Research Proposal: Health Care Delivery Service

Research Proposal: Health Care Delivery Service

Introduction

A conclusion frequently drawn from some such analyses is that country differences, particularly those between the USA and various European countries, are in large part a function of the presence or absence of nationalized healthcare. While these types of studies yield important information about aggregate patterning of social inequality in different types of nation states, less is known about the mechanisms by which state-level programs translate to individual-level health outcomes. Studies focusing on such meso-level questions have found that a series of organizational, economic, and cultural factors accounts for some additional portion of observed practice variation. For example, reimbursement structures influence physician behavior, with fee-for-service payment resulting in more patient visits and greater continuity of care compared to salaried reimbursement. Similarly, Maisey et al. (2008) examined pay for performance reimbursement and find that non-incentivized activities receive less attention than their incentivized counterparts. Beyond payment structures, other types of organizational features have been shown to influence provider decision making, including issues such as time constraints, the presence of ancillary treatment staff, and the ways interaction among staff leads to contingent knowledge and 'communities of practice' (Jonas & Kovner, 2008).

Within-system practice cultures, including physicians' sense of autonomy and the business orientation of a practice, also affect providers' diagnostic and treatment decisions. In a recent vignette-based survey of US physicians, Sirovich et al. (2008) found that variations in healthcare spending across regions of the USA were strongly correlated with the tendency of local physicians to recommend discretionary interventions (as opposed to variations in adherence to clinical practice guidelines). Beyond organizational and economic aspects of healthcare provision, additional work considers how different societal (beyond medical practice) cultures affect how conditions are medicalized, defined, and treated in various places (Harrington & Estes, 1997).

Literature Review

Bates et al. (1997) show how cultural values, beliefs, and standards resulted in different medical care in New England and Puerto Rico, with the former showing evidence of a strong biomedical mind-body dualism shared by providers and patients, while in the latter there was more emphasis on a shared view of mind-body integration. In her well-known work comparing medical culture in the United States, England, West Germany, and France, Payer (1988) argues, for example, that British tendencies to perform less medical action is less the result of 'Draconian rationing placed upon them by the National Health Service' as commonly interpreted by Americans, but also a reflection of other aspects of British character, including having a 'stiff upper lip' (Anderson & Kominski, 2001).

By comparison, the aggressiveness of American medical practice is a reflection of a Manifest Destiny mentality in which anything can be accomplished if only the natural environment can be conquered and controlled - that is, if the 'virus in the machine' can be reined in. Together, this range of factors provides a complex tapestry of underlying reasons for observed differences in medical practice variation. Furthermore, the relative importance of these factors has importance beyond immediate questions of how to ...