The study was an investigation into health care accessibility for children with autism spectrum disorder (ASD) following the transition to a private Medicaid system in the state of Florida. Pilot studies of managed Medicaid programs focused on costs and did not address how changes to the system impacted access to health care services. There were limited studies designed to understand how a change in the system, such as a privatization, would affect vulnerable populations such as young children with ASD. Additional concerns existed for children that were historically underserved by the health care system such as African American and Latino children because they typically had more difficulty accessing health care services in general. A modified version of the Consumer Assessment of Health Providers and System (CAHPS) Survey 4.0 was used in this study. The modifications to the survey included reducing the number of survey questions and adding open-ended questions. 86 participants were recruited from local organizations that supported children and families affected by ASD. Findings generated using nonparametric tests such as the Mann-Whitney U test and chi-square revealed delays in accessing therapeutic health care services that were pervasive in both private and public insurance groups. Furthermore, the qualitative analysis indicated that participants did not view their difficulties in accessing therapeutic health care services as related to race or ethnicity. Limitations of the study included the modifications made to the survey instrument. Implications for positive social change include a better understanding of the scope of the issue of therapeutic health care access for those advocating on behalf of children and families affected by autism.

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13109号 / 論医博第2127号 / 新制||医||1022(附属図書館) / (主査)教授 今中 雄一, 教授 川上 浩司, 教授 髙折 晃史 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

Introduction Choice and access to health care are important determinants of health outcomes. Various issues influence choice and determine the degree of, and differences in access to health care. Choice of health care facilities by individuals is often determined by the interplay between patient and provider characteristics. The influence of factors that determine choice of a health care facility or a provider varies depending on individual patient's socio-ecological factors, type and severity of illness (including the presence or absence of co-morbidities), cost of healthcare (including travel costs), and the presence or absence of a third party such as a health insurance plan. On the other hand, provider or facility factors, which include spatial and non-spatial factors such as technical and functional dimensions of quality of care, are the supply–side factors that influence choice of provider and facility. In order to achieve universal health coverage and attain the Sustainable Development Goals, Nigeria adopted a prepayment health care financing method through the National Health Insurance Scheme (NHIS) in 2005. However, population coverage of the scheme remains very low, while it also has a reputation of less than optimal performance. Evidence showed that while some accredited NHIS facilities were burdened with a high volume of enrolees, others had registered low volume (of enrolees). This study explored the influence and magnitude of the various factors responsible for the poor performance of the scheme as well as the lopsided/uneven distribution of enrolees across these health care facilities. Findings will assist in repositioning the scheme for better performance as well as serve as a guide for other countries planning to design and implement similar schemes. This will enable such schemes to learn from and avoid mistakes made under the present scheme. Methods This study was cross-sectional in design, with descriptive and analytical components. Data were collected using a mixed-method approach (geo-spatial, quantitative and qualitative). The geo-spatial component was achieved using three data layers of x and y coordinates: the enrolees' locations, locations of NHIS facilities and locations of health care facilities typically used by enrolees, were used in the spatial analysis to identify the closest NHIS accredited health care facility to each enrolee's residence and also estimate the distance between enrolee's location and NHIS facility being utilised. The Distance to the Nearest Hub (points) function in Quantum GIS 3.10 was used to automatically assign enrolees to the nearest NHIS facility while the Join by lines (Hub Lines) function was used to assign enrolees to the NHIS facility they used. Spider web diagrams that depict geo-spatial relationship between enrolees' residence, patronised health care facilities and health care facilities closest to the residences were constructed. Quantitative data were collected from 432 NHIS enrolees using an adapted questionnaire. A checklist was also used to collect data on structural components of health facilities such as the number and cadre of the health workforce, availability and functionality of medical equipment and facility infrastructure. Quantitative data were analysed using STATA and frequency tables were generated. Qualitative data were collected through in-depth interviews conducted among 29 participants of the NHIS, HMOs, enrolees, head of facilities and an academic. Qualitative data analysis was done using an inductive thematic approach. Audio-taped interviews were transcribed and codes were generated. Themes were thereafter searched for and generated from the codes. Emerging themes were named, documented and analysed accordingly. A conceptual framework that illustrated the Nigeria contextual environment, the health system and the current governance of the NHIS with a highlight on the relationships, factors and patterns of interaction among stakeholders was designed. Results The majority of the enrolees received care across a small proportion of the accredited facilities and bypassed nearby health facilities to receive care. Almost all the study respondents, 405 (93.9%) bypassed, however, only 147 (34.0%) reported to have done so. In this study, predictors of bypass of healthcare facilities were younger age (OR 0.67, CI 0.46 – 0.99, p = 0.046) and employment in the civil service (OR 0.49, CI 0.31-0.79, p = 0.003). Older age (1.66, CI 1.07-2.58, p = 0.024), attainment of tertiary level of education (OR 1.57, CI 1.02-2.44, p = 0.043), high socioeconomic status (OR 1.94, CI 1.24 -3.02, p = 0.003) and presence of multiple morbidities (OR 1.66, CI 0.99-2.78, p = 0.053) were predictors of personal choice of health facility. Physical infrastructure was poor in all the facilities; most of the facilities depended on more than one source of power supply and water supply was mainly from other sources apart from pipe-borne. Identified predictors of satisfaction with care were age, occupation and seeking information about quality of care. Knowledge of the NHIS and patronage of faith-based health facilities were also predictors of satisfaction with care. Respondents who were younger than 35 years of age were more likely to be satisfied with care than those who were older (OR 1.85, CI = 1.05 – 3.25, p< 0.05). Private sector workers under the scheme (OR 1.84, CI 1.03 – 3.28, p< 0.05) were more likely to be satisfied with care than those employed in the civil service. Likewise, compared with those who did not seek information, those who did (OR 1.63, CI = 1.04 – 2. 53, p< 0.05) were more likely to report satisfaction with care. Respondents who claimed not to have a knowledge of the NHIS were more likely to be satisfied with care (OR 1.65, CI = 1.06 – 2.55, p< 0.05). Likewise, patronage of faith–based facilities was identified to be a predictor of satisfaction with care (OR 1.84, CI = 1.09 – 3.08, p< 0.05). Qualitative data revealed that there was a very low level of trust among the stakeholders. The design and operations of the scheme indicated that the NHIS managers lacked the technical and managerial skills required to manage the scheme and other stakeholders. Both the NHIS officials and the health care providers were of the opinion that the HMOs had more political influence than other stakeholders in the scheme, and were using this to take advantage of others. Enrolees and health care providers were reluctant to collaborate with the scheme at inception, because of the low level of trust in government policies generally. In addition, at inception of the scheme, the majority of the enrolees were arbitrarily allocated to the few available health care providers. For some of the enrolees, choice of health care facilities was based on perceived quality of care and occasionally, as a result of proximity to places of residence. Instances of corrupt and unethical practices were reported across the board among the scheme stakeholders. Discussion There was a high level of facility bypassing among study respondents, though only a few of them claimed to be aware of this. This finding is because of the allocation or assignment of majority of the enrolees to the few facilities that were available to participants in the scheme at its inception. The study also revealed that younger age enrolees and civil servants bypassed more than their respective counterparts did. Studies have shown that younger people are more likely to explore and become more adventurous than older individuals. The apparent bypassing among civil servants was largely because of the arbitrary allocation of reluctant enrolees to the available few health care providers at the inception of the scheme. This also explained the skewed distribution of the enrolees in these few facilities under the scheme. Findings also support the observation that most of the facilities with fewer enrolees were those that stayed away from the scheme at inception. However, the observed lopsided/uneven pattern was difficult to reverse despite the complaints of the facilities with fewer enrolees and the efforts of the scheme to address the skewness. It should also be noted that high social economic class is a strong factor of personal choice of healthcare facilities. The only plausible explanation was the fact that this group of enrolees were not civil servants and who had the financial capacity to pay the premiums, which enabled them buy into the scheme voluntarily and personally chose facilities where to receive care. The state of physical infrastructure in all the facilities that were involved in the study is illustrative of the weak health system in Nigeria. Poor facility infrastructure is a known recipe for the failure of social health insurance. Ability to search for healthcare facilities and in the process, the phenomenon of bypass as seen in this study appeared to play a major role in satisfaction with care amongst younger people, and among those from the private sector, the economic ability to search for and receive care in healthcare facilities of choice, and that meets their expectations. Similarly, enrolees who had the opportunity and sought information about the quality of care in the facilities before enrolment were more likely to be satisfied with care than those who did not seek information. Enrolees who claimed they had no knowledge of the scheme were more likely to be satisfied than those who had knowledge of it and may have had a higher expectation of the quality of care than they received. Satisfaction with care that was attributed to patronage of faith-based facilities in this study has similarities with findings in previous studies. Compared with other types of facilities, it has been reported that the likelihood of higher levels of satisfaction with care among those who patronise faith-based facilities, may have been as a result of higher levels of functional quality, (including spiritual care, that is more valued in this setting) in addition to the technical quality of care. The fundamental finding from the qualitative component of the study was a high level of mistrust of government by almost all the stakeholders involved in the scheme. This manifested itself in the reluctance of the majority of the private health facilities to collaborate with the government in providing health care services to enrolees on the scheme at inception. The same explanation goes for the then potential enrolees' outright refusal to take up the opportunity to access health care services through the scheme. Previous failed government policies both in the health and in the non-health sectors were cited as reasons for the low interest in the scheme. Because of this, except for the government health facilities that were instructed to do so, majority of the private facilities stayed away from providing care to enrolees on the scheme until some years later. Thus, the majority of these enrolees at inception were assigned to the few health facilities that were available. This is what was primarily responsible for the lopsided/uneven distribution of enrolees across the NHIS accredited facilities, whereby some had a high volume of enrolees, while the majority, especially those that showed interest in the scheme much later had very low volumes. Unfortunately, this pattern of enrolees' distribution may be irreversible. In addition, mistrust also exists between the NHIS and the HMOs, between the HMOs and providers, and to some extent between the enrolees and providers. It is important to note that the design of the scheme put the HMOs in a powerful position, which they used to influence the political class to their advantage. To compound the situation, NHIS officials had poor technical and managerial skills to administer the scheme. These are indications of an inefficiently managed health intervention. Under these circumstances, it is highly unlikely that universal health coverage could be achieved unless the observed challenges are appropriately addressed. In addressing these issues, a reform should be considered in the design of the scheme and appropriate training given to the NHIS officials saddled with its day-to-day operation. Conclusion This study has elucidated the reasons for the poor uptake and skewed distribution of enrolees across accredited NHIS facilities in the study area. In addition to poor structure and inefficient management, the high level of mistrust among the stakeholders has played a major role in the lopsided/uneven geo-spatial pattern of enrolees' distribution across the NHIS accredited health facilities. As it is presently structured and managed, the NHIS is highly unlikely to achieve its set objectives. It is advocated that a reform that addresses the observed anomalies be instituted to enable the scheme achieve its goals. This is a lesson for other countries planning to design and implement similar schemes.

No description available.

A pattern of health insurance policy among smokers in the United States Abdulrasak Ejiwumi, Nathan Hale and Melissa White, Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City, TN Previous research has noted that Medicaid expansion has had a positive impact health care access and the quality of healthcare services among individuals with lower incomes. However, only a few studies have been conducted to describe the association between smoking and having any type of healthcare insurance in the United States. Health insurance provides access to important smoking cessation programs that are critical for enabling quit attempts. This study examines the extent to which insurance is associated with smoking cessation. We obtained data from the 2021 nationally representative Behavioral Risk Surveillance System Dataset. A descriptive analysis was conducted on adult smoking status and enrollment in any health insurance policy and variation based on race, gender, income, marital status, and level of education was examined using a Chi-square test. Current smoking status and any health insurance enrollment was also examined using an adjusted logistic regression analysis controlling for age, sex, income, marital status, and race/ethnic group. Among adult smokers in the United States (Sample size 167,079), 85.7% have health insurance while 10.2% do not have any type of health insurance. Approximately 69.5% of individuals with health insurance reported quitting smoking compared to 42.8% of those who do not have health insurance (p=0.001). Adjusting for additional covariates of interest, the odds of quitting smoking was 1.6 times higher for respondents with any type of health insurance compared to uninsured respondents (AOR 1.55, 95% CI=1.49 – 1.61). This study found that the access to health insurance is an important predictor of quitting smoking, even when adjusting for age, race, gender, marital status, levels of education, and income. Insurance remains an important enabling factor that provides the resources and supports necessary to enable smoking cessation programs and ultimately support smoking cessation. Continued efforts to increase access to health insurance are needed.

No description available.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23758号 / 医博第4804号 / 新制||医||1056(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 今中 雄一, 教授 川上 浩司, 教授 小濱 和貴 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

The National Health Insurance Scheme (NHIS) in Ghana was introduced to alleviate the problem of citizens having to pay for healthcare at the point of delivery, given that many did not have the financial resources needed to do so, and as such were unable to adequately access healthcare services. The scheme is managed from the national headquarters in the capital Accra, through satellite offices located in districts right across the length and breadth of the country. It is the job of these offices to oversee the operations of the scheme within that particular district. Current literature however shows us that there is a digital divide that exists between the rural and urban areas of the country which has led to differences in the management of information within urban-based and rural-based districts. This thesis reviews the variables affecting the management of information within the scheme, and proposes an information management model to eliminate identified bottlenecks in the current information management model. The thesis begins by reviewing the theory of health insurance, information management and then finally the rural-urban digital divide. In addition to semi-structured interviews with key personnel within the scheme and observation, a survey questionnaire was also handed out to staff in nine different district schemes to obtain the raw data for this study. In identifying any issues with the current information management system, a comparative analysis was made between the current information management model and the real-world system in place to determine the changes needed to improve the current information management system in the NHIS. The changes discovered formed an input into developing the proposed information management system with the assistance of Natural Conceptual Modelling Language (NCML). The use of a mixed methodology in conducting the study, in addition to the employment of NCML was an innovation, and is the first of its kind in studying the NHIS in Ghana. This study is also the first to look at the differences in information management within the NHIS given the rural-urban digital divide.

Thesis (Ph. D.)--University of Wisconsin--Madison, 2001. / Includes bibliographical references (p. 517-547). Also available on the Internet.

Thesis (Ph. D.)--Michigan State University. Dept. of Economics, 2008. / Title from PDF t.p. (viewed on July 23, 2009) Includes bibliographical references (p. 89-94). Also issued in print.