Hey, Big Spender! Why Does Your Quality Lag So Far Behind Other Countries?

The United States is the world's biggest spender on health care by far. And what do we get for it? Not as much as we should. Our quality shortcomings are not for lack of knowledge: Stakeholders know what to do to close these gaps. So why aren't they doing it?

Funding profiles of multisector health care alliances and their positioning for sustainability.

Purpose The purpose of this paper is to examine the relationship between different aspects of alliance funding profiles (e.g. range of sources, dependence on specific sources) and participant' perceptions of how well the organization is positioned for the future. Design/methodology/approach A mixed method study in the context of eight alliances participating in the Robert Wood Johnson Foundation's Aligning Forces for Quality program. Data collection approaches included surveys of alliance participants and semi-structured interviews with alliance leaders. Findings The findings indicate that dependence on grant revenues, in particular, may be problematic for how well alliances are positioned for sustainability. While a number of approaches were identified to reduce dependence on grants, implementing these strategies presented more of a challenge for alliances due to the contextual demands of their external environment and a need to strike a balance between pursuing alternative revenue sources and fidelity to the mission and identity of the organization. Practical implications Alliance leaders need to have not only a broad and accurate understanding of their external environment, but also an appreciation of the alliance's identity in that environment. Collectively, the findings can help organizational leaders be more informed about their funding choices and the implications those choices have for the future of their organization. Originality/value Collaborative forms of organizations (e.g. alliances, coalitions, networks) are increasingly viewed as an effective means of addressing complex, multifaceted health, and social challenges. For collaborative organizations that depend on the coordinated efforts of volunteers, addressing such complex issues is predicated on sustaining programmatic activities as well as the interest and participation of stakeholders over extended periods of time. This study sheds light on how leaders of these organizations may improve their prospects for sustainability.

A mixed-method evaluation of the New York State Eat Well Play Hard Community Projects: Building local capacity for sustainable childhood obesity prevention.

This study used a mixed-method, comparative case study approach to assess the level of capacity built for childhood obesity prevention among seven New York State Eat Well Play Hard-Community Projects (EWPH-CP). Data were collected through a self-reported survey in 2007, semi-structured interviews in 2009, and EWPH-CP program documentation throughout the 2006-2010 funding cycle. Quantitative and qualitative analyses were used along with an integrative framework for assessing local capacity building to characterize the capacity built by the study coalitions. Four coalitions rated membership characteristics as a challenge at the beginning of the funding cycle. Towards the end of the funding cycle, all seven coalitions reported activities that were initially focused on building their membership (i.e., member capacity) or positive working relationships (i.e. relational capacity), before eventually pursuing support and resources (i.e., organizational capacity) for implementing their chosen community-oriented programmatic goals (i.e., programmatic capacity). Five coalitions reported environmental changes aimed at increasing physical activity or fruit and vegetable intake. Technical assistance provided to coalitions was credited with contributing to the achievement of programmatic goals. These results suggest that the coalitions succeeded in building local capacity for increasing age-appropriate physical activity or fruit and vegetables intake in the target communities.

In Preparation or Response: Examining Health Care Coalitions Amid a Changing Economic and Political Landscape.

The Office of the Assistant Secretary for Preparedness and Response within the US Department of Health and Human Services leads the nation in preparing for, responding to, and recovering from the adverse health effects of public health emergencies, in part through formal collaborations between hospitals, health systems, community health centers, public health departments, and community organizations via health care coalitions (HCCs). HCCs endeavor to meet the medical surge demands inherent to disasters and to improve health outcomes before, during, and after public health emergencies. Nevertheless, significant changes in health economics and policy can impact the operations, capabilities, and scope of HCCs. Specifically, hospital consolidation and the Affordable Care Act (ACA) are altering the national health care landscape, as well as the emergency preparedness sector, and are challenging HCCs to adapt to large-scale, industry-wide transformations. This article examines HCCs in the context of the developments of hospital consolidation and the ACA in order to facilitate future discourse regarding the strategy and policy of HCCs amid a changing economic and political landscape.

Identifying Indirect Benefits of Federal Health Care Emergency Preparedness Grant Funding to Coalitions: A Content Analysis.

OBJECTIVE: This study aimed to identify the indirect benefits of health care preparedness funding as perceived by current and former recipients of the US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response's Hospital Preparedness Program. METHODS: This was a qualitative inductive content analysis of telephone interviews conducted with regional stakeholders from several health care coalitions to identify their perceptions of the indirect benefits of preparedness funding. RESULTS: Content analysis of interviewee responses resulted in 2 main categories of indirect benefits of federal health care preparedness funding: (1) dual-use technology and programs and (2) impact of relationships on day-to-day operations. Within the dual-use technology and programs category, 3 subcategories were identified: (1) information systems, (2) clinical technology, and (3) health care operations. Similarly, 3 subcategories relating to the indirect benefits in the impact of relationships on day-to-day operations category were identified: (1) cooperation, (2) information sharing, and (3) sense of community. CONCLUSION: This study identified indirect benefits of federal investment in hospital and health care preparedness in day-to-day operations. Major categories of these benefits included dual-use technology and programs and impact of relationships on day-to-day operations. Coalition members placed a high value on these benefits, even though they were not direct outcomes of grant programs. Further research is needed to quantify the economic value of these indirect benefits to more accurately measure the total return on investment from federal grant funding.

Mental health services commissioning and provision: Lessons from the UK?

The commissioning and provision of healthcare, including mental health services, must be consistent with ethical principles - which can be summarised as being "fair", irrespective of the method chosen to deliver care. They must also provide value to both patients and society in general. Value may be defined as the ratio of patient health outcomes to the cost of service across the whole care pathway. Particularly in difficult times, it is essential to keep an open mind as to how this might be best achieved. National and regional policies will necessarily vary as they reflect diverse local histories, cultures, needs and preferences. As systems of commissioning and delivering mental health care vary from country to country, there is the opportunity to learn from others. In the future international comparisons may help identify policies and systems that can work across nations and regions. However a persistent problem is the lack of clear evidence over cost and quality delivered by different local or national models. The best informed economists, when asked about the international evidence do not provide clear answers, stating that it depends how you measure cost and quality, the national governance model and the level of resources. The UK has a centrally managed system funded by general taxation, known as the National Health Service (NHS). Since 2010, the UK's new Coalition* government has responded by further reforming the system of purchasing and providing NHS services - aiming to strengthen choice and competition between providers on the basis of quality and outcomes as well as price. Although the present coalition government's intention is to maintain a tax-funded system, free at the point of delivery, introducing market-style purchasing and provider-side reforms to encompass all of these bring new risks, whilst not pursuing reforms of a system in crisis is also seen to carry risks. Competition might bring efficiency, but may weaken cooperation between providers, and transparency too. On the other hand, it is hard to implement necessary governance and control without worsening bureaucracy and inefficiency. The pursuit of market efficiencies has been particularly contentious in mental health care, where many professionals are defensive about the risks to vulnerable patients and to traditional ways of professional working. Developments and debates in the UK may be instructive for others. We conclude this paper with a set of questions that may help inform debate and evaluation of mental health services internationally.

A role for communities in primary prevention of chronic illness? Case studies in regional Australia.

In regional Australia "communities of place," defined as bounded geographic locations with a local society, undertake community-wide primary prevention programs. In helping to prevent chronic illness, communities provide valuable resources to the health system. To understand the role of community-health sector partnerships for primary prevention and the community contextual factors that affect them, we studied eight partnerships. We used an embedded multiple case study design and collected data through interviews, nonparticipant observation, and document analysis. These data were analyzed using a typology of community-health sector partnerships and community interaction theory to frame the key community contextual factors that affected partnerships. The dominant factor affecting all partnerships was the presence of a collective commitment that communities brought to making the community a better place through developing health. We call this a communitarian approach. Additional research to investigate factors influencing a communitarian approach and the role it plays in partnerships is required.

The effects of a community-based partnership, Project Access Dallas (PAD), on emergency department utilization and costs among the uninsured.

BACKGROUND: Approximately 19% of non-elderly adults are without health insurance. The uninsured frequently lack a source of primary care and are more likely to use the emergency department (ED) for routine care. Improving access to primary care for the uninsured is one strategy to reduce ED overutilization and related costs. METHODS: A comparison group quasi-experimental design was used to evaluate a broad-based community partnership that provided access to care for the uninsured-Project Access Dallas (PAD)-on ED utilization and related costs. Eligible uninsured patients seen in the ED were enrolled in PAD (n = 265) with similar patients not enrolled in PAD (n = 309) serving as controls. Study patients were aged 18-65 years, <200% of the federal poverty level and uninsured. Outcome measures include the number of ED visits, hospital days and direct and indirect costs. RESULTS: PAD program enrollees had significantly fewer ED visits (0.93 vs. 1.44; P < 0.01) and fewer inpatient hospital days (0.37 vs. 1.07; P < 0.05) than controls. Direct hospital costs were ∼60% less ($1188 vs. $446; P < 0.01) and indirect costs were 50% less ($313 vs. $692; P < 0.01). CONCLUSIONS: A broad-based community partnership program can significantly reduce ED utilization and related costs among the uninsured.

Practices to improve transitions of care: a national perspective.

Improving transitions of care has significant importance to our health care system. While care transitions has been studied and researched by many individuals over the past 20 years, more work is needed to further improve the process. Those beginning to focus on transitions need not begin from scratch, but can use information and research from national and regional collaborative models, as well as other tools and resources to enhance the quality of transitions programs.