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.     

Reconciling commodities and personal relations in industrial society

Conclusions I began this article with Colin Campbell's lament about the productionist bias in sociology and the related point that most sociologists concerned with consumption have ignored private meanings and small-scale structures in favor of public meanings and large-scale structures. This article calls attention to and builds on an emerging alternative approach to what happens after production, using an understanding of the social nature of objects that springs from Marcel Mauss's distinction between gifts and commodities.Mauss's model directs attention to the conflict in industrial societies between the two realms of commodity exchange and gift exchange, which I have cast as the conflict between the world of work and the world of family, and as the contrast between commodities and possessions. Thus, the model directs attention to the fact that objects are not simply transformed in production and displayed in consumption. However important these facts may be for understanding objects and society, they do not exhaust the important ways that people experience, use, and think about the objects that surround them. In particular, Mauss's model throws into relief the problematic nature of the objects that surround us and that we use in our social relations. And in doing so it directs attention to the ways that people try to reconstruct and redefine those objects by transforming them into personal possessions. This transformation makes objects acquired as commodities suitable for gift transactions, and hence suitable for the key task of recreating social relationships and social identities, the task of creating, not merely defining, who we are and how we are related to each other.Although the Maussian model addresses many of the links between people in the worlds of work and the home, and many of the ways that objects are part of these links, I am concerned here primarily with the ways that people can appropriate commodities in the process of purchase: shopping. This concern with shopping points out the social significance of retail trade, which I take to include advertising and shopping. This is not simply a passive conduit between production and consumption. Instead, it is an important point at which objects begin to leave the realm of work, commodities, and commodity relations and enter the realm of home, possessions, and gift relations. Shopping is an ubiquitous activity in industrial society and one that is highly significant culturally: we spend vast amounts of time, energy, money, and attention on it. Doubtless part of the reason for this is utilitarian, for we need to buy to live, but it would be foolish to reduce the significance of shopping to some combination of the need of individuals to acquire in order to survive and the need of companies to generate demand in order to profit. Thus, retail trade needs to be seen as well as a set of relations and transactions between seller and buyer that define and are defined by the objects and services involved, their history, and their future. My focus on purchasing food in supermarkets has the advantage of throwing into relief the problem of appropriation, because of the impersonality of object and social relations in large, self-service supermarkets. However, the very extremity of this example can create a false impression. As I noted, in other forms of shopping the social relations between buyer and seller, like the social identity of objects, can be more personal. This personality can be real, as when buyer and seller know each other or where the object is hand-made or even unique. Alternatively, it can be more purely symbolic, as when the selling company touts itself or its employees as friendly and caring or where the manufacturer advertises the personal nature of its commodities. In some cases, indeed, the manufacturing or trading company can present itself in such a way that the company itself becomes the person with whom the purchaser transacts. In addition, because of the focus on the appropriation of commodities in purchasing, I have touched only briefly on production and the world of work more generally. As does life at home, so life at work involves the transaction of objects and labor. Relations at work, then, will shape and be shaped by the nature of what is transacted. Co-workers who transact things that are more clearly stamped with their own identity, as among service workers and craft producers, will likely have more personal relations with fellow workers than will those who transact things that are themselves relatively impersonal, as in assembly-line production. This variability in the objects and relations at work suggests that people will have diverse understandings of work, and hence of manufactured objects more generally, which will affect the need they feel to appropriate commodities. In all, though, the point of this article is simple. People use objects to create and recreate personal social identities and relationships, and in industrial capitalist societies these objects are likely to be produced and purchased as commodities and understood as manufactures in Miller's sense. Our experience with and understanding of the production and sale of objects will affect the way we use them in transactions that create and recreate social identity and relationship, and will affect our understanding of the social identities and relationships that are created and recreated. Thus, the objects that people use in social relationships mediate between realms of economy and society, between the public realms where those objects are produced and distributed, and the private realms where those objects are transacted as part of social reproduction. The fact of this mediation and its effects on people's understanding of objects and social relations deserve careful attention.

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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.     

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.