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.     

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.     

Origins and destinies: Immigration to the United States since World War II

Contemporary immigration to the United States and the formation of new ethnic groups are the complex and unintended social consequences of the expansion of the nation to its post-World War II position of global hegemony. Immigrant communities in the United States today are related to a history of American military, political, economic, and cultural involvement and intervention in the sending countries, especially in Asia and the Caribbean Basin, and to the linkages that are formed in the process that open a variety of legal and illegal migration pathways. The 19.8 million foreign-born persons counted in the 1990 U.S. census formed the largest immigrant population in the world, though in relative terms, only 7.9% of the U.S. population was foreign-born, a lower proportion than earlier in this century. Today's immigrants are extraordinarily diverse, a reflection of polar-opposite types of migrations embedded in very different historical and structural contexts. Also, unlike the expanding economy that absorbed earlier flows from Europe, since the 1970s new immigrants have entered an hourglass economy with reduced opportunities for social mobility, particularly among the less educated, and new waves of refugees have entered a welfare state with expanded opportunities for public assistance. This paper seeks to make sense of the new diversity. A typology of contemporary immigrants is presented, and their patterns of settlement, their distinctive social and economic characteristics compared to major native-born racial-ethnic groups, and their different modes of incorporation in—and consequences for—American society are considered.     

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.     

What affects nonprofit survival?

This article describes mortality patterns for nonprofit organizations in a major U.S. metropolitan area between 1980 and 1988. Twenty percent of the nonprofits in a panel ceased operations during this period. Mortality rates were found to vary widely. In some instances, high mortality was found in parts of the sector that were growing rapidly. Overall, nonprofits that ceased to operate were younger and smaller, used fewer strategies to attract funders, and had less diversified income streams than survivors. These patterns also varied substantially. The results point to the drawbacks of using limited or commonsense information and the necessity of theory-based research.