Samuel J. Bosch

The role and functions assumed by a Department of Community Medicine in planning a group practice

This paper describes the technical assistance role and the functions assumed by the Department of Community Medicine of the Mount Sinai School of Medicine in a planning process that led to the development of a group practice in the Department of Medicine of the Mount Sinai Hospital. Three distinct phases are identified in the process: how the planning was planned, how the plan was prepared, and how the implementation was planned. The role of Community Medicine in each phase is analyzed.

An Experiment to Test the Feasibility of Integrating Occupational Health Services into an HMO

rasaGw CCUPATIO NAL illness is a majorcontributor to total morbidity and mortality in the United States. It is estimated that 390,000 new cases of occupational disease occur annually and that occupational illness results in some 100,000 deaths each year. These figures may, however, understate the influence of occupational factors on health status (1). Former Secretary of Health, Education, and Welfare Joseph Califano, for example, stated that 20% of future cancers alone might be associated with occupational exposures (2). As recognition of the significance and extent of occupational exposure has expanded over the past few years, consumer groups and representatives of the labor movement have begun to insist that measures be taken to prevent or limit exposure to toxic substances, and that the capacity of the health care system be enhanced to meet the needs of exposed workers. In 1970, the Occupational Safety and Health Act was passed to protect workers from job-related injuries and illness. No similarly organized federal or private program has been mounted to address medical care issues. At present, occupational health services are provided in an uncoordinated manner in a variety of settings. Large industrial firms may have on-site occupational health staff or may contract with specialized industrial clinics, hospitals, group practices, or individual providers to meet their medical needs. Small and medium-sized firms often find such programs prohibitively expensive. In many cases, the medical system has tended to separate occupational care from other family care services. Isolating occupational health services has served not only to fragment further the personal health

A proposed network to improve access to high-quality health care for medicaid-eligible families

There is today both a need and an opportunity to develop and test a variety of models—organizational and financial—for improving the delivery of health care services. This article describes the structure and functioning of one such model and highlights the organizational problems expected to arise during its implemèntation. The proposed health plan is intended to facilitate the access of Medicaideligible, inner-city families to already available health services. The central hypothesis is that in low-income urban areas the elementary schools offer an organizational focus for the development of a health plan. As a prepaid, community-based model, this plan is designed to address the issues of accessibility, equity, accountability, continuity of care, and consumer participation, primarily through the development of a coordinating agency, the health plan office (HPO), which assures the linking of consumers and providers of health care. Adapted from the Kaiser-Permanente model, the HPO also assumes responsibility for marketing, enrollment, coordination of services, consumer advocacy, and quality surveillance.

An experiment to change medical education and medical care in Argentina (A personal essay)

Abstract In 1959, an innovative medical program was launched in Argentina, which gradually evolved into a demonstration project encompassing three distinct but interrelated programs: (a) a graduate program for advanced training in internal medicine, (b) an undergraduate program in community medicine and behavioral sciences, and (c) a program designed to organize and test the feasibility of a prepaid group practice health plan based on a teaching hospital. Although differing in scope and immediate objectives, the three programs shared the single purpose of furthering the advancement of medicine and promoting a needed change in the patterns of delivery of care and medical education. For those who planned and developed this program, the goal was to create a coherent organization, integrating mutually interacting elements. By this standard, the threefold experiment must be reckoned a failure. Yet, some changes were achieved which in Argentina were considered important. Some of the factors involved, of course, were essentially local, prescribed by the political, economical and social circumstances prevailing in Argentina at the time. On the other hand, the experience and fate of the program may contain more universal meaning. In spite of its failure to achieve the stated major goals, there was achieved a limited demonstration of the feasibility of change in Argentinas current approach to health care and medical education. The primary task of this paper will be to describe this demonstration project, called CEMIC (Centro de Educacion Medica e Investigaciones Clinicas). In recapitulating the history of CEMIC, some critical analysis will be attempted especially with reference to its meaning for the organization and delivery of health care and medical education, but the main effort will be on reproducing the essential elements of the experience.

Is Argentina Ready for Managed Care

The author describes the evolution and present status of health insurance and prepaid medical care in Argentina, with particular reference to the opportunities for the development of managed care systems and techniques there. He claims that as US health care corporations enter that countrys marketplace there are lessons to be learned that will probably be applicable in other countries of the Americas.

HMO development in an academic medical center: The rise and fall of a prepaid health program in New York City

Through a documented case study the authors identify the critical factors that impede the introduction of prepaid medical care as part of education and practice within a prestigious and well established academic medical center. The inherent conflicts between individual fee-for-service practice and population-based prepaid practice and the resistance to innovations in medical care organization as they surfaced in that center, are presented. The need for a clear understanding of the complexities of HMO development and of an appreciation for the importance of a planning process in which all interested parties are involved, is emphasized. A clear commitment by policy makers, administrators and providers is highlighted as fundamental for the implementation of a system where practitioners are motivated to assume responsibility for the comprehensive care of a defined population that prepays for their services. The rewards as well as the difficulties for institutionalizing commitment to this form of health care delivery and impacting on medical education are discussed.

Community-oriented health services education: a strategy for international cooperation.

This paper describes the approach of the Department of Community Medicine of the Mount Sinai School of Medicine in the education of local and foreign physicians and their participation in the development of community oriented health care systems. It also presents the first steps taken by this medical school to create an international program whose aims are to develop long-term partnership agreements with foreign universities by bringing together and integrating medical education with the development of community-oriented health care services.