Showing papers in "Journal of Health Politics Policy and Law in 1984"
138 citations
83 citations
TL;DR: The case of aerobic exercise provides an instructive example to social scientists and policymakers seeking to understand or to encourage widespread behavioral change.
Abstract: Individual lifestyle was held accountable for health and disease throughout much of American history. Since the advent of the germ theory of disease, the focus on the etiology of disease has shifted to factors beyond individual control. But in the past two decades, there has been a resurgence of interest in the role of personal habits in producing sickness. This paper examines the history of one facet of the health promotion movement--aerobic exercise, primarily jogging. Initially, concepts in exercise physiology were adapted from non-medical fields--such as competitive sports and the military--for use in cardiac rehabilitation. Subsequently, a few physicians generalized their experience with cardiac patients to the general population, concluding that aerobic exercise could prevent heart attacks. This idea of exercise as a prophylaxis was seized upon by the public, who were receptive because of the political climate of the sixties. Once the popular movement was underway, researchers began studying the role of exercise in preventing coronary heart disease, confirming that exercise does confer some benefit. In the seventies, exercise attracted a new, wider audience--not because of the justification for its use provided by the scientific community, but because of the appeal of upright living as a means to personal and social redemption. The case of aerobic exercise provides an instructive example to social scientists and policymakers seeking to understand or to encourage widespread behavioral change.
63 citations
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TL;DR: The background and development of the Community Mental Health Centers Act of 1963 is examined, tracing how an important shift in national policy toward the mentally ill grew out of changing perceptions--among policymakers, professional groups, and the general citizenry in the post-World War II era.
Abstract: In recent decades the community mental health movement has achieved a dramatic reduction in the census of state and county mental hospitals in the United States, and hundreds of federally-funded community mental health centers have been established nationwide. At the same time, national controversy has arisen in response to what in places has seemed the haphazard process of implementing "deinstitutionalization" and the fate of many chronically mentally ill persons who are without needed social services and psychological care. Despite the widespread attention that this contemporary program has received, theoretical analysis of the complex social, scientific, intellectual, and political origins of America's community mental health policy remains deficient. This article examines the background and development of the Community Mental Health Centers Act of 1963, tracing how an important shift in national policy toward the mentally ill grew out of changing perceptions--among policymakers, professional groups, and the general citizenry in the post-World War II era--of the nature of the problem of mental illness.
49 citations
TL;DR: The number of years since medical residency is positively related to physicians' claims incidence during the first 27 years of practice, and that OBGs and medical specialists who spend more time with their patients per office visit incur fewer claims.
Abstract: This study analyzes the incidence of medical malpractice claims since 1976, using data drawn from the 1982 core survey of the American Medical Association's Socioeconomic Monitoring System. The data show that, on average, physicians incurred twice as many claims per year in the years 1976 to 1981 as they did during their careers prior to that period. Using Tobit analysis, we find the annual frequency of claims to be greater among surgeons, obstetricians and gynecologists (OBGs), physicians in group practice, and physicians in states which apply the legal doctrine of informed consent. In addition, we find that the number of years since medical residency is positively related to physicians' claims incidence during the first 27 years of practice, and that OBGs and medical specialists who spend more time with their patients per office visit incur fewer claims.
36 citations
35 citations
TL;DR: It is found that the differential payment is not justified; that the cost-containment efforts of the dominant payers have reduced total payments to hospitals somewhat, but a substantial amount of cost-shifting remains; and that the savings is in profits, rather than in costs.
Abstract: This study uses hospital data from the 1979 American Hospital Association Reimbursement Survey in a multivariate framework to assess the impact of discounts and third-party reimbursement on hospital costs and profitability. Three central issues are addressed: (1) Is a differential payment justified for Medicare, Medicaid, and/or Blue Cross on the basis of differential costs? (2) Have the cost-containment efforts of the dominant payers reduced total payments to hospitals? and (3) What part of the overall savings in payments to hospitals is in the form of reduced costs rather than reduced profits? On the basis of the evidence in this study, we find (1) that the differential payment is not justified; (2) that the cost-containment efforts of the dominant payers have reduced total payments to hospitals somewhat, but a substantial amount of cost-shifting remains; and (3) that the savings is in profits, rather than in costs.
33 citations
33 citations
TL;DR: It is shown that insufficient revenues, not inefficiency or underuse, that creates these hospitals' financial problems, and several policies that could be adopted to alleviate this financial pressure and sustain care to the poor are assessed.
Abstract: In 1980, while most hospitals were in reasonably good financial health, hospitals heavily involved in serving the poor ran a considerable risk of financial trouble. Fewer than 9 percent of the nation's hospitals accounted for 40 percent of the nation's total care to the poor. These hospitals, almost half of which were in the 100 largest cities, not only devoted more of their care to the poor than other hospitals, they also served substantially smaller proportions of privately-insured patients. The result was that one-third of these hospitals--by themselves accounting for over 15 percent of all care to the poor--ran deficits in 1980. Using data from a 1980 survey of nonfederal, nonprofit hospitals, this paper examines the fiscal situation of hospitals heavily involved in serving the poor. The analysis shows that it is insufficient revenues, not inefficiency or underuse, that creates these hospitals' financial problems. The article concludes with an assessment of several policies that could be adopted to alleviate this financial pressure and sustain care to the poor.
TL;DR: Professional opposition to treatment refusal is not based on a wide extent of actual refusal; rather it derives from a defense against challenges to professional and institutional autonomy, an opposition to legal interference, and a belief that the community as well as the patient must be protected.
Abstract: The right to refuse treatment is the most controversial of the rights of mental patients, and usually polarizes the movement for mental health reform between providers of care and external activist reformers. A broad alliance supported earlier struggles for recognition of patients' rights, but most professionals oppose recognizing this most extreme right of treatment refusal. Professional opposition to treatment refusal is not based on a wide extent of actual refusal; rather it derives from a defense against challenges to professional and institutional autonomy, an opposition to legal interference, and a belief that the community as well as the patient must be protected. These three reasons for opposition are examined by reviewing studies of attitudes toward patients' rights, knowledge about patients' rights, and implementation of patients' rights. Finally, the implications of these studies for future directions in the movement for patients' rights are examined.
TL;DR: The article focuses on the alteration of power relationships occasioned by the emergence of business interests as an active force in the formulation of health policy.
Abstract: In 1982 the state of California adopted a package of legislation collectively known as "the Medi-Cal reform." This article examines the background of this reform, the process through which it was adopted by the state legislature, and its effects on the various interests involved. In particular, the article focuses on the alteration of power relationships occasioned by the emergence of business interests as an active force in the formulation of health policy.
TL;DR: This paper argues that nonprofits are on the whole superior from the point of view of professional ideology and practice, given a commitment to the values of professionalism.
Abstract: Many professionals prefer to work in nonprofit organizations, rather than in either for-profit or bureaucratic organizations. This preference suggests that nonprofits may be successful in reducing the tension between professional principles and institutional requirements. Professionals in for-profit organizations must submit to the control of a manager who is motivated to overrule them whenever their decisions come into conflict with the goal of profit maximization. Bureaucratic organizations stress predictability of results and adherence to rules as the overriding criteria of evaluation and control. This paper argues that nonprofits are on the whole superior from the point of view of professional ideology and practice. Thus, given a commitment to the values of professionalism, the preference for the nonprofit form becomes understandable, even without the usual assumptions about income-maximizing behavior.
TL;DR: This paper analyzes Congressional voting behavior on the Gephardt Amendment to President Carter's hospital cost containment legislation and the impact of opposing interest groups is examined.
Abstract: This paper analyzes Congressional voting behavior on the Gephardt Amendment to President Carter's hospital cost containment legislation. The impact of opposing interest groups is examined: on one side were hospital and medical interest groups; on the other was the Carter Administration and its political party, as well as states with large Medicaid expenditures. The effect of political contributions from MEDPACs is evaluated, and the relative importance of various factors affecting the vote's outcome is analyzed.
TL;DR: It is suggested that the illegal status of undocumented workers intensifies their health risks; that the immigrants' responsibility for budget short-falls in public services is not as clearcut as frequently assumed; and that legislation aimed at regulating the status of immigrant workers in the U.S. is unlikely to solve many of the central problems.
Abstract: Immigrant workers are a large segment of the lower echelon of the U.S. labor force, and as many as 3.6 to 6 million of these workers and their families are living in the U.S. illegally. This paper examines who the recent immigrants are: explains why their current situation in the U.S. is an important public health matter; discusses the ethical and policy issues stemming from their health needs and from illegal status; and concludes with a brief look at some implications of the Simpson-Mazzoli Immigration and Reform Act, currently before Congress. The paper suggests that the illegal status of undocumented workers intensifies their health risks; that the immigrants' responsibility for budget short-falls in public services is not as clearcut as frequently assumed; and that legislation aimed at regulating the status of immigrant workers in the U.S. is unlikely to solve many of the central problems.
TL;DR: The influence of market forces and state regulations on enrollment in prepaid group practices (PGPs) is investigated and it is found that restrictions on corporate employment of physicians hinder the growth of PGPs.
Abstract: This paper investigates the influence of market forces and state regulations on enrollment in prepaid group practices (PGPs)--the dominant form of HMO. Using data at the metropolitan-area level, the paper estimates a lagged-adjustment model in two stages. The first stage estimates the determinants of the existence of a PGP of viable size. Using a technique appropriate for censored samples, the second stage estimates the determinants of enrollment given viability. The result of greatest relevance for policymakers is that restrictions on corporate employment of physicians hinder the growth of PGPs.
TL;DR: Legislative reforms, HMO organizational structures, and marketing strategies thought to encourage enrollment of the elderly are discussed.
Abstract: Although there has been increased interest in use of the health maintenance organization (HMO) model to resolve a variety of problems relating to provision of health care to older individuals, less than 2 percent of Medicare beneficiaries are currently enrolled in HMOs. This paper examines both legislative and operational barriers to HMO enrollment of the elderly. Legislative reforms, HMO organizational structures, and marketing strategies thought to encourage enrollment of the elderly are discussed.
TL;DR: An experimental program of care to the indigent that combines elements of capitation and competition is described and the extent to which the expectations of various groups have been met during the program's first year of operation is assessed.
Abstract: In October of 1982 the State of Arizona, which had no Medicaid program, initiated an experimental program of care to the indigent that combines elements of capitation and competition. This article describes the new program, explains why key political actors in Arizona reversed their earlier stand and enacted the program, and assesses the extent to which the expectations of various groups have been met during the program's first year of operation.
TL;DR: The competitive nature of the 1930s made altogether clear that entry control was a necessary, but not sufficient, condition for the maximization of dentist profits, and thus organized dentistry began its turn inward, focusing on the competitive behavior of existing dentists.
Abstract: Organized dentistry spent nearly a century laboring to obtain control over entry into the profession. The first attempt, the American Society of Dental Surgeons, failed because the issue of using amalgam so split the Society that collective action became impossible. The second attempt, state licensing during 1870-1900, gave preferential treatment (automatic licensing) to dental school graduates and appeared at first to be the solution to the entry problem, given the small number of schools in operation. However, dental school entrepreneurs recognized a profitable opportunity, and the supply of dental schools expanded rapidly. Thus, in the third and final attempt at obtaining entry control, organized dentistry attacked the for-profit schools. The dental practice acts were amended to require all candidates to pass a licensing examination, provided first that they were graduates of a school considered "reputable" by the state board of dental examiners. Moreover, rising costs generated by increased school standards took the profit out of for-profit operation, and by 1930 such schools ceased to exist. However, the competitive nature of the 1930s made altogether clear that entry control was a necessary, but not sufficient, condition for the maximization of dentist profits, and thus organized dentistry began its turn inward, focusing on the competitive behavior of existing dentists.
TL;DR: Implementation of competitive bidding in Arizona encountered problems which appear to be common to the implementation of innovative public programs and uncovered political liabilities that suggest that effective implementation ofcompetitive bidding for indigent medical care contracts in other environments will be difficult, even if technical implementation problems can be overcome.
Abstract: The State of Arizona recently instituted a competitive bidding process, in order to establish a health services delivery system for indigents and to determine capitated reimbursement levels for providers in that system. This article describes the implementation of that bidding process, and identifies factors which had a significant impact on the implementation experience. Implementation of competitive bidding in Arizona encountered problems which appear to be common to the implementation of innovative public programs. It also uncovered political liabilities that suggest that effective implementation of competitive bidding for indigent medical care contracts in other environments will be difficult, even if technical implementation problems can be overcome.
TL;DR: The SHARE program, which set per diem prospective rates for New Jersey hospitals during the period 1975-1982, is evaluated, and indirect evidence suggests that there was cost-shifting in response to this program.
Abstract: The SHARE program, which set per diem prospective rates for New Jersey hospitals during the period 1975-1982, is evaluated. Analysis suggests that this program did contain hospital cost increase. However, the program threatened the viability of most inner-city hospitals. Indirect evidence suggests that there was cost-shifting in response to this program, which regulated payment for only Blue Cross and Medicaid patients. Structural features of this program and its successor, the New Jersey DRG program, are analyzed; and implications for the Medicare prospective payment system are examined.
TL;DR: The scientific books will also be the best reason to choose, especially for the students, teachers, doctors, businessman, and other professions who are fond of reading.
Abstract: In what case do you like reading so much? What about the type of the the new health care for profit doctors and hospitals in a competitive environment book? The needs to read? Well, everybody has their own reason why should read some books. Mostly, it will relate to their necessity to get knowledge from the book and want to read just to get entertainment. Novels, story book, and other entertaining books become so popular this day. Besides, the scientific books will also be the best reason to choose, especially for the students, teachers, doctors, businessman, and other professions who are fond of reading.
TL;DR: It appears likely that financial incentives did play a role in physician decisions on whether to perform cesarean deliveries, due primarily to the high percentage of private patients recorded as having prolonged or obstructed labor, combined with a high rate of prior cESarean sections.
Abstract: This paper examines factors associated with the cesarean birth rate including medical condition and method of payment in the largest maternity hospital of Fortaleza Brazil. Data were collected on 5996 women who delivered at the Maternidade Escola Assis Chateaubriand from October 1980-July 1980. All women were classified according to how they paid for their care: private (financed at least part of their care with their own funds) insured (federal or state) or indigent. Private pattients were found to be far more likely than patients in other 2 groups to have cesarean deliveries due primarily to the high percnetage of private patients recorded as having prolonged or obstructed labor combined with a high rate of prior cesarean sections. From this data it appears likely that fininancial incentives did play a role in physician decisions on whether to perform cesarean deliveries. (authors)
TL;DR: Rate regulation in the United States usually is inspired by widespread indignant pressures to protect the public against venal exploitation, but rate regulation of American hospitals does not ride such a wave of outrage but is motivated by the need to restrain Medicaid spending and insurance premium increases in some states.
Abstract: Rate regulation in the United States usually is inspired by widespread indignant pressures to protect the public against venal exploitation Rate regulation of American hospitals does not ride such a wave of outrage but is motivated by the need to restrain Medicaid spending and insurance premium increases in some states Hospital rate regulation in America lacks strong political support, makes many politically prudent concessions to hospitals, and is often threatened by repeal Since Americans distrust regulators and since individual scrutiny of so many hospitals is burdensome and contentious, they often seek automatic formulae that will produce equitable results by rational calculation In contrast, rate regulation in Europe is a method of refereeing between hospitals and alert third parties Hospitals' prospective budgets are always scrutinized by regulators Guidelines are transmitted by government to link public policy to hospital payment, and the regulators apply the guidelines to each hospital's individual situation The system results in less contention and more stability in European than in American regulation Certain features of European hospital practice have kept hospital costs high, but the regulators are now reducing annual increases in costs below America's In order to reduce cost increases further, Europe is moving toward global budgeting and public grants of hospitals' operating costs, instead of regulation of unit rates However, regulators may still be essential to scrutinize hospital prospective budgets and to investigate the merits of the claims by individual establishments
TL;DR: This article describes an attempt to persuade the members of a presidential commission on ethics in medicine to open a public dialogue on the rationing of medical care to defuse some of the controversy surrounding the word rationing.
Abstract: This article describes an attempt to persuade the members of a presidential commission on ethics in medicine to open a public dialogue on the rationing of medical care. The need for limits on the health care individuals receive, and the reasons why the existing delivery system fails to set such limits in an ethically acceptable manner, were outlined. It was argued that although the term "rationing" is appropriate to describe the process of setting equitable limits, the word generates so much controversy that it is avoided; this very avoidance is an obstacle to the development of sound policy. As an ethics commission, it was argued, the Commission was in a unique position to educate the public about the need for limits, and to defuse some of the controversy surrounding the word rationing. The Commissioners were not persuaded. They accepted the case for limits, in substance, but refused to use the word rationing in their report.
TL;DR: A study of procedural public-participation mandates and financial sanctions imposed by California to hold counties to their obligations to provide indigent health care found noncompliance by some counties, although all counties complied after a state Health Services Department unit was established to monitor the counties and provide them with state aid.
Abstract: State governments have used several types of mandates to assure that local governments fulfill state-defined responsibilities, including public health care for the poor. This article reports the findings of a study of procedural public-participation mandates and financial sanctions imposed by California to hold counties to their obligations to provide indigent health care. An inventory of the laws' implementation in all California counties found noncompliance by some counties, although all counties complied after a state Health Services Department unit was established to monitor the counties and provide them with state aid. Case studies in eight counties identified factors that influenced the effectiveness of the laws in modifying or reversing county proposals to close county hospitals or reduce other health services. Policy guidelines are suggested for states that want to develop mandates to enforce indigent-care responsibilities of local governments.