Old and thin

Viewing an elderly patient's refusal of food from the perspective of the jain tradition of sallekhana (voluntary starvation) permits the author to reconcile her need to "do something" with her belief in the principle of patient autonomy.     

Effects of fixed costs in two-person sequential bargaining

Rubinstein (1982) considered the problem of dividing a given surplus between two players sequentially, and then proposed a model in which the two players alternately make and respond to each other's offers through time. He further characterized the perfect equilibrium outcomes, which depend on the players time preferences and order of moves. Using both equal and unequal bargaining cost conditions and an unlimited number of rounds, two experiments were designed to compare the perfect equilibrium model to alternative models based on norms of fairness. We report analyses of final agreements, first offers, and number of bargaining rounds, which provide limited support to the perfect equilibrium model, and then conclude by recommending a shift in focus from model testing to specification of the conditions favoring one model over another.     

How to fight the regulator glut: the role of the HCFA-type survey

More and more hospitals in this country are being threatened by the removal of their Health Care Financing Authority (HCFA) Medicare Certification. A perception of competitiveness among HCFA, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and other organizations has heightened this concern. This unpleasant situation has provoked many hospitals to prevent any type of regulator decertification. One of the practical methods of prevention is the use of a HCFA-type survey. These surveys prepare institutions for unexpected, unarmored review by regulators and should be part of the quality improvement (QI) process even in institutions with limited resources. This article discusses the means to accomplish the HCFA-type survey. The development of the survey process involves institutional commitment, hospital policy and procedures, a department review schedule, selection of review personnel, preparation of review personnel, record keeping, and department education.     

The medical examiner and deaths in the hospital setting

There has been a perceived increase in the number of medical negligence claims in recent years. The modern metropolitan medical examiner is increasingly called upon to deal with numerous medical, legal, social, and ethical issues. Nowhere is the role of the medical examiner more important than in the investigation of deaths related to surgical, diagnostic, anesthetic, or therapeutic procedures. Medical examiners have an important role in the investigative process. Through utilization of the offices and services of the medical examiner, questions raised by families, physicians, and other hospital employees may be satisfactorily answered a priori, and litigation may therefore be averted.     

Practice standards use with internal partners

U.S. Department of Defense experience with internal partnership programs has indicated that a lack of close supervision by medical treatment facilities can result in cost increases. The use of medical practice guidelines or standards is the subject of active investigation. The global guidelines tend to be too rigid or too vague to affect the provision of care. Their general acceptance can often be low. The use of clinical guidelines, with supervision by a clinic peer, has been determined to be a provider-friendly method of delivering cost-effective, high-quality care. Comparisons were made between the supervised partners against the total expenditures for ENT outpatient CHAMPUS care. The results indicated not only a savings but a reduction in the rate of cost increases by more than 250 percent. It is our feeling that specialty provider, peer-directed medical standards can be applied in a cost-effective manner. Their adoption as an organization-wide standard for referral can be an important tool in maintaining quality while containing costs.     

Employment-based health benefits: analysis of the April 1993 Current Population Survey

The April 1993 CPS differs from the March 1993 CPS in a number of respects. The April 1993 CPS supplement surveys only workers, whereas the March CPS examines the noncash benefits received by all Americans. The April CPS asks workers about health coverage in the week in which the questions were fielded, whereas the March CPS asks about coverage in the preceding year. In April 1993, there were 112.5 million civilian American workers between the ages of 18 and 64 with jobs. Eighty-two million (73 percent) of them worked for an employer that sponsored a health insurance plan, and 65 million (58 percent of all workers) participated in their employer's health plan. About one-third of workers at firms with fewer than 10 employees had employers who offer health benefits; about one-quarter of all of the workers in these firms participated in their employer's plan. Conversely, 94 percent of workers at firms with more than 1,000 employees had an employer who sponsored health benefits, and over 77 percent of these workers participated in their employer's plan. There are 16.5 million American workers whose employers sponsored health benefits but who did not participate in these benefits. Over one-half of these workers (8.5 million) chose not to be covered. Another 36 percent of these workers (5.9 million) did not participate because they were ineligible or denied coverage. Over 66 percent of the ineligible workers did not participate because they were part-time, contract, or temporary workers. Another 26 percent had not yet completed a probationary period. Among the reasons that those who chose not to participate in their employer's coverage, the vast majority (75 percent) stated they were covered by another health care plan. Twenty-nine percent stated that they chose not to purchase coverage because it was too costly or that they did not need or want the coverage. In 1993, there were 16.7 million workers with no health insurance coverage. The vast majority of these workers (95 percent) were employed by private employers. Sixty-six percent of the workers with no health insurance coverage were self-employed or worked for firms with fewer than 100 employees.     

The print media and aging policy: how differential coverage of Medicare Catastrophic led congress astray

This article examines the role of the print media in covering complex policy issues. Two models of journalism are considered. "Pack journalism" predicts that print media coverage will be highly consistent in content due to the reliance by those in the media on the same sources of information. In this article, another model--"Beltway journalism"--is proposed. It implies that coverage by the print media indigenous to the Washington, D.C. area (inside the Beltway) will diverge from that of other print media, presenting a potentially distorted view of the world to policymakers in Washington. Using the Washington Post and the Los Angeles Times as possible indicators of the two models, aging policy is addressed through a case study of newspaper coverage during passage and repeal of the Medicare Catastrophic Coverage Act of 1988. Findings suggest that Congress was unduly influenced by the way that Medicare Catastrophic was framed in the Washington Post, lending credence to the Beltway journalism model. By paying insufficient attention to the way Medicare Catastrophic was being framed by sources of print outside the Beltway area, lawmakers allowed themselves to assume a grassroots-level understanding of the issue and support for the bill, both of which turned out to be illusory.     

The new health care civilization: integration of physician land and manageria

Changes occurring in health care demand that physicians expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, will become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care. Our research findings and conclusions strongly suggest that economic, management, and leadership competencies need to be incorporated into the professional development of physicians, especially in postgraduate and continuing education curricula.