AIDS Capitation

AIDS Capitation

Social Science & Medicine 52 (2001) 1471–1476 Book reviews AIDS Capitation D.A Cherein and G.J. Huba (Eds); Hogath Press, Binghamton, NY, 1998, 115pp...

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Social Science & Medicine 52 (2001) 1471–1476

Book reviews AIDS Capitation D.A Cherein and G.J. Huba (Eds); Hogath Press, Binghamton, NY, 1998, 115pp., price $34.95 (cloth) Providing a ‘seamless’ clinical service is an aim shared by many health care professionals around the world. One of the goals of the most recent reforms of the English National Health Service was to make the service ‘seamless’, thereby preventing people falling between professional or institutional ‘‘cracks’’ of service provision. Another factor which drives health care reforms, in both industrialized and industrializing countries, is a concern about the cost of service provision and the need for cost-containment within a perceived context of ever increasing expenditure on health care. The irony in England was that proportional expenditure on health before, during and after these latest reforms had been kept at around 6% of GDP, before the most recent policy change introduced by the Blair Government. Expenditure on health care has been a major issue in the US system for a considerable period and attempts have been made to reform the system, with various degrees of success. While currently 14% of GDP is spent on health and health care, the system itself is extremely diverse and incorporates direct fee-for-service health care provision, insurance based health care cover } usually employment based } health maintenance organizations, the Veterans Administrative system, Medicare and Medicaid. The HIV pandemic has forced health care professionals all over the world to re-assess health care provision and develop new methods of reaching HIVinfected and HIV-affected people. One of the fascinating aspects of the book AIDS Capitation, edited by Cherin and Huba, is the description in its opening chapter of some of the novel ways through which health care professionals and community members have been attempting to plan, implement and evaluate HIV service provision in the US. The book is a collation of multiauthored papers and describes some of the work of the HIV Innovative Models of Care Initiative. This initiative was part of the Special Projects of National Significance Program, funded by the Health Resources and Services Administration (HRSA) which commenced 1st October 1994. It brought together 27 HRSA funded projects to establish common goals and objectives, develop common evaluation methods and produce measurable and comparable outcome measures. Five projects had as

a specific central theme to evaluate models of health care provision which were funded on a ‘capitation’ or ‘flat fee’ basis, instead of the ‘fee-for-service’ basis by which most health care is provided in the US. Most of these initiatives, according to the authors, aimed to control health care costs while ensuring quality of care. Each of these five projects had to determine the cost of providing acute (secondary or tertiary), primary or community care services to HIV infected individuals while ensuring that high quality care continued to be provided. The first chapter provides an overview of the HIV Innovative Models of Care Initiative and describes the range of services which were involved with the initiative. The 27 projects involved different aspects of HIV service provision, which were linked through the development of an agreed dataset, with different organizations providing similar or complementary data. This was an interesting way of trying to achieve the aim of cost-containment while trying to ensure the quality of HIV service provision. Unfortunately, many of the details of how this was achieved were not described to any great extent and left this reader wanting more details. The ensuing chapters of the book provide the reader with an example of how, within this capitated context, services for terminal care could be provided. In an attempt to overcome the short comings of traditional models of providing terminal care, in which care is dichotomized between curative and terminal care, the authors described and subsequently evaluated a ‘blended’ model of care in which individuals received both curative and palliative services throughout their care process. It was argued that the acute care bias present in traditional models of terminal care often not only sacrifices the patient’s quality of life but also significantly contributes to high end of life costs. According to these authors, treatment for HIV infected people and especially patients with terminal AIDS, requires a mixing of treatment orientations, and palliative and curative care need to be used throughout. A description of the main models of care and their shortcoming were provided, including the Case Management Model of Continuity of Care, the Trajectory Model and the Blended Intent Model. While the case management approach attempts to link services in treating the terminal patient, it is considered to remain tied to the medical curative model of terminal care. As such it adopts a structural approach but fails to alter the intent

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Book reviews / Social Science & Medicine 52 (2001) 1471–1476

of the model of care received by terminal patients. This shortfall was recognized by proponents of the Trajectory Model, which builds on the recognition of the need to accomplish inclusion of intents in care provided for terminal patients as well as linking of services. At the time of writing the paper the model had not yet been tested empirically. The Blended Intent Model like the Trajectory Model, is also based on providing an integrated, multi-disciplinary continuing care for patients at the end of their disease course and their families. Both of these models are moving towards a blending of intent, palliative and curative focus on treatment, and bridging venues of care so that community based services and acute episodes are linked. The blended model the authors evaluated is the Transprofessional Model. In this model the dichotomy between curative and palliative care is blended and the boundaries between active curative treatment and hospice care are bridged. The focus of care becomes the patient and regulating his/her illness. It does not only involve acute care but also care in the community as part of home care services. Hospital, clinic and community are linked through the care management process of an home-based hospice trained nurse and social worker, who are in part responsible for communication between the various aspects of service provision for that individual. Comparisons between conventional and transprofessional models of service provision were provided involving both quantative and qualitative approaches. Use of services and associated costs were reported to be less for those using a blended model of terminal care compared with traditional ones while being able to maintain or improve the quality of these services. While the reader is provided with interesting studies and results, they are unfortunately poorly presented in a rather complicated fashion which may put-off potentially interested readers. After a chapter on qualitative interviews of health care professionals, who had been using the Transprofessional Model in their own practice, the final chapter briefly addresses the role of managed care for disadvantaged groups or groups least attractive to commercial insurers. This collection of papers has something for many health care professionals but suffers from the fact that it has not been clearly presented. Apart from an overzealous reporting of statistical findings, the title of the book itself is very ambiguous and unlikely to attract the general reader. For those directly interested in terminal

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care, the issues described will be of great interest. For those interested in health care evaluation in general, the linkages made between different organizations, enabling them to collect empirical data routinely on the use, cost and outcome of health service provision, is a very interesting model, in particular the linkages made between the different health care sectors. While HIV service provision is now starting to be monitored prospectively across treatment centres in England (NPMS-HHC), France (DMI 2), the Netherlands (Athena) and Canada (PMIC in Que´bec and HIIP in Ontario), most of these systems currently only capture hospital based information. Partly because of technical reasons but often because of political reasons, such linkages across health care sectors remain few and far between in most countries. To implement such monitoring systems, especially across health care sectors, requires adequate resources. While certainly industry can and should be involved with such exercises, as they have direct interests in ascertaining the cost-effectiveness of health care provision, this will also require dedicated support from public sources. Many governments and government officials have been riding high on ‘‘value-for-money’’ rhetoric and promoting the need to provide cost-effective and acceptable services. Unfortunately most of these same officials have to date been reluctant to actively develop coherent national information strategies or provide resources for infrastructure requirements and operational costs to enable health care professionals to routinely evaluate the use, cost and outcome of service provision. To the detriment of users of services, those who provide services and those who pay for these services, many governments remain reluctant to put their money where there mouth is. E.J. Beck1 Joint Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Avenue West, Montreal, Que., Canada H3A 1A2 E-mail address: [email protected] (E.J. Beck). 1

Coordinator of the NPMS-HHC and Director of the NPMS-HHC Coordination and Analytic Centre, Chelsea Westminster Hospital Trust, London, UK. 369 Fulham Road, London, SW10 9NH, UK.