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Resumo Objetivo: analisar a frequência e fatores associados à cobertura por planos privados de saúde na região metropolitana de Manaus, AM, Brasil. Métodos: estudo transversal de base populacional realizado em 2015, por meio de entrevista domiciliar; as razões de prevalência (RP) e intervalos de confiança (IC95%) foram calculadas pela regressão de Poisson, com variância robusta ajustada por sexo e faixa etária. Resultados: foram entrevistados 4.001 indivíduos, dos quais 13% (IC95% 12,0 a 14,1%) tinham plano de saúde; maior cobertura por planos foi observada entre militares (RP=3,18 - IC95% 1,64;6,15), empregados dos setores privado (RP=1,91 - IC95% 1,46;2,52) e público (RP=1,75 - IC95% 1,23;2,49); a cobertura por planos de saúde foi menor entre pessoas mais pobres (RP=0,21 - IC95% 0,13;0,33) e de menor escolaridade (RP=0,66 - IC95% 0,46;0,99). Conclusão: a frequência de planos de saúde foi baixa e associou-se a melhor poder aquisitivo, escolaridade e situação de trabalho. Resumen Objetivo: analizar la frecuencia y los factores asociados a la cobertura por planes de salud en la región metropolitana de Manaus, AM, Brasil. Métodos: estudio transversal de base poblacional por entrevista domiciliar. Las razones de prevalencia (RP) e intervalo de confianza (IC95%) fueron calculadas por regresión de Poisson con varianza robusta, ajustadas por sexo y edad. Resultados: se entrevistaron 4.001 individuos; 13% (IC95%: 12,0 a 14,1%) tenían plan de salud; la mayor cobertura por planes fue observada entre militares (RP=3,18 - IC95% 1,64;6,15), empleados del sector privado (RP=1,91 - IC95% 1,46;2,52) y del sector público (RP=1,75 - IC95% 1,23;2,49); la cobertura fue menor en personas más pobres (RP=0,21 - IC95% 0,13;0,33) y de menor escolaridad (RP=0,66 - IC95% 0,46;0,99). Conclusión: la frecuencia de planes de salud fue baja y se asoció con mejor poder adquisitivo, escolaridad y situación de trabajo. Abstract Objective: to analyze the frequency and factors associated with coverage by health insurance in the metropolitan region of Manaus, AM, Brazil. Method: a cross-sectional population-based study was conducted in 2015, with data collected through household interviews; prevalence ratios (PR) and confidence intervals (95%CI) were calculated using Poisson regression with robust variance adjusted for sex and age. Results: we interviewed 4,001 individuals; 13% (95%CI - 12.0;14.1%) had health insurance; greater insurance coverage was observed among military personnel (PR=3.18 - 95%CI 1.64;6.15), private sector employees (PR=1.91 - 95%CI 1.46;2.52) and public sector employees (PR=1.75 - 95%CI 1.23;2.49); health insurance was lower among poorer people (PR=0.21 - 95%CI 0.13;0.33), and those with less schooling (PR=0.66 - 95%CI 0.46;0.99). Conclusion: frequency of health insurance was low and was associated with better purchasing power, schooling, and employment.

OBJECTIVE: To verify the association of sociodemographic and clinicai variables to different levels of physical activity in older adults enrolled in a health insurance plan in Brazil. METHODS: A quantitative cross-sectional study was conducted on a sample of 361 older adults enrolled in a health insurance plan in the city of São Paulo, SP, Brazil. Levels of physical activity were measured using the International Physical Activity Questionnaire (IPAQ), which has been translated, adapted and validated for use in Brazilian geriatric populations. Sociodemographic characteristics, functional capacity for activities of daily living, cognitive function, depressive symptoms, risk of falls, self-perceived health and nutritional status were also evaluated. Results were analyzed using descriptive methods followed by ANOVA and Chi-Square tests. When homogeneity of variances was violated, the Brown-Forsythe test was used, followed by Dunnett’s test for multiple comparisons. RESULTS: Low levels of physical activity were reported by 63.3% of participants, with only 5.6% practicing vigorous physical activity. In this sample, variables such as positive self-perceived health (p = 0.032), adequate sleep without medication (p = 0.020) and independence for activities of daily living (p < 0.001) were positively associated with higher levels of physical activity. Advanced age (p < 0.001), cognitive decline (p < 0.001), depressive symptoms (p < 0.001) and mobility impairments (p < 0.001) were associated with low levels of physical activity. CONCLUSION: Demographic and clinical variables displayed positive and negative associations with different levels of physical activity in older adults receiving health insurance plans.

Objective: To measure the Quality of Life (QoL) and associated factors in a group of elderly persons receiving care through a health plan operator in the city of São Paulo, Brazil. Method: A cross-sectional study was carried out with 169 elderly persons enrolled in a health plan and who were participants in a program to promote health and prevent risks and diseases. The Bref and Old versions of the World Health Organization Quality of Life (WHOQOL) instruments were adopted for the evaluation of the QoL of the elderly. After descriptive analysis, a comparative analysis was performed through the Student’s t-tests and ANOVA. The Brown-Forsythe test was applied for situations in which no homogeneity was found and the Tukey test for multiple comparisons was applied. Results: The highest mean QoL values were found in the Psychological [72.1 (±14.3)] and Environment [68 (±15.4)] and Intimacy [72.5 (±20.8)] domains, while the worst results were found in the Physical [64.3 (±18)] domain and in the Death and Dying facet [61.2 (±23.2)]. In this group, factors such as obesity, neoplasia and previous hospitalizations were negatively associated with QoL, whereas young elderly, female, widows, carriers of chronic non-communicable diseases and those limited to two morbidities, who practiced physical activity and had clinical care provided by a reference physician had a positive influence. Conclusion: The findings of this research showed high levels of satisfaction with health and QoL, in addition to raising relevant discussions about predictors that influence the QoL of the elderly receiving care from the supplementary sector. It also emphasizes the need for new strategies of action to ensure improvements in the health care of the elderly. Resumo Objetivo: Mensurar a qualidade de vida (QV) e os fatores associados a um grupo de idosos assistidos por uma operadora de plano de saúde da cidade de São Paulo, Brasil. Método: Estudo transversal com 169 idosos vinculados a um plano de saúde e participantes de um programa de promoção à saúde e prevenção de riscos e doenças. Adotou-se os instrumentos World Health Organization Quality of Life (WHOQOL) versão Bref e Old para a avaliação da QV dos idosos. Após análise descritiva, realizou-se análise comparativa por meio do Teste t Student e ANOVA. O Teste de Brown-Forsythe foi aplicado para situações em que não foram encontradas homogeneidade e o Teste de Tukey para comparações múltiplas. Resultados: As maiores médias de QV foram encontradas nos domínios Psicológico [72,1 (±14,3)] e Meio Ambiente [68,0 (±15,4)] e na faceta Intimidade [72,5 (±20,8)], enquanto que no domínio Físico [64,3 (±18,0)] e na faceta Morte e Morrer [61,2 (±23,2)] foram observadas as piores. Neste grupo, fatores como obesidade, neoplasia e internação hospitalar prévia foram associados negativamente a sua QV, enquanto que idosos jovens, do sexo feminino, viúvos, portadores de doenças crônicas não transmissíveis e limitadas a duas morbidades, praticar atividade física e ter assistência clínica prestada por um médico de referência influenciaram positivamente. Conclusão: Os achados desta pesquisa mostraram altos níveis de satisfação com a sua saúde e a QV, além de trazer relevantes discussões sobre preditores que influenciam na QV de idosos assistidos pelo setor suplementar. Ressalta ainda, a necessidade de novas estratégias de ação que assegurem melhorias de cuidados à saúde do idoso.

Objective: to study the main elements of the iatrogenic triad in a group of elderly women with a Chronic Non-Communicable Disease (CNCD) contracted to a health plan. Method: A cross-sectional and descriptive epidemiological study was carried out by analyzing 3,501 medical prescriptions of 725 elderly women aged ≥65 years. The medications were determined to be Potentially Inappropriate Medications (PIM) based on four instruments (AGS Beers 2015, PRISCUS List, EU(7)-PIM, Brazilian Consensus of PIM - CBPIM). In addition, the most prescribed drugs were assessed for possible Drug Interactions (DI) and classified according to degree of severity. Results: the present study revealed that 89.3% of the studied group used at least one element of the iatrogenic triad, and 44.9% of the sample were associated with the use of polypharmacy and PIM. A total of 48.0% were taking at least five continuous use medications. The main DI were omeprazole, simvastatin and levothyroxine, all of which are of significant severity and have potential drug-food interactions. A total of 35.1% of PIM were identified through the four criteria used, 26.6% were identified by the CBPIM, 25.8% by the EU(7)-PIM, and 24.6% and 6.6% by AGS Beers and PRISCUS, respectively. Conclusion: a high index of continuous use medications, PIM and potential DI were identified, mainly enzymatic inhibitors in a group of elderly women at risk due to their clinical characteristics. Old age was associated with the presence of all the elements of the iatrogenic triad. It was also noted that there were no significant differences between the criteria applied, except for the PRISCUS list. Resumo Objetivo: Investigar os principais elementos da Tríade Iatrogênica em um grupo de mulheres idosas, com doenças crônicas não transmissíveis (DCNT) e vinculadas a um plano de saúde. Método: Estudo epidemiológico, transversal e descritivo, realizado mediante a análise de 3.501 prescrições médicas realizadas à 725 mulheres idosas com ≥65 anos. As medicações foram determinadas como medicamentos potencialmente inapropriados (MPI) segundo quatro instrumentos (AGS Beers 2015; lista PRISCUS; EU(7)-PIM; Consenso Brasileiro de MPI - CBMPI). Além disso, os medicamentos mais prescritos foram estudados segundo as possíveis interações medicamentosas (IM) e classificados quanto ao grau de severidade. Resultados: Este estudo revelou que 89,3% do grupo estudado faziam uso de, pelo menos, um elemento da Tríade Iatrogênica, sendo que 44,9% estavam associados ao uso de polifarmácia e MPI. Um total de 48,0% estavam em uso contínuo de pelo menos cinco medicamentos. As principais IM foram entre omeprazol, sinvastatina e levotiroxina, todos de gravidade significativa e com potencial de interação medicamento-alimento. Encontrou-se 35,1% de MPI através dos quatro critérios utilizados, sendo identificado 26,6% pelo CBMPI, 25,8% através do EU(7)-PIM, 24,6% e 6,6% pelo AGS Beers e o PRISCUS, respectivamente. Conclusão: Evidenciou-se um alto índice de medicamentos em uso contínuo, MPI e interações medicamentosas potenciais, principalmente de inibidores enzimáticos em um grupo de idosas de risco, devido às suas particularidades clínicas. A idade avançada esteve associada à presença de todos os elementos da tríade iatrogênica. Notou-se ainda que todos os critérios aplicados não apresentaram diferenças significativas, com exceção da lista PRISCUS.

Objective: To analyze publications regarding judicial demands related to the violation of the rights of the client who uses private health insurance in Brazil. Method: Integrative review, from September to October 2017, of national character, with complete texts online, in Portuguese and English, published between 2012 and 2017 in the Virtual Health Library portal, excluding studies that were duplicated or with indiscriminate methodology. Results: The judicial demands were for: medication (32%); ward hospitalization (11%); surgical procedures (9%); orthosis, prothesis and special materials (9%); others (9%); and diagnostic procedures, outpatient service, hospitalization in Intensive Care Units, food formulas and disposable diapers (30%). Conclusion: The prevalence of legal disputes arising from the failure in providing health service by private health insurances was observed, which makes it easier for the administrators to identify the sought health products and services in order to reorganize the administrative sphere and provide quality care.

Objective To identify the financial resources and investments provided for preventive medicine programs by health insurance companies of all kinds. Methods Data were collected from 30 large health insurance companies, with over 100 thousand individuals recorded, and registered at the Agência Nacional de Saúde Suplementar. Results It was possible to identify the percentage of participants of the programs in relation to the total number of beneficiaries of the health insurance companies, the prevention and promotion actions held in preventive medicine programs, the inclusion criteria for the programs, as well as the evaluation of human resources and organizational structure of the preventive medicine programs. Conclusion Most of the respondents (46.7%) invested more than US$ 50,000.00 in preventive medicine program, while 26.7% invested more than US$ 500,000.00. The remaining, about 20%, invested less than US$ 50,000.00, and 3.3% did not report the value applied. RESUMO Objetivo Identificar os recursos financeiros e os investimentos disponibilizados para os programas de medicina preventiva em operadoras de saúde suplementar de todos os tipos. Métodos Foram levantados dados referentes a 30 operadoras de saúde registradas na Agência Nacional de Saúde Suplementar, de grande porte, com registro acima de 100 mil vidas. Resultados Foi possível identificar o porcentual de participantes dos programas em relação ao número total de beneficiários da operadora, as ações de prevenção e promoção realizadas nos programas de medicina preventiva, os critérios de inclusão nos programas, bem como a avaliação dos recursos humanos e da estrutura organizacional dos programas de medicina preventiva pesquisadas. Conclusão A maior parte dos pesquisados (46,7%) investiu mais de US$ 50,000.00 no programa de medicina preventiva, enquanto 26,7% investiram mais de US$ 500,000.00. Os restantes, cerca de 20%, investiram menos de US$ 50,000.00 e 3,3% não informaram o valor aplicado.

Background To reduce costs and improve care, states are increasingly enrolling individuals with disabilities in Medicaid managed care. Many states allow or require adults who are dually eligible for Medicaid and Medicare to enroll in these plans. Objective This study (1) quantifies changes in enrollment by managed care arrangement for duals under age 65, between 2005 and 2008 and (2) compares enrollment and spending between dual eligibles and Medicaid-only beneficiaries. Methods We used Medicaid Analytic eXtract data to compare the Medicaid enrollment and spending for all-year, full-benefit dual eligibles ages 21–64 with that of Medicaid-only Supplemental Security Income (SSI) and disabled beneficiaries. The study population was classified into 9 types of managed care to quantify enrollment and calculate expenditures by year. Results Nationwide, the proportion of adult duals in managed care increased from 2005 to 2008, with the expansion of prepaid health plans (PHPs) (31.0%–46.6%), particularly behavioral health PHPs, driving the increase. In 2008, Medicaid-only disabled adults were three times as likely as dual adults to enroll in comprehensive managed care (CMC) (35.1% versus 11.7%). Average Medicaid expenditures per enrollee differed markedly by managed care arrangement and state. Conclusions From 2005 to 2008, there was little expansion of CMC among adult duals, while the use of PHPs to cover carved out services increased greatly. New federal initiatives aim to reduce barriers to enrolling duals into comprehensive, integrated managed care. With expanded enrollment, it will be important to monitor enrollment and evaluate whether integration improves care.

Evaluate the association of multimorbidity, primary health care model and possession of a private health plan with hospitalization.A population-based cross-sectional study with 1,593 elderly individuals (60 years old or older) living in the urban area of the city of Bagé, State of Rio Grande do Sul, Brazil. The outcome was hospitalization in the year preceding the interview. The multimorbidity was evaluated through two cut-off points (≥ 2 and ≥ 3). The primary health care model was defined by residence in areas covered by traditional care or by Family Health Strategy. The older adults mentioned the possession of a private health plan. We performed a gross and adjusted analysis by Poisson regression using a hierarchical model. The adjustment included demographic, socioeconomic, functional capacity disability and health services variables.The occurrence of overall and non-surgical hospitalization was 17.7% (95%CI 15.8-19.6) and 10.6% (95%CI 9.1-12.1), respectively. Older adults with multimorbidity were admitted to hospitals more often when to older adults without multimorbidity, regardless of the exhibition' form of operation. Having a private health plan increased the hospitalization by 1.71 (95%CI 1.09-2.69) times among residents in the areas of the Family Health Strategy when compared to elderly residents in traditional areas without a private health plan.The multimorbidity increased the occurrence of hospitalizations, especially non-surgical ones. Hospitalization was more frequent in older adults with private health plan and those living in Family Health Strategy areas, regardless of the presence of multiple diseases.Avaliar a associação da multimorbidade, modelo de atenção básica e posse de plano de saúde com hospitalização.Estudo transversal de base populacional com 1.593 idosos (60 anos ou mais) residentes na zona urbana do município de Bagé, Rio Grande do Sul. O desfecho foi a hospitalização no ano anterior à entrevista. A multimorbidade foi avaliada por meio de dois pontos de corte (≥ 2 e ≥ 3). O modelo de atenção básica foi definido pela residência em áreas cobertas pela atenção tradicional ou da Estratégia Saúde da Família. A posse de plano de saúde foi referida pelos idosos. Realizou-se análise bruta e ajustada por regressão de Poisson utilizando modelo hierarquizado. O ajuste incluiu variáveis demográficas, socioeconômicas, capacidades funcionais e de serviços de saúde.A ocorrência de hospitalização geral e não cirúrgica foi de 17,7% (IC95% 15,8-19,6) e 10,6% (IC95% 9,1-12,1), respectivamente. Idosos com multimorbidade hospitalizaram mais em comparação com os idosos sem multimorbidade, independentemente da forma de operacionalização da exposição. O plano de saúde aumentou em 1,71 (IC95% 1,09-2,69) vezes a internação hospitalar entre residentes nas áreas da Estratégia Saúde da Família em comparação aos idosos residentes nas áreas tradicionais sem plano de saúde.A multimorbidade aumentou a ocorrência de hospitalizações, principalmente aquelas não cirúrgicas. Idosos com plano de saúde e residentes em áreas de Estratégia Saúde da Família internaram mais, independentemente da presença de múltiplas doenças.

Gastroesophageal reflux disease (GERD) may link the obesity epidemic to an array of adverse health outcomes including chronic esophageal inflammation and, consequentially, to pathophysiological changes of the esophagus. Although obesity and GERD are associated in adults, data in children are scarce and inconclusive. The aim of this study is to investigate whether, similar to adults, obesity is associated with GERD in youth.For this population-based, cross-sectional study, measured weight and height and diagnosis of GERD were extracted from electronic medical records of 690 321 patients, aged 2-19 years, who were enrolled in an integrated prepaid health plan between 2007 and 2008. Weight class (normal weight, overweight, moderate and extreme obesity) was assigned based on body mass index-for-age.Overall, GERD was diagnosed in 1.5% of boys and 1.8% of girls (P0.001). Moderately and extremely obese children, aged 6-11 years, were more likely to have a diagnosis of GERD compared with normal weight (OR 1.16, 95% CI: 1.02-1.32 and 1.32, 95% CI: 1.13-1.56, respectively). Children aged 12-19 years showed similar associations (OR 1.16, 95% CI: 1.07-1.25 and 1.40, 95% CI: 1.28-1.52, respectively). These associations remained with adjustment for sex and race/ethnicity. By contrast, obesity was not related to increased odds for GERD in children aged 2-5 years of age.The association between childhood obesity and GERD may have important implications for their future risk of GERD-associated diseases, such as esophageal adenocarcinoma.

Background Few health plans provide maintenance medication for opioid dependence. This study assessed the cost of treating opioid-dependent members in a commercial health plan and the impacts of methadone maintenance on costs of care. Methods Individuals with diagnoses of opioid dependence (two or more diagnoses per year) and at least 9 months of health plan eligibility each year were extracted from electronic health records for the years 2000 through 2004 (1,518 individuals and 2,523 observations across the study period—some individuals were in multiple years). Analyses examined the patterns and costs of health care for three groups of patients: (1) one or more methadone visits during the year (n = 1,298; 51%); (2) no methadone visits and 0 or 1 visits in the Addiction Medicine Department (n = 370; 15%); (3) no methadone visits and 2 or more visits in addiction medicine (n = 855; 34%). Results Primary care (86%), emergency department (48%) and inpatient (24%) visits were common. Mean total annual costs to the health plan were $11,200 (2004 dollars) per member per year. The health plan's costs for members receiving methadone maintenance were 50% lower ($7,163) when compared to those with two or more outpatient addiction treatment visits but no methadone ($14,157) and 62% lower than those with one or zero outpatient addiction treatment visits and no methadone treatment ($18,694). Conclusions Use of opioid maintenance services was associated with lower total costs of care for opioid-dependent members in a commercial health plan.

The education of the U.S. surgeon was traditionally based on a system in which surgeons-in-training cared for a population of largely indigent patients in a setting of graded responsibility. To ensure an ethically appropriate bargain, senior surgeons served as mentors, assumed ultimate responsibility for the patient, and supervised the surgical care of the ward patient by the surgical trainee. During the 20th century, changes in health care financing challenged this comfortable accommodation between charity care and medical education. As others have also written, the introduction of prepaid health insurance plans such as Blue Cross/Blue Shield in the early third of the century, the rapid expansion of employment-based health benefits during World War II, and the enactment of the Medicare and Medicaid legislation under Titles XVIII and XIX of the Social Security Act all contributed to a dramatic reduction in hospital ward (i.e., service) populations. The tension between education and patient care remains incompletely resolved; the proper balance between supervision and graded responsibility for the resident is ultimately worked out on an individual basis. Newer issues facing U.S. surgical education, including the justifiable demand for greater transparency, are likely to upset this suspended truce and lead to renewed discussions about such fundamental concepts as the definition of the resident and the role of the patient in the education of future surgeons.

Herpes zoster (HZ), or shingles, is caused by reactivation of latent varicella-zoster virus after a primary infection with either wild-type or vaccine-type varicella-zoster virus, the latter having been introduced in 1995 for children. Since then, few population-based data about the incidence of childhood HZ are available.We identified children agedor = 12 years who were vaccinated with 1 dose of varicella vaccine between 2002 and 2008 in a prepaid health plan and followed them through their electronic health records for a diagnosis of HZ. The medical records of these children were reviewed. Persistent and chronic conditions for these children before HZ were identified.There were 172,163 children vaccinated, with overall follow-up of 446,027 person-years (Incidence rate = 27.4 per 100,000 person-years, 95% confidence interval: 22.7-32.7). Children vaccinated after age 5 years had a higher but not statistically significant different rate than children vaccinated between 12 and 18 months (34.3 vs. 28.5 per 100,000 person-years). Among children vaccinated between 12 and 18 months, incidence rates gradually increased each year in the first 4 years after vaccination (P0.001). Among the HZ cases, there were 1 (0.7%) case of lymphoid leukemia, 1 (0.7%) case of drug abuse, 16 (11.1%) cases of asthma with 3 or more acute exacerbations, 12 (8.3%) cases of developmental disorders, and 3 (2.1%) cases of psychological or mental disorders.These data demonstrate that diagnosed HZ is rare among children following varicella vaccine. Despite the small numbers, the roles of delayed vaccination, severe asthma, and development disorders warrant further investigation. In the future, analyses of HZ isolates will be needed to identify the virus strains causing reactivation.

Classifying endometrial hyperplasia (EH) according to the severity of glandular crowding (simple hyperplasia (SH) vs complex hyperplasia (CH)) and nuclear atypia (simple atypical hyperplasia (SAH) vs complex atypical hyperplasia (CAH)) should predict subsequent endometrial carcinoma risk, but data on progression are lacking. Our nested case–control study of EH progression included 138 cases, who were diagnosed with EH and then with carcinoma (1970–2003) at least 1 year (median, 6.5 years) later, and 241 controls, who were individually matched on age, date, and follow-up duration and counter-matched on EH classification. After centralised pathology panel and medical record review, we generated rate ratios (RRs) and 95% confidence intervals (CIs), adjusted for treatment and repeat biopsies. With disordered proliferative endometrium (DPEM) as the referent, AH significantly increased carcinoma risk (RR=14, 95% CI, 5–38). Risk was highest 1–5 years after AH (RR=48, 95% CI, 8–294), but remained elevated 5 or more years after AH (RR=3.5, 95% CI, 1.0–9.6). Progression risks for SH (RR=2.0, 95% CI, 0.9–4.5) and CH (RR=2.8, 95% CI, 1.0–7.9) were substantially lower and only slightly higher than the progression risk for DPEM. The higher progression risks for AH could foster management guidelines based on markedly different progression risks for atypical vs non-atypical EH.

Although states have had difficulty extending Medicaid managed care (MMC) to rural areas, rural models of capitated MMC are expected to grow in response to new federal regulations and the serious budget problems facing nearly all states. As such, understanding the effects of capitated MMC in rural settings is important for policy considerations.To evaluate the effects of capitated MMC on beneficiary access and use in rural Minnesota.We took advantage of delays in the timing of the introduction of MMC across rural counties in Minnesota to estimate the effects of managed care on adults and children under Medicaid using a difference-in-differences framework.We found that Minnesota's shift from fee-for-service Medicaid to MMC in its rural counties had little effect on access to health care for either adults or children.Because Minnesota reports that Medicaid costs under MMC are below expected costs under FFS Medicaid, it appears that the primary accomplishment of Minnesota's rural MMC initiative is one of cost savings: MMC provides the same access to care as FFS Medicaid, but at lower cost. With steep budget deficits in nearly all states, other states may want to consider Minnesota's rural MMC model as a mechanism for reducing their Medicaid costs.

Objective: To evaluate the patterns of e-Health use over a four-year period and the characteristics of users. Design: Longitudinal, population-based study (1999–2002) of members of a prepaid integrated delivery system. Available e-Health services included ordering prescription drug refills, scheduling appointments, and asking medical questions. Measurements: Rates of known access to e-Health services, and of e-Health use each quarter. Results: The number of members with known e-Health access increased from 51,336 (1.6%) in 1999 to 324,522 (9.3%), in 2002. The percentage of households in which at least one person in the household had access increased from 2.7% to 14.1%. Among the subjects with known access, the percentage of subjects that used e-Health at least once increased from 25.7% in 1999 to 36.2% in 2002. In the multivariate analysis, subjects who had a low expected clinical need, were nonwhite, or lived in low socioeconomic status (SES) neighborhoods were less likely to have used e-Health services in 2002. Disparities by race/ethnicity and SES persisted after controlling for access to e-Health and widened over time. Conclusion: Access to and use of e-Health services are growing rapidly. Use of these services appears to be greatest among persons with more medical need. The majority of subjects, however, do not use any e-Health services. More research is needed to determine potential reasons for disparities in e-Health use by race/ethnicity and SES as well as the implications of these disparities on clinical outcomes.

Nonmelanoma skin cancer is the most common malignancy. Multiple therapies prevent recurrence but vary widely in cost. The most common therapies are local destruction, excision, and Mohs surgery (histologically guided tumor removal). Clinical variables that may affect treatment choices can be identified, but little is known about how clinicians choose among therapies.The objective of this study was to learn if variations exist in the treatment of nonmelanoma skin cancer in different practice settings.Prospective cohort study.Subjects consisted of consecutive patients with nonmelanoma skin cancer at a university-affiliated private dermatology practice and the dermatology clinic at the nearby affiliated Veterans Affairs (VA) medical center.We studied data from medical records and patient surveys.Overall, 1777 nonrecurrent nonmelanoma skin cancers were diagnosed in 1375 patients. Compared with the VA site, patients at the private site were younger, more likely to be female, and less likely to be poor, and their tumors were smaller and less likely to be on visible areas of the body. Treatments varied between the 2 sites (P0.001). The proportions of tumors treated at the private and VA sites, respectively, were 23% and 19% for destruction, 25% and 48% for excision, and 37% and 25% for Mohs surgery. In multiple clinical subgroups, Mohs surgery was more likely to be performed at the private site than at the VA. Moreover, in multivariable models controlling for clinical features that may have affected treatment choice, tumors at the private site were more likely than tumors at the VA to be treated with Mohs surgery (odds ratio, 2.39; 95% confidence interval, 1.54-3.70).Care for nonmelanoma skin cancer varied at 2 academic practice sites that are near each other and that share some clinician staff. These findings raise questions not only about overuse or underuse of procedures at the 2 sites, but also about systematic differences in patient preferences and/or physician incentives in prepaid and fee-for-service settings.

Background An optional capitation prepayment system has been implemented in Swedish dental care, supplementary to the traditional fee-for-service scheme within the Public Dental Service. The implementation of a new system may have a variety of preferred and adverse effects, arguably dependent on the individual patient’s attitudes, health beliefs and course of action. The aim of this study was to describe potential differences regarding socioeconomic and lifestyle factors, perceived oral health and attitudes towards oral health between patients in the two payment systems. Methods Questionnaire data were consecutively collected from 13,719 patients, who regularly attended 20 strategically selected clinics within the PDS in Region Västra Götaland, before they were offered the choice between the traditional and the new payment system. Results Capitation patients were more often female and well educated. They had healthier habits, were more motivated to follow self-care advice, more often judged their oral health to be very good and considered oral health to be very significant for their wellbeing. The results were statistically significant and described a gradient. Conclusions The more explicitly affirmative the answer, the more likely the patient was to choose the prepayment scheme. There appears to be a pattern of differences with respect to important individual views on oral health between patients choosing a capitation system or a fee-for-service system. These differences may be important when assessing outcomes in the new payment system and in public dental care.

The Medicare system is facing a financial crisis, brought on by a combination of factors: 1) a financing system that relies on intergenerational transfers from workers to the elderly as its major source of revenue; 2) a payment scheme that traditionally has provided neither the demand nor the supply side of the market with strong incentives to hold down costs; and 3) the penchant of Congress to expand the coverage of the system over time, every time a worthy cause or group can be identified. The expansion of Medicare benefits began almost immediately after the passage of the legislation. In 1967, just one year after Medicare had passed, Congress increased the number of days of in-patient hospital care covered by the program. In 1972, payment for the services of interns and residents in podiatry training was added to the benefit package. Also, Medicare coverage was extended to disabled persons under age 65 who were eligible for benefits under Social Security or Railroad Retirement and to certain other individuals under age 65 suffering end-stage renal disease. Later, Medicare benefits were extended to state and local government employees not covered by Social Security, and then coverage was extended to spouses of workers who were not yet covered, but would be eligible to be covered. In 1980, unlimited home health visits were covered, as was the use of alcohol detoxification facilities. In 1985, Medicare provided payment for liver transplant services. 1 There is current political pressure to

Objective: To present preliminary data on the health-related consequences for people with spinal cord injury (SCI) of participation in a prepaid, risk-based, managed care plan. Design: Baseline data from a longitudinal interview survey. Setting: Massachusetts. Participants: Subjects were 114 independently living adults with SCI recruited from 6 independent living centers and 2 managed care plans; 45 received care from a risk-based prepaid managed care plan and 69 from other sources. Main Outcomes: Self-reports of use of health services; self-assessments of health, health at interview versus 12 months earlier; hospital admissions; numbers of secondary conditions, and experiences of specific secondary conditions (eg, pressure ulcers, depression, fatigue, and chronic pain). Results: Persons in the managed care plan do not differ from their counterparts in terms of age, gender, education, level of SCI, number of comorbid conditions, activity of daily living profiles, household composition, and reliance upon health maintenance programs and routines (eg, bowel and bladder care). In terms of processes of care, they appear generally better-served. There also are a few differences in outcome that are statistically significant, or approach significance, and generally favor the managed care plan. Conclusion: Preliminary data suggest that thoughtfully and sensitively designed and implemented risk-based managed care may improve both access and outcomes.

Background Employers have not yet begun to focus on chronic kidney disease (CKD) as a major health issue in the workplace. CKD is part of the metabolic and cardiovascular health burden, which is a major threat to the future survivability of the employer-based health financing system. It represents one opportunity for employers to intervene now to save health care costs later. Objective To describe the impact of CKD in non-Medicare payer populations (i.e., employer group health plans) and the importance of early screening and detection of the disorder to improve patient quality of life and reduce the future cost burden of this disease. Summary Twenty million Americans suffer from CKD, and 20 million more are at elevated risk; soon, 1 in 9 Americans will have CKD. Control of comorbidities may slow its progression, and 2 are critical -- type 2 diabetes and hypertension. Health care costs are made up of 2 categories and 5 subcategories: direct costs, which are (1) inpatient, (2) outpatient, and (3) drug costs -- roughly three quarters of the total costs associated with patients who have nondialysis renal insufficiency -- and indirect costs, which are lost productivity due to (4) disability and (5) absenteeism. Conclusion CKD should be considered part of a larger picture of metabolic health. As CKD is related to cardiometabolic health, it is beginning to capture payers' and purchasers' interest. Investing health care dollars today to identify the disease and slow its progression should improve patient quality of life and reduce the future cost burden of this disease and its associated conditions.

The organization, financing, and delivery of publicly funded behavioral health services are undergoing massive changes nationwide. Managed care principles and practices are being implemented widely and are being relied on increasingly to meet the challenges of containing costs and improving service effectiveness. To meet these goals, comprehensive systems are under development for measuring and reporting outcomes experienced by individuals who received services and for assessing the impact of managed care strategies on the service delivery system. This article presents an example from the Prepaid Mental Health Program in New York State. It highlights the development, implementation, and early experiences with the plan's performance management system for public sector managed behavioral health, a basis for continuous quality improvement activities and information reporting products such as report cards. Policy, administrative, and financial implications are illuminated.

Changes in the process of psychiatric care received by Medicaid beneficiaries with schizophrenia were examined after the introduction of capitated payments for enrollees of some community mental health centers (CMHCs) under the Utah Prepaid Mental Health Plan.Data from the medical records of 200 patients receiving care in CMHCs participating in the prepaid plan were compared with data from the records of 200 patients in nonparticipating CMHCs, which remained in a fee-for-service reimbursement arrangement. Using the Process of Care Review Form, trained abstracters gathered data characterizing general patient management, social support, medication management, and medical management before implementation of the plan in 1990 and for three follow-up years. Using regression techniques, differences in the adjusted changes between third-year follow-up and baseline were examined by treatment site.By year 3 at the CMHCs participating in the plan, psychotherapy visits decreased, the probability of a patient's terminating treatment or being lost to follow-up increased, the probability of having a case manager increased, the probability of a crisis visit decreased (but still exceeded that at the nonplan sites), and the probability of treatment for a month or longer with a suboptimal dosage of antipsychotic medication increased. Only modest changes in the process of care were observed at the nonplan CMHCs.Change in the process of psychiatric care was more evident at the sites participating in the plan, where traditional therapeutic encounters were de-emphasized in response to capitation. The array of changes raises questions about the vigor of care provided to a highly vulnerable group of patients.

Financial risk management of pharmacy benefits in integrated health systems is explained. A managed care organization should assume financial risk for pharmacy benefits only if it can manage the risk. Horizontally integrated organizations often do not have much control over the management of drug utilization and costs. Vertically integrated organizations have the greatest ability to manage pharmacy financial risk; virtual integration may also be compatible. Contracts can be established in which the provider is incentivized or placed at partial or full risk. The main concerns that health plans have with respect to pharmacy capitation are formulary management and the question of who should receive rebates from manufacturers. The components needed to managed pharmacy financial risk depend on the type of contract negotiated. Health-system pharmacists are uniquely positioned to take advantage of opportunities opening up through pharmacy risk contracting. Functions most organizations must provide when assuming pharmacy financial risk can be divided into internal and external categories. Internally performed functions include formulary management, clinical pharmacy services and utilization management, and utilization reports for physicians. Functions that can be outsourced include claims processing and administration, provider- and customer support services, and rebates. Organizations that integrate the pharmacy benefit across the health care continuum will be more effective in controlling costs and improving outcomes than organizations that handle this benefit as separate from others. Patient care should not focus on payment mechanisms and unit costs but on developing superior processes and systems that improve health care.

Article-at-a-Glance Background Initiatives on the part of many groups to provide American consumers with information about the quality of health care may have several goals. Symbolic aims include recognizing consumers, increasing the sense of accountability, providing reassurance about health care quality, and emphasizing quality. Instrumental aims include improving system performance, increasing satisfaction with care and/or plans, and reducing random plan switching. These efforts may have both good effects and bad effects. Benefits and risks The possible positive byproducts of consumer information initiatives are learning about consumer preferences and variations, learning how to help consumers use health plans and providers, changing consumer–provider relationships, and building an infrastructure of consumer-centered intermediaries. Possible bad effects are generating demands that cannot be met, skewing the system to certain consumers' preferences, discouraging consumers from using information, adding another new program that will die, contributing to biased plan selection, and decreasing trust in providers. Discussion Before health care professionals can gather evidence about outcomes signaling success, they must address several major issues. How should high-quality performance be defined and by whom? Whose vision will be embedded in these definitions? Will it be the consumer's vision or the patient's vision that will be maximized? How long will it take before expected consequences occur? A strategy to measure success calls for beginning immediately to develop consensus on outcomes and a "theory of action" specifying the pathways and timing for different players.

To determine whether the incidence of multiple sclerosis (MS) varies by race/ethnicity in a multiethnic, population-based cohort.We conducted a retrospective cohort study of more than 9 million person-years of observation from the multiethnic, community-dwelling members of Kaiser Permanente Southern California health plan from January 1, 2008 to December 31, 2010. Incidence of MS and risk ratios comparing incidence rates between racial/ethnic groups were calculated using Poisson regression.We identified 496 patients newly diagnosed with MS who met McDonald criteria. The average age at diagnosis was 41.6 years (range 8.6-78.3 years) and 70.2% were women. The female preponderance was more pronounced among black (79.3%) than white, Hispanic, and Asian individuals with MS (67.8%, 68.1%, and 69.2%, respectively; p = 0.03). The incidence of MS was higher in blacks (10.2, 95% confidence interval [CI] 8.4-12.4; p0.0001) and lower in Hispanics (2.9, 95% CI 2.4-3.5; p0.0001) and Asians (1.4, 95% CI 0.7-2.4; p0.0001) than whites (6.9, 95% CI 6.1-7.8). Black women had a higher risk of MS (risk ratio 1.59, 95% CI 1.27-1.99; p = 0.0005) whereas black men had a similar risk of MS (risk ratio 1.04, 95% CI = 0.67-1.57) compared with whites.Our findings do not support the widely accepted assertion that blacks have a lower risk of MS than whites. A possible explanation for our findings is that people with darker skin tones have lower vitamin D levels and thereby an increased risk of MS, but this would not explain why Hispanics and Asians have a lower risk of MS than whites or why the higher risk of MS among blacks was found only among women.

In an effort to provide medical care that is both more effective and less costly, the new variants of managed care organizations have instituted a variety of incentives and administrative controls that impact on the types and quantity of care provided to patients. Evidence suggests that the early forms of managed care, namely prepaid group practices, showed particular promise in improving the primary care delivered to children, ie, care that is accessible, person-focused in the long term, comprehensive, coordinated, and oriented toward achieving better outcomes. However, recent evidence concerning the quality of care delivered to children in the newer variants of managed care is mixed and scant; the newer organizational forms may not facilitate and may even have a negative impact on the attainment of primary care. Managed care can have a positive effect on first contact care, because it contractually defines a primary care provider and reduces use of the emergency room as a source of care. It may, however, have mixed effects on other aspects of access and use, depending on the plan's particular characteristics. Longitudinality is threatened by the disruption of prior relationships with out-of-plan providers and by the instability of both enrollees and providers in managed care plans. Children's benefits in managed care arrangements tend to include more preventive services, but access to specialty services has generally been found to be more restrictive. Coordination of care is not inherent to managed care, and many plans are no more likely to foster communication than are traditional indemnity plans. Evidence for the superior clinical quality afforded to children by new variants of managed care is lacking. Because managed care arrangements are proliferating rapidly, better studies are needed to prove or refute the contention that managed care has a significant positive effect on quality of care.

This paper provides an overview of the medical care system in the People's Republic of China, and assesses the impact of market reforms on the evolution of the medical care system. There is clear indication that China is moving towards a 'prepaid' system closely related to the HMO of the west. Decentralization of the medical care system administration has paved the way for a diversity of local experiments with different ways of reform, but the main direction is towards a integration of decisions over medical services and the insurance function. It is argued that reforms in this direction, while retaining a degree of socialization, will improve the efficiency and equity aspects of the Chinese medical care system.

Qualified Student Health Plans (QSHPs) have gained increasing support since the authors introduced the proposal to the field of college health in 1994. This article answers 10 of the most frequently asked questions about QSHPs and summarizes changes in the proposal that have resulted from discussions among college health professionals throughout the country. The QSHP proposal, which has been endorsed by the board of directors of the American College Health Association, offers the following benefits for the college health field and for students: It is founded on the traditional prepaid college health model and assures that control remains with higher education; participation is voluntary for employers and for institutions of higher education; no new tax funding is required; QSHPs preclude state interference and provide employers with incentives to contribute to the cost of student healthcare; both the cost of student health insurance and duplication of coverage are reduced and benefits are shifted to where the students live; the problem of uninsured and underinsured students is eliminated at participating institutions. With incremental healthcare reform continuing at the state level, the time to move forward with the proposal is viewed as ideal.

Background . Using the medical records of a large, prepaid health plan, our purpose was to assess the accuracy of self-reported data on cancer detection practices and to evaluate any differences in accuracy between Hispanics and non-Hispanic whites. Methods . Data were collected on six procedures: mammography, clinical breast examination, Pap smear, sigmoidoscopy, fecal occult blood tests, and digital rectal examination. We audited the medical records of 815 randomly selected Hispanic and 483 non-Hispanic white members of the Kaiser Permanente Medical Care Program in Northern California. All responded to a telephone survey. Using a standardized form, we recorded any of the six target examinations that had been performed within 5 years of the telephone interview. We then compared the times of the most recent screening tests as reported in the telephone survey with those in the medical record. Results . For the 2 years before the telephone interview, self-reports for screening tests overestimated the actual rates at which these tests were performed as documented in the medical records. Lack of agreement between self-report and medical record audits was substantial for all screening procedures except sigmoidoscopy. Hispanic members had fewer procedures done for most tests, but the differences were not statistically significant. Overestimates in self-reported screening rates did not differ substantially between Hispanics and non-Hispanic whites. Conclusions . Self-reported data on early cancer detection procedures can substantially overestimate their occurrence among both non-Hispanic white and Hispanic populations. These findings confirm earlier findings for Pap smear and affect decisions on cancer prevention procedures that rely on the accuracy of self-reported data.

We analyzed switches between prepaid and fee-for-service health care plans among depressed outpatients in the longitudinal part of the Medical Outcomes Study. Patients of mental health specialists in fee-for-service plans had the lowest adjusted rate of plan switching (8.1%), compared to fee-for-service general medical patients (13.5%) and prepaid patients of both types of providers (10.1% to 11.7%). Although there were no substantial differences in initial sickness by payment system among enrolled patients, differing switching rates by provider specialty and payment system indicated biased selection over time. In addition, we found that married, nonwhite, and wealthier individuals were significantly more likely to leave fee-for-service than prepaid care plans. We analyzed whether system switching had an effect on patient satisfaction and outcomes. None of the results were highly significant, but the power of the data to analyze this issue was limited. Nevertheless, it appears that patients switching from prepaid to fee-for-service may be at risk for poorer functioning outcomes, although there was no similar effect on mental health status.

Background Population-based data on the demographics and clinical characteristics of patients with multiple unrelated drug class intolerances noted in their medical records are lacking. Objectives To provide population-based drug "allergy" incidence rates and prevalence, and to identify individuals with multiple drug intolerance syndrome (MDIS) defined by 3 or more unrelated drug class "allergies," and to provide demographic and clinical information on MDIS cases. Methods Electronic medical record data from 2,375,424 Kaiser Permanente Southern California health plan members who had a health care visit and at least 11 months of health care coverage during 2009 were reviewed. Population-based drug "allergy" incidence rates and prevalence were determined for 23 unrelated medication classes. Results On January 1, 2009, 478,283 (20.1%) health plan members had at least one reported "allergy." Individuals with a history of at least 1 "allergy" and females, in general, reported higher population-based new "allergy" incidence rates. Multiple drug intolerance syndrome was present in 49,582 (2.1%). The MDIS cases were significantly older, 62.4 ± 16.1 years; heavier, body mass index 29.3 ± 7.1; and likely to be female, 84.9%, compared with average health plan members. They had high rates of health care utilization, medication usage, and new drug "allergy" incidence. They sought medical attention for common nonmorbid conditions. Conclusions Multiple drug intolerance syndrome is in part iatrogenic. It is associated with overweight elderly women who have high rates of health care and medication usage. Urticarial syndromes only explain a small fraction of MDIS cases. Multiple drug intolerance syndrome is associated with anxiety, but not predominately with immunoglobulin E (IgE)-mediated allergy or life-threatening illness. Multiple drug intolerance syndrome can be managed by medication avoidance and judicious rechallenge.

O artigo expõe as mudanças das regras de reajuste das contraprestações por faixas etárias assim como as mudanças demográficas observadas entre 1998 e 2008. Avaliam-se, através do cálculo de indicadores de envelhecimento e da construção de pirâmides etárias, se as mudanças demográficas e a regulação provocaram alguma alteração na adesão da população jovem à saúde suplementar. Os indicadores mostram o envelhecimento populacional entre os beneficiários de planos de saúde, em especial entre os com planos de contratação individual, e também que isso não implicou abandono da saúde suplementar pelos jovens. The paper exposes the changes in rules of price readjustment of health plans by age thresholds and demographic changes observed between 1998 and 2008. By calculating aging indicators and building population pyramids, it assesses whether the demographic changes coupled with the regulation caused any alteration in young people subscribing to supplementary healthcare plans. The indicators reveal the aging trend of beneficiaries of health plans, especially among those contracted individually, and also that this has not resulted in young people quitting supplementary healthcare plans.

Background Purchasers can play an important role in eliminating racial and ethnic disparities in health care. A need exists to develop a compelling "business case" from the employer perspective to put, and keep, the issue of racial/ethnic disparities in health care on the quality improvement agenda for health plans and providers. Methods To illustrate a method for calculating an employer business case for disparity reduction and to compare the business case in two clinical areas, we conducted analyses of the direct (medical care costs paid by employers) and indirect (absenteeism, productivity) effects of eliminating known racial/ethnic disparities in mammography screening and appropriate medication use for patients with asthma. We used Markov simulation models to estimate the consequences, for defined populations of African-American employees or health plan members, of a 10% increase in HEDIS mammography rates or a 10% increase in appropriate medication use among either adults or children/adolescents with asthma. Results The savings per employed African-American woman aged 50-65 associated with a 10% increase in HEDIS mammography rate, from direct medical expenses and indirect costs (absenteeism, productivity) combined, was $50. The findings for asthma were more favorable from an employer point of view at approximately $1,660 per person if raising medication adherence rates in African-American employees or dependents by 10%. Conclusions For the employer business case, both clinical scenarios modeled showed positive results. There is a greater potential financial gain related to eliminating a disparity in asthma medications than there is for eliminating a disparity in mammography rates.

Obesity strongly increases the risk of endometrial cancer and is projected to increase current and future endometrial cancer incidence. In order to fully understand endometrial cancer incidence, one should also examine both hysterectomy, which eliminates future risk of endometrial cancer, and endometrial hyperplasia (EH), a precursor that prompts treatment (including hysterectomy). Hysterectomy and EH are more common than endometrial cancer, but data on simultaneous temporal trends of EH, hysterectomy and endometrial cancer are lacking. We used linked pathology, tumor registry, surgery and administrative datasets at the Kaiser Permanente Northwest Health Plan to calculate age-adjusted and age-specific rates, 1980-2003, of EH only (N = 5,990), EH plus hysterectomy (N = 904), hysterectomy without a diagnosis of EH or cancer (N = 14,926) and endometrial cancer (N = 1,208). Joinpoint regression identified inflection points and quantified annual percentage changes (APCs). The EH APCs were -5.3% (95% confidence interval [CI] = -7.4% to -3.2%) for 1980-1990, -12.9% (95% CI = -15.6% to -10.1%) for 1990-1999 and 2.4% (95% CI = -6.6% to 12.2%) for 1999-2003. The EH-plus-hysterectomy APCs were -8.6% (95% CI = -10.6% to -6.5%) for 1980-2000 and 24.5% (95% CI = -16.5% to 85.7%) for 2000-2003. Hysterectomy rates did not significantly change over time. The endometrial cancer APCs were -6.5% (95% CI = -10.3% to -2.6%) for 1980-1988 and 1.4% (95% CI = -0.2% to 3.0%) for 1988-2003. Hysterectomy rates were unchanged, but increased endometrial cancer incidence after 1988 and the reversal, in 1999, of the longstanding decline in EH incidence could reflect the influence of obesity on endometrial neoplasia.

The incidence of reoperation and mortality after prostatectomy was studied in 8,219 men who underwent surgical treatment for benign prostatic hypertrophy between 1976 and 1987 while they were members of the Kaiser Permanente Medical Care Program, Northern California Region. The vast majority (94.5%) received transurethral prostatectomy (TURP). The cumulative 8-year probability of a second prostatectomy was 7.6% after TURP and 2.1% after open prostatectomy. The risk of mortality associated with transurethral prostatectomy relative to open prostatectomy was 1.6 (95% confidence interval 1.2, 2.1) 8 years postsurgery. The increased risk of mortality associated with transurethral prostatectomy was most prominent during the first 5 years postsurgery (relative risk 1.8, 95% confidence interval 1.3, 2.5) and declined to 1.1 (95% confidence interval 0.8, 1.6) for deaths occurring after the first 5 years. The finding of an increased risk of mortality associated with transurethral prostatectomy is consistent with other studies and is unexplained.

Health care reform seems to be a two-act play. We are moving toward the conclusion of the first act, universal coverage. The second act will consist of controlling the cost of health care, or “bending the cost curve.” A recent article by Atul Gawande traced the historical development of universal coverage in England, France, and Switzerland.1 These countries' solutions were all “path-dependent,” which suggests that the final outcome of universal coverage in the United States and the manner in which care will be delivered here will evolve from the path or paths that have been grooved by our country's historical . . .

This paper analyzes the relationship between the financial health and organizational form of private health care providers in Brazil. It also examines the major determinants of customer satisfaction associated with the provider's organ-izational form. An adjusted Altman's z-score is used as an indicator of financial health. A proxy variable based on customer complaints filed at the Brazilian National Agency for Supplementary Health is used as an indicator for customer satisfaction. The study uses a sample of 270 private health care providers and their operations over the period 2003-2005. Panel data analysis includes control variables related to market, operations, and management. Principal results indicate that: (1) private health care providers benefit from economies of scale; (2) self-funded health plans have better financial health; (3) spending on marketing does not have a signif-icant impact on customer satisfaction in Brazil; (4) weak empirical evidence exists showing that good financial performance enhances customer's satisfaction. Este artigo analisa a situação financeira das operadoras de saúde suplementar no Brasil, de acordo com a modalidade de gestão. Adicionalmente, examina os principais determinantes para a satisfação do consumidor desses serviços. Como indicador principal de saúde financeira, utiliza-se uma versão adaptada do z-score de Altman. A proxy para satisfação do consumidor é o nível de reclamações fundamentadas registradas junto à Agência Nacional de Saúde Suplementar. Utilizamos uma amostra de 270 operadoras de saúde suplementar para o período 2003-2005, e regressões de dados em painel, com variáveis de controle de mercado, operacionais e de gestão. Os resultados principais indicam que (1) as operadoras de saúde se beneficiam de economias de escala; (2) as empresas que operam no modelo de autogestão têm situação financeira melhor que as demais; (3) as despesas com marketing não impactam a satisfação dos consumidores dos planos de saúde; (4) finalmente, encontra-se também alguma evidência empírica indicando que a boa situação financeira implica maior satisfação do consumidor.

Objective Although depression is one of the most common problems of medical and psychiatric outpatients, it has not been clear whether the extent of medical comorbidity among depressed patients varies across major types of clinical settings in which depressed patients receive care--especially by type of treating clinician (general medical versus mental health specialty) or type of payment for services (prepaid versus fee-for-service). Methods The authors examined these issues using data on 1,152 adult outpatients with current depressive symptoms and a lifetime history of unipolar depressive disorder who received care in one of three health care delivery systems in three U.S. sites. Results Depressed patients had a similarly high prevalence (64.9%-71.0%) of any of eight common chronic medical conditions whether they were seen in the general medical or specialty mental health sector; however, those visiting medical clinicians had a significantly higher prevalence of the two most common chronic medical conditions, hypertension and arthritis. Among depressed patients with hypertension, those visiting the general medical sector were more likely to be taking antihypertensive medication than were those visiting the mental health specialty sector. Type of payment (prepaid versus fee-for-service) was unrelated to either prevalence or severity of comorbid medical conditions, suggesting that the typical depressed patient in all types of practices studied had medical comorbidity. Conclusions These data suggest that clinicians in all health care settings must be prepared to encounter chronic medical conditions and complaints in the depressed patients who visit them.

Background Delays in accessing care for malaria and other diseases can lead to disease progression, and user fees are a known barrier to accessing health care. Governments are introducing free health care to improve health outcomes. Free health care affects treatment seeking, and it is therefore assumed to lead to improved health outcomes, but there is no direct trial evidence of the impact of removing out-of-pocket payments on health outcomes in developing countries. This trial was designed to test the impact of free health care on health outcomes directly. Methods and Findings 2,194 households containing 2,592 Ghanaian children under 5 y old were randomised into a prepayment scheme allowing free primary care including drugs, or to a control group whose families paid user fees for health care (normal practice); 165 children whose families had previously paid to enrol in the prepayment scheme formed an observational arm. The primary outcome was moderate anaemia (haemoglobin [Hb] < 8 g/dl); major secondary outcomes were health care utilisation, severe anaemia, and mortality. At baseline the randomised groups were similar. Introducing free primary health care altered the health care seeking behaviour of households; those randomised to the intervention arm used formal health care more and nonformal care less than the control group. Introducing free primary health care did not lead to any measurable difference in any health outcome. The primary outcome of moderate anaemia was detected in 37 (3.1%) children in the control and 36 children (3.2%) in the intervention arm (adjusted odds ratio 1.05, 95% confidence interval 0.66–1.67). There were four deaths in the control and five in the intervention group. Mean Hb concentration, severe anaemia, parasite prevalence, and anthropometric measurements were similar in each group. Families who previously self-enrolled in the prepayment scheme were significantly less poor, had better health measures, and used services more frequently than those in the randomised group. Conclusions In the study setting, removing out-of-pocket payments for health care had an impact on health care-seeking behaviour but not on the health outcomes measured. Trial registration: ClinicalTrials.gov (#NCT00146692)., Evelyn Ansah and colleagues report on whether removing user fees has an impact on health care-seeking behavior and health outcomes in households with children in Ghana., Editors' Summary Background. Every year, about 10 million children worldwide die before their fifth birthday. About half these deaths occur in developing countries in sub-Saharan Africa. Here, 166 children out of every 1,000 die before they are five. A handful of preventable diseases—acute respiratory infections, diarrhea, malaria, measles, and HIV/AIDS—are responsible for most of these deaths. For all these diseases, delays in accessing medical care contribute to the high death rate. In the case of malaria, for example, children are rarely taken to a clinic or hospital (formal health care) when they first develop symptoms, which include fever, chills, and anemia (lack of red blood cells). Instead, they are taken to traditional healers or given home remedies (informal health care). When they are finally taken to a clinic, it is often too late to save their lives. Many factors contribute to this delay in seeking formal health care. Sometimes, health care simply isn't available. In other instances, parents may worry about the quality of the service provided or may not seek formal health care because of their sociocultural beliefs. Finally, many parents cannot afford the travel costs and loss of earnings involved in taking their child to a clinic or the cost of the treatment itself. Why Was This Study Done? The financial cost of seeking formal health care is often the major barrier to accessing health care in poor countries. Consequently, the governments of several developing countries have introduced free health care in an effort to improve their nation's health. Such initiatives have increased the use of formal health care in several African countries; the introduction of user fees in Ghana in the early 1980s had the opposite effect. It is generally assumed that an increase in formal health care utilization improves health—but is this true? In this study, the researchers investigate the effect of removing direct payment for health care on health service utilization and health outcomes in Ghanaian children in a randomized controlled trial (a trial in which participants are randomly assigned to an “intervention” group or “control” group and various predefined outcomes are measured). What Did the Researchers Do and Find? The researchers enrolled nearly 2,600 children under the age of 5 y living in a poor region of Ghana. Half were assigned to the group in which a prepayment scheme (paid for by the trial) provided free primary and basic secondary health care—this was the intervention arm. The rest were assigned to the control group in which families paid for health care. The trial's main outcome was the percentage of children with moderate anemia at the end of the malaria transmission season, an indicator of the effect of the intervention on malaria-related illness. Other outcomes included health care utilization (calculated from household diaries), severe anemia, and death. The researchers report that the children in the intervention arm attended formal health care facilities slightly more often and informal health care providers slightly less often than those in the control arm. About 3% of the children in both groups had moderate anemia at the end of the malaria transmission season. In addition, similar numbers of deaths, cases of severe anemia, fever episodes, and known infections with the malaria parasite were recorded in both groups of children. What Do These Findings Mean? These findings show that, in this setting, the removal of out-of-pocket payments for health care changed health care-seeking behavior but not health outcomes in children. This lack of a measured effect does not necessarily mean that the provision of free health care has no effect on children's health—it could be that the increase in health care utilization in the intervention arm compared to the control arm was too modest to produce a clear effect on health. Alternatively, in Ghana, the indirect costs of seeking health care may be more important than the direct cost of paying for treatment. Although the findings of this trial may not be generalizable to other countries, they nevertheless raise the possibility that providing free health care might not be the most cost-effective way of improving health in all developing countries. Importantly, they also suggest that changes in health care utilization should not be used in future trials as a proxy measure of improvements in health. Additional Information. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000007. This research article is further discussed in a PLoS Medicine Perspective by Valéry Ridde and Slim Haddad The World Health Organization provides information on child health and on global efforts to reduce child mortality, Millennium Development Goal 4; it also provides information about health in Ghana The United Nations Web site provides further information on all the Millennium Development Goals, which were agreed to by the nations of the world in 2000 with the aim of ending extreme poverty by 2015 (in several languages) The UK Department for International Development also provides information on the progress that is being made toward reducing child mortality

Background Breast cancer incidence has been rising since at least 1935 – 1939, but recent US data reveal a statistically significant decline in breast cancer incidence in 2003 that persisted through 2004. Identifying the specific contributions of the potential causes of this long-term increase and the recent decrease in incidence has been challenging. Marked changes in rates of mammography screening and use of menopausal hormone therapy since 1980 have added further complexity. We examined the potential association between menopausal hormone therapy use and recent changes in breast cancer incidence. Methods Using tumor registry, clinical, pathology, and pharmacy data from Kaiser Permanente Northwest, a large prepaid US health plan, we compared age-specific and age-adjusted breast cancer incidence rates (2-year moving averages) with use of screening mammography and dispensed menopausal hormone therapy prescriptions between 1980 and 2006. Temporal changes in incidence rates were assessed via joinpoint regression. Results A total of 7386 incident invasive breast cancers were diagnosed in plan members from 1980 through 2006. Overall age-adjusted breast cancer incidence rates per 100 000 women rose 25% from the early 1980s (105.6) to 1992 – 1993 (131.7) and an additional 15% through 2000 – 2001 (151.3), then dropped by 18% to 2003 – 2004 (123.6) and edged up slightly in 2005–2006 (126.2). These patterns were largely restricted to women aged 45 years or older and to estrogen receptor – positive (ER+) breast cancers. Incidence rates of ER-negative tumors experienced neither of the rises seen for ER+ tumors but also fell precipitously from 2003 through 2006. Rates of mammography screening sharply increased from 1980 to 1993 but then leveled off, and 75% – 79% of women aged 45 years or older received a mammogram at least once every 2 years from 1993 through 2006. Menopausal hormone therapy dispensings, particularly of estrogen-plusprogestin formulations, increased from 1988 to 2002 but then dropped by approximately 75% after 2002. Conclusions From 1980 through 2006, quantitative and qualitative trends in breast cancer incidence rates, particularly for ER+ tumors, parallel major changes in patterns of mammography screening and use of menopausal hormone therapy.

Background We established a male, multiethnic cohort primarily to study prostate cancer etiology and secondarily to study the etiologies of other cancer and non-cancer conditions. Methods/Design Eligible participants were 45-to-69 year old males who were members of a large, prepaid health plan in California. Participants completed two surveys on-line or on paper in 2002 – 2003. Survey content included demographics; family, medical, and cancer screening history; sexuality and sexual development; lifestyle (diet, physical activity, and smoking); prescription and non-prescription drugs; and herbal supplements. We linked study data with clinical data, including laboratory, hospitalization, and cancer data, from electronic health plan files. We recruited 84,170 participants, approximately 40% from minority populations and over 5,000 who identified themselves as other than heterosexual. We observed a wide range of education (53% completed less than college) and income. PSA testing rates (75% overall) were highest among black participants. Body mass index (BMI) (median 27.2) was highest for blacks and Latinos and lowest for Asians, and showed 80.6% agreement with BMI from clinical data sources. The sensitivity and specificity can be assessed by comparing self-reported data, such as PSA testing, diabetes, and history of cancer, to health plan data. We anticipate that nearly 1,500 prostate cancer diagnoses will occur within five years of cohort inception. Discussion A wide variety of epidemiologic, health services, and outcomes research utilizing a rich array of electronic, biological, and clinical resources is possible within this multiethnic cohort. The California Men's Health Study and other cohorts nested within comprehensive health delivery systems can make important contributions in the area of men's health.

This study analyzes data from the World Health Survey (WHS) conducted in 2003, with a sample of 5,000 individuals 18 years and older. Some 24.0% of the interviewees had private health insurance, and the main variables associated with private coverage were number of household assets, age, level of education, formal employment, living in municipalities with more than 50,000 inhabitants, and good self-rated health. The socioeconomic profiles of needs for and use of health services in the population covered by private health plans are different, confirming the findings of other studies reporting that this population segment as a whole presents better health conditions and greater use of services as compared to the population without private coverage, even after adjusting for socio-demographic variables and self-rated health. The WHS data also suggest that individuals with private health plans do not always use their insurance to pay for services, except in the case of mammograms. Esse estudo analisa os dados da Pesquisa Mundial de Saúde (PMS), realizada em 2003, em uma amostra de 5 mil indivíduos com 18 anos ou mais. Cerca de 24,0% dos indivíduos entrevistados têm seguro privado de saúde, sendo que os fatores associados à posse do plano são o número de bens, idade, escolaridade, ter emprego formal, residir em municípios com menos de 50 mil habitantes e referir boa auto-avaliação do estado de saúde. Os perfis sócio-demográficos de necessidades e uso de serviços de saúde da população coberta por plano de saúde são distintos, confirmando os achados de outros trabalhos que referem que esse segmento populacional como um todo apresenta melhores condições de saúde e um maior uso de serviços em relação à população não coberta por seguro de saúde, mesmo após o controle por variáveis sócio-demográficas e a auto-avaliação do estado de saúde. Os dados da PMS também sugerem que pessoas cobertas por plano de saúde nem sempre utilizam o plano para pagamento de serviços, excetuando-se o caso da mamografia.