Paying Their Way? Do Nonprofit Hospitals Justify Their Favorable Tax Treatment?

This study addresses the effect of hospital ownership on the delivery of services to medically indigent patients and on their communities, using two alternative definitions of community benefits. Using data from hospitals in California, the study finds that in similar markets, the amount of community benefits provided by a tax-exempt private hospital is equivalent in value to that provided by an investor-owned hospital. These results are sensitive to the definition of community benefits, thus indicating need for a more explicit identification and minimum standard of the community benefits expected of nonprofit hospitals in return for their special tax treatment.

Predicting Rural Practice and Service to Indigent Patients: Survey of Dental Students Before and After Rural Community Rotations

Community-based clinical rotations in rural areas expose dental students to diverse patient populations, practice models, and career opportunities as well as rural culture. The aims of this study at West Virginia University were to determine the best predictors of rural practice, assess the predictive validity of students' intention to practice in a rural area before and after their rural rotations, and evaluate the relationship between students' intention to practice in a rural area and intention to provide care for indigent patients. Online survey data were submitted pre- and post-rural clinical rotation by 432 of 489 dental students over the study period 2001-12, yielding an 88% response rate. In 2013, practice addresses from the West Virginia Board of Dentistry were added to the student database. The results showed that significant predictors of rural practice site were intended rural practice choice, rural hometown, and projected greater practice accessibility for indigent patients. The likelihood of students' predicting they would choose a rural practice increased after completion of their rural rotations. After the rotations, students predicted providing greater accessibility to indigent patients; these changes occurred for those who changed their predictions to rural practice choice after the rotations and those who subsequently entered rural practice. The dental students with a rural background or a greater service orientation were also more likely to expect to enter a rural practice and actually to do so after graduation. These findings suggest that dental school curricula that include rural rotations may increase students' sensitivity to issues of indigent patients and increase students' likelihood of rural practice choice.

Raising Awareness and Providing Free Screening Improves Cervical Cancer Screening Among Economically Disadvantaged Lebanese/Armenian Women

Women need to practice cervical screening regularly to reduce morbidity and mortality. The purpose of this study was to examine the impact of an intervention program on knowledge, attitude, and practice of cervical screening in the population of Lebanese/Armenian women. The design was a cross-sectional, quasi-experimental posttest survey following a yearlong intervention program. The sample included 176 women, who were members of the Armenian Relief Cross in Lebanon. Interventions consisted of educational classes, media messages, and free screening. The instrument was a self-administered questionnaire. Knowledge of women with intervention was higher (p > .05) and practice rate increased between intervention and comparison groups. No difference in attitude was noted. The study was successful in raising awareness and increasing screening in the sample. It is recommended to continue helping women to overcome barriers for cervical screening.

[Roma populations and health]

The health status of the so-called "Roma" is usually much poorer than that of neighbouring non-Roma populations with a life expectancy gap of 5-15 years. This results from prolonged exposure to adverse determinants of health and to persistent exclusion from social and political arenas. Scientific and social research has only poorly addressed the health issues of Roma and evidences are scarce. Insufficient access to public services, including to health care and non optimal clinical practices are modifiable factors. If correctly addressed, this could contribute to reduce health disparities, including in Switzerland.

SWs become detectives when patients have no ID

As a Level 1 trauma center, Lutheran Medical Center treats a lot of patients who come in unconscious, appear to be homeless, or are confused as to their identify. In those cases, social workers search to find families and funding sources. Many unidentified patients have loved ones who are looking for them and want to care for them after discharge. Some homeless patients are eligible for Social Security, but the checks stopped coming when they were with no permanent address. The hospital contacts an attorney to determine if undocumented patients who have lived in the U.S. for a long time or who have been in the hospital for six months with no change in condition may qualify for Medicaid under Permanent Residence Under Color of Law (PRUCOL) status.

SW follows patients with discharge challenges

Patients at Medical City Dallas Hospital who are likely to have discharge challenges are assigned a dedicated social worker who spends time with patients and family members and starts to identify resources early in the stay. In some cases the patient's psychosocial issues take more time to address than their clinical needs. Whenever possible, the social workers encourage patients and families to pay a portion of the cost of their post-discharge medications. Social workers and case managers educate unfunded patients about resources such as clinics for low-income patients and the new healthcare exchange.

Meet the challenge of discharging patients with no way to pay

Case managers and social workers have to look for creative solutions as hospitals struggle with finding a safe discharge for uninsured, undocumented, and homeless patients. It's often more cost-effective for hospitals to pay for post-discharge care rather than keeping unfunded patients as inpatients after they no longer meet acute care criteria. Undocumented patients sometimes want to go back to their home country for post-discharge care, but many have families in this country who are willing to care for them. Some homeless patients have families who are looking for them, but some have been on the street for many years and want to be discharged to the only living situation they know.

Prescription coverage in indigent patients affects the use of long-acting opioids in the management of cancer pain

PURPOSE

We tested the hypothesis that prescription coverage affects the prescribing of long-acting opiates to indigent inner city minority patients with cancer pain.

MATERIALS AND METHODS

We conducted a chart review of 360 patients treated in the Oncology Practice at University of Medicine and Dentistry of New Jersey University Hospital, who were prescribed opiate pain medications. Half the patients were charity care or self-pay (CC/SP), without the benefit of prescription coverage, and half had Medicaid, with unlimited prescription coverage. We evaluated patients discharged from a hospitalization, who had three subsequent outpatient follow-up visits. We compared demographics, pain intensity, the type and dose of opiates, adherence to prescribed pain regimen, unscheduled emergency department visits, and unscheduled hospitalizations.

RESULTS

There was a significantly greater use of long-acting opiates in the Medicaid group than in the CC/SP group. The Medicaid group had significantly more African American patients and a greater rate of smoking and substance use, and the CC/SP group disproportionately more Hispanic and Asian patients and less smoking and substance use. Hispanic and Asian patients were less likely to have long-acting opiates prescribed to them. Pain levels and adherence were equivalent in both groups and were not affected by any of these variables except stage of disease, which was equally distributed in the two groups.

CONCLUSION

Appropriate use of long-acting opiates for equivalent levels of cancer pain was influenced only by the availability of prescription coverage. The group without prescription coverage and receiving fewer long-acting opiates had disproportionately more Hispanic and Asian patients.

Studying complex interventions: reflections from the FEMHealth project on evaluating fee exemption policies in West Africa and Morocco

BACKGROUND

The importance of complexity in health care policy-making and interventions, as well as research and evaluation is now widely acknowledged, but conceptual confusion reigns and few applications of complexity concepts in research design have been published. Taking user fee exemption policies as an entry point, we explore the methodological consequences of 'complexity' for health policy research and evaluation. We first discuss the difference between simple, complicated and complex and introduce key concepts of complex adaptive systems theory. We then apply these to fee exemption policies.

DESIGN

We describe how the FEMHealth research project attempts to address the challenges of complexity in its evaluation of fee exemption policies for maternal care. We present how the development of a programme theory for fee exemption policies was used to structure the overall design. This allowed for structured discussions on the hypotheses held by the researchers and helped to structure, integrate and monitor the sub-studies. We then show how the choice of data collection methods and tools for each sub-study was informed by the overall design.

DISCUSSION

Applying key concepts from complexity theory proved useful in broadening our view on fee exemption policies and in developing the overall research design. However, we encountered a number of challenges, including maintaining adaptiveness of the design during the evaluation, and ensuring cohesion in the disciplinary diversity of the research teams. Whether the programme theory can fulfil its claimed potential to help making sense of the findings is yet to be tested. Experience from other studies allows for some moderate optimism. However, the biggest challenge complexity throws at health system researchers may be to deal with the unknown unknowns and the consequence that complex issues can only be understood in retrospect. From a complexity theory point of view, only plausible explanations can be developed, not predictive theories. Yet here, theory-driven approaches may help.

High prevalence of human T-lymphotropic virus infection in indigenous women from the peruvian Amazon

Background

In an earlier study, we detected an association between human T-cell lymphotropic virus (HTLV) infection and cervical human papillomavirus (HPV) in indigenous Amazonian Peruvian women of the Shipibo-Konibo ethnic group. As both HTLV and HPV can be transmitted sexually, we now report a population-based study examining the prevalence and risk factors for HTLV-1 and HTLV-2 infection in this population.

Methods

Between July and December 2010, we conducted a comprehensive screening for HTLV among Shipibo-Konibo women 15 to 39 years of age living in two communities located in Lima and in 17 communities located within four hours by car or boat from the Amazonian city of Pucallpa in Peru.

Results

We screened 1,253 Shipibo-Konibo women for HTLV infection 74 (5.9%) tested positive for HTLV-1, 47 (3.8%) for HTLV-2 infection, and 4 (0.3%) had indeterminate results. In the multivariate analysis, factors associated with HTLV-1 infection included: older age (Prevalence Ratio (PR): 1.04, 95% CI 1.00–1.08), primary education or less (PR: 2.01, 95% CI: 1.25–3.24), younger or same age most recent sex partner (PR: 1.66, 95% CI: 1.00–2.74), and having a most recent sex partner who worked at a logging camp (PR: 1.73, 95% CI: 1.09–2.75). The only factor associated with HTLV-2 infection was older age (PR: 1.08, 95% CI: 1.03–1.12).

Conclusion

HTLV infection is endemic among Shipibo-Konibo women. Two characteristics of the sexual partner (younger age and labor history) were associated with infection in women. These results suggest the need for implementation of both HTLV screening during the antenatal healthcare visits of Shipibo-Konibo women, and counseling about the risk of HTLV transmission through prolonged breastfeeding in infected women. We also recommend the implementation of prevention programs to reduce sexual transmission of these viruses.

Alliance of support for low-income Latino men with prostate cancer: God, doctor, and self

Utilizing qualitative methods, this study describes the perceptions of and reliance on spirituality among indigent Latino men with prostate cancer. Sixty men were interviewed in Spanish. Transcripts were transcribed verbatim, translated, and analyzed using grounded theory techniques. Common across all men was a process involving the formation of an alliance of support that included God, doctors, and self. From this alliance, men drew strength to manage their disease, maintained hope for the future, and found new existential meaning. By recognizing the potential value of this alliance, health care professionals may tap into a beneficial empowering resource for some Latino men.

Meningococcal infections in hospitalised patients in Pretoria

We report on 13 patients diagnosed with meningococcal infections in patients attending state-owned hospitals serving an indigent population in Pretoria in 2009. The case fatality rate was 27%. Ceftriaxone was the main antibiotic (9 out of 13 patients) for therapy. Five isolates (39%) were serogroup B and 4 (31%) serogroup W135. Most isolates (12/13) were fully susceptible to penicillin (MIC range 0.016 - 0.047 μg/ml). A single isolate was intermediately resistant to penicillin (MIC, 0.125 μg/ml) while all isolates were uniformly susceptible to ceftriaxone, ciprofloxacin and rifampicin. This pattern reveals a shift in serogroups with an increase of serogroup B disease in the Pretoria region, and the need for ongoing monitoring of antimicrobial susceptibility profiles and the value of ceftriaxone for favourable therapeutic outcome.

Learning the moral economy of commodified health care: "community education," failed consumers, and the shaping of ethical clinician-citizens

Leaders of health professional schools often support community-based education as a means of promoting emerging practitioners' awareness of health disparities and commitment to serving the poor. Yet, most programs do not teach about the causes of health disparities, raising questions regarding what social and political lessons students learn from these experiences. This article examines the ways in which community-based clinical education programs help shape the subjectivities of new dentists as ethical clinician-citizens within the US commodified health care system. Drawing on ethnographic research during volunteer and required community-based programs and interviews with participants, I demonstrate three implicit logics that students learned: (1) dialectical ideologies of volunteer entitlement and recipient debt; (2) forms of justification for the often inferior care provided to "failed" consumers (patients with Medicaid or uninsured); and (3) specific forms of obligations characterizing the ethical clinician-citizen. I explore the ways these messages reflected the structured relations of both student encounters and the overarching health care system, and examine the strategies faculty supervisors undertook to challenge these messages and relations. Finally, I argue that promoting commitments to social justice in health care should not rely on cultivating altruism, but should instead be pursued through educating new practitioners about the lives of poor people, the causal relationships between poverty and poor health, and attention to the structure of health care and provider-patient interactions. This approach involves shining a critical light on America's commodified health care system as an arena based in relations of power and inequality.

A systematic approach to diabetes mellitus care in underserved populations: improving care of minority and homeless persons

BACKGROUND AND OBJECTIVES

Discrepancy in care of diabetes between racial and ethnic minority groups and Caucasians is well documented in America. System-based practices have been shown to improve quality of care outcomes. We implemented a disease registry and management system proven successful in a suburban practice network in four community health centers to improve diabetes process outcomes.

METHODS

Diabetes care measures including HbA1C, LDL, microalbumin testing, and testing for retinopathy were compared for suburban practices and Community Health Center practices within the same health system. A comprehensive systems-based disease management process including a diabetes registry that had been successful with the suburban practices was implemented at the Community Health Centers. Diabetes care measures were followed to determine whether disparity in care could be improved with process-based initiatives.

RESULTS

Following implementation of a diabetes registry and system-based disease management process, the percent of Community Health Center patients meeting guidelines improved significantly in all quality measures except the percentage of patients with HbA1C>9%. Despite this improvement, there remained a statistically significant discrepancy in performance between the Community Health Clinics and the suburban practices in most measures including percentage of patients with HbA1C<7%, HbA1C>9%, LDL<130, LDL<100, and percentage of patients with retinopathy screen or microalbumin test within the past year, with the Community Health Centers lagging behind in all comparisons.

CONCLUSIONS

A structured systems-based approach to care of minority and at-risk populations utilizing diabetes registries resulted in significant improvement in clinical outcomes and helped to reduce but not eliminate disparities in diabetes outcome measurements between vulnerable and Caucasian populations.

Making a difference: initiating and maintaining a faith-based free health clinic

This article is a summary of the challenges, struggles, and barriers that a group of churches encountered in developing a faith-based free health clinic. From the inception, this clinic has existed for the uninsured whose total household income aligns with the 2009 Fedral Poverty Guidelines. A voluntary interview with the executive director of The Good Samaritan Clinic revealed the experiential evolvement of this free health clinic. Numerous examples are shared that depict how this clinic has made a difference in the lives of many people.

[EMTALA: what it is, its origins, and how it functions in Puerto Rico]

EMTALA (Emergency Medical Treatment and Active Labor Act) is a law born during the mid-eighties as an anti-discrimination law. Initially, its intention was to protect the uninsured population from being denied medical care due to inability to pay medical bills. Presently, EMTALA helps assure that patients get a screening evaluation about their medical condition, that they are stabilized or transferred to an appropriate medical facility, and that hospitals are obliged to accept patient's in transfer if they offer the medical services needed and have the capacity to manage the patient's condition. EMTALA is a Federal Law that has been interpreted and adapted for its use in Puerto Rico. It is the intention of this article to describe the events that led to the Law's creation, explains how it is applied in our hospitals, and describes the implications of EMTALA in our daily practice.

SCHIP renewal

IN FEBRUARY OF THIS YEAR, THE STATE CHILDREN’S HEALTH Insurance Program (SCHIP) Reauthorization Act of 2009 was officially extended through 2013. SCHIP is a joint insurance program between the federal government and the states, which provides health insurance for low-income children and pregnant women who are not eligible for Medicaid. That is, states provide SCHIP for children in families with incomes up to 200 percent of the federal poverty level ($21,000 to $42,000 for a family of four). SCHIP currently provides health care insurance to approximately 7 million children who otherwise would not receive health care benefits.1 There are an additional 6 million children who are eligible, but not enrolled in either SCHIP or Medicaid.2 As more families face job loss and the associated loss of health insurance, SCHIP is even more important for the health and development of infants and children in low income families.

Cost-related medication nonadherence and spending on basic needs following implementation of Medicare Part D

CONTEXT

Cost-related medication nonadherence (CRN) has been a persistent problem for individuals who are elderly and disabled in the United States. The impact of Medicare prescription drug coverage (Part D) on CRN is unknown.

OBJECTIVE

To estimate changes in CRN and forgoing basic needs to pay for drugs following Part D implementation.

DESIGN, SETTING, AND PARTICIPANTS

In a population-level study design, changes in study outcomes between 2005 and 2006 before and after Medicare Part D implementation were compared with historical changes between 2004 and 2005. The community-dwelling sample of the nationally representative Medicare Current Beneficiary Survey (unweighted unique n = 24,234; response rate, 72.3%) was used, and logistic regression analyses were controlled for demographic characteristics, health status, and historical trends.

MAIN OUTCOME MEASURES

Self-reports of CRN (skipping or reducing doses, not obtaining prescriptions) and spending less on basic needs to afford medicines.

RESULTS

The unadjusted, weighted prevalence of CRN was 15.2% in 2004, 14.1% in 2005, and 11.5% after Part D implementation in 2006. The prevalence of spending less on basic needs was 10.6% in 2004, 11.1% in 2005, and 7.6% in 2006. Adjusted analyses comparing 2006 with 2005 and controlling for historical changes (2005 vs 2004) demonstrated significant decreases in the odds of CRN (ratio of odds ratios [ORs], 0.85; 95% confidence interval [CI], 0.74-0.98; P = .03) and spending less on basic needs (ratio of ORs, 0.59; 95% CI, 0.48-0.72; P < .001). No significant changes in CRN were observed among beneficiaries with fair to poor health (ratio of ORs, 1.00; 95% CI, 0.82-1.21; P = .97), despite high baseline CRN prevalence for this group (22.2% in 2005) and significant decreases among beneficiaries with good to excellent health (ratio of ORs, 0.77; 95% CI, 0.63-0.95; P = .02). However, significant reductions in spending less on basic needs were observed in both groups (fair to poor health: ratio of ORs, 0.60; 95% CI, 0.47-0.75; P < .001; and good to excellent health: ratio of ORs, 0.57; 95% CI, 0.44-0.75; P < .001).

CONCLUSIONS

In this survey population, there was evidence for a small but significant overall decrease in CRN and forgoing basic needs following Part D implementation. However, no net decrease in CRN after Part D was observed among the sickest beneficiaries, who continued to experience higher rates of CRN.

Restoring fiscal integrity to medicaid financing?

Using survey data, we examined Medicaid supplemental payments (SPs), including disproportionate-share hospital (DSH) and upper payment limit (UPL) payments in 2005 and changes in these payments between 2001 and 2005. We found that states increased their use of general funds in financing of DSH payments while expanding the size and scope of other SPs considerably. Although the federal government has made some headway in reforming state Medicaid financing, our findings suggest that more work remains.

Access to health care in contexts of livelihood insecurity: a framework for analysis and action

The authors present a framework for analysis and action to explore and improve access to health care in resource-poor countries, especially in Africa.

Provider perceptions of patient psychosocial needs after orofacial injury

PURPOSE

Vulnerable populations are at particular risk for developing psychosocial sequelae after they experience orofacial injury. To enhance understanding of awareness, perspectives, and beliefs regarding attendant psychosocial issues, surgeons who provide orofacial injury care to indigent patients were surveyed.

MATERIALS AND METHODS

We surveyed 26 oral and maxillofacial surgeons and 15 otolaryngology surgeons at a large, urban, Level 1 trauma center. The survey, which measured providers' perceptions of pertinent contextual elements and patients' psychosocial needs after assaultive orofacial injury, was based on semistructured interviews with 15 oral and maxillofacial surgeons. The overall survey response rate was 85.4% (35 of 41).

RESULTS

Respondents ranked interpersonal violence as the dominant cause of orofacial injury among patients. Anxiety (eg, post-traumatic stress), depression, and legal issues were the most significant psychosocial sequelae identified by respondents. Alcohol abuse, drug abuse, and homelessness were identified as the most important contributors to orofacial reinjury and patient noncompliance with postsurgical instructions. Less than half of respondents (44.7%) believed that patients' problems with depression, anxiety, or substance abuse were currently addressed in an adequate way in the hospital. The vast majority (94.7%) believed that a psychosocial aftercare program was needed, and most agreed that such a program would decrease the risk of reinjury and would promote patient compliance with aftercare instructions and return for scheduled follow-up care. Respondents identified the specialty mental health service in their hospital or a community-based setting as the preferred locations for such a program, and they indicated that lack of financial resources and trained personnel were the most significant barriers to implementation of such a program within the setting of trauma services.

CONCLUSIONS

Surgeons who provide care to indigent patients with orofacial injury perceive a great need for psychosocial aftercare programs for patients, and they believe that such programs could reduce the risk of reinjury and promote patient compliance.

Evaluating the Effect of Teaching Modules on Underserved Clients’ Perceived Health

Underserved individuals need comprehensive health care. Educational resources that meet health care needs can promote wellness. This descriptive study evaluated effects of preferred teaching modules on perceived health of underserved clients of a nurse-managed center. Participants (N = 101) were between 19 and 61 (M = 38.7); the majority was female (68.3%) with a high-school education (M = 12.17). Most participants (65%) identified health education as very important; 92% used at least one teaching module. Age, gender, and education were not related to importance of health education. Use of various teaching modules was positively correlated with perceived improved health (p < .05). Participants who used a combination of videos and pamphlets reported the greatest improvement (p < .000).

Costs to physician offices of providing medications to medically indigent patients via pharmaceutical manufacturer prescription assistance programs

BACKGROUND

Prescription assistance programs (PAPs) are offered by pharmaceutical manufacturers to provide medications at no out-of-pocket cost to various categories of medically indigent patients. some PAPs require only 1 application whereas others require as many as 4 applications per year per drug per patient, depending on the manufacturer's requirements.

OBJECTIVE

to measure the costs incurred by a medical clinic that provides chronic prescription medications via PAPs.

METHODS

this project was conducted in a free-standing, inner-city, Midwestern health clinic on the PAP application process for 1 representative drug for 32 pharmaceutical manufacturers that offered PAPs for drugs taken on a long-term basis for chronic conditions. time and motion studies were conducted using a medical assistant with the greatest amount of PAP experience. Assessment of time-to-access and time-to-complete forms was performed outside of normal clinic business hours to avoid interruptions. Personnel time costs also included receipt and delivery of drug to the patient (drug distribution time), which were assessed during normal business hours for actual medications received for 10 patients and included the time required to notify the patient of the arrival of the drug and to dispense the medication to the patient. supply costs for this PAP service included printing and copying costs. submission costs associated with mailing or faxing the documents were determined and calculated using the price of materials only. total application cost was calculated by adding the personnel time cost, supply cost, and submission cost. Annual PAP time was the time spent completing PAPs for 1 medication for 1 patient for 1 year. the time and resources required and the associated costs were aggregated separately for the pharmaceutical manufacturers that required 1, 2, or 4 applications per drug per patient per year.

RESULTS

The total average application cost for all 32 companies was $25.18 [SD, $17.23]. Personnel time costs accounted for half or more of the total application cost, regardless of submission mode. the time to complete the form for any PAP was 0:06:20 [SD, 0:05:03] minutes with a range from 0:03:01 to 0:34:22 minutes. Printing costs were $0.20 [SD, $0.10] and copying costs were $1.96 [SD, $0.21]. Average supply costs were $2.16 [SD, $0.23]. Faxing versus mailing PAPs saved $17.90 per application. total annual clinic cost to assist patients in obtaining drugs through a PAP ranged from $10.42 per patient for a drug that requires 1 application per year (15 manufacturers, 47%) to $46.30 per patient for a drug in a PAP that requires 4 (re)applications per year (12 manufacturers, 38%). PAPs transmitted by mail required 0:49:18 [SD, 0:32:18] minutes, approximately 0:25:00 [SD, 0:21:00] minutes more than by fax (0:24:13 [SD, 0:11:32] minutes) or by Internet submissions (0:28:20 minutes), respectively.

CONCLUSION

The number of PAP applications required per patient per medication annually has the greatest impact on clinic time and financial resources. Application submission method also influences the overall costs of providing this service in the clinical setting. Medical clinics should base their decision to provide a PAP application service to patients on the time and costs associated over the course of 1 year and not on the 1-time application cost.

Bedlam Community Health Clinic: A collaborative interdisciplinary health care service for the medically indigent

OBJECTIVE

To describe a collaborative interdisciplinary health care service delivery system for the medically indigent in the Tulsa and northeastern Oklahoma area independent of state or federal funding.

SETTING

Northeastern Oklahoma and Tulsa.

PRACTICE DESCRIPTION

Community and ambulatory care for indigent patients.

PRACTICE INNOVATION

Bedlam Community Health Clinic (BCHC), which opened in August 2003, provides services to patients through partnerships among the health care disciplines of the University of Oklahoma College of Pharmacy, Nursing, and Medicine; is staffed by community physicians and pharmacists who volunteer their time and expertise; and is funded by the local community.

MAIN OUTCOME MEASURES

Experiences and patients served.

RESULTS

BCHC is a collaborative interdisciplinary clinic that addresses the needs of the medically indigent in Tulsa and northeastern Oklahoma. Conceived, developed, and funded by the local community, it does not depend on state or federal funding. A variety of services, both general medicine and specialty, are provided through BCHC. Since its opening in August 2003, the clinic has provided hands-on training for students from a variety of health care disciplines. The pharmacist-patient encounters provide helpful, meaningful drug information. The participation of volunteer pharmacists enables medically underserved or indigent patients to access pharmaceutical care and addresses the diverse health care needs of this often overlooked population.

CONCLUSION

Health professionals and students in the Tulsa area have created an innovative mechanism for serving indigent patients who otherwise would lack adequate health care services.

Evaluation of breast cancer care under Puerto Rico's Health Care Reform

Puerto Rico has implemented Health Care Reform legislation that shifted medically indigent and underserved persons from direct care by public sector institutions to managed care arrangements through the private sector. Our aim is to assess how previously underserved women with breast cancer have fared during the first three years of the Reform. Medical claims data were obtained on breast cancer cases in San Juan who were either enrolled in the capitated Reform plan or in a commercial policy offered by the same insurer. A set of indicators reflecting initial therapy, use of key services, and cumulative utilization rates of various medical procedures were constructed. Statistical tests were conducted to assess whether these indicators differed between Reform- and commercially-insured patients. Failure to reject null hypotheses of indicator differences were then used to judge Reform progress. We found some differences, but they were neither pervasive nor unidirectional. On balance, we conclude that previously underserved women are being treated for breast cancer roughly on par with other patients. This conclusion, however, is preliminary and subject to important qualifications.

Indian community health insurance schemes provide partial protection against catastrophic health expenditure

BACKGROUND

More than 72% of health expenditure in India is financed by individual households at the time of illness through out-of-pocket payments. This is a highly regressive way of financing health care and sometimes leads to impoverishment. Health insurance is recommended as a measure to protect households from such catastrophic health expenditure (CHE). We studied two Indian community health insurance (CHI) schemes, ACCORD and SEWA, to determine whether insured households are protected from CHE.

METHODS

ACCORD provides health insurance cover for the indigenous population, living in Gudalur, Tamil Nadu. SEWA provides insurance cover for self employed women in the state of Gujarat. Both cover hospitalisation expenses, but only upto a maximum limit of US$23 and US$45, respectively. We reviewed the insurance claims registers in both schemes and identified patients who were hospitalised during the period 01/04/2003 to 31/03/2004. Details of their diagnoses, places and costs of treatment and self-reported annual incomes were obtained. There is no single definition of CHE and none of these have been validated. For this research, we used the following definition; "annual hospital expenditure greater than 10% of annual income," to identify those who experienced CHE.

RESULTS

There were a total of 683 and 3152 hospital admissions at ACCORD and SEWA, respectively. In the absence of the CHI scheme, all of the patients at ACCORD and SEWA would have had to pay OOP for their hospitalisation. With the CHI scheme, 67% and 34% of patients did not have to make any out-of-pocket (OOP) payment for their hospital expenses at ACCORD and SEWA, respectively. Both CHI schemes halved the number of households that would have experienced CHE by covering hospital costs. However, despite this, 4% and 23% of households with admissions still experienced CHE at ACCORD and SEWA, respectively. This was related to the following conditions: low annual income, benefit packages with low maximum limits, exclusion of some conditions from the benefit package, and use of the private sector for admissions.

CONCLUSION

CHI appears to be effective at halving the incidence of CHE among hospitalised patients. This protection could be further enhanced by improving the design of the CHI schemes, especially by increasing the upper limits of benefit packages, minimising exclusions and controlling costs.