What ethicists talk about when they talk about managed care

Defining the values at stake as we move into managed care is an awesome--yet necessary--endeavor. To help sort things out, the Society for Health and Human Values brought together health care ethicists and medical humanists to discuss how human values are being incorporated into health care reform. Here's an excerpt from that conversation.     

Update on prostate cancer screening

Prostate cancer is the second most common cause of death in men; it is diagnosed in about 1 in 10 men. Significant risk factors include, but are not limited to, race and age; the peak age at diagnosis is the seventh decade. A through screening program, sensitive to the risk factors and targeted to patients with curable prostate cancer, can decrease the rates of mortality and morbidity associated with this disease, without overtreating patients who have latent cancer. Screening methods include annual digital rectal examinations and prostate-specific antigen tests. Staging is important when treatment options are considered and treatment morbidity rate is weighed against disease mortality rate. Research concerning genetics changes and chemoprevention trials of vitamins and hormonal agents are targeted toward primary prevention. Implications for practice should include primary prevention, screening and detection, public education, and monitoring of the disease.     

Cues to action in prostate cancer screening

PURPOSES/OBJECTIVES: To describe factors that cue men of all ages to participate in prostate cancer screening programs and to explore the relationship of age to the rating of the cues. DESIGN: Exploratory survey. SETTING: A large community prostate cancer screening program in the Midwest. SAMPLE: 127 men (mean = 66.3 years of age) who participated in community prostate screening. METHODS: Subjects completed and returned by mail the 13-item Prostate Screening Follow-Up Questionnaire developed, piloted, and refined by the investigator for measuring the rating of the cues to action. MAIN OUTCOME MEASURES: Results of the rating of each cue to action, selected demographic variables, and comparison of the cue ratings by age group. FINDINGS: Appointment scheduling, reminder cards, a friend/family member with cancer, and newspaper promotion were perceived by the sample as most influential in their decision to have prostate cancer screening. No practical significant differences in cue ratings were found between the two age groups: 70 years of age and older and less than 70 years of age. CONCLUSION: Reminder cards, specific appointments, and newspaper promotion should be used when structuring community prostate cancer screening programs. Men who have a friend or family member with cancer may be more likely to participate in screening activities. IMPLICATIONS FOR NURSING PRACTICE: By incorporating influential cues to action into their everyday practice, nurses can be instrumental in reaching the population of men who are at risk for prostate cancer. Strategies for promoting prostate cancer screening should include: educating patients and family members about prostate cancer screening guidelines, using specific influential promotional practices when setting up prostate screening programs, and networking with seniors programs in the community.     

Mass screening for prostate cancer in Japan

Since 1975 mass screening for prostate cancer has been performed in Japan. The Prostate Research Foundation has analysed the data every year that collected from all institutes performing a mass screening. Up to 1993, 67, 225 subjects were examined. The detection rate of prostate cancer was 0.69%. Approximately half of the cancer were stage B, and the subjects who have metastatic stage were only 20% and the pattern of stage seemed to be different from that of patients who visited hospitals. In Chiba prefecture the subjects lived in a district of south Boso peninsula received a mass screening for prostate cancer with total of 1,964 men from 1985, and 17 cancers were diagnosed (0.87%). The distribution of prostate-specific antigen (PSA) assayed with Tandem-R kit was examined using the stocked sera (n = 976) of the screening for prostate cancer in Chiba prefecture. The percentage of 0.05-4.0 ng/ml, 4.1-9.9 ng/ml, over than 10.0 ng/ml of the PSA, were 89.6%, 7.0%, 3.4%, respectively. This distribution is approximately as same as the previous reports by the United States and Canada.     

Effectiveness of screening for prostate cancer

In this, our second article, we assess the value of screening for prostate cancer. There is insufficient evidence to recommend for or against routine digital rectal examination as an effective screening test for prostate cancer in asymptomatic men. It is recommended that tumour markers, such as prostate specific antigen, and transrectal ultrasound are not used for routine screening purposes.     

What is proper cancer care in the era of managed care?

Managed care and proper cancer care need not be mutually exclusive entities. Managed-care organizations (MCOs) that are committed to patients and society should have the following characteristics: accountability for results, cost containment, measurement of outcomes, health promotion and disease prevention programs, resource consumption management, emphasis on primary care, and continuous quality improvement. Whether these commitments are upheld depends on when and with whom the MCO contracts to provide care and which medical and quality assurance protocols it follows. If proper cancer care is to become a reality in the managed-care era, the oncology community must take a proactive stance. Oncologists must provide the market with an appropriate, efficient disease management plan for cancer. In concert with MCOs, the oncology community must define and, through partnerships, promote the seamless integration of proper cancer care. Patients and advocates should insist that MCOs' quest for efficiency allows for flexibility to address individual patients' circumstances.     

Characteristics of men reporting for prostate cancer screening

A survey to determine demographics, prostate cancer screening practices, and prostate cancer-related knowledge and beliefs was administered to over 1,700 participants at five sites during Prostate Cancer Awareness Week (1991) screening events. Findings are presented by site since significant differences in demographics existed. Results suggest that screenings conducted at the major medical centers attract primarily white males, a number of whom already practice adequate secondary prevention. Thus, if optimal benefit is sought through mass prostate cancer screening, innovative strategies to reach populations that are currently underserved and at risk are necessary.     

Liability issues in managed care

The explosive growth in Managed Care Organizations as a mechanism for providing health care in the United States has generated an equal explosion in litigation and new legislation related to problems within this delivery system. Abuses have included the "gagging" of physicians from providing full disclosure of medical options for their patients, inappropriate denial of care, denial of specialty referral, false claims data, insurer insolvency, economic credentialling, deselection, financial disincentives to render care, and lack of appeal or grievance mechanisms. These issues and others have resulted in injuries to patients and damage to the patient/physician relationship. This article discusses some of the more dramatic litigated cases and endeavors to alert both physicians and patients to potential legal matters that should be considered before becoming involved within this structure.     

The effect of screening versus nonscreening on treatment authorization in a managed care setting.

Many psychologists believe that screening evaluations required for treatment authorization are merely mechanisms to restrict needed patient care. Managers of behavioral health organizations, in contrast, fear that providers will misdiagnose patients to ensure reimbursement for unneeded services if not monitored. This study compared the managed behavioral health organization screening evaluation with direct therapist referral in terms of treatment eligibility determination. Only 5% of patients in the nonscreened group failed to meet diagnostic requirements for insurance reimbursement compared with 22% in the screened group. However, patient dropout was nearly double for the nonscreened group as compared with the screened group. The importance for psychologists to render well-documented, unbiased diagnoses of their patients is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)