Amy Roussel

Managed Care and Physician Referral

In the era of managed care, fundamental changes are occurring in the American health care system that are altering physician referral patterns. Faced with higher premiums that erode profits and competitiveness, employers, government, and nonprofit agencies are contracting with managed care organizations, which control costs partly by imposing constraints and incentives on physician referral behavior. As more and more Americans are covered by managed care plans, it becomes more important to understand how managed care organizations control access to specialists and how these controls affect health outcomes. The authors present a model defining the expected influence of managed care on physician referral based on social exchange theory and the empirical literature. They conclude with a discussion of the future research implications of the model.

Linkages between clinical practices and community organizations for prevention: A literature review and environmental scan

CONTEXT A literature review and environmental scan were conducted to develop a framework for interventions that utilize linkages between clinical practices and community organizations for the delivery of preventive services, and to identify and characterize these efforts. EVIDENCE ACQUISITION A search was made of four major health services and social science electronic databases and an Internet search was conducted to identify examples of linkage interventions in the areas of tobacco cessation, obesity, nutrition, and physical activity. EVIDENCE SYNTHESIS In all, 49 interventions were identified, of which 18 examples described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes. Outcomes in these evaluations were primarily patient-focused and did not include organizational or linkage characteristics. CONCLUSIONS An attractive option to increase the delivery of preventive services is to link primary care practices to community organizations; evidence is not yet conclusive, however, that such linkage interventions are effective. Findings provide recommendations to researchers and organizations that fund research, and call for a framework and metrics to study linkage interventions.

Linkages between clinical practices and community organizations for prevention: a literature review and environmental scan.

OBJECTIVES We conducted a literature review and environmental scan to develop a framework for interventions that utilize linkages between clinical practices and community organizations for the delivery of preventive services, and to identify and characterize these efforts. METHODS We searched 4 major health services and social science electronic databases and conducted an Internet search to identify examples of linkage interventions in the areas of tobacco cessation, obesity, nutrition, and physical activity. RESULTS We identified 49 interventions, of which 18 examples described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes. Outcomes in these evaluations were primarily patient-focused and did not include organizational or linkage characteristics. CONCLUSIONS An attractive option to increase the delivery of preventive services is to link primary care practices to community organizations; evidence is not yet conclusive, however, that such linkage interventions are effective. Findings provide recommendations to researchers and organizations that fund research, and call for a framework and metrics to study linkage interventions.

Managed care and the US health care system a social exchange perspective

Many countries are importing managed care and price competition from the US to improve the performance of their health care systems. However, relatively little is known about how power is organized and exercised in the US health care system to control costs, improve quality and achieve other objectives. To close this knowledge gap, we applied social exchange theory to examine the power relations between purchasers, managed care organizations, providers and patients in the US health care system at three interrelated levels: (1) exchanges between purchasers and managed care organizations (MCOs); (2) exchanges between MCOs and physicians; and (3) exchanges between physicians and patients. The theory and evidence indicated that imbalanced exchange, or dependence, at all levels prompts behavior to move the exchange toward power balance. Collective action is a common strategy at all levels for reducing dependence and therefore, increasing power in exchange relations. The theoretical and research implications of exchange theory for the comparative study of health care systems are discussed.

The association between funding for statewide programs and enactment of obesity legislation.

OBJECTIVE As part of a national effort to prevent and control obesity, the Centers for Disease Control and Preventions (CDCs) Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases (NPAO) provides funding to states to improve access to healthful food and increase opportunities for physical activity. The CDC also provides funding to states to build Coordinated School Health (CSH) programs across agencies and within schools to help reduce chronic disease risk factors. This paper investigates the possible role of these programs in state policy change. METHODS Descriptive study of state legislation targeting obesity prevention passed in 2005. Units of analysis were 135 pieces of obesity-related state legislation identified within 4 legislative databases. Legislation was coded into programmatic setting and obesity-prevention strategy categories. RESULTS On average, states receiving NPAO or CSH program funding passed twice as many bills as states not yet funded. CONCLUSIONS AND IMPLICATIONS The statewide obesity prevention and school health programs may have contributed to states enacting more obesity-related legislation. Further research into the process by which state programs influence the enactment and effective implementation of policies could help build the evidence base for policy changes that help prevent obesity.

Pathways to Program Success: A Qualitative Comparative Analysis (QCA) of Communities Putting Prevention to Work Case Study Programs.

Objective: To examine the elements of capacity, a measure of organizational resources supporting program implementation that result in successful completion of public health program objectives in a public health initiative serving 50 communities. Design: We used crisp set Qualitative Comparative Analysis (QCA) to analyze case study and quantitative data collected during the evaluation of the Communities Putting Prevention to Work (CPPW) program. Setting: CPPW awardee program staff and partners implemented evidence-based public health improvements in counties, cities, and organizations (eg, worksites, schools). Participants: Data came from case studies of 22 CPPW awardee programs that implemented evidence-based, community- and organizational-level public health improvements. Intervention: Program staff implemented a range of evidence-based public health improvements related to tobacco control and obesity prevention. Main Outcome Measure: The outcome measure was completion of approximately 60% of work plan objectives. Results: Analysis of the capacity conditions revealed 2 combinations for completing most work plan objectives: (1) having experience implementing public health improvements in combination with having a history of collaboration with partners; and (2) not having experience implementing public health improvements in combination with having leadership support. Conclusion: Awardees have varying levels of capacity. The combinations identified in this analysis provide important insights into how awardees with different combinations of elements of capacity achieved most of their work plan objectives. Even when awardees lack some elements of capacity, they can build it through strategies such as hiring staff and engaging new partners with expertise. In some instances, lacking 1 or more elements of capacity did not prevent an awardee from successfully completing objectives. These findings can help funders and practitioners recognize and assemble different aspects of capacity to achieve more successful programs; awardees can draw on extant organizational strengths to compensate when other aspects of capacity are absent.