Evaluating risk: global fees and episodic care

In 1999, two articles in The Physician Executive -- "Part I: Global Theory and the Nature of Risk (July-August)." and "Part II: Towards a Choice-Based Model of Managed Care (October-November)" -- outlined the flaws of orthodox managed care theory and highlighted the unique advantages of moving to a genuinely market-based model, which included the concept of direct contracting for integrated episodes of care. This follow-up focuses on comparing an episode contracting system to a traditional capitated program and outlines the features that make this approach much more attractive to physicians, payers, and most importantly patients.     

Conflict and Creativity in Groups

Consultants and researchers have long recognized the debilitating effects that conflict between group members can have on both group and individual outcomes . Yet less attention has been paid to the important role that conflict may play in helping generate innovative solutions to ill-structured problems . Furthermore , conflict (properly managed) is critical to the avoidance of groupthink (i . e ., the tendency to sacrifice quality decision making and problem solving for the sake of consensus and conflict avoidance) . What strategies can group members use to incorporate conflict , or more specifically , dissent in group problem solving? We argue that the delivery of dissenting opinions (negative evaluations) affects the extent to which dissent fosters creativity . We report the results of an experiment in which the target of negative evaluations was varied (e . g ., source of an idea vs . idea itself ) and compared to a condition in which no negative evaluations were incorporated . The results show that (1) creativity is higher in the conditions involving idea-targeted negative evaluations than source-targeted or no negative evaluations; (2) negative evaluations from others increase in conditions in which there are source-targeted negative evaluations and idea-targeted negative evaluations , compared to no negative evaluations; and (3) group members report higher levels of satisfaction when working under conditions involving idea-targeted negative evaluations , compared to source-targeted or no negative evaluations . We discuss the implications of this research for organizational settings , with particular attention to how they might inform the design of group decision support systems .     

Conflicts of interest in academic research: policies, processes, and attitudes

Few studies have examined academic researchers' understandings or attitudes toward conflict of interest policies even though these understandings and attitudes represent a crucial component of both compliance and educational efforts. This study reports the results of a large-scale, cross-sectional survey of research faculty at the nine campuses of the University of California regarding their understandings of and attitudes toward campus conflict of interest policies. We gathered information on their general assessments of investigators with financial ties to industry sponsors and reactions to the process of implementing conflict of interest policies at their respective campuses. We surveyed 1,971 faculty members from the nine-campus University of California system and had 779 responses (39% response rate). The sampled faculty were in the ten departments with the most number of financial disclosures at each campus. We utilized the WebSurveyor software to create a secure, online, 21-item survey. Our study reveals faculty with complex, sometimes contradictory, feelings about academic-industry relationships and highlights perceived gaps in policy and process. Most respondents were concerned about unlimited financial relationships, but a sizable number also viewed campus policies as irrelevant. Some expressed considerable anger over the process of policy implementation, rejecting the policies on the basis of professional and individual self-determination and moral integrity. Our study suggests the need for renewed efforts to encourage awareness of the relevance of conflict of interest policies for all faculty, new efforts to increase understanding of the situational nature of conflicts of interest, and reexamination of the processes of policy implementation at the campus level.     

A spiritual framework in incest survivors treatment

Through an examination of recent incest treatment development, this article emphasizes the theoretical concept of integration within the treatment process for female adult incest survivors. Spirituality as a therapeutic foundation is discussed with examples of therapeutic techniques. A case study illustrates the psycho-spiritual process of treating a 29-year-old female incest survivor and describes how self-integration has helped this client heal from trauma and change her worldview. Significant outcomes of treatment include the client's gaining of self-awareness and freeing herself from emotional blindness. The recommended practice framework includes a three-step healing process of building alliance with the client in a safe environment, disputing faulty religious assumptions in a learning process, and affirming the needs for reconnection and continuous spiritual support.     

Stalking and other forms of intrusive contact after the dissolution of adolescent dating or romantic relationships

Social science research has recently begun to focus on stalking and other forms of intrusive contact occurring among adolescents and young adults. This article presents results from a survey of 681 undergraduates about their experiences with stalking or other forms of intrusive contact occurring after the end of a dating or romantic relationship. Twenty percent of the respondents had been the target of intrusive contact, 8% had initiated intrusive contact, and 1% had been the target of intrusive contact after one relationship and had initiated intrusive contact after another. More females than males were the target of intrusive contact; however, there were no sex differences associated with initiating intrusive contact. About 20% of the respondents had feared for their safety during the intrusive contact. Thirty-one percent of the respondents described the intrusive contact as having a decidedly negative influence on either their subsequent dating relationships or their lives in general.     

Sex Related Factors in the Perception of Threatening Facial Expressions

This study replicated and extended previously reported sex differences involving both viewer and target in the recognition of threatening facial expressions. Based on the assumption that the evolved cognitive mechanisms mediating anger recognition would have been designed by natural selection to operate quickly in the interests of survival, brief tachistoscopic presentation of stimulus photographs was used. Additionally, in contrast to prior published studies, the statistical methods of signal detection research were used to control for the confounding effects of non-random guessing. The main hypothesis, that anger posed by males would be more accurately perceived than anger posed by females, was supported. A secondary hypothesis, that female-posed anger would be more accurately perceived by women than by men, received partial support. Testosterone levels, measured inferentially in terms of diurnal cycles, failed to show the hypothesized positive relationship to accuracy of anger perception.     

“Fear Runs Deep:” The Anticipated Needs of LGBT Older Adults in Long-Term Care

Objectives: Older lesbian, gay, bisexual, and transgender (LGBT) adults are a vulnerable yet resilient population who face unique stressors as they foresee health decline. This paper presents the results of a study about community-dwelling LGBT older adults’ anticipated needs and fears related to nursing homes and assisted living. Methods: This qualitative study collected data through seven focus groups. The sample (N = 50) consisted of LGBT-identified adults age 55 and over. We used an inductive, thematic analysis approach to data analysis. Results: Participants seek an inclusive environment where they will be safe and feel connected to a community. They fear dependence on healthcare providers, dementia, mistreatment, and isolation. Importantly, these fears can lead to identity concealment and psychological distress, including suicide ideation. Discussion: This study adds to the existing literature about the worries of older LGBT adults as they anticipate long-term care. The results suggest that older LGBT adults seek LGBT-inclusive residential care settings that encompass two distinct yet related aspects of LGBT-affirmative care: the procedural (e.g. culturally competent skills and knowledge of practitioners) and the implicit (e.g. the values and mission of the organization). This paper identifies implications for practice, policy, and training.     

Quantifying the Distribution of Inhalation Exposure in Human Populations: 2. Distributions of Time Spent by Adults, Adolescents, and Children at Home, at Work, and at School

Using distributions of time spent at various ventilation levels, ranges of inhalation exposure in the population can be established. Distributions of exposure time were determined using results of a study by the California Air Resources Board (CARB) which focused on time spent by humans participating in various activities and the locations where the activities occurred. The daily at-home activities from the CARB study were assigned to one of three ventilation levels, generating aggregate time periods. Distinct age and gender populations were identified, and distributions for aggregate time were established for these populations at each of the ventilation levels. In addition to aggregate time spent at home, distributions for various ages and genders were established for aggregate time spent at school and work. By combining distributions of aggregate time with corresponding ventilation rates, the distribution of inhalation rates can be established for at home, at work, and at school exposures.     

Uncertainty and Variability in Health-Related Damages from Coal-Fired Power Plants in the United States

The health‐related damages associated with emissions from coal‐fired power plants can vary greatly across facilities as a function of plant, site, and population characteristics, but the degree of variability and the contributing factors have not been formally evaluated. In this study, we modeled the monetized damages associated with 407 coal‐fired power plants in the United States, focusing on premature mortality from fine particulate matter (PM_2.5). We applied a reduced‐form chemistry‐transport model accounting for primary PM_2.5 emissions and the influence of sulfur dioxide (SO₂) and nitrogen oxide (NO_x) emissions on secondary particulate formation. Outputs were linked with a concentration‐response function for PM_2.5‐related mortality that incorporated nonlinearities and model uncertainty. We valued mortality with a value of statistical life approach, characterizing and propagating uncertainties in all model elements. At the median of the plant‐specific uncertainty distributions, damages across plants ranged from $30,000 to $500,000 per ton of PM_2.5, $6,000 to $50,000 per ton of SO₂, $500 to $15,000 per ton of NO_x, and $0.02 to $1.57 per kilowatt‐hour of electricity generated. Variability in damages per ton of emissions was almost entirely explained by population exposure per unit emissions (intake fraction), which itself was related to atmospheric conditions and the population size at various distances from the power plant. Variability in damages per kilowatt‐hour was highly correlated with SO₂ emissions, related to fuel and control technology characteristics, but was also correlated with atmospheric conditions and population size at various distances. Our findings emphasize that control strategies that consider variability in damages across facilities would yield more efficient outcomes.