This article reports on the design and implementation of a prenatal outreach and education intervention for low income, Hispanic women living in three migrant and seasonal farmworker communities in Arizona. The program included three major elements: a Spanish language prenatal curriculum; a group of mature Hispanic women recruited from the target communities and trained as "Comienzo Sano" (healthy beginning) Promotoras (health promoters), and the organization of a support network of local health professionals. The rationale for the demonstration is reviewed, and the structure of the intervention is described. Factors which facilitated and constrained implementation of the program are identified, and guidelines are provided for other health care providers and health educators interested in developing similar programs.

This article contains the findings from an evaluation of a prenatal education program to Hispanic migrant farmworker families using peer health workers. The focus of the evaluation was on establishing the validity of the intervention model in the target population. Data are presented on the program setting, characteristics of the clients served, and effects of the educational program on the clients and peer health workers. The evaluation identified factors that established confidence in the program model: (1) there were existing barriers to health care and health information; (2) the program served a culturally specific and disadvantaged population; (3) the prenatal curriculum was culturally sensitive; (4) the peer workers were accepted by the target community; and (5) the model did not threaten the medical community. The directions for future research are presented.

In this article, the authors review the health services research literature regarding physician attitudes and opinions relating to managed care and how managed care has affected their clinical practice. This literature suggests that physician perceptions of managed care are largely related to the nature of their ties to managed care plans and to their selection of practice setting. There are substantial limitations in study designs and execution, suggesting that many of the published findings should be viewed with caution; the research basis regarding physicians’ perceptions of managed care is not as strong as the number of articles published on this subject would suggest. The review concludes with suggestions for the conduct of future research on this topic.

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Policy Points:r In order to develop effective policies on the consolidation of community health systems, policymakers must understand both the motivations and processes for consolidation.r We found that physician practice consolidation is often a strategic response by providers to public and private cost containment efforts; therefore, it will be difficult to reverse using traditional policy options.r Many current health care cost containment policies incentivize continued provider consolidation, which presents a direct challenge to health care reform models that rely on competition among providers to accomplish cost control and quality improvement.Context: Health care delivery systems are becoming increasingly consolidated in urban areas of the United States. While this consolidation could increase efficiency and improve quality, it also could raise the cost of health care for payers. This article traces the consolidation trajectory in a single community, focusing on factors influencing recent acquisitions of physician practices by integrated delivery systems. Methods:We used key informant interviews, supplemented by document analysis. Findings:The acquisition of physician practices is a process that will be difficult to reverse in the current health care environment. Provider revenue uncertainty is a key factor driving consolidation, with public and private attempts to control health care costs contributing to that uncertainty. As these efforts will likely The Milbank Quarterly, Vol. 92, No. 3, 2014 (pp. 542-567) 542Dynamics of Community Health Care Consolidation 543 continue, and possibly intensify, community health care systems now are less consolidated than they will be in the future. Acquisitions of multispecialty and primary care practices by integrated delivery systems follow a common process, with relatively predictable issues relating to purchase agreements, employment contracts, and compensation. Acquisitions of single-specialty practices are less common, with motivations for acquisitions likely to vary by specialty type, group size, and market structure. Total cost of care contracting could be an important catalyst for practice acquisitions in the future. Conclusions:In the past, market and regulatory forces aimed at controlling costs have both encouraged and rewarded the consolidation of providers, with important new developments likely to create momentum for further consolidation, including acquisitions of physician practices.Keywords: health facility merger, integrated health care system, community health systems.T here is growing evidence that health care delivery systems are becoming increasingly consolidated in medium and large metropolitan areas across the United States.1 Recently, the hospital, or integrated delivery system (IDS), acquisition of physician practices has become integral to the consolidation process at the community level. These acquisitions could benefit consumers by improving quality of care through several mechanisms. For instance, larger systems may be better positioned ...