Health Care Rationing Affecting Older Persons

Abstract

Health care resources are finite and, therefore, need to be rationed among potential users. Over the past decade and a half in the United States, a variety of explicit, official rationing schemes have been proposed, including some in which chronological age would play a significant role. For ethical and political reasons, it is very unlikely that any age-based rationing schemes will be adopted explicitly and officially. However, various de facto forms of health care rationing are occurring at present. This article outlines the implications of payer behavior, physician practice patterns, the development of evidence-based clinical practice parameters or guidelines, and reliance on consumer choice of health plans as unofficial and generally unacknowledged mechanisms of health care rationing that may exert an important impact on the accessibility of health services for older persons.     

The informal rationing of primary medical care

All social services are rationed, yet the effects of such rationing on the client are rarely fully explored. This article reviews the evidence on the existence of informal rationing devices in general practice. It examines the effects on patients of a wide range of informal rationing devices now used by individual general practitioners. Various suggestions for reforming the present rationing of primary medical care are evaluated and the likelihood of any reform being carried out is assessed. Although this article concentrates solely on rationing in the primary care sector of the National Health Service, the issues discussed are relevant to most welfare agencies as they are presently organized.     

SOCIAL DEATH AS SELF-FULFILLING PROPHECY:

In his classic Passing On , David Sudnow described how the presumed social value of patients affects whether the staff will attempt to revive them. Since this study was published, the health care field has undergone dramatic changes and commentators have questioned whether the social rationing described by Sudnow is still relevant. Specifically, critics point to the increased rationalization of medical practice via protocols, a widely accepted resuscitation theory, and legal initiatives to promote resuscitative efforts and protect patient autonomy. Based on observations of 112 resuscitative efforts and interviews with forty-two health care workers, I demonstrate that the recent changes in the health care system did not weaken but instead fostered social inequality in death and dying.     

Rationing in the presence of baselines

We analyze a general model of rationing in which agents have baselines, in addition to claims against the (insufficient) endowment of the good to be allocated. Many real-life problems fit this general model (e.g., bankruptcy with prioritized claims, resource allocation in the public health care sector, water distribution in drought periods). We introduce (and characterize) a natural class of allocation methods for this model. Any method within the class is associated with a rule in the standard rationing model, and we show that if the latter obeys some focal properties, the former obeys them too.     

When Death Isn't Dead: Implicit Social Rationing during Resuscitative Efforts

In this paper, I address the relationship between social death and clinical-biological death during resuscitative efforts. In Western societies, resuscitative efforts are the medical intervention of choice when sudden death occurs. The widespread use of this technology puts emergency department staff in a difficult gatekeeping position. They are expected to save lives, but, at the same time–when their efforts become futile–to prepare for a dignified death. I show that certain groups of patients are much more likely to be considered socially dead regardless of their clinical viability, while others are less likely to be considered socially dead even when irreversible biological death has set in. The result is an implicit rationing of the lifesaving endeavors based on the social worth of the patient. This rationing annihilates initiatives, such as advance directives, which were instituted to empower patients. Social scientists usually suggest that the solution to the negative effects of rationing is to increase accessibility for all populations; however, resuscitative efforts are a prime example in which less access for all groups–instead of for some–might be preferable. This paper is based on observations of 112 resuscitative efforts during a fourteenth-month period and interviews with 42 health care providers.     

The Construction of Arguments Over the Rationing of Health Care

Abstract

The aim of this paper is to uncover arguments over rationing health care as outlined in the British broadsheets. Following a brief introduction to the development of rationing in Britain, it considers the role of the media in society and looks at the arguments developed by the right wing media and contrasts these with the perspectives of the center left. It is argued that although these two perspectives have things in common, they differ significantly in the ways they view the social responsibilities of the state and in the way they interpret the health needs of the nation.     

Changing health culture in rural Appalachia: Implications for serving the elderly

This article explores the dual themes of place and time as influences on health care service delivery to the rural elderly, through a case study of rural Appalachia. Traditional patterns of indigenous health care practice and values are contrasted with more “professional” formal models of health care service delivery that have entered the region. The result has been a clash of health care cultures. The continuing validity of this perspective is appraised in relation to apparent generational differences between the old-old and the young-old in the degree to which contemporary health care practices and values are adopted. It is concluded that traditional and contemporary health care cultures can be reconciled through an expanded vision of health care service delivery premised on: understanding health care within a total community context; redefining the role of the health practitioner; improving education of both the rural elderly and service providers; and enhancing communication in the rural health care environment.     

Texts in action: how nurses are doing the fiscal work of health care reform

Canada's publicly insured system of socialized health care is coming under intense scrutiny by governments firmly focused on the politics of national indebtedness and public spending. Contemporary health care reforms aimed at cutting costs and increasing productivity place new emphasis on “official knowledge” constituted through particular textual practices. Since 1994 the Canadian Institute of Health Information (CIHI) has become a powerful regulator of patient care. It has entered business-like accountability and rationing practices based on competitive, market-like comparisons into Canadian hospitals in order to “assist leaders in the health sector make informed decisions” (CIHI 2000). Using Canadian sociologist Dorothy E. Smith's (1987) Institutional Ethnography, with a specific focus explicating a Smithian textual analysis (1990a, 1990b, 1999), this paper explores, in depth, one feature of how a business genre is being inserted into the everyday practices of nurses and doctors who work with the frail elderly in a small community hospital in British Columbia.     

The Evolution of Community Mental Health Services in Asian American Communities

This paper explores the history of Asian immigration to the United States, and its intersections with the mental health system. As mental health care have evolved since the 1960s from institutions to the community, public mental health services for Asian Americans have become increasingly culturally relevant. Major policy shifts, trends in immigration, and mental health practice will be presented with a focus on the Bridge Program at the Charles B. Wang Community Health Center. Integrative practice and research models that extend evidence-based knowledge to Asian American communities and practice implications are discussed.     

Health and mental health services for children in foster care: the central role of foster parents

It is well documented that children enter foster care with special health and mental health needs and, while in care, those conditions are often exacerbated. However, less attention has been given to foster parents who have the most contact with these children. Results are presented from a national study on the developmental, health and mental health care needs of children in foster care that included foster parents' perspectives and observations. Their role in improving child well being is explained and recommendations for policy, practice and advocacy also are included.     

Integrated physical and mental health care at a nurse-managed clinic: report from the trenches

The Health and Wellness Center (HWC), located in Joliet, Illinois, is a nurse-managed universally accessible primary health care center funded by a grant from the Health Resources and Services Administration. The goals of the HWC are to improve access to quality primary health care services for all patients, including those who are uninsured and underserved, and to develop and implement a model of nurse-managed primary health care that integrates both physical and mental health assessment and treatment. After 5 years of developing and using this model, it is clear that integration requires strategic supports from the financial, political, and professional sectors to be considered a cost-effective model of health care delivery. Recommendations for policy and practice change are offered based on the author's experiences of providing integrated health care at the HWC and the health care industry's responses to uninsured or underinsured patients' needs.     

HEALTH CARE REFORM IN THE UNITED STATES: IMPLICATIONS FOR TRAINING AND PRACTICE IN MARRIAGE AND FAMILY THERAPY

Americans are spending 12-14% of their income on health care, and costs are rising about 11-12% per year. These increases are fueled by many social problems and are not limited strictly to health matters. Many alternatives have been examined to limit the rapidly increasing costs. The long-term results of these efforts are likely to be a reduction in health care benefits for many and the continued development of a two-tier system of health care. This article addresses the place of mental health care in general and marriage and family therapy in particular in the emerging system. Suggestions for training and practice for the new health care system are given.     

Promoting Children's Welfare by Inter‐professional Practice and Learning in Social Work and Primary Care

Social work in the United Kingdom is an activity that benefits from, and often requires, co‐operation between different staff and across different professions. How this is to be achieved has been a central dilemma for practice and policy for many years. Primary care health services often play a key role. New policy and practice developments are designed to promote inter‐professional working with children, where research has shown significant problems in the community‐based health care of looked after children, children leaving care, and children at serious risk. There is, however, little evidence from research that supports current developments in inter‐professional practice; analysis of the particular nature of the inter‐professional problems is lacking, as are therefore the relevant inter‐professional solutions. A framework for better analysis, linked to developments in practice‐based research, one that would yield significant improvements for children's welfare, is presented here.     

An Explorative Study of the Place of the Ethics of Care and Reflective Practice in Social Work Education and Practice

The moral development and identity of social work students have been shown to be enhanced by education in caring. Important aspects of this education are training in reflective practice and learning to have a perspective focused on professional loving care. In this study, we have explored how reflective processes can be implemented in both educational settings and working practice from an ethical point of view. Elaborating upon reflective practice from an ethical perspective focuses on reciprocity in relationships and relational capacity in institutional contexts. The study took the form of interviews with social work teachers and health care professionals. Interview and focus group data were analysed, three main topics were identified and statements were coded with relation to these topics. Use of both educators and practitioners in this study showed the importance of not neglecting the transition from education to practice. Responses also showed the value placed upon continuous education and development over the course of a health care professional's career.     

Variations in provider capacity to offer accessible health care for people with disabilities

Since social workers are likely to practice in a range of health care settings, their training focusing on human behavior in the social environment could help providers develop strategies to improve access to care for people with disabilities. In this article, results from a comprehensive survey of providers about access to health care for people with a broad range of disabilities are reported. Results suggest that a minority of providers report difficulty serving people with disabilities. However, dentists and mental health/substance abuse providers are significantly less likely than other providers to report that they provide accessible services to individuals with disabilities. These providers are less likely to report having had training related to mobility impairments, providing mirrors at their facility, having an accessible door, or providing assistance with personal care needs, and are more likely to report that their building poses a barrier for people with disabilities. Social workers are well positioned to take a leadership role in working with providers and patients to improve access to health care for people with disabilities. A social work framework of understanding the individual in a social environment may be the most appropriate perspective for creating innovative strategies for addressing the complex, multidimensional needs of people with disabilities who experience limited access to care.     

Applying health determinants and dimensions in social work practice

Dimensions and determinants related to physical health, mental health and well-being can be used as tools in social work practice. These frameworks are useful for assessment, planning and intervention activities in complex client situations, alerting social workers to consider diverse features and processes that influence well-being in people's lives. They can be applied in social work with individuals, families, groups, and communities. In our view health and well-being need to be viewed holistically, broadly and in each unique situation, changing over time over the life course. Literature based on key word searches of concepts we use in our teaching and research and that has informed our conceptualisation of dimensions and determinants in physical health, mental health and well-being, is reviewed. A case illustration is presented to illustrate how the dimensions and determinants are used to inform practice and compare and apply alternative frameworks. Finally, the implications of these and other frameworks for social work, not only in health care settings, but also in other fields of social work practice, are discussed.     

Coordinating health, extended care, and community support services: reforming aged care in Australia

Under pressure to maximize the cost-effectiveness of programs, efforts to improve coordination have become increasingly central to the development of the broader health and welfare service delivery system in Australia in the past few years. This article reviews recent experience in two related fields: (1) the coordination of different community care services for older people and people with disabilities, funded by the Home and Community Care program; and (2) the attempt to enhance links between community and residential care services, hospitals, and other health care providers. Why coordination has emerged as such an important issue in the field of community care and, increasingly, across the entire system of what the Australian government now terms health and family services is discussed. A number of measures that have been introduced or are proposed to improve a coordination of services are briefly reviewed. These range from individualistic approaches based on information and referral, through schemes involving gatekeeping, case management and brokerage of services, to models involving the reconfiguration of organizational structures, linkages, and finances. These measures are not mutually exclusive and are increasingly likely to be applied in more complex mixed models of service coordination. It is argued that coordination at the level of direct-service provision is difficult if government policies that direct services lack coordination.     

Variations in Provider Capacity to Offer Accessible Health Care for People with Disabilities

Abstract

Since social workers are likely to practice in a range of health care settings, their training focusing on human behavior in the social environment could help providers develop strategies to improve access to care for people with disabilities. In this article, results from a comprehensive survey of providers about access to health care for people with a broad range of disabilities are reported. Results suggest that a minority of providers report difficulty serving people with disabilities. However, dentists and mental health/substance abuse providers are significantly less likely than other providers to report that they provide accessible services to individuals with disabilities. These providers are less likely to report having had training related to mobility impairments, providing mirrors at their facility, having an accessible door, or providing assistance with personal care needs, and are more likely to report that their building poses a barrier for people with disabilities. Social workers are well positioned to take a leadership role in working with providers and patients to improve access to health care for people with disabilities. A social work framework of understanding the individual in a social environment may be the most appropriate perspective for creating innovative strategies for addressing the complex, multidimensional needs of people with disabilities who experience limited access to care.     

Educating Social Workers for Health Care’s Brave New World

A transforming health care system challenges educators to formulate curriculum that is relevant and anticipates evolving expectations and demands. This article reviews key features of the changing health care landscape, describes a Centers for Disease Control funded prototypical social work practice model designed to fit the contours of that landscape, and suggests five fundamental principles to guide successful adaptation of social work health care practice and educational preparation. Curricular implications of these principles are discussed.