Changes in health, mortality, and disability and their impact on long-term care needs

The need for long-term care is driven both by the growth of the elderly population and changes in the age relations of morbidity, disability, and mortality. Data show these relations changed in the U.S. elderly population from 1982 to 1989. Chronic disability prevalence declined between the 1982 and 1989 U.S. National Long Term Care Surveys. Among those impaired, many persons using personal assistance to meet their needs shifted to the use of assisted housing and special equipment. The relation of these trends to other changes--such as the increasing educational level of the elderly population--is examined to estimate how future changes in disability and morbidity may affect the demand for long-term care. Disabilities at specific times as well as their transition rates were examined to determine how long individuals need long-term care. The analyses suggest that, while the amount of long-term care services needed will increase rapidly, the types and amounts of services used by the U.S. elderly population will undergo significant change.     

Ways of thinking about the long-term care of the baby-boom cohorts

In examining various ways of thinking about the development of long-term care policy for the baby-boom cohorts, this article discusses the importance of basing long-term care policy discussions on a recognition of social and economic trends, as well as on the informal exchanges of care that occur over life and the diversity within the baby-boom cohorts. The implications of two ways of thinking about challenges posed by the aging of baby boomers--the generational equity/crisis perspective and the generational investment/gradual adjustment perspective are also discussed. It is suggested that the generational equity perspective is consonant with proposals to expand private savings for long-term care contingencies and private long-term insurance and, secondarily, with proposals to expand means-testing for benefits. The second perspective is more consistent with proposals to create new universal services through a traditional social insurance approach, or through a block grant such as the one discussed in the context of the Clinton health care reform plan.     

The challenge of an aging work force: keeping older workers employed and employable

This article reviews labor-force trends and older-worker employment policies in Japan and the United States. Both countries have aging work forces, but Japan's labor force is and for some time has been older than that of the United States. Japan's Ministry of Labor began addressing older-worker issues over 30 years ago and in the ensuing years has promulgated numerous initiatives to extend working life. Mandatory retirement, however, remains both legal and common in Japan, yet labor-force participation rates are higher for older persons in that country than in the United States, where mandatory retirement is illegal. Japan's older-worker programs and policies clearly seem to have an impact on labor-force rates, although those rates are dropping among the elderly in Japan as well as in the United States. The transferability of these programs and policies to the United States is discussed.     

Statistics in epidemiology: the case-control study

This article presents a general review of the major trends in the conceptualization, development, and success of case-control methods for the study of disease causation and prevention. "Recent work on nested case-control, case-cohort, and two-stage case control designs demonstrates the continuing impact of statistical thinking on epidemiology. The influence of R. A. Fisher's work on these developments is mentioned wherever possible. His objections to the drawing of causal conclusions from observational data on cigarette smoking and lung cancer are used to introduce the problems of measurement error and confounding bias."     

Characterizations,length-biasing,and infinite divisibility

SupposeL(X) is the law of a positive random variableX, andZ is positive and independent ofX. Admissible solution pairs (L(X),L(Z)) are sought for the in-law equation $\hat X \cong X o Z$ °Z, where $L\left( {\hat X} \right)$ is a weighted law constructed fromL(X), and ° is a binary operation which in some sense is increasing. The class of weights includes length biasing of arbitrary order. When ° is addition and the weighting is ordinary length biasing, the class of admissibleL(X) comprises the positive infinitely divisible laws. Examples are given subsuming all known specific cases. Some extensions for general order of length-biasing are discussed.     

Physician organizations. Part 1: A report from the trenches of a start-up PO

How has Community Health Partners, a physician organization based in Kansas City, turned the corner as it rolls into the second year of operation? The biggest indicator is that CHP hammered out the city's first professional risk contracts and the PO has grown from 23 to more than 50 physician member/owners. Looking back, there are at least 10 reasons why CHP made it this far. These are not reasons you learn about in medical school or an MBA program. There is no one-size-fits-all template for building POs. No fixed organizational chart. No neon signs pointing to the best capital partner. Part I explores five reasons for success, such as having a strong board and physician leadership, as well as educating participating physicians about capitation and affiliating with any hospital or payer that really knows how to partner with physicians. Part 2 will focus on five more lessons learned from the trenches of a start up PO.     

Medical savings accounts. Power and choice

As the market becomes more saturated and matures, keeping people healthy will become a bigger source of profits and true health maintenance will become increasingly important. Right now, however, the name of the game is restricting services, particularly in new markets. What is sorely needed is a balance between the individual and organizational agendas, between the individual and society. There is a tremendous opportunity for hospital-physician groups contracting directly with employers using Medical Savings Accounts (MSAs) and catastrophic insurance as a core strategy. Are MSAs a viable insurance vehicle? Some argue that those enrolled in MSAs will put off receiving needed medical care. But it can also be viewed that MSAs, by their very nature, put costs back into the negotiation phase between patients as customers and physicians and hospitals as providers--and save money and resource consumption as patients shop around for competitive prices to do what needs to be done.     

Re-Visioning Attention Deficit Hyperactivity Disorder (ADHD)

Constructionist notions have become commonplace in theoretical discussions of the self, but are seldom translated into consideration of specific social work practice concerns such as ADHD. Explorations of ADHD, on the other hand, typically emphasize a narrow, medically-oriented symptom picture that is devoid of the psychosocial context in which the so-called symptoms emerge. A transactional approach to the understanding of ADHD is advanced. This article promotes a link between constructionism and social work's psychosocial or person-in-environment perspective. Such a perspective supports approaches to the assessment of ADHD that illuminate larger cultural messages and their constraining influence on individual meaning-making. Intervention, conducted at multiple levels, must be geared to the establishment of more hopeful and affirming narratives.     

Implementation and process evaluation of a student "school-as-community" group. A component of a school-based drug abuse prevention program

Little documentation exists regarding the functioning of formalized adolescent groups as drug abuse prevention agents. Two studies are described that were conducted at high schools whose students are at high risk for drug abuse. Twenty-one schools were randomly assigned to one of three conditions: (a) standard care, (b) classroom drug abuse education only, or (c) classroom plus school-as-community. Results of the first study indicated that the school-as-community component--which involved weekly meetings and periodic events at seven schools--was implemented as planned, drug abused focused, and perceived as productive in discouraging drug abuse. In the second study, staff in the classroom plus school-as-community condition self-reported involvement in the greatest number of community activities across the school year, compared with staff from the other two conditions. These two studies support the feasibility of formalized groups of high-risk youth to promote drug-free events.     

Genetic screening technology: ethical issues in access to tests by employers and health insurance committees

Whereas the introduction of new technologies previously has raised the ethical question of who ought to have access to a new procedure or device, genetic testing technology raises the new ethical question of to whom access to a new technology ought to be limited. In this article we discuss the implications of employers and private health insurance companies having access to genetic testing technology. Although there may be legitimate business interests in allowing employers and insurers to conduct genetic screening, there are other valid societal interests in regulating or limiting the use of this technology by third parties. Public policy developed in the area of new genetic technology must reflect such interests.