Illusions of necessity: evading responsibility for choice in health care

Discretionary power is commonly defended by denial of its existence, the allegation of inevitability. Objective external conditions and forces are claimed to dictate policy decisions with tangible distributional effects. In health policy, such forces include the aging of the population, the extension of technology, and the demands of ethical standards. Taken together, these forces create relentless upward pressure on costs, to levels which society "cannot afford," necessitating sacrifice of the interests of the "less eligible." Yet quantitative analysis of these forces does not sustain the argument; in each case the source of cost escalation is not external pressure but the way in which the health care system itself reacts. Less costly and equally effective options are demonstrably available, but would threaten provider interests and broader ideologies. A spurious cloak of inevitability serves to promote and justify political choices.     

Prospective payment in perspective

Prospective payment promises improvement for a health care system plagued by inefficiency and rising costs, but is likely to disappoint. Serious efforts to control costs threaten the system's access and quality objectives and will be resisted. Moreover, serious cost containment, whether the result of all-payer regulation or competition, requires a stronger civil service than America seems capable of providing. A comparison with the experience in defense demonstrates the important limitations in applying incentive-based models in policy areas with conflicting goals. The search for panaceas will go on, but there are none.     

Barriers to achieving a cost-effective workforce mix: lessons from anesthesiology

As pressures to control health care costs increase, competition among physicians, advanced practice nurses, and other allied health providers has also intensified. Anesthesia care is one of the most highly contested terrains, where the growth in anesthesiologist supply has far outstripped total demand. This article explains why the supply has grown so fast despite evidence that nurse anesthetists provide equally good care at a fraction of the cost. Emphasis is given to payment incentives in the private sector and Medicare. Laudable attempts by the government to make Medicare payments more efficient and equitable by lowering the economic return to physicians specializing in anesthesia have created a hostile work environment. Nurse anesthetists are being dismissed from hospitals in favor of anesthesiologists who do not appear "on the payroll" but cost society more, nonetheless. Claims of antitrust violations by nurse anesthetists against anesthesiologists have not found much support in the courts for several reasons outlined in this essay. HMO penetration and other market forces have begun signaling new domestic physician graduates to eschew anesthesia, but, again, Medicare payment incentives encourage teaching hospitals to recruit international medical graduates to maintain graduate medical education payments. After suggesting desirable but likely ineffective reforms involving licensure laws and hospital organizational restructuring, the article discusses several alternative payment methods that would encourage hospitals and medical staffs to adopt a more cost-effective anesthesia workforce mix. Lessons for other nonphysician personnel conclude the article.     

ERISA, agency costs, and the future of health care in the United States

Because so many Americans receive health insurance through their employers, the Employee Retirement Income Security Act (ERISA) of 1974 plays a dominant role in the delivery of health care in the United States. The ERISA system enables employers and insurers to save money by providing inadequate health care to employees, thereby creating incentives for these agents to act contrary to the interests of their principals. Such agency costs play a significant role in the current health care crisis and require attention when considering reform. We evaluate the two major health care reform movements by exploring the extent to which each reduces agency costs. We find that agency cost analysis clarifies the benefits, limits, and uncertainties of each approach.     

Employers: passive purchasers or provocateurs?

This article addresses the potential role of business leadership in diverse efforts to reform health care financing: exploring managers efforts to alter health care markets in their role as large purchasers of health insurance, their potential contributions to future national policy proposals, and their involvement with community-level activities to control local health costs and quality. I argue that managers' leadership in market restructuring and community health initiatives will be difficult to reproduce in the realm of major national health policy initiatives due to constraints related to ideas, interests, and organization.     

Politics and economics of hospital cost containment

Voluntary and regulatory efforts toward hospital cost-containment have accelerated with rapid increases in those costs and under pressures of national health insurance. Possible causes of hospital cost inflation are examined in the context of market analysis and with reference to the nature of hospitals as institutions facing special combinations of economic and political conditions and pressures. Some details of voluntary experiments and state regulatory efforts are examined in order to assess the elements of experience to date and their relationships to causes of hospital cost inflation. Federal proposals for a regulatory cap on costs are also discussed along with a view of how such proposals are related to probable causes of hospital cost inflation and of the relevance of other experience.     

Trilateral commission and Latin American economic development

Conclusion Thus while the Trilateral Commission has been successful in identifying problem areas, each of the Trilateral countries has been unable to subordinate the immediate interests of its major economic components for the historic interests of the whole. While the Trilateral Commission has been successful in formulating an outlook that encompasses the major capitalist countries, that ideology has not been the operative basis of policies. While the Trilateral Commission's influence is manifest in the frequent summit meetings, the decisive decisions that shape the course of each country are taken elsewhere. Finally, and most fundamental of all, the Trilateral Commission has not been able to contain social and national revolution — to put the Third World in its place. For, above all else, the most basic challenge to Trilateralism is the emerging mass democratic social revolutions which are challenging the social relations upon which Trilateral power rests. The Trilateral adaptations to this struggle — the attempt to contain it within the framework of conservative civilian regimes (Frei in Chile, APRA in Peru, Estenssoro in Bolivia) is doomed to failure: the demands of the newly aroused mass movements far exceed the bounds compatible with these regimes. The scheme of so-called viable democracies is neither viable nor democratic — in any popular sense. The export oriented free market economies and industrialization from outside and above promoted by the Trilateralists will be the first to succumb as these popular forces move from opposition to power. Let us make no mistake, the present crisis of the Trilateral countries is just beginning.     

政府治理与公民社会参与

社会主义的本义要求以"社会至上"为主义,公民、公民社会参与市政管理和建设,是社会主义本质应有之义.宪法上的人具有"私人"与"公人"的双重身份和人的"私权利"与"公权利"的双重权利.与之相对应的,社会也可以分为"私人社会"与"公民社会".公民权或公民的公权利,主要是参与国家政治的权利,是公民的政治参与权和政治防卫权.公民社会既参与、支持又监督、制约政府行使权力,是推进政府治理的基本动力.     

Health care in Canada: patterns of funding and regulation

During the 1970s the share of health care expenditure in Canadian GNP remained roughly stable, in the range of 7-71/2 percent of GNP, in marked contrast to its escalation in most other countries (the U.S. in particular) and to previous Canadian experience. The shift to a stable pattern coincided with the completion of the Canadian system of universal comprehensive public hospital and medical care insurance. This paper explores how and why the public insurance system served to contain cost escalation. It then discusses the inadequacy of expenditure experience per se as a basis for health system evaluation--the same data will support claims of both "underfunding" and "spiralling costs." More serious questions involve the influence of alternative patterns of health care funding and delivery on the effectiveness and efficiency of care provision, and the resulting distributional patterns of care and income. A brief sketch is given of the present situation and future possibilities of Canadian health care under these heads.     

疫情防控中妨害公务罪的法教义学解析

为了个人自由而抗拒防疫管控,是对国家公务活动正常秩序的公然侵犯,具有法益侵害性。对于妨害公务罪之"暴力、威胁",应结合其侵害法益、实务经验予以合理界定。参与疫情管控的基层工作人员能否作为妨害公务罪之对象,需根据司法解释的规定,紧扣从事疫情防控职权之公务性质深入分析。以暴力、威胁方法抗拒不当防疫措施的,因防疫执法之合法性丧失,不构成妨害公务罪。行为人对防疫执法行为合法性的认识错误,属于对构成要件的事实认识错误,阻却犯罪故意的成立。     

Death certificates in Germany, England, The Netherlands, Belgium and the USA

Every country has its own legal system regarding post mortem examinations and death certificates. The authorities want to know the cause and the manner of death of their citizens and especially whether someone is responsible for the death of someone else. In this article a comparison is made between the legal regulations in the Netherlands, Belgium, Germany, England and the USA. Specific attention is given to the following aspects: which official performs the post mortem exam, what is the role of the attending physician by issuing the death certificate and how is the privacy of the deceased protected.     

The deterioration of deterrence effects of driving legislation: Have we been giving wrong signals to policymakers?

This paper suggests that the apparently observed initial success of legislation to control drunken driving accidents by law enforcement and sanctions, followed by a return of accident levels to initial trends may be an artifact of failure to properly model the accident process. The point is illustrated by simulating a model of accidents in which drunken driving is controllable with a change in laws. It shows that this control effect can easily be swamped by other plausible accident inducing forces. Finally, it is argued that the cost of failing to maintain efforts to control drunken driving may be greater than the social costs of maintaining high enforcement levels and stiff penalties.     

Comment on Kartell v. Blue Shield of Massachusetts, Inc.: an antitrust analysis of Blue Shield's reimbursement schemes

In Kartell v. Blue Shield of Massachusetts, Inc., the First Circuit held that Blue Shield's reimbursement practice known as the "ban on balance billing" did not constitute an unlawful restraint of trade in violation of the antitrust laws. Underlying the First Circuit's decision was deference to what it viewed as efforts by Blue Shield and by the Commonwealth to promote cost containment. This Comment argues that, to the contrary, under an appropriate analysis of antitrust law, the practices employed by Blue Shield did constitute unreasonable restraints of trade on the physicians' service industry in Massachusetts, given Blue Shield's market dominance in the Commonwealth. The Comment also argues that such inhibition of the competitive functioning of this industry is unwise, and that costs should instead be contained by effectuating the antitrust laws and encouraging the development of competitive forces within this industry.     

On Medical Secrecy

The Constitution of the USSR proclaims the right of citizens to privacy (Article 56). The harmony of personal and public interests in socialist society presupposes the existence of a certain area of personal life that is free of direct interference by society. Individual freedom in personal life is one of the most important and specific components of personal liberty. The state does not regulate many aspects of personal life unless such regulation is indicated by society's interests or else legislatively prohibits the invasion of privacy. Thus, the purely personal is granted the right to exist, and every citizen's right to privacy is assured.     

Side effects: a dose of competition and access to care

The Federal Trade Commission and Department of Justice 2004 report Improving Health Care: A Dose of Competition argues in favor of increasing competition among health care providers. Several of the proposals within the report, however, may pose risks for access to care. The report urges that the current system of implicit cross-subsidies for indigent care be replaced with insurance expansions that provide coverage to individuals. Such a substitution would certainly enhance access, but would be very costly and likely require considerable government intervention in the health care system. In the absence of a substantial expansion in coverage, reductions in cross-subsidies could limit access to care through the existing safety net. The report argues that insurance mandates limit access to care by driving up cost and reducing choice. In some cases, such as mental health and substance abuse, however, the unregulated market may not cover a benefit at all, leaving people with less coverage and less choice. Finally, the report stresses the importance of linking costs to quality. Such a linkage is likely to lead to a health care system in which poor people obtain poor-quality care at low prices--a result that many would find disturbing.     

Seeking common ground: a history of labor and Blue Cross.

In recent years, voluntary health insurance costs have become a major source of friction in labor-management negotiations. What was once a "fringe" has led to job actions, strikes, and intensive bargaining. We examine the history of labor's participation in New York Blue Cross from the 1930s to the recent past and show that labor's participation in the plan was crucial to Blue Cross's success in the plan's early decades. By the late 1950s, serious tensions developed over rate increases and the participation of labor in Blue Cross governance. Ultimately, the issue was one of the control over what was provided by the plans and who would pay for the costs of care. We posit that labor was never able to achieve an important role in the control of the third-party payer, and in the antilabor environment of the 1980s this proved detrimental to labor's interests.     

权利换和谐：中国传统法律的秩序路径

传统中国,法律要求个体放弃部分权利,以获得特定共同体的资格,并因而享受共同体所提供的某种利益或利益期待;由于利益或利益期待的存在,个体之间形成有利于共同体存在和发展的和谐关系。个体放弃或让渡部分权利,以置换共同体的整体和谐,这是中国传统社会的价值追求,也是中国传统法律实现国家统治和社会控制、构建稳定的社会秩序的主要路径。     

Challenging Australia's "closed" model of neonatal care: the need for reform following Re baby D (No 2)

The withdrawal or withholding of life-sustaining treatment to compromised newborns is a subject of controversy in countries where there is now highly advanced neonatal care to keep such newborns alive. The topic has generated comparatively less debate in Australia, where case law is sparse and parents and clinicians themselves make decisions regarding the cessation of care, largely free from extemal oversight. The recent case of Re Baby D (No 2) [2011] FamCA 176 endorses this "closed" approach to neonatal decision-making. This article critically discusses some of its implications and makes suggestions for reform to ensure meaningful oversight of decisions to withdraw or withhold treatment. The authors argue that the judgment fails to address some fundamental issues, such as ensuring that those with the responsibility to make decisions are doing so on a "best interests" basis. This is important because, in a society where disability remains stigmatised and poorly understood, there is no opportunity under the approach adopted in Baby D to guarantee adequate protection of the rights of individuals born with physical or intellectual impairments.     

Health, Social Movements, and Rights-based Litigation in South Africa

This article investigates the impact of rights-based litigation on social struggles in the South African health sector. It considers the manner in which individuals and social movements have utilized rights and the legal process in their efforts to dismantle the ill-health/poverty cycle, in the particular context of the struggle for universal access to treatment for HIV/AIDS. Relying on literature concerning the transformative potential of socio-economic rights litigation and on examples from South African case law, the article critically evaluates the gains that have been made and the obstacles that have been encountered in this context. It argues that rights-based litigation presents a powerful tool in the struggle against poverty, but also elaborates on structural and institutional hurdles that continue to inhibit the effectiveness of rights-based strategies in this regard.