catchment Area Study, collected in 1982-83 (n = 2,158). Results indicate that number of prior losses moderates the health-enhancing effect of being currently married; higher order marriages are associated with worse mental health. Although results vary across the mental illnesses examined (depression, anxiety, and substance use), the negative effect of multiple loss also is observed for the currently divorced and widowed. There is less evidence that the type of prior loss (i.e., divorce or widowhood) moderates the effect of current marital status on mental health; however, some support is found among the presently widowed. The analyses of duration in current status suggest that the rate of decline in symptoms of anxiety following one's most recent loss varies by marital history among the currently widowed.     

Use of Various Health Care Services by Students in Helsinki

Abstract

Review of the working of various health care schemes has revealed predominant use by a certain group of “large-scale consumers.” The concomitant use of various services (health, dental, and mental health care) was studied within the Helsinki Health Center of the Finnish Student Health Service from January 1, 1980 to August 31, 1980. The group consisted of 16,174 students. The characteristics of the groups of patients who used only the mental health care service and of those who used all three services were also studied. Within each sector, there were fewer patients than expected who did not use the services of other sectors. The number of patients visiting dental and health care services, mental health and health care services, and all three services were greater than expected. The groups of patients who used only the mental health care service and those who used all three services were surprisingly similar. The greatest difference between the groups probably lay in their need for somatic and dental care. The organization, which incorporates mental health, dental, and health care services in the same building offers improved possibilities for care of the patient as a whole. On the basis of this study, there is no reason to think that such an organization leads to misuse of the various services.     

Latent classes of older foster youth: Prospective associations with outcomes and exits from the foster care system during the transition to adulthood

Youth in the foster care system face considerable challenges during the transition to adulthood. However, there is significant variability within this population. This study uses person-oriented methods and a longitudinal dataset of youth aging out of foster care to examine differences in how subgroups of foster youth fare during the transition to adulthood. We identified four distinct latent classes, consistent with prior person-oriented studies of this population, and validated these classes by examining differences on additional relevant factors at age 17. After establishing these classes, we tested their predictive validity by examining differences in outcomes at age 19 in domains relevant to the transition to adulthood, including education and employment, problem behaviors, and mental health problems. Finally, given the importance of extended foster care in promoting better outcomes, we used survival analysis to prospectively examine whether class membership was associated with differences in the rates at which youth left foster care between ages 17 and 19. One large group of youth exhibited moderate behavior problems and left care quickly, while another large group of resilient youth had favorable outcomes and left care relatively slowly. A small group exhibited considerable behavior and mental health problems, but left care more slowly, and a very small group was characterized by a history of pregnancy. Findings suggest considerable variability in service need among older foster youth. Implications for service provision during the transition to adulthood are discussed.     

The Development and Challenges in Health Care Policy and Health Care Financing in Contemporary China

China’s market-oriented reform has had great success in the past few decades. Along with the rapid economic growth of the country, the economic development also influenced various aspects of China’s social, economical, and political life. Recent debate has criticized the overheated market reform in social provision, thus arguing for the return of government interventions. However, in the health care sector, it is inappropriate to attribute all distortions to market imperfection. It is rather the design of the health care system and the lack of government interventions in regulating the health care market that obstruct the functions of health care provision. To examine the proposed hypotheses, the paper focuses on China’s medical care provision, evaluating the actual performance of China’s medical care provision in the environment of economic transition from a multidimensional analysis, hence providing forward-looking suggestions for the design of China’s health care provision. Findings from this study indicate that government interventions are indispensable in regulating the health care market as well as ensuring health care delivery.      

Medical Utilization and Health Expenditure of the Elderly in Taiwan

The present analysis, based upon data from the 1989 Taiwan Labor Force Survey, includes two parts. First, the determinants of physician visits and hospitalization by the elderly are analyzed according to the behavioral systems approach, and, second, variation in health expenditures among the elderly are examined using the Tobit model with sample selection. Findings show that elderly with good or poor health conditions are less likely to use medical services than the frail elderly and that married elders are less likely than the non-married to use medical care. The higher the educational level, the lower the probability of using formal medical services, and elderly who have health insurance are more likely to use formal health care than those who have no health insurance. The elderly who live with their children are less likely to use formal medical services than those who do not live with their children. Finally, among the elderly who have used formal health care, individual health expenditures are influenced primarily by three factors: health condition, health insurance, and residential location. Implications for Taiwan's relatively newly established national health insurance program (effective April 1, 1995) are discussed based upon the findings of this research.     

Measuring Social Return on Investment

Strategic decision making and evaluation in philanthropic giving and social investment requires good‐quality information about the social impacts of that investment. One way to meet this need is by calculating a social return on investment (SROI) measure, akin to the return on investment (ROI) approach used in business analysis. Despite much buzz in the field, SROI measurements are rarely used, in part because of the complexity of the calculations but also because of a number of thorny and often expensive organizational challenges associated with implementing an SROI process. This article explores these implementation challenges by comparing four social venture organizations in the health care field—two in the Netherlands and two in the United States—that have utilized some sort of SROI measurement. We summarize the SROI process and identify the specific organizational challenges in each case. Lessons learned from this analysis include the value of process versus product and the importance of fitting the type of measurement to the organizational context. We conclude with a summary of best practices for organizations and social investors who might try to make effective use of SROI measures.     

Vitamins, herbs, and supplements: tools of empowerment

1. Consumers who elect to use natural products are electing to do more than simply use a product. Their choice is an act of self-empowerment. 2. Education is necessary because these products most often are not being obtained in a professional, consultative setting but rather in chain discount department stores and supermarkets. 3. If consumers choose to address their health concerns using a natural-based treatment plan, consultation with a health care practitioner who shares this shift in perspective and who follows the literature is important. 4. A paradigm shift could be on the health care horizon, which when complete would make herbs and other natural products part of mainstream health care practice.     

Racial/Ethnic Disparities in Mental Health Service Use for Older Foster Youth and Foster Care Alumni

Studies have shown that foster care alumni have disproportionally high rates of poor mental health outcomes compared to the general population. The purpose of this study was to examine differences in mental health service use for Latino, African American, and White youth while in foster care and upon exit from the foster care system. Secondary data were used to identify youth 1 year prior to exiting the foster care system (N?=?934) and 1 year after exit from the foster care system (N?=?433). Racial/ethnic disparities in mental health service use upon exit from the foster care system were found, with Latino youth using the least amount of services after foster care exit. Racial/ethnic service disparities in type of services used were also found. Findings suggest that a lack of support (e.g., mandatory or voluntary) may be significant in overcoming challenges in the continuation or disruption of services.