Managed care became the dominant model for moderating healthcare costs in the 1990's. The later half of this past decade witnessed early signs of a return to escalating premiums. Providers and consumers have reacted negatively to perceptions of health plan micro-management and restriction of choice.

TCC (Transitions of care clinic) is a specialized clinic visit where patients present to their primary clinic after a hospital stay. TCC deploys an interprofessional team to address a gamult of patient concerns. Traditionally, TCC interprofessional team includes a nurse and a doctor. The nurse calls the patient’s house within 2 days to check up on the patient and then they schedule a clinic visit, usually within 7-14 days. However it has been proposed that addition of team members from other disciplines could contribute to better health outcomes for patients seen in TCC. We studied a TCC model with an interprofessional team of not only physicians and nurses but also pharmacists and behavioral therapists for two months. Our aim was to uncover the utility of having a behavioral health team member in TCC visits. This was a prospective study of patients who attended a TCC clinic in a residency setting. An observer collected data on the time the behavioral health provider was in the patient room and the interventions/consultations he/she provided. Data collection is ongoing. We expect to find the following: the percentage of patients within TCC who utilized some form of behavioral therapy in their TCC visits; the percentage of common interventions that were used; average time spent in each visit; average age of patients; and average number of hospitalizations per patient. We expect that these results will demonstrate how behavioral health providers function on interprofessional TCC teams.

Practice managers are facing challenging expectations when deploying a managed-care paradigm. The problem addressed in this study was a gap in knowledge regarding practice managers' decision-making strategies that affect, or could be perceived to affect, a climate of excellence with business and client relationships, primary health care, physicians, and patients in a managed-care paradigm. The purpose of the qualitative exploratory study was to explore practice managers' decision-making strategies affecting primary health care, physicians, and patients. Guided by Simon's ideology of decision-making strategies in a management environment, the overarching research question and 3 subquestions centered on how practice managers delineate their decision-making strategies and how those strategies affect primary health care, physicians, and patients. To close the gap in knowledge, the study included (a) a homogeneous purposive sampling of 14 practice managers (n = 2, pilot study; n = 12, main study) as research participants; (b) face-to-face interviews with semistructured, open-ended questions to collect data; and (c) in vivo and pattern coding during data analysis. The study results indicated a need for change agents, interactions, partnerships, and accountability in a managed-care paradigm. Managing health care is complex and practice managers will continue to be challenged. Alliances between practice managers and stakeholders are recommended to meet those challenging expectations. As a result, positive social changes may be observed in improved access to primary health care, better health care treatments, and collaborative interactions in a managed-care paradigm.

No description available.

Submitted by Silvana Teresinha Dornelles Studzinski (sstudzinski) on 2015-06-23T14:32:23Z No. of bitstreams: 1 Marcelo Antunes Marciano.pdf: 3212195 bytes, checksum: d0978d66fd9d22e11d99ba2207b6a553 (MD5) / Made available in DSpace on 2015-06-23T14:32:23Z (GMT). No. of bitstreams: 1 Marcelo Antunes Marciano.pdf: 3212195 bytes, checksum: d0978d66fd9d22e11d99ba2207b6a553 (MD5) Previous issue date: 2014 / Nenhuma / Este trabalho investiga como aumentar a qualidade dos serviços entregues à população pela gestão de operações em serviços de saúde, tanto no sistema público quanto na saúde suplementar, mais especificamente, em operadoras de plano de saúde e em hospitais do estado do Rio Grande do Sul (RS). O objetivo principal do presente trabalho consiste em analisar possibilidades de elevar a qualidade do sistema de saúde público e suplementar do estado do Rio Grande do Sul à luz do sistema dinâmico em que se inserem. Os objetivos específicos são: Mapear o sistema de saúde, por meio do pensamento sistêmico, e propor pontos de alavancagem à qualidade do sistema de saúde pública do RS; e Analisar a aderência aos critérios do Managed Care e de inovações em gestão de saúde, pelos atores “operadora de plano de saúde” e “hospital”. A dissertação é formada por dois artigos, cada um entregando um objetivo específico, e por capítulos adicionais que consolidam a entrega do objetivo geral. Quanto aos procedimentos metodológicos, a pesquisa parte de um paradigma positivista e orienta-se qualitativamente, fazendo uso de entrevistas, análise documental, coleta de dados secundários em bancos de dados de acesso público, análise por julgamento em dinâmica de grupo multidisciplinar e modelagem. Como resultados obteve-se a construção de um mapa que evidencia os atores e as relações desse sistema dinâmico, possibilitando a identificação de possíveis cenários, pontos de alavancagem e a sugestão de estratégias para auxiliar no aumento da qualidade do sistema de saúde pública do RS, bem como a construção de uma ferramenta, no caso, um questionário, por meio do qual foi possível verificar que os atores hospitalares contatados encontram-se mais aderentes do que as operadoras de plano de saúde contatadas com relação às boas práticas de gestão orientadoras do estudo. Argumenta-se que um sistema integrado de gestão, padronizado, empregado de forma sistêmica, com auxílio de estratégia organizacional, de inovações e com foco na cadeia de valor, contempla aspectos assistenciais, econômicos e competitivos, desses atores e, como consequência, pode contribuir para que as operadoras e hospitais possam aumentar a qualidade dos serviços prestados. / This work examines how to improve quality in health services, both in the public system and in supplementary health, more specifically, in health insurance companies and hospitals in the state of Rio Grande do Sul (RS). The main goal of the present work is to improve quality for the public and supplementary health systems in the state of Rio Grande do Sul under the dynamic system they are included into. Specific goals are: Mapping the health system through systemic thinking, proposing points of leverage regarding the quality of the public health system in RS; and analyzing the compliance with the Managed Care criteria and innovation in health management by the players, namely, “health insurance companies” and “hospitals”. The work is composed of two articles, each delivering a specific goal, and by additional chapters that consolidate the delivery of the general goal. As for the methodological procedures, the research develops from a positivist paradigm and it is based on a qualitative perspective, making use of interviews, document analysis, secondary data collection in public-access databases, analysis based on multidisciplinary group dynamics assessment and modeling. As a result, this led to the creation of a map that highlights players and relations of this dynamic system, allowing for the identification of possible scenarios, points of leverage, and the suggestion of strategies to help improve the quality of the public health system in RS, as well as the awareness that contacted hospital players were found to be more compliant than the contacted health insurance companies as far as good management practices that guided this study are concerned. We argue that a integrated and standardized management system, which is systematically used, with the help of organizational strategies, innovation, and a focus on the value chain, takes into account assistance-related, economic, and competitive aspects of these players and, as a consequence, it may contribute to improve quality to services provided.

Background. The study objective was to determine how the population located in five remote rural areas responded to HIV testing offered by mobile clinics operating under Family Health International, an international NGO that provides health services, especially HIV prevention and family planning. The study sought to identify how different segments of the population, classified according to their socio-demographic characteristics, responded to HIV testing. The analysis is based on secondary data, collected between October 2009 and September 2010, on clients who came to seek health services at mobile clinics. The population is geographically located in five districts: OR Tambo in Eastern Cape, Amajuba in KwaZulu-Natal, Gert Sibande and Ehlanzeni in Mpumalanga, and Sekhukhune in Limpopo. Although these mobile clincs provided comprehensive health services, HIV prevention and family planning were the main focus of attention. Methods. A total number of 9015 individuals aged 18 years and older visited the mobile clinics during the period October 2009 to September 2010. Eight socio-demographic characteristics were collected and used to determine the association between HIV testing and the aforementioned eight variables. The association between the independent variables (sex, age, level of education, marital status, occupation, number of living children, district of residence and area of residence) and HIV testing (the dependent variables) was first investigated using a descriptive analysis and then performing a logistic regression. Results. More than 88% of individuals aged 18 years and older who visited the mobile clinics in the areas covered by the FHI project are from rural areas. HIV testing is still low in these areas, even though the services are provided close to their homes by the mobile clinics. It was found that only 34.7% of the mobile clinic’s clients tested for HIV during the period from October 2009 to September 2010. Out of eight independent variables included in the logistic regression model, five were found to have a statistically significant association with HIV testing, being: sex, age, education, occupation and area of residence Although the majority of these mobile clinics’ clients are females (77.1%), males tested in higher proportion than females accross all areas. The results showed that HIV testing decreases with age, with the age category 18 - 24 years testing for HIV in higher proportion than the age group 25 - 34 years and decreasing further when people become older. Individuals are more likely to take an HIV test when their level of education is higher than matric and tend to respond the same to a HIV testing offer when they have no education, primary or secondary level. Employment was found to be an enabling factor to test for HIV. People who are employed tested for HIV in a higher proportion than people who were unemployed or still in school. The area of residence (classified as rural, semi-urban and urban) showed that HIV testing is higher in urban than in semi-urban areas, and low in rural areas. The analysis by sex showed that education is important for women because women who had either primary, secondary or a higher level of education tested for HIV better than women who do not have any level of education. For males, education was not statistically significant regarding HIV testing. The different age groups showed the same pattern for both sexes regarding HIV testing, but young males in the category 18-24 years showed higher odds of testing for HIV than females in the same age category. With occupation variable, females who are either students or employed tested for HIV almost in the same proportion and their odds of testing for HIV were double that of unemployed females. Employed males showed a notably higher difference in testing for HIV than males who were either in school or unemployed. The area of residence showed the same pattern for males and females, with both testing in higher proportions in urban and semi-urban areas than in rural areas. Conclusion. Women from rural areas, with no education, were found to test for HIV less than any other individual in the areas under study. Women tested better when they had been exposed to any form of education. The provision of education to women in the form of an extensive and aggressive door to door HIV awareness campaign should therefore make a difference in increasing the uptake of HIV testing in the five areas covered by the mobile clinics. / Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2012.

Thesis (MMed) -- Stellenbosch University, 2010. / Bibliography / Objectives: To describe the establishment of a colposcopy service in a district hospital in a rural sub-district and to assess its impact on the uptake of colposcopy. Design: A retrospective double group cohort study using a laboratory database of cervical cytology results, clinical records and colposcopy clinic registers. Setting: The Overstrand sub-district in the Western Cape: 80 000 people served by 7 clinics and a district hospital in Hermanus, 120 km from its referral hospitals in Cape Town and Worcester. A colposcopy service was established at Hermanus Hospital in 2008. Subjects: All women in the Overstrand sub-district who required colposcopy on the basis of cervical smears done in 2007 and 2009. Outcome measures: The number of women booked for colposcopy at distant referral hospitals in 2007 and at the district hospital is 2009, the proportion of those women who attended colposcopy, the time from cervical smear to colposcopy, comparison between the two years. Results: The uptake of colposcopy booked for distant referral hospitals was 67% in 2007. The uptake improved by 18% to 79% for the local district hospital colposcopy service in 2009 (p=0.06). When analysed excluding patients from an area with no transport to the district hospital, the improvement was more marked at 22% (p=0.02). The delay from cervical smear to colposcopy improved significantly from 170 to 141 days (p=0.02). Conclusion: The establishment of a colposcopy service in a rural sub-district increased the uptake of colposcopy and decreased the delay from cervical smear to colposcopy. This district hospital colposcopy service removed 202 booked patients in one year from the colposcopy load of its referral hospitals.

Ethiopia has two stories to tell: a fast progress and unfair distribution of the gains in child health care. Despite Ethiopia’s achievement in meeting MDG4, wealth-related mortality inequality increased by 1.5 for every 1,000 live births between 2000 and 2011. Two major dividing lines contribute to child health inequality in Ethiopia: place of residence and wealth status. Lack of proper studies on health inequality policy making is affecting the comprehensiveness and quality of inequality reduction in Ethiopia. This study wished to assess child health inequality and policy factors that affect progress in inequality reduction. Accordingly, the study explored policy-makers’ attitude and interest; policy contents, and institutions to make recommendations that promote child health equity in Ethiopia. The research is mainly a qualitative policy research. Conducted between 2013 and 2017, it was design based on health policy researching and health inequality theories. The researcher conducted semi-structured interviews among health policy makers; policy analysis; and a review of the literature. Twenty policy-makers, 15 policy documents, over 350 literatures were selected through purposing and theoretical open sampling methods. Data was synthesised and analysed with ATLAS.ti 7.1.4 through applying the tools of critical interpretive synthesis and ground theory. The study found that Ethiopia is in an early state of recognizing and intervening against health inequalities. The quality and level of knowledge is mixed and gets reduced as one goes far from the centre. Consensus is still growing on the major underlying causes of child health inequalities in Ethiopia. Most of the policy makers focus on down-stream factors than broader determinants of health. Wealth inequality is less discussed and intervened than geographical inequalities. The production of a new Plan of Action can helped to resolve the challenges of lack of detailed approaches that can help reduce the gap in Ethiopia. However, the content of the health policy documents is not comprehensive and based on global lessons. Policy makers from the central government in Ethiopia tend to reject the use of redistribute justice intervention as policy options. There were multiple reasons including: fear of sustainability, ethics and effectiveness were used to reject these interventions. However, leaders from DRS and DPs broadly support the proper adaption of these interventions. The recent surge of interest to address health inequalities is mainly led by small groups from the top leaders. The engagement of the middle level leaders, Developing Regional States (DRSs), civil society and development partners has been limited. The relation between different institutes is very important in the Ethiopian federal state to reduce inequality. Without an improved level of awareness; change in attitude; broader engagement of citizens; use of independent data source and review of resource distribution Ethiopia’s progress towards Universal Health Coverage in 2030 could get delayed. Finally, this research provided a list of recommend interventions that Ethiopia might take in its plan, to narrow down health inequalities among children by 2030. / Health Studies / D. Litt. et Phil. (Health Studies)

Text in English / This study investigated practices, motivations, perceived benefits and barriers to outsourcing of support services by general hospitals in Uganda. The aim was to contribute to the evidence base to increase adoption and effectiveness of outsourcing by hospitals in Uganda. An explanatory sequential mixed methods design was used. Quantitative data was collected from hospital managers in 32 randomly selected hospitals using a self-administered questionnaire. Qualitative data was collected through in-depth interviews from 8 purposively selected hospital managers using an interview guide. Quantitative data was statistical analysed (frequencies, contingency tables and Wilcoxon-Mann-Whitney tests) using SAS 9.3. Qualitative data was managed using ATLAS ti 7, coded manually and content analysis conducted to identify emerging themes, subthemes and categories. A cost benefit analysis was conducted for outsourcing cleaning services in a selected hospital using financial data provided by the managers. Quantitative findings indicate that many (72%) hospitals were outsourcing some of their support services; many were satisfied with their outsourcing (>60%). The key motivation for outsourcing was to gain access to quality service (68%). Most hospitals have a system for monitoring outsourcing (71%). Managers perceive improved productivity and better services as the main benefit from outsourcing (90%). The main barrier to outsourcing is limited financing. A key challenge encountered during outsourcing was limited number of service providers (57%). Managers perceive regulatory violations as a key risk during outsourcing (87%). Hospital location is a determinant of outsourcing (p=0.0033). Managers’ perceptions towards outsourcing have no impact on outsourcing (p>0.05). These findings were confirmed and explained by the qualitative data. Qualitative findings reveal masquerading, impersonation and extortion of patients by outsourced staff as an outsourcing risk. They reveal a concern that outsourcing may lead to job loss for community members. The cost benefit analysis indicates that outsourcing in the studied hospital for the year considered was cheaper than insourcing by UGX 669,575.00. The savings increase to UGX 48,753,689.94 when adjusted for quality differences between insourced and outsourced services. Sensitivity analysis shows that the assumptions used in the analysis were robust. Recommendations, interventions and guidelines are proposed for increasing outsourcing and its effectiveness. / Health Studies / D. Litt. et Phil. (Health Studies)

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Esta dissertação analisou as Empresas Promotoras de Salud (EPS), seguradoras de saúde introduzidas no sistema de saúde colombiano através da reforma sanitária instaurada com a Lei n 100/1993, desde uma perspectiva de economia política crítica, através do método de análise documental. A maioria delas são empresas privadas com finalidade lucrativa que conformaram rapidamente um oligopólio que reproduziu problemas dos modelos de Managed Care e Managed Competition já conhecidos internacionalmente. Esta dissertação analisou as relações entre os processos de financeirização do sistema capitalista e o processo de ajuste estrutural na Colômbia, com a reforma sanitária e a dinâmica financeira das EPS. Também foi analisada a introdução de mecanismos próprios do processo de financeirização na gestão financeira das EPS, como: a alavancagem; a reprodução ampliada de capital através da dívida pública; e os investimentos em ativos securitizados. Dado que o sistema de saúde atual se caracteriza por altos níveis de inequidade e injustiça, as consequências da finalidade lucrativa neste, com suas expressões concretas de sofrimento e morte na população, foram preocupações transversais deste trabalho. Os resultados desta dissertação demonstraram a concentração oligopólica do mercado de seguros privados de saúde, cujas empresas se organizaram como um cartel, dificultando o acesso aos serviços de saúde para seus segurados, o que contribuiu para a piora de indicadores de saúde da população. Quando a mobilização social obrigou a aumentar o controle sobre as EPS, estas começaram a sair do mercado declarando-se em falência, ou entrando subitamente em balanços financeiros negativos. / This thesis analyzes the Empresas Promotoras de Salud (EPS meaning health promoting entity), which are health insurance companies that act in the Colombian health system since the health reform law of 1993 (Law 100). Based on a document analysis and within a critical political economy framework, we firstly address the relations between the financialization process in the capitalist system, the structural reforms and the health care reform, with the EPSs financial dynamics, and secondly address the reproduction of financialization mechanism inside the EPS including financial leverage; expanded reproduction of capital through the public debt; and investments in securitized assets. Most EPS are private for profit companies, which quickly formed an oligopolistic market and exemplify internationally recognized contradictions of the Managed Care and Managed Competition models, also as its forprofit orientation and functioning has been related to the exacerbation of health inequities and has further been recognized as a driver of suffering and death in the population. This has primarily been related to the oligopolistic concentration of the private health insurance market, whose companies are organized as a cartel, hindering access to health services for the population. When social mobilization forced to increase control over the EPS, they began to leave the market declaring themselves bankrupt, or suddenly entered negative financial statements.