Women's legal knowledge: a case study of Mexican urban dwellers

In Mexico, the nongovernmental organization Sevisio, Desarrollo y Paz, A.C. (SEDEPAC) is helping poor women acquire legal knowledge in an economic climate characterized by the increased feminization of poverty brought about by the Structural Adjustment Program. The Mexican legal system is grounded in a patriarchal tradition, and the codified laws continue to favor men. Women were not granted full citizenship until 1953, and discrimination against women was not addressed in Mexican law until 1974 as the country prepared to host the First UN International Women's Conference. However, legal advances are not being applied in the family or in larger society where men remain in power. Mexico also distinguishes between private law and public law. Because domestic violence falls in the realm of private law, authorities are loathe to follow-up on women's complaints in this area. Since its founding in 1983, SEDEPAC has applied a gender perspective to its activities and programs. SEDEPAC held its first women's legal workshop in 1987 and realized that most poor women have no knowledge of existing laws or their rights, that alternative legal services for women are scarce, that existing laws must be changed, and that the authoritarian and conservative legal system helps maintain cultural stereotypes. Since then, SEDEPAC has held annual workshops, follow-up meetings, and training sessions and has provided counseling. The main topics addressed are women's social conditions; violence and the penal code; civil rights, power, and dependency; women's bodies and reproductive rights; and women's organization and leadership. The workshops use techniques of popular education such as group participation and use of gossip as a communication tool. The workshops have changed participants' lives and led to the formation of an independent Popular Defenders' Coordination.     

Capitation and informatics

When physicians, hospitals, and allied health professionals bill for services they render, their information processing requirements are relatively simple, at least compared to those of capitated organizations. When payers (insurers or employers) accept financial risk for the health care services of beneficiaries, they have usually invested in claims processing, membership tracking, and, under managed care, utilization review and provider profiling systems. But payers, for the most part, have not invested in electronic collection of clinical information about beneficiaries, nor have they tended to keep all claims they have processed in electronic form for study after accounts are settled and payments disbursed. In this article, we will explore why informatics is so important to capitated organizations and why payers that have traditionally taken financial risk for insuring the health care costs of populations are also learning about the importance of informatics.     

Getting the most for your consulting dollars

Major changes in the health care financing and delivery system have usually been accompanied by an increase in demand within the health care field for consulting services. The passage of Medicare/Medicaid in 1965 is one example. The passage of the DRG-based prospective pricing system in 1983 is another. Both spawned a substantial amount of work, and income, for consulting firms. Now the health care field is engaged in nearly total transformation as the forces of health care reform at the national level are met with myriad adjustments at the local and regional levels. Managed care, already a byword, is being strengthened by a multitude of so-called integrated system initiatives. It is not easy to survive, and the call is out to consultants to save the day, or at least stave off disaster. In the following four articles, Marilyn Kennedy, a member of the ACPE faculty and a consultant herself, gives some advice on how to make the consulting arrangement successful; three physician executives provide a glimpse at consults that have worked, and some that did not work.     

Personal trainer, personal coach

The increasing number of fresh faces in the management ranks, many of them with highly polished credentials but little in the way of practical experience in the work-a-day management world, has increased the need for a new consulting professional--the personal coach. There simply aren't enough volunteer mentors to accommodate the growing medical management profession. Whatever the conditions under which this new professional's services are sought, both the individual to be coached and the organization for which the individual works should approach the arrangement with care and planning. The author offers some guidance for making the arrangement pay off.     

What lies ahead for medical management?

The consensus is that, in spite of a reluctance in Washington to undertake any drastic reform of the health care financing and delivery system, the changes that are already in place in individual organizations and that are in place or being contemplated at the state level are certain to make the health care system of tomorrow very different from that of today. Physician executives can play an important role in the transition that will be required, but they will have to use a flexible, especially nondogmatic approach if they wish to cope successfully in this increasingly whirling environment. For such physicians, the author says, the opportunities, though unknown, are enormous.     

Keeping the "care" in managed care: the importance of the therapeutic relationship and psychosocial factors in the managed care setting

There is much truth in the adage that "the more things change, the more they stay the same." Nowhere does this seem more apparent than in health care where, amidst monumental reconfiguration, basic foundations of physician-patient relationships and attention to the impact of psychosocial factors on health and health care delivery remain as critical influences. While the importance of the therapeutic relationship and the influence of psychosocial factors in medical care has been clear in traditional systems of delivery, these factors may be even more critical in managed care systems. These emphases must be incorporated by design, however, and not left to default.     

A comparison of quality and utilization problems in large and small group practices

Physicians practicing in large, multispecialty medical groups share an organizational culture that differs from that of physicians in small or independent practices. Since 1980, there has been a sharp increase in the size of multispecialty group practice organizations, in part because of increased efficiencies of large group practices. The greater number of physicians and support personnel in a large group practice also requires a relatively more sophisticated management structure. The efficiencies, conveniences, and management structure of a large group practice provide an optimal environment to practice medicine. However, a search of the literature found no data linking a large group practice environment to practice outcomes. The purpose of the study reported in this article was to determine if physicians in large practices have fewer quality and utilization problems than physicians in small or independent practices.     

Quantification of quality: a commentary

The literature is replete with theoretical discussions of medical quality management, particularly of the measurement of quality in the health care setting. While there is a growing body of knowledge on both quality and its measurement, this author questions whether medical quality can ever be quantified. He says that the concept of quality is still a moving target, so that the value of attempts at quantification can only be short-lived.     

A model of numbers of births in three countries,with persistent forty-year cycles

This paper describes a model which relates fertility to partner availability, an aspect of relative cohort size. Partner availability is affected by the tendency for males to reproduce at a later age than females. For women born at a time of rising birth rates, there is a shortage of slightly older men as potential partners. Women born when birthrates are falling enjoy a surplus of older men from which to choose. This model is believed to be the first non-linear demographic feedback model involving feedbacks through marriage squeezes in which empirically estimated values of the parameters imply persistent limit cycles. The deterministic model makes births in each five-year period a function of births in previous five-year periods. The form of the function is chosen to model the effect of partner availability upon entry into reproductive relationships, and therefore on age-specific fertility. Marriage rates are not modeled directly. The model was developed from data for more than a century from England and Wales, New Zealand, and the US. The demographic transition is modeled with a logistic function and age-specific fertility rates are estimated using lognormal distributions. The stepwise inclusion of a partner availability estimate in the model showed that it accounts for 29% of otherwise unexplained variance. Projected future births stabilize in sustained or limit cycles with periods a little longer than 40 years, and amplitudes of at least 7% of the mean. The necessary conditions for cycle persistence are outlined on a graph of maximum and minimum fertility parameters.