Why hasn't integrated health care developed widely in the United States and not at all in England?

There have been influential advocates for financing and organizing health care in the United States and England based on the model of integrated health care delivery systems (IHCDSs). Despite good evidence that a few IHCDSs provide high-quality health care economically, such organizations are rare and localized in a few market areas in the United States and are absent in the English National Health Service (NHS). The explanation of why this is so includes various contributory factors: the way the development of the medical profession in each country pursued specialization; the division in British medicine between general practitioners and specialists; and the characteristics that we identify of established successful IHCDSs, which created formidable barriers to entry for a new IHCDS. This explains why currently the most promising organizational developments in U.S. health care are hybrids resulting from vertical integration. In England government policies of an "internal market," as adopted in the 1990s and currently, were and are based on a purchaser-provider split with the objectives that providers would compete and be funded by a system in which "money follows the patient." These policies recognize the division in British medicine, which also means that it is difficult to implement a reorganized English NHS based on high-performing IHCDSs.     

HELP IS ON THE WAY (OUT): PROHIBITING THE USE OF NONCOMPETITION AGREEMENTS IN THE MENTAL HEALTH PROFESSION

The use of noncompetition agreements in the mental health profession has created unfortunate consequences for patients and families seeking and receiving care within their respective communities. In addition to exacerbating issues in access and the availability of care in the mental health delivery system, noncompetition agreements (1) undermine the goals of therapy and injure the public's welfare; (2) potentially conflict with professional ethics and standards of practice guiding the mental health profession; and (3) conflict with promising proposals to reform mental health care delivery. This Note advocates that states adopt a statute prohibiting mental health practitioners from entering into noncompetition agreements with their employers as against public policy.     

The Financial Rewards of Elite Status in the Legal Profession

This article focuses on the role of intergenerational status attainment for legal careers. By decomposing the earnings gap between elite and nonelite lawyers at two points in their careers, we find that inherited cultural capital produces an earnings advantage as soon as lawyers begin their careers and that this gap persists over time. We further find that the processes underlying this gap change as lawyers make their way through the profession. While in early careers, the elite advantage is due to stronger starting endowments, the advantage for junior lawyers results from a more complex process, which combines starting endowments, professional capital gained during the first years of practice, and the rate at which endowments are differentially rewarded in the profession. Elaborating on work that identifies the importance of maintaining and concentrating diverse forms of capital in the legal profession, we explain the process through which elite lawyers gain and retain their advantage over time.     

Expertise in law, medicine, and health care

As the practice of science-based medical evidence has challenged the medical profession to consider the scientific bases for its methods and procedures, on a seemingly parallel path, the United States Supreme Court's 1993 decision in Daubert v. Merrell Dow Pharmaceuticals has challenged the legal system to consider the science underlying claims of medical expertise. This article examines how the legal system has responded to that challenge and why the response has been more limited than many had expected; the implications of the legal system's approach to scrutiny of claims of medical expertise for the practice of science-based medical evidence; and, the central elements of any meaningful change in legal assessments of expertise in medicine and health care.     

“冲突法理论”论纲

“冲突法理论”应当被理解为对于“为何适用外国法”做出解释的理论，而关于“如何适用外国法”的理论则毋宁属于“冲突法中的理论”。“冲突法理论”的生成基础落实于多元私法体系共存的实在界存在以及观念界中理性的反思品质之上。并且，其赖以生成的实在界基础作为影响因素而言时，就必须理解为“多元私法体系的共存状态”。“冲突法理论”是关于整个冲突法体系的“元理论”，它代表冲突法体系参与其他知识体系间的互动，而这种互动的出发点和归宿，就在于解释关于冲突法体系的根本问题，并对整个冲突法体系的存在负责。     

Undermining Gender Equality: Female Attrition from Private Law Practice

The number of women in the legal profession has grown tremendously over the last 40 years, with women now representing about half of all law school graduates. Despite the decades‐long pipeline of women into the profession, women's representation among law firm partnerships remains dismally low. One key reason identified for women's minority presence among law firm partners is the high level of attrition of women associates from law firms. This high rate of female attrition undermines efforts to achieve gender equality in the legal profession. Using a survey of 1,270 law graduates, we employ piecewise constant exponential hazard regression models to explore gendered career paths from private law practice. Our analysis reveals that, for both men and women, the time leading up to partnership decisions sees many lawyers exit private practice, but women continue to leave private practice long after partnership decisions are made. Gender differences in leaving private practice also surface with reference to cohorts, areas of law, billable hours, firm sizes, and career gaps. Notably, working in criminal law augmented women's risk of leaving private practice, but not for men, while taking time away from practice for reasons other than parental leaves, hastens both men's and women's exits from private practice.     

Embracing the new professionalism: self-regulation, mandatory reporting and their discontents

In response to perceived failures in medical self-regulation in Australia, first in two States (for doctors) and now under the National Registration and Accreditation Scheme (for all health practitioners), mandatory reporting of peer status or practice that poses risks to patients has been introduced. Yet now, in response to the lobbying of State and federal health ministers by the medical profession, mainly in relation to the impairment provisions, this is to be reviewed. This column argues that claims concerning the negative consequences for practitioners of mandatory reporting are illogical and lack supporting evidence. There is, however, evidence that the medical profession does not consistently act in accordance with its professed positions in the area of physician impairment and departure from accepted clinical standards. The call for a review of mandatory reporting reflects an outdated model of regulation that does not align with increasing calls for a "new professionalism". In its own interests, but primarily in the interests of patients, the medical profession should embrace new attitudes and practices that will at first appear to threaten the privilege of self-regulation, but on proper scrutiny will be seen as necessary to retain it.     

Medical Error and Patient Safety: Understanding Cultures in Conflict

Evidence documenting the high rate of medical errors to patients has taken a prominent place on the health care radar screen. The injuries and deaths associated with medical errors represent a major public health problem with significant economic costs and erosion of trust in the health care system. Between 44,000 and 98,000 deaths due to preventable medical errors are estimated to occur each year, making medical errors the eighth leading cause of death in the United States. However, the recent prominence of the issue of safety or error does not reflect a new phenomenon or sudden rift in the quality of health care (although it is a system fraying at the edges). Rather, the prominence of the issue reflects a radical change in the culture of health care, and in how relationships within the health care system are structured and perceived. In this paper, I discuss the multiple factors responsible for the change in the culture of health care. First, the culture has shifted from a clinician cantered system, in which decision making is one–sided, to a shared system of negotiated care between clinician and patient, and, often, between administrator or payer. Second, the nature of quality in health care has changed due to the geometric increase in the availability of technological and pharmaceutical enhancements to patient care. Third, the health care culture continues to rely on outdated models of conflict resolution. Finally, the regulatory structure of health system oversight was set in place when fee–for–service care governed physician–patient relationships and where few external technologies were available. In the current health care culture, that structure seems inadequate and diffuse, with multiple and overlapping federal and state regulatory structures that make implementation of patient safety systems difficult.     

Ethical decisions at the edge

Medicine grows incrementally in its ability to treat patients and at the growing edge it poses problems about the appropriateness of treatments that are different from those where good practice conforms to widely agreed standards. The growth of access to medical knowledge and the diversity of contemporary theoretical and clinical medicine have spawned deep divisions in the profession and divergent opinions about what constitutes reasonable care. That hallmark of acceptable practice is also under pressures from the threat of litigation, a highly commercialised contemporary medical environment, patient demands based on medical journalism and the internet and the exponential growth of bio-medical technology. Patient empowerment can result in complaints arising in new and complex areas and expert opinion can often differ markedly depending on where on the medical spectrum the experts are aligned. This column lays out some broad-brush principles to assess the adequacy of medical advice in such a climate.     

Medical professionals convicted of accessing child pornography--presumptive lifetime prohibition on paediatric practice? Health Care Complaints Commission v Wingate

Health Care Complaints Commission v Wingate [2007] NSWCA 326 concerns an appeal from the New South Wales Medical Tribunal regarding its findings on professional misconduct outside the practice of medicine in relation to a doctor convicted of possessing child pornography. The latest in a number of cases on this issue in Australia, it highlights the complexity of such decisions before medical tribunals and boards, as well as the diversity of approaches taken. Considering both this case and the recent Medical Practitioners Board of Victoria case of Re Stephanopoulos [2006] MPBV 12, this column argues that Australian tribunals and medical boards may not yet have achieved the right balance here in terms of protecting public safety and the reputation of the profession as a whole. It makes the case for a position statement from Australian professional bodies to create a presumption of a lifetime prohibition on paediatric practice after a medical professional has been convicted of accessing child pornography.     

THE BOLDT DECISION

In 1974 Federal District Judge H. Boldt mandated that 50% of the salmon resource of Washington State be allocated to Indian treaty tribes. His decision produced what has been characterized as "except for some desegregation cases … the most concerted official and private efforts to frustrate a decree of a federal court witnessed in this century." This article argues that fishing rights litigation has played a significant role in defining and structuring the conflict over the salmon resource. An unanticipated or unavoidable "side effect" of the successful tribal litigation strategy is the restructuring of the conflict in a way that is likely ultimately to prove as detrimental as outright legal defeat. Focusing on the Indian fishing rights issue, the article also studies the use of litigation as a weapon for social change. The underlying assumption is that a legal order that denies impoverished and powerless constituents a meaningful avenue for social change is gravely flawed.     

Futile treatment: the need for legislation and uniform policies

As a matter of social policy, providers should place a top priority on educating colleagues and the public, including lawyers and the courts, so that there is genuine understanding that certain medical conditions, like anencephaly and brain death, cannot be ameliorated, changed, or improved through medical treatment even though the patient may continue to breathe with mechanical assistance for years. If health care professionals do not articulate and adhere to clear, universal standards of practice in this area, the courts will continue to define the duty of the medical profession, and, as Baby K illustrates, that is not acceptable.     

The Legal Profession as Gatekeeper to the Judiciary: Design Faults in Measures to Enhance Diversity

The gate‐keeping role played by the legal profession in the judicial appointments process gives rise to the translation of entrenched group‐based identity hierarchies from legal practice into the judiciary. The relationship between the composition of the legal profession and the judiciary has been almost completely unaffected by recent reforms designed to increase diversity in the composition of the judiciary. This article identifies legal and institutional defects which help to explain the failure to disrupt the reproduction of these patterns of appointment. We identify two particular defects which we call ‘soft target radicalism’ and ‘regulatory bind’ as important factors inhibiting change. We conclude that if the legal profession is to retain its gate‐keeping role, equality law which directly regulates legal practice should be strengthened and the regulatory binds in which the Judicial Appointments Commission and other public entities are caught should be loosened.     

Whom do physicians work for? An analysis of dual practice in the health sector

This article presents a thorough analysis of dual practice among physicians who work in both the public and private sectors. A conceptual framework is presented to help the reader understand dual practice and the contexts where it takes place. The article reviews the existing theoretical and empirical literature on this form of dual practice among physicians. It analyzes the extent of this phenomenon, the underlying factors that motivate physicians to engage in dual practice, and the main implications of their decision to do so. It also examines and discusses current policies that address dual practice. In this regard, the article provides some qualified support for the use of "rewarding" policies to retain physicians in the public sectors of more developed countries, while "limiting" policies are recommended for developing countries - with the caveat that the policies should be accompanied by the strengthening of institutional and contracting environments. The article highlights the lack of quality evaluative evidence regarding the consequences of dual practice on the delivery of health care services. It concludes that the overall impact of dual practice remains an open question that warrants more attention from researchers and policy makers alike.     

Bushwhacking the Ethical High Road: Conflict of Interest in the Practice of Law and Real Life

A long‐standing scholarly tradition regards professions, in general, and ethics rules, in particular, as “projects” of market control. It is no surprise, critics charge, that in the latest assault on the monopoly of the American legal profession–waged by multidisciplinary professional service firms–lawyers are hiding behind their ethics rules to protect their turf. In this article, I report on an extensive empirical study of conflict of interest in private legal practice and look comparatively at other fiduciaries, among them, accountants, psychotherapists, physicians, journalists, and academics. I investigate the role of ethics rules that seek to insure fiduciary loyalty in structuring the delivery of services. How does social and institutional change, roiling the fiduciary world, threaten disinterestedness and loyalty and how, if at all, do fiduciaries respond? How is the regulation of conflict of interest accomplished? Where are the conflicts rules most likely to be honored or ignored? What incentive structures encourage compliance? What are the costs and unexpected consequences of compliance? What is foregone? And is it all worth it? In what might come as a surprise to many, I find that the legal profession takes conflict of interest more seriously than many of the rest of us. As the title implies, legal practitioners largely travel alone, bushwhacking through the underbrush snarling the ethical high road. As critical scholarship predicted, lawyers do enjoy a monopoly at the end of the road. But this monopoly is achieved, not by restraint of trade or some other artifice or stratagem of market control, but by lack of competition. It seems that no one else is trudging alongside the lawyers. Lawyers are not necessarily more ethical than the others; they just behave more ethically–at least with respect to conflict of interest. The question is why. And what difference does it make?     

Do Health Interventions Support Peace Through “Disaster Diplomacy?”

Health problems and health interventions do not stop in conflict zones. Conversely, many health-related topics fail to be addressed adequately because conflict interferes with health systems, health personnel, and health-related actions. Based on these experiences, health diplomacy, medical diplomacy, and vaccine diplomacy have developed as fields of research, policy, and practice. From the Journal of Health Diplomacy, initiated in 2013 to the United Nations World Health Organization’s (WHO) “Health as a Bridge for Peace” program, academics, decision makers, and practitioners have been examining and trying to apply health work for diplomatic, peace-related, and conflict resolution endeavors.     

Legal education in the training of health professionals in Ghana: the need for legislative and curricular reforms

The present paper critically analyses the essence of legal education in the training of medical professionals in Ghana. It argues that health professionals lack the requisite knowledge in law, especially the legal implications of medical malpractice, and calls for legislative and curricular reforms in institutions engaged in the training of health professionals to reflect a legal education component. The authors opine that the basic medical law curriculum should be focused on the kinds of legal problems that physicians encounter most frequently in practice rather than on sensational cases. The authors are of the view that the curriculum should address the clarification of central concepts in law, the ability to apply the concepts, decision‐making procedures, acquisition of legal knowledge in tortuous and criminal matters relevant to the medical profession. This view sets objectives for teaching medical law to medical students and young doctors.     

试论国家对健康权与药品知识产权保护制度的平衡简

健康权在任何与健康熙护议题有关的政策上（包括药品知识产权制度）都不可忽略.然而, 《多哈宣言与2003年决议仍未触及药品知识产权保障与健康权冲突的核心问题,这就需要将健康权作为一项政策工具对药品知识产权的影响做补充性的解释.国家保障药物获得权利的义务应根据其实质内涵的多样性与复杂性掺入防卫权的特色；换言之,药品获得权应区分为国家仅有义务渐进实现的受益权与国家有义务立即实现的受益权.这种通过细化国家保障药品获得权的义务,在具有相同重要性的健康权及药品知识产权产生冲突时,便有足够的基础从权利本质审视两者在冲突时的平衡关系是否适当.     

冲突法之本位探讨

从冲突法的理论和实践来看,法律冲突的解决可归纳为以“私人”、“政府”和“社会”为本位三种情形。无疑,仅从法律逻辑上将无法对冲突法之本位的取舍做出完整的评估,就此,需要广泛地运用其他学科的理论。其中,依国际关系理论对这三种本位制进行分析,得出的结论是,“私人本位制”应成为各国冲突法立法的普遍选择;然而,以“私人”为本位的冲突法体系也应在有限的范围内或有限的程度上,以各种途径和方式有机地整合“政府本位制”和“社会本位制”的因素。同时,这也是健全和完善我国冲突法立法的一个重要方面。     

Making sense of the global health crisis: policy narratives, conflict, and global health governance

Health has become a policy issue of global concern. Worried that the unstructured, polycentric, and pluralist nature of global health governance is undermining the ability to serve emergent global public health interests, some commentators are calling for a more systematic institutional response to the "global health crisis." Yet global health is a complex and uncertain policy issue. This article uses narrative analysis to explore how actors deal with these complexities and how uncertainties affect global health governance. By comparing three narratives in terms of their basic assumptions, the way they define problems as well as the solutions they propose, the analysis shows how the unstructured pluralism of global health policy making creates a wide scope of policy conflict over the global health crisis. This wide scope of conflict enables effective policy-oriented learning about global health issues. The article also shows how exclusionary patterns of cooperation and competition are emerging in health policy making at the global level. These patterns threaten effective learning by risking both polarization of the policy debate and unanticipated consequences of health policy. Avoiding these pitfalls, the analysis suggests, means creating global health governance regimes that promote openness and responsiveness in deliberation about the global health crisis.