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By conventional measures that focus on diseases, injuries, and mortality, children in the United States are healthier now than even a few decades ago. They are less likely to die in childhood and more likely to be protected by immunizations against serious infectious diseases. Rates of death from injuries and exposures to some environmental hazards have decreased. The infant mortality rate has declined from 26 per 1000 in 1960 to 7 per 1000 in 2003, while the mortality rate among those younger than 5 years has declined from 30 per 1000 to 8 per 1000 during these years. Should these facts be reassuring? Are correct measures being used to evaluate child health? If not, how should child health be assessed? Language: en

ContextMost health maintenance organizations offer products with loosened restrictions on patients' access to specialty care. One such product is the point-of-service (POS) plan, which combines "gatekeeping" arrangements with the ability to self-refer at increased out-of-pocket costs. Few data are available from formal evaluations of this new type of plan.ObjectivesTo comprehensively describe the self-referral process in POS plans by quantifying rates of self-referral, identifying patients most likely to self-refer, characterizing patients' reasons for self-referral, and assessing satisfaction with specialty care.DesignRetrospective cohort analysis using administrative databases composed of members aged 0 to 64 years who were enrolled in 3 POS health plans in the Midwest (n = 265 843), Northeast (n = 80 292), and mid-Atlantic (n = 39 888) regions for 6 to 12 months in 1996, and a 1997 telephone survey of specialty care users (n = 606) in the midwestern plan.Main Outcome MeasuresSelf-referred service use and charges, reasons for self-referral, and satisfaction with specialty care.ResultsOverall, 8.8% of enrollees in the midwestern POS plan, 16.7% in the northeastern plan, and 17.3% in the mid-Atlantic plan self-referred for at least 1 physician or nonphysician clinician visit. The proportions of enrollees self-referring to generalists (4.7%-8.5%) were slightly higher than the proportions self-referring to specialists (3.7%-7.2%) across all 3 plans. Nine percent to 16% of total charges were due to self-referral. The chances of self-referral to a specialist were increased for patients with chronic and orthopedic conditions, higher cost sharing for physician-approved services, and less continuity with their regular physician. Patients who self-referred to specialists preferred to access specialty care directly (38%), reported relationship problems with their regular physicians (28%), had an ongoing relationship with a specialist (23%), were confused about insurance rules (8%), and did not have a regular physician (3%). Compared with those referred to specialists by a physician, patients who self-referred were more satisfied with the specialty care they received.ConclusionsHaving the option to self-refer is enough for most POS plan enrollees; 93% to 96% of enrollees did not exercise their POS option to obtain specialty care via self-referral during a 1-year interval. The potential downside of uncoordinated, self-referred service use in POS health plans is limited and counterbalanced by higher patient satisfaction with specialist services.

RECENT history reflects a myriad of problems with the US health service system. In the 1960s, physician manpower shortages received the most attention from policymakers. When efforts to increase the number of physicians succeeded, maldistribution was recognized as a problem. In the 1970s, rapid increases in costs attracted attention and led to the development of several regulatory mechanisms, including the diagnosis related groups, to reduce expenditures associated with hospitalization. In the 1980s, observations of variations in physician practice patterns without concomitant variations in outcomes of care led to a realization that much of medical care lacked benefit, and the movement toward quality control and total quality improvement assumed prominence. In the 1990s, compromised access resulting from the absence of universal health insurance and excessive costs consequent to unnecessary care share the stage in the policy drama. See also p 3156. The poor development of primary care within the US health

Ten Western industrialized nations were compared on the basis of three characteristics: the extent of their primary health service, their levels of 12 health indicators (eg, infant mortality, life expectancy, and age-adjusted death rates), and the satisfaction of their populations in relation to overall costs of the systems. Information was derived primarily from published sources. Indices were developed to characterize the extent of primary care in each country and the standing of each country relative to the others on the health indicators. There was general concordance for primary care, the health indicators, and the satisfaction-expense ratio in nine of the 10 countries. Ratings for the United States were low on all three measures. West Germany also had low ratings. In contrast, Canada, Sweden, and the Netherlands had generally high ratings for all three measures. The lack of concordance in the ratings in the United Kingdom may be a result of relatively low expenditures for other social services and public education in that country. The findings may add to the debate and deliberations concerning modifications in organization and financing of care that are currently being considered in the United States. (JAMA. 1991;266:2268-2271)

In this study in an urban prepaid group practice, patients and practitioners agreed less than half the time as to what problems required follow-up at a subsequent visit. Problems that were mentioned by both practitioner and patient were much more likely to be followed up subsequently by the practitioner than problems initially mentioned only by the practitioner or only by the patient. Patients reported much more improvement of problems at follow-up when both practitioner and patient mentioned the problem as requiring follow-up than when they had been mentioned only by the patient. The involvement of patients in the process of care may be augmented by a variety of mechanisms. We believe greater patient participation in the processes of care should result in better follow-up of problems and better results, at least as perceived by patients. ( JAMA 242:344-346, 1979)

The success of modern perinatal management techniques has led to the recommendation of the regional organization of perinatal services. This report summarizes the evaluation of a national demonstration program of such regionalization that was funded by the Robert Wood Johnson Foundation (RWJF) in 1975. In both funded regions and comparison areas, the neonatal mortality rates decreased sharply over the decade of the 1970s. This decline was linked to shifts in the hospital of delivery that indicated antepartum risk identification and transfer of management of high-risk pregnancies to tertiary centers for delivery, a change in service pattern consistent with some aspects of regionalization. The centralization of high-risk deliveries appeared so widespread that the special effect of the RWJF program could not be detected. Surveys of surviving 1-year-old infants showed that the decrease in neonatal mortality was accompanied by a decrease in selected morbidity. ( JAMA 1985;253:799-804)