Ethics and empathy in a changing health care system

The formation of regional physician-hospital organizations will be the next step in the evolution of managed care. Regional PHOs will have advantage over single-hospital PHOs by covering a wider population and geographic area, offering greater cost-effectiveness, and being able to contract as a unified provider. This, in turn, will set the stage for the next step in the process: the development of provider-sponsored networks.     

Ethics in reproductive health care: a midwifery perspective

To monitor personal exposure to biologically effective solar-UV radiation, Bacillus subtilis spores on a membrane filter and UV-coloring labels were incorporated into a monitoring badge. The samples were covered with one of three types of filter sheet, dependent on the season, to reduce the amounts of exposure to measurable levels. Five fifth- or sixth-grade classes of primary schools, each consisting of 30-40 children, were chosen in northern (Sapporo), central (Tsukuba and Tokyo), and southern (Miyazaki and Naha) cities in Japan. In all four season, each child wore a badge on an upper arm for the entire waking hours, changing it daily, for a week. Upon collection of the badges, the survival of spores and the extent of coloration of the label were determined. The results were used to estimate the amount of daily exposure to biologically effective UV radiation, expressed as the value of spore inactivation dose. Unexpectedly, the average amounts of exposure were not directly correlated with the outdoor UV irradiance: in the two southern cities, despite high outdoor irradiance from spring to autumn, the average amounts of exposure were less than 3.1% of the average irradiance. Highly concentrated exposures occurred in two central cities on three days when extensive outdoor exercise took place. These results contradict the simple notion that children's exposure is in proportion to the outdoor UV irradiance, and support the view that the extent of solar-UV exposure is primarily determined by life-style rather than living location.     

Ethics in hospice care.

Discusses 4 ethical issues that arise in hospice care: (1) What are the ethical responsibilities to the patient, family, and authorities when hospice workers discover that a patient has been given incompetent and shoddy care at a previous institution? (2) Hospices that advertise themselves as offering complete care should be prepared to deal with psychological and legal issues as well as medical ones. (3) The idea of treating the entire person must include responding to the likelihood that the patient and family may raise profound philosophical and religious questions. (4) Hospice staff should periodically examine themselves on a spiritual or philosophical level. (3 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ethics of allocating intensive care unit resources

ICU clinicians commonly make decisions that allocate resources. Because of the high cost of ICU care, these practitioners can expect to be involved in the growing dilemma of trying to meet increasing demand for healthcare services within financial constraints. In order to participate meaningfully in a societal discussion over fairness in allocating scare and expensive resources, ICU practitioners should have more than a superficial knowledge of the principles of distributive justice. Distributive justice refers to fairness in the distribution of limited resources and benefits. Fairness refers to giving equal treatment to all those who are the same with regard to certain morally significant characteristics and treating in a different manner those who are not the same. Although theoretical issues remain unresolved as to which characteristics should be most significant, the United States has a strong cultural value that regards individuals as inherently valuable and having equal social worth. From this, it is likely that only an egalitarian approach to allocation of lifesaving healthcare resources will be acceptable. Studies of how ICU resources have been allocated during times of scarcity indicates that, in general, when beds are scarce, the average severity of illness of those admitted to the ICU increases. However, in some hospitals, political and economic factors appear to play important roles in determining who has access to scarce ICU beds. Of great concern is documentation of a widespread pattern in which fewer hospital resources, including ICU resources, are provided to seriously ill patients of minority status or with low levels of insurance reimbursement. How society's values get translated into allocation decisions is another unresolved issue. One recent example of how this occurred is the Oregon Medicaid Plan. This plan extended Medicaid coverage to additional people in poverty, despite the same amount of state and federal funds. This was accomplished by not reimbursing what were regarded as marginally beneficial services on the basis of medical and community input. Portents of how society might be involved in the future of health care are illustrated by the argument that society should limit access to all therapies except palliative care solely on the basis of advanced age. Until an open consensus develops in U.S. society about how to allocate scarce healthcare resources, the delivery of ICU care will continue to be at risk of covert, de facto rationing based on ability to pay, race, or other nonmedical personal characteristics.     

Managed care: the third reorganization of health care

A 60-day-old neonate boy received hepatic portojejunostomy for biliary atresia under PFK. Pharmacokinetics of propofol and ketamine during and after PFK was also studied. Plasma levels of propofol (Cp) and ketamine (Ck) were maintained at 2 to 3 micrograms ml-1 and at 200 to 300 ng ml-1 during surgery, respectively. Both Cp and Ck decreased quickly after the end of infusions. From the pharmacokinetic point of view, PFK may be safely applied even for neonates.     

Home health care

Home health care is the fastest-growing expense in the Medicare program because of the aging population, the increasing prevalence of chronic disease and increasing hospital costs. Patients and families are choosing the option of home care more frequently. Medicare's regulations are often considered the standard of care for all home health agency interactions, even when a patient does not have Medicare insurance. These regulations require patients who receive home health care services to be under the care of a physician and to be homebound. The patient must have a documented need for skilled nursing care or physical, occupational or speech therapy. The care must be part time (28 hours or less per week, eight hours or less per day) and occur at least every 60 days except in special cases. A detailed referral and specific care plan maximize the care to the patient and the reimbursement received by the physician.     

Reforming the Israeli health care market

Israel's experience in attempting to implement a health system reform based in large measure on managed competition should provide important data to other countries considering reliance on competitive mechanisms for third-party purchase of health care. In this paper, current proposals for reform of the Israeli market for third-party purchase of health care are examined in light of ideal market structures, particularly the theory of managed competition. The relationship between the theory, the notion of a 'purchaser-provider split' and the Israeli case are explored. The current Israeli health care market, which features enrollment of 96% of the population in competing sick funds, is presented. The changes necessary to base third-party purchase of health-care on managed competition are discussed. Special conditions of the Israeli health care system likely to influence implementation of a managed competition strategy are considered. Beyond a 'purchaser-provider' split, the proposals call for other restructurings, such as a split between finance and insurance functions, which the standard theory of managed competition does not take into account. The implications of these proposals for smooth functioning of the health care market must be weighed against political and ethical considerations unique to the Israeli environment.     

Ensuring health care quality: a purchaser's perspective--a health care coalition

This paper explores how one health care purchasing coalition in Minnesota, the Buyers Health Care Action Group (BHCAG), has taken an active role in restructuring its local health care market. BHCAG started with the belief that the consumer should be the motivating force in health care delivery. Unfortunately, providing consumers with the information and incentives they need to make informed, effective health care decisions has triggered numerous problems. This paper examines groups of providers who network to form care systems, and explores the roles of consumers, employers, and health plans in the current market. It identifies specific methods for gathering data and distributing information to the consumer, and discusses the problems associated with attempting to implement quality improvement, as well as the questions that arise when the market does not support those improvements.