Desde o início da década de 1990, as reformas gerenciais têm sido apresentadas como fundamentais para melhorar os serviços públicos e viabilizar a consecução dos direitos sociais. A partir de revisão da bibliografia e da análise de documentos, o trabalho faz uma análise crítica da privatização da gestão dos serviços públicos de Atenção Primária à Saúde no município de São Paulo, contextualizando tais medidas tanto no cenário do capitalismo contemporâneo sob dominância financeira, como também da construção da assistência pública à saúde no Brasil no século XX. Após retomar aspectos conceituais e históricos relacionados ao capitalismo contemporâneo sob a supremacia do capital financeiro, o estudo retoma a construção da assistência pública à saúde no Brasil na sua relação com a acumulação capitalista, além de fazer breve retrospectiva da construção do processo de privatização da Atenção Primária a Saúde no município de São Paulo, com destaque para as Organizações Sociais. Ao discutir em que medida foram alcançadas as melhorias prometidas e também a maior participação da comunidade no planejamento e execução dos serviços públicos, o estudo levanta a hipótese de que tais reformas estariam menos relacionadas às tentativas de viabilizar o direito universal à saúde. Tais medidas estariam, na verdade, submetidas a uma ofensiva das classes proprietárias em sua tentativa de superar as crises de acumulação capitalista, assim como também à concomitante ascensão internacional da finança e sua insaciabilidade sobre os recursos do Estado em benefício da lógica mais geral do movimento do capital. / Since the early 1990s, the managerial reforms have been presented as fundamental to the improvement of public services and to facilitate the achievement of social rights. From a review of the literature and the analysis of documents, the study perform a critical analysis of the privatization of the management of public services of primary health care in São Paulo, contextualizing such measures in both the scenario of contemporary capitalism under financial dominance as also the construction of public health care in Brazil in the twentieth century. After resuming conceptual and historical aspects related to contemporary capitalism underthe supremacy of financial capital, the study takes up the construction of public health care in Brazil in its relation to the capitalist accumulation, in addition to brief review of the process of privatization of Primary Health Care in São Paulo, with emphasis on Social Organizations. When discussing to what extent the promised improvements and also the greater community participation in the planning and execution of public services were achieved, the study hypothesizes that such reforms would be less related to the attempts to make possible the right to universal health care. Such measures would be, in fact, subjected to an offensive of the proprietary classes in their attempt to overcome the crisis of capitalist accumulation, as well as the concurrent international rise of finance and its insatiability of State resources in favor of the more general logic to the movement of capital.

Health psychologists with training in integrated care are ideal candidates to work in Federally Qualified Health Centers (FQHCs). However, despite the large documented need for more behavioral health providers in FQHCs, psychologists are underrepresented in this setting compared to other behavioral health professions. The purpose of this study was to: 1) examine the specific beliefs that are most relevant to executives’ intentions to hire psychologists, 2) determine how executives’ perceived control over hiring psychologists varies by several demographic variables, and 3) examine how well the Theory of Planned Behavior (TPB) predicts executives’ intentions to hire psychologists. Method: Executives (N = 222) from every US Census defined division of the country completed an online TBP survey assessing demographics and beliefs about hiring psychologists. Path analysis was used to examine the relationships between TPB variables. Results: Executives ranked psychologists as highly proficient in integrated care and general clinical skills but less proficient in research and leadership skills. Compared to other skills, executives ranked research skills as lower in importance for clinical staff to possess. Longer executive job tenures (but not FQHC budget or rural status) predicted more perceived control over hiring practices. The standard TPB was a poor fit with the data, but a modified version explained 78% of the variance in executives’ intent to hire psychologists. In this model, executives’ normative beliefs were most predictive of their intent to hire. Implications: Results point to the importance of internal champions within FQHCs who advocate for psychologists as well as the need for early interprofessional education. Opportunities exist for health service psychologists to promote the value of research to executives and to differentiate themselves by emphasizing their skills in research and implementation science.

In July 1980, the Barren River District Health Department (BRDHD), serving eight counties (combined population approximately 204,000) in Southcentral Kentucky, was selected as a demonstration site under the auspices of the federal Health Education Risk Reduction (HERR) Program. With continued HERR funding for eight years, the BRDHD developed several successful health promotion projects. Major components of these projects include: 1) community health promotion, which serves to identify high -risk groups in the community and provide them with health education-health promotion services, 2) school health education which included the development of a preschool health education curriculum, 3) teacher education workshop, which instructs primary and secondary public school teachers in health education methods, 4) smoking cessation. and 5) a large industrial wellness program. This study reports on an eight year program evaluation of the HERR demonstration. Overall, the program evaluation suggests an increase in health knowledge and some attitude and behavior change for many of the participants ii BRDHD programs.

This study is intended to determine the feasiblity of establishing a high-quality, free-standing MR imaging center dedicated to the breast in or about the City of Redlands.

This project fills a void in the area of dual immersion program implementation. Although there are general guidelines that exist, there is a paucity of specific guidelines that explicitly delineate the implementation of these critical components in the current accountability climate. We need to move beyond general categories and tailor them to the unique needs program models within situated contexts.

The scope of this analysis encompasses the feasibility of establishing a vascular diagnostics laboratory at Downtown hospital.

Provider incentives are a commonly used policy tool to mold provider behaviors.1 However, while we frequently measure the change in patient outcomes, failure to consistently produce changes in outcomes does not mean that providers are not changing their behavior. This paper focuses on two programs with null or inconsistent quality outcomes to try to identify why such inconsistency occurs. The two programs, both ratified in the Affordable Care Act, are 1) patient-centered medical homes (PCMHs), and 2) the Medicare Hospital Value-Based Purchasing (HVBP) program. Chapter 1: Using data from the Medical Expenditure Panel survey (MEPS), I match provider characteristic surveys to member experience with care in order to evaluate characteristics key to patient-centered medical homes. I find that patient-perceived patient-centeredness of a practice is not related to the number of PCMH attributes a practice reports. However, some characteristics do play specific and significant roles in patient perception and outcomes. For instance, case management is not only associated with increased patient perception of after-hours access to care, but overall costs were reduced. Interestingly, having after hours clinic hours was more common with practices highly consistent with PCMH criteria, but these hours did not result in decreased emergency department use or cost of care. Chapter 2: The second provider incentive studied is the Medicare Hospital Value-Based Purchasing Program (HVBP). This program assigns payment adjustments based on performance on a series of rotating quality metrics. To date, changes in patient outcomes cannot be attributed to the program; however, it should not be concluded that hospitals are not responding at all. I identify changes in staffing by provider type as an early indicator of hospital response to payment incentives. Data come from the Virginia Health Information (VHI) Hospital Cost Report, 2010-2017. Using a generalized linear model, I find that when receiving a penalty, hospitals reduce staffing among the most and least expensive personnel (physicians and nursing aides). Hospitals increase nursing and administrative staff following a bonus. These findings are consistent with hospitals responding to incentives both by aiming to improve efficient use of resources and maintain or improve quality of care. Chapter 3: Finally, I assess potential unintended consequences of the HVBP program, specifically the provision of charity care. Using the VHI cost reports for year 2013 to 2017 with a regression discontinuity model, I find that hospitals receiving a bonus decrease their charity care among the lowest income patients (under 100% federal poverty level (FPL)). Hospitals receiving a penalty tend to reduce charity care among higher income patients (100%-200% FPL). These findings are consistent with two separate responses to the incentives. Hospitals receiving bonuses appear to be cream-skimming healthier, wealthier individuals while hospitals receiving penalties appear to be shifting the focus of their charity care to the most needy, likely in an effort to reduce cost of care levels overall while maintaining their community benefit programs, potentially as a result of goal gradient cognitive bias.

Background: The 30-day readmission rate is considered a quality of care measure for providers and has become important because providers might face reduced reimbursement from any increase in unplanned readmissions Objective: The aim of the first chapter is to investigate the waiting-length of stay (WLOS) and post-length of stay (PLOS) on the 30-day readmission. In the second chapter, we examined the hospital procedural volume and hospital quality on the 30-day readmission. Our objective in the third chapter is to examine the zip code-level SES factors on the 30-day readmission rates. Participants: patients undergoing isolated coronary artery bypass grafting (CABG) in Virginia Methods: A retrospective study design has been conducted using a multi-level logistic model of increasing complexity for all three chapters. The sample used was from the Virginia Cardiac Surgery Quality Initiative (VCSQI) of the periods 2008-2014, the dataset included patient characteristics. Afterward, we merged the sample with both the Virginia Health Information (VHI) to obtain hospital characteristics (ownership, teaching status, and location), and Agency for Healthcare Research and Quality (AHRF) to obtain county-socio-economic status (SES) characteristics (education, employment, and median household income), the previous SES was used for chapter’s one and two. In chapter three, instead of AHRF, we merged the sample with the American Community Survey (ACS) to obtain zip code-SES characteristics (employment, median household income, education, median house price). The main outcome was the 30-day readmission rate. The analytical sample of chapter one n = 22,097, in chapter two the sample n = 25,531, while in chapter three the sample n= 25,829. We conducted a sensitivity analysis in all three chapters. In chapter one we analyzed the data at the patient level, in chapter two we analyzed the data at the hospital level, while in chapter three we conducted the analysis at the area zip code level. Results: In chapter one, we found that readmitted patients after a prolonged PLOS had increased odds of readmission, by 68.7%, compared to readmitted patients with a shorter PLOS in the fully adjusted model; while, WLOS was not significant at the P < 0.05. In chapter two, the fully adjusted model displayed significant results with a reduced odds in readmissions by 22.8% in the middle-volume hospitals compared to the low-volume hospitals, while the middle-quality hospitals had increased odds of readmission by 23.5% compared to the low-quality hospitals. In chapter three, statistically, we did not find that area zip code-SES had an effect on the 30-day readmission rate. While, geographically, we found that addresses of individuals were clustered in certain areas of Virginia. Conclusion: In chapter one, patients undergoing CABG and experience a prolonged PLOS of > 6 days are at risk to be readmitted within 30-days of the procedure. In chapter two, the higher volume hospitals (middle-volume) compared to low-volume hospitals showed a significant reduction in odds in the 30-day readmissions, especially after adjusting the model with hospital quality. In chapter three, even though, there was no association of area-SES with 30-day readmission, in the maps, we found a cluster of patient addresses in the southern parts of Virginia with an increased readmission, which is considered underprivileged area; and the fact might be due to the proximity of these areas to cardiovascular hospitals. Policy Implication: In chapter one, the study provided a model for clinicians to stratify patients at risk of readmission, especially patients with risks of staying longer in the hospital after CABG. In chapter two, policymakers and the CMS should find new ways to help hospitals with low-volumes to reduce their isolated-CABG readmission rates and be able to compete with high-volume hospitals. In chapter three, no significant correlation between area-SES and readmission for patients who underwent CABG was found; these backs prior notion that SES should not be adjusted for the reimbursement penalties of the Hospital Readmission Reductions Program (HRRP) on hospitals

Bibliography: leaves 494-519. / ix, 519 leaves ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Examines the influence of the medical profession on health policy in Australia. Case studies of policy struggles under Federal Labor governments since 1983 illustrate both the nature and scope of that influence. / Thesis (Ph.D.)--University of Adelaide, Dept. of Politics and Dept. of Community Medicine, 1994

"April, 2004." / Includes bibliographical references. / 2 v. : ill (some col.), photos ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Seeks to make visible some of the effects on nursing practice and the nursing profession of the political and organisational changes in the New Zealand health reforms in 1995. / Thesis (Ph.D.)--University of Adelaide, Dept. of Clinical Nursing, 2004