Chronic Care, Health Care Systems and Services Integration: Volume 22

Subject:

Table of contents

(16 chapters)

Aging is a growing concern in American society, whether one examines the issue in terms of growth of the elderly population, growth in expenses related to this population segment, or a concern about quality of life for people as they grow older. The population of the U.S. has aged throughout the twentieth century. While in 1900, only 4.1% of all Americans were over 65, the figure increased to 12.8% by 2000. The oldest old in the population, those 85 and over, increased even more, from only 590,000 people in 1900 to 3.7 million people in 2000. It is estimated that by 2030, when the baby boomers have become old, more than 20% of the U.S. population will be over 65. Some estimates are that those 85 and over will quadruple in size by 2030. Even given the reality that people are remaining physically healthy and may work longer than in the last generation, it is overwhelmingly clear that one of the major overall policy issues of the next several decades will be how to fund both the social and health services needs of the ever increasing elderly portions of the U.S. population. Nor is this issue of an aging population only a U.S. problem. Most developed countries are already experiencing this issue, and there are some European countries, such as Italy, that are already experiencing a declining population due to birth rates below replacement. When this happens in a country, then the elderly as a proportion of the population increase, and the issues of rising health care costs linked to changing population demographics become important policy issues in that country (Quadagno, 2005).

The relationships of physician practice characteristics, care management effectiveness, autonomy, and managed care involvement, and physicians’ practice and career satisfaction were investigated. A panel sample (N=660) of 6800 physicians was made up of eleven physicians randomly selected from each of the sixty communities. Three latent constructs include care management effectiveness, practice autonomy, and openness in private practice. Multilevel modeling was performed. A statistically insignificant association was found between the perceived effectiveness of care management and physician satisfaction, holding the practice characteristics and other perception factors constant. The study demonstrated direct effects of practice characteristics and care management effectiveness on the practice of gate-keeping functions and on earnings. Only two contextual variables, managed care penetration and median income in the study communities, were related to physicians’ practice.

This paper focuses on the impact of recent federal health policy on local community efforts to support the survival of rural hospitals. Rural communities in the United States have an established tradition of providing public financial support to local hospitals. The Balanced Budget Act of 1997 (BBA) expanded Medicare’s prospective payment system to non-acute care services, which promised reduced hospital reimbursement. Part of this legislation, the Critical Access Hospital (CAH) program, was specifically designed to counter the negative impact the broader legislation was expected to have. This study was designed to investigate the hypothesis that counties receiving financial relief for local hospitals through participation in the CAH program would show decreases in county subsidy levels compared to other hospitals. All 123 hospitals in Kansas were studied in 1994, well before BBA legislation, and again in 2001. Data on county-level health care spending for each of the two years were abstracted from all county budgets in Kansas. The amounts counties contributed to local hospitals were calculated and compared in terms of CAH versus non-CAH hospitals with attention to patterns of increase. Results showed that CAH hospitals, in spite of participation in the federal program, received greater local public financial support and experienced greater funding increases than other community hospitals. The implications of these findings are discussed in terms of the circumstances of rural hospitals and recent changes in the CAH program.

Literature suggests that the poor often face a myriad of health care constraints and health problems. This study uses bivariate and multivariate analyses to examine the effects of systemic factors such as the availability of health care providers and neighborhood poverty on individual health decisions for a sample of African Americans, Whites, Mexicans, and Puerto Ricans in poor Chicago neighborhoods. Results show that Medicaid usage and having a regular physician increase the number of days home ill and days hospitalized, while frequenting clinics decreases such activity. Additionally, residents in more impoverished urban areas are less likely to stay home ill. Differences in health profiles and providers are also evident based on race/ethnicity. These findings illustrate the important relationship between macro-level factors and specific health choices many residents in poor urban areas make at the micro-level.

This paper examines the health care experiences of older adults over a five-year period, including continuity in care, changes in health insurance coverage, and satisfaction with care.

Face-to-face interviews were conducted annually with 415 older adults (mean age = 84, range = 72–105), 100 of whom were originally health maintenance organization (HMO) subscribers and 315 of whom were receiving fee-for-service care. Several predictors of health care experiences were examined, including personal characteristics, health status and health care variables. Coverage type (HMO or fee-for-service) was the most consistent predictor. HMO subscribers were more likely than fee-for-service recipients to experience changes in insurance (both negative and positive changes) and discontinuity in physician care, although satisfaction with care did not vary among HMO and non-HMO members. Two-thirds of HMO subscribers and nearly one-third of fee-for-service recipients reported changes in insurance coverage over the five-year study period. In terms of perspectives on HMO care, the most frequently mentioned advantage of HMO care among those in HMOs was diminished costs, while fee-for-service subscribers did not believe there were any advantages to being in an HMO. Those not in HMOs viewed loss of physician choice and poor quality care as major disadvantages of HMOs. Results of this study demonstrate that older adults commonly experience changes in their health care coverage and physician care. They adapt to these changes through positive appraisals of the type of case they receive.

Pharmaceuticals are essential for the management of many chronic conditions. As a result, it is important to examine how the administration of pharmaceutical benefits affects physicians and pharmacists providing chronic care services. In the 1990s, HMOs and PPOs began to more aggressively manage outpatient pharmaceutical benefits, leading to the growth of pharmaceutical benefit management companies (PBMs).

In this exploratory study, 10 primary care physicians and 12 pharmacists in the San Francisco area were interviewed in 1999, and 11 more pharmacists in 2004, on how they worked with PBMs and their controls on prescribing and dispensing. Responses indicated major problems for both health professionals in negotiating with the PBM as a third party payor, in coping with switches and multiple formularies, and in added work for the health care professional. Increased risk to chronically ill patients for poorer outcomes is an important related problem with PBMs.

The Medicare drug benefit law passed in 2003 will likely result in similar problems for many beneficiaries, including those with chronic care needs. The paper proposes some policy solutions to reduce PBM problems for physicians, pharmacists and the Medicare population.

Despite the long-term interest of medical sociologists in persons’ expectations of care, there is little known about older persons’ expectations of home care. Because satisfaction with home care is important to older persons, the construct of home-care satisfaction (H-CS) is an important concern of practitioners and researchers. Influenced by theories of expectations and satisfaction, researchers have characterized expectations of home care as pre-existing variables in relation to which persons appraise satisfaction. Although theorists have emphasized the importance of obtaining data about expectations when measuring satisfaction, there are few data about expectations of home care. This narrative review points out the gaps between the current research and related theories. The frameworks and methods of studies designed to measure HC-S are reviewed with particular attention to expectations. The need to add to the knowledge base about expectations (and thereby to increase the validity of the HC-S construct) is emphasized. Definitions and categories of expectations from various disciplines are presented as untapped realms for exploring expectancies and expectations in descriptive studies. An interface between the principle of individual differences and the parameter of personal importance of home-care issues is highlighted as a framework for descriptive research.

The purpose of this study was to re-examine racial and gender differences in home and community-based services utilization. Using the 1999 National Long Term Care Survey, the Anderson-Newman (1995) health behavioral model, social supports and structural factors were used to examine predictors of service use among four in-home and two community-based services. The results showed that race did not have a significant main effect on service use, but gender had a significant main effect for housework, home delivered meals, and congregate meals. Using an interaction term, older white women reported higher usage of housework. Among the predictors, enabling factors had the strongest effect on the use of personal care/nursing, home delivered meals, transportation and senior centers’ services. The results also indicated the importance of social supports and structural factors, particularly service awareness, in predicting service use. Implications for policies and practice to improve community outreach, access and utilization of services by different racial groups of elders are discussed.

Chronic illnesses require long term, ongoing medical care as well as the provision of a variety of social support services. These diverse systems of care need to be integrated. However, under managed care, health care systems adhere to a disease model where emphasis is placed upon cure rather than care. While managed care can increase system coordination, the logic of cost containment favors acute services over the long term supportive services needed by chronic care clients. In this paper I describe efforts in one community which has received funding to integrate services for individuals with chronic mental illness as well as a planning grant to integrate multiple chronic care systems (HIV, mental health, and substance abuse) for minority clients. I describe various models of system integration and how diverse systems can be coordinated. In the conclusion I examine the barriers to system integration and argue that sociologists need to play a stronger role in understanding systems of care.

The purpose of the present study is to investigate whether family caregivers with a stronger sense of coherence (SOC) who are caring for community dwelling older adults with cognitive impairment are less likely to use mental health services. An adaptation of the Anderson behavioral model of access to health care was employed as a conceptual framework. Data were collected for 304 impaired older adult/family caregiver dyads. Caregiver mental health service use and sense of coherence were measures as well as predisposing factors (age, gender, race, education, type of familial relationship, family size, and co-residence with impaired family member), enabling factors (self-reported awareness of services, travel times to mental health services, social support, and insurance), and need factors (chronic health conditions and distress). The impaired elder’s age, level of physical impairment, and level of memory impairment were also examined. Logistic regression results indicated that caregivers who have a stronger SOC were less likely to use mental health services (OR=0.91, p=0.006). Other significant independent predictors of mental health service use were social support (OR=0.34, p=0.032) and caregivers aiding family members with higher levels of physical impairment (OR=1.14, p=0.033). The results of this study support clinicians and planners developing mental health services that use SOC to mitigate the detrimental effects of caregiving. Future research is needed to target effective measures to positively manipulate this variable.

We identify the key social and political forces that brought about the Self Managed Attendant Service Direct Funding Pilot (SMAS-DFP). Attendant Services are services for people with physical disabilities (PWD) to assist with daily activities. Direct Funding means that individuals obtain funds through direct funding mechanisms and/or through third parties. Self-direction refers to consumers who know their attendant service needs and can instruct workers to meet these needs. Self-management refers to (PWD) who are employers under the law and are legally responsible for hiring, training, scheduling and paying their attendants. Our analysis of the success of the SMAS-DFP is based on pre-conditions and facilitating elements. The pre-conditions were the: (1) existence of social movements; (2) precedents to direct funding programs; (3) prior experience with the governance of attendant services; and (4) government health reform. Five elements facilitated the SMASD-FP: (1) a clear vision by the community; (2) a core group of leaders; (3) supporters of the SMAS-DFP came from inside and outside of the community; and (4) supporters provided key resources to be used and to deal with barriers. PWD successfully led the pilot (1994–1997) and continue to administer the expanded government program (began 1998).

Late nephrology referral, a problem currently identified across many high income countries, has been associated with reduced opportunities for delaying or halting the progression of chronic kidney disease (CKD), delayed dialysis initiation, reduced choice in treatment modality, increased morbidity and hospitalization, and premature death. Despite a recent finding that the progression of CKD nearly always presents warning signs, and despite the fact that all Canadians are entitled to receive medically necessary health care free at the point of patient entry, each year in the province of British Columbia (BC) a substantial number of people with CKD experience late or no referral to nephrology care prior to requiring renal replacement therapy. A subset of these CKD patients experience no referral and “crash” onto dialysis (experience an acute or emergent start). Existing research has not fully explored the range of potential health determinants that may affect the timing of nephrology referral. This paper adopts a “determinants of health” framework and assesses the impact of a variety of indicators on patients’ physical health, demographics, socioeconomic status, social support, geographic and health system characteristics. Using a late referral definition of <3 months and data on BC patients who began dialysis between April 2000 and March 2003, multiple regression analysis indicates that the following determinants have an independent effect on the timing of referral: cause of end-stage renal disease (p=<0.0001); age (p=<0.0001); race/ethnicity (p=0.0019); English ability (p=0.0158); marital status (p=0.0202); proximity to care (p=0.0118); and, “age by first language” (p=0.0244).

Public health policy often excludes access to essential medicines. Drawing on an in-depth case study examining access to essential medicines in the context of the HIV/AIDS pandemic in South Africa, and more briefly, making reference to the U.S. diabetes epidemic, we highlight the relationship between the need for essential medicines in world populations, and the role of groups external to government in promoting access to essential medicines in public health policy. We consider how, in the context of health stratification, the activities of patient advocacy groups, and “third way” social policies of the pharmaceutical industry generate “social capital,” creating enhanced access to essential medicines for a few, and promoting the ideal of the right to access for all. The implications for the development of public health policy inclusive of essential medicines are discussed.

In the majority of the literature on the social organization of care work, care is often defined in more traditional terms to refer to work on or directly related to the body. In this paper, we would like to venture beyond the body to elaborate upon a particular type of care work – negotiating care – that involves negotiations and sometimes petitions for the purpose of securing care. It is a concept that was salient in a comparative study of the experiences of health care providers with the increasing management of health care in Canada and the United States. For physicians and nurses in both settings we find a sense of the increasing burden of negotiating for care for patients – particularly textually mediated negotiations – as the access to and amount of care is increasingly limited through managed care policies. Moreover, the contexts for these negotiations are continually in flux exacerbating the time devoted to negotiate care. It is in the U.S. context, however, that textual negotiation of care is most extensive and differs in terms of audience – insurers as opposed to providers – and purpose – securing payment and not just care.

DOI
10.1016/S0275-4959(2004)22
Publication date
Book series
Research in the Sociology of Health Care
Editor
Series copyright holder
Emerald Publishing Limited
ISBN
978-0-76231-147-7
eISBN
978-1-84950-300-6
Book series ISSN
0275-4959