Investigational: what's in a name

The term "investigational" has become the fulcrum upon which coverage decisions turn. All third-party payers, including the federal government, use varying definitions of the term for the purpose of excluding treatments from coverage for payment. Unfortunately, no consistent definition of the term is available to payers to guide them in their coverage decisions.     

Coverage, technology assessment, and the courts

Coverage decisions by third-party payers are relying more and more heavily on the conclusions of technology assessment programs about the safety and effectiveness of technologies applied in specific clinical situations. Assessment programs vary markedly in the sophistication and rigor of their methodology. Payers differ as to how such assessment information is integrated into their decision-making processes. Finally, coverage decisions about a specific technology can vary widely across the country.     

The challenge of world health

2 development specialists have expounded on the demands world health has placed on public health. Striking declines in infant and child mortality occurred with the advent of biomedical and technical interventions in developing countries after World War II. At the same time, these interventions promoted longer lives by curing and/or treating chronic diseases in developed countries. In the 1970s, however, it was apparent that the hospital based, curative approach could not meet health needs and was very costly. In developed countries, biomedical and social sciences showed that chronic diseases did not occur due to modernization but from unhealthy behaviors, diet, and lifestyle. In fact, in 1975, the US Centers for Disease Control announced that unhealthy lifestyles contributed to 50% of all deaths while the medical system was responsible for only 11%. The US and other developed countries then began to promote healthy lifestyles, and in the 1980s, considerable improvements in health occurred, especially among adults. Developing countries which depended on the Western medical model did not experience health gains in the 1970s. Yet developing countries where health systems concentrated on carrying essential services to all people and promoted basic hygiene and sound dietary practices continued to achieve considerable health gains. In 1978, WHO an UNICEF hosted the International Conference on Primary Health Care in Alma Ata, the Soviet Union to hold these developing countries with community based health systems as models of primary health care (PHC). The 1980s witnessed the spread of PHC especially in the form of child survival which focused on oral rehydration therapy and breast feeding. The biomedical and social sciences are needed to move this health policy and program strategy forward. Governments must see to policies that promote healthy people. Political will is needed to make human welfare a high priority.     

Audience effects on solitary faces during imagery: Displaying to the people in your head

Subjects imagined situations in which they reported enjoying themselves either alone or with others. Electromyographic (EMG) activity was recorded bilaterally from regions overlying thezygomatic major muscles responsible for smiling. Controlling for equal rated happiness in the two conditions, subjects showed more smiling in high-sociality than low-sociality imagery. In confirming imaginary audience effects during imagery, these data corroborate hypotheses that solitary facial displays are mediated by the presence of imaginary interactants, and suggest caution in employing them as measures of felt emotion.Avery Gilbert and Amy Jaffey had compelling insights throughout the course of study. We thank Paul Ekman, Carroll Izard, and Paul Rozin for extensive comments on earlier drafts. We also thank Bernard Apfelbaum, Jon Baron, Janet Bavelas, John Cacioppo, Linda Camras, Dean Delis, Rob DeRubeis, Alan Fiske, Stephen Fowler, Greg McHugo, Harriet Oster, David Premack, W. John Smith, and David Williams for their valuable comments and suggestions.     

Minimal treatments and problem gamblers: A preliminary investigation

In view of the increasing popularity of minimal intervention treatments for problem drinking, a self-help manual for people who wish to reduce or stop gambling was prepared. Twenty-nine (ACT residents) who responded to advertisements for help with problem gambling were allocated to either of two minimal treatments, Manual (only) and Manual & Interview. On average, clients from both groups reduced the frequency of their gambling sessions, frequency of overspending, and amount spent per week in the first three months and next three months after first contact, but expenditure per session increased from three to six months, after an initial improvement. There was no evidence that a single in-depth interview added to the effectiveness of the manual.This project was funded by a grant from the Australian National University Faculties Research Fund.     

Legal implications of managed care arrangements

Prior to the 1980s, managed care was virtually nonexistent as a force in health care. Presently, 64 percent of employees in America are covered by managed care plans, including health maintenance organizations (20 percent) and preferred provider organizations (44 percent). In contrast, only 29 percent of employees were enrolled in managed care plans in 1988 and only 47 percent in 1991. To date, the primary reason for this incredible growth in managed care has been economic-market pressure to reduce health care costs. For the foreseeable future, political pressures are likely to fuel this growth, as managed care is at the center of President Clinton's national health care plan. Although there are numerous legal issues surrounding managed care, this article focuses primarily on antitrust implications when forming managed care entities. In addition, the corporate practice of medicine doctrine, certain tax issues, and the fraud and abuse laws are discussed.     

Interrupted stories, interrupted lives

In attempting to manage their practices efficiently, doctors may not allow seriously ill patients enough time to sort out their feelings and raise important questions. What is at stake here is not information about prognosis and treatments but the very survival of the soul.