Report from the front lines: rural Medicaid primary care providers as gatekeepers of rural health service networks.

This study of primary care practitioners in Louisiana's Medicaid managed care program, Community Care, focused on the program's implementation and perceived impact. PCPs were interviewed to assess their perceived responsibilities as gatekeepers and how well they believed the system facilitated or impeded their fulfillment of those responsibilities, to examine issues of access and quality, and to determine their knowledge and use of local referral networks. Findings indicate that although they appreciated the financial stability derived from having a larger patient base and understood their roles well, they were concerned with several facets of the program, including perceived limitations imposed on their medical decision making, an added burden of paperwork, and a lack of both downward and upward communication. They also believed the referral network of available providers for medical and social services to be more limited for their Medicaid patients than for their private patients. Policy implications are discussed.

Racial variations in cesarean section rates: an analysis of Medicaid data in Louisiana.

The objective of this study was to investigate racial variation in cesarean section rates among Medicaid beneficiaries in Louisiana. Results indicate that over a three-year period, white women had higher rates than women of other races when stratified by age, locality, accompanying diagnoses, and hospital ownership. Comparing Louisiana Medicaid data with birth certificate records, rates among all births were slightly higher than Medicaid births, with the same racial trend. These variations imply significant differences in costs and reimbursement to providers and raising questions about efficiency of current obstetric practices in Louisiana. Implications for a managed care system are discussed.

Managing change in the era of health reform: organized delivery systems of public health.

As U.S. Medicaid managed care programs proliferate, it appears that traditional clinical training and practice often provide insufficient preparation for physicians to meet the care requirements of Medicaid beneficiaries adequately. State and local health departments have extensive experience with this population's need for preventive care, social support services, care coordination, and referral. Organized delivery systems of managed care can merge the expertise of primary care practitioners, public health professionals, and other community resources to deliver comprehensive care. Although the described model includes Medicaid as the payer, it would remain viable should Medicaid be terminated and universal coverage enacted.

Supervisors matter more than you think: components of a mission-centered organizational climate.

A study was conducted in a medical center among a diverse sample of employees to examine whether components of organizational climate related to workers' knowledge of the organization's mission and mission-centered values. Findings supported a mediated relationship between supervisor behaviors, mission knowledge, and customer service orientation (the organization's key mission value). Employee perceptions of coworker and organizational support and knowledge of their own performance expectations also related positively to customer service orientation. Results suggest that supervisors are in an ideal position to disseminate a mission-centered climate. Practical applications of these findings for management wishing to develop mission-centered climates in health care organizations are discussed.

Integrating bottom-up and top-down theories of subjective well-being: the case of health.

As a means of integrating bottom-up and top-down theories of subjective well-being (SWB), a framework was proposed that, in part, posits that both objective life circumstances and global personality dimensions indirectly affect SWB through their effects on the interpretation of life circumstances. This proposition was tested both cross-sectionally and longitudinally among a sample of approximately 375 men and women. Personality was operationalized in terms of the dispositional trait negative affectivity (NA), and the life circumstance investigated was health. Strong support was obtained for the hypothesized indirect effects of NA and objective health on SWB. Implications of the integrative framework for the study of SWB are discussed.

HIV-related sexual behaviors of college students.

A follow-up study explored the prevalence of behavioral risk factors for HIV infection in a population of college students. Two hundred forty-three single students ranging in age from 17 to 24 years who identified themselves as heterosexual completed questionnaires related to planned and unplanned sexual intercourse and such other factors as alcohol and nonprescription drug use that might increase the risk of HIV infection. Forty-seven percent of the men and 57% of the women stated that they had had sexual intercourse from 1 to 5 times primarily because they were intoxicated, a phenomenon that increased with age until only 19% of those over 21 had never had sex because of intoxication. Seventeen percent of the sexually active men and 21% of the women said that they had used condoms. Nineteen percent of the men and 33% of the women acknowledged consenting to sexual intercourse because they felt awkward in refusing. The dangerous interaction between alcohol use and high-risk sexual activities suggested that college HIV prevention efforts should make the connection between the two risk factors explicit.

Heart Smart: a school health program meeting the 1990 Objectives for the Nation.

The importance of health promotion is recognized throughout the nation. The Surgeon General's report of 1980, Promoting Health/Preventing Disease, delineates objectives for intervention in 15 health priority areas. Approximately one-third of the objectives relate directly to the health of children, and many are addressed by a comprehensive cardiovascular (CV) health promotion program for elementary school children--Heart Smart. Priority areas addressed by this program are high blood pressure control, nutrition, fluoridation and dental health, smoking, misuse of alcohol and drugs, physical fitness and exercise, and control of stress and violence. Heart Smart is a cognitive behavioral intervention designed to address health enabling and reinforcing factors within the school environment. It is based on data from the Bogalusa Heart Study which clearly document the need for CV health intervention beginning early in life. Heart Smart includes a longitudinal classroom curriculum, an aerobic fitness program taught within physical education classes, a school lunch program offering CV healthy foods, and a teacher staff development program. The goal is to reduce CV risk factors in children. With health-enhancing behavior change of the students, family, and elementary school staff, objectives for CV risk reduction in our nation can be achieved.