Primary and managed care. Ingredients for health care reform.

The use of primary and managed care is likely to increase under proposed federal health care reform. I review the definition of primary care and primary care physicians and show that this delivery model can affect access to medical care, the cost of treatment, and the quality of services. Because the use of primary care is often greater in managed care than in fee-for-service, I compare the two insurance systems to further understand the delivery of primary care. Research suggests that primary care can help meet the goal of providing accessible, cost-effective, and high-quality care, but that changes in medical education and marketplace incentives will be needed to encourage students and trained physicians to enter this field.     

Minimally invasive surgery. Implications for hospitals,health workers,and patients.

Minimally invasive surgery is one of the great innovations of health care in the 20th century. It promises to revolutionise surgery by allowing many more operations to be performed with minimal hospitalisation. Pressure from patients has caused many techniques to spread rapidly before they have been adequately assessed. This must be resisted, and policy makers must pay more attention to minimally invasive surgery to ensure that good assessments are made. The widespread use of minimally invasive techniques has important implications for hospitals and health workers. As more patients are treated on an outpatient basis, fewer hospital beds will be needed, and traditional operating rooms will have to adapt to a greater turnover of patients. Surgeons will have to acquire new operating skills, possibly requiring formal training and accreditation, and, as different specialties fight for control of new technologies, surgery may eventually be merged with internal medicine so that specialists will deal with organ systems. Postoperative care will have to be carried out in the community rather than in hospitals, and policy makers will need to reorganise their health systems to cope with these developments.     

Educating primary care clinicians about health disparities

Background

Primary care research has recently garnered greater attention at the national level. Yet, primary care (i.e., family medicine, internal medicine, pediatrics, and obstetrics and gynecology) departments within academic institutions struggle to develop and sustain strong research frameworks.

Methods

This paper discusses a successful model that was developed in the department of family medicine at the University of North Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine.

Results

Overall, the framework revolves around three core values: training future primary care researchers, providing resources to emerging and junior faculty members, and creating a partnership with the community and clinicians to conduct primary care clinical research.

Conclusion

Significant effort is required to establish a successful research framework in family medicine. The framework presented herein serves as an example for other departments to use and adapt in developing their research division.     

Power, blame, and accountability: Medicaid managed care for mental health services in New Mexico

I examine the provision of mental health services to Medicaid recipients in New Mexico to illustrate how managed care accountability models subvert the allocation of responsibility for delivering, monitoring, and improving care for the poor. The downward transfer of responsibility is a phenomenon emergent in this hierarchically organized system. I offer three examples to clarify the implications of accountability discourse. First, I problematize the public-private "partnership" between the state and its managed care contractors to illuminate the complexities of exacting state oversight in a medically underserved, rural setting. Second, I discuss the strategic deployment of accountability discourse by members of this partnership to limit use of expensive services by Medicaid recipients. Third, I focus on transportation for Medicaid recipients to show how market triumphalism drives patient care decisions. Providers and patients with the least amount of formal authority and power are typically blamed for system deficiencies.     

Bioethics for clinicians: 15. Quality end-of-life care

A physician who receives a call from the emergency department to see a patient with heart failure will have a clear framework within which to approach this problem. The thesis of this article is that physicians do not have an analogous conceptual framework for approaching end-of-life care. The authors present and describe a framework for end-of-life care with 3 main elements: control of pain and other symptoms, the use of life-sustaining treatments and support of those who are dying and their families. This 3-part framework can be used by clinicians at the bedside to focus their effort in improving the quality of end-of-life care.     

Implications for health services.

Health services for older people in the NHS have developed pragmatically, and reflect the nature of disease in later life and the need to agree objectives of care with patients. Although services are likely to be able to cope with the immediate future, the growth of the elderly population anticipated from 2030 calls for long-term planning and research. The issue of funding requires immediate political thought and action. Scientifically the focus needs to be on maximizing the efficiency of services by health services research and reducing the incidence of disability in later life through research on its biological and social determinants. Senescence is a progressive loss of adaptability due to an interaction between intrinsic (genetic) processes with extrinsic factors in environment and lifestyle. There are grounds for postulating that a policy of postponement of the onset of disability, by modifications of lifestyle and environment, could reduce the average duration of disability before death. The new political structures of Europe offer under exploited-unexploited opportunities for the necessary research.     

Bioethics for clinicians: 17. Conflict of interest in research,education and patient care

A conflict of interest occurs in a situation in which professional judgement regarding a primary interest, such as research, education or patient care, may be unduly influenced by a secondary interest, such as financial gain or personal prestige. Conflicts of interest exist in every walk of life, including medicine and science. There is nothing inherently unethical in finding oneself in a conflict of interest. Rather, the key questions are whether one recognizes the conflict and how one deals with it. Strategies include disclosing the conflict, establishing a system of review and authorization, and prohibiting the activities that lead to the conflict.     

Routine smoking cessation intervention in health care systems.

Everyone agrees that insurance for long-term care is inadequate in the United States. Disagreement exists, however, on whether such insurance should be provided through the private or public sector. Private insurance generally uses the experience-rating principle that persons with higher risk of illness are charged higher premiums. For private insurance for long-term care, this principle creates a dilemma. Most policies will be purchased by the elderly; yet, because the elderly have a high risk of needing long-term care, only about 20% of them can afford the cost of premiums. A public-private partnership by which the government partially subsidizes private long-term-care insurance is unlikely to resolve this dilemma. Only a social insurance program for long-term care can provide universal, affordable, and equitable coverage.