Moral hazard in health insurance: are consumer-directed plans the answer?

The concept of moral hazard in relation to health insurance is an area that has both haunted and fascinated economists, policy-makers, and payers almost since the first health insurance plans were offered by employers. Through the years since Kenneth Arrow's groundbreaking work in 1963, the health care industry has been looking for the proper level of cost-share for patient insureds that will affect their health care choices. The approach of some newer plan offerings, termed 'consumer-directed' or 'consumer-driven' plans by their promoters, seem to have the potential of affecting moral hazard in health insurance.     

How do parents experience relocation disputes in the family courts?

Relocation cases are known to be amongst the most difficult decisions for family court judges. This article reports the findings of an empirical study of parents who were involved in relocation disputes, reporting their views on the experience of being involved in one of these difficult cases. We consider the origins of the disputes and parents’ perceptions of how their cases were resolved, as well as some initial discussion of the aftermath of the cases as seen in the first few months.     

Representation and participation in child care proceedings: what about the voice of the parents?

In Ireland, the Constitution guarantees very strong rights to parents and the family, and there has been a long and unfortunate history of failures to adequately protect children at risk. As a result, there has been much discussion in recent years about the need to improve legal mechanisms designed to protect the rights of children. By comparison, little attention has been given to establishing whether the theoretically strong rights of parents translate into strongly protected rights in practice. This paper presents new empirical evidence on the manner in which child care proceedings in Ireland balance the rights and interests of children and parents, including the rates at which orders are granted, the frequency of and conditions in which legal representation is provided, and the extent to which parents are able to actively participate in proceedings. A number of systemic issues are identified that restrict the capacity of the system to emphasise parental rights and hear the voice of parents to the extent that would be expected when looking at the legal provisions in isolation.     

Patient termination of a life-sustaining medical device: Suicide or natural death?

Medical technology has made tremendous strides in extending the lives of patients who have suffered organ failure. Machines can now replace the function of the kidneys, the heart, and other vital organs. Much has been written about a patient's right to refuse or direct the withdrawal of medical treatment, especially at the end of life, under the guise of “death with dignity.” However, little attention has been paid to the situation where a patient elects to deactivate their life-sustaining medical device without a physician's involvement. This raises the challenging question of whether the patient's manner of death should be classified as suicide or natural. Surprisingly, common law, statutes, medical ethics, and public health practice are not in alignment on the answer. This article will explore the ramifications and far-reaching impact that such divergence has on the survivors and the medical community, as well as recommend corrective actions and practical approaches for the medical and legal practitioner.     

Clinical practice guidelines in the witness box: can they replace the medical expert?

Clinical practice guidelines aim to synthesise a vast amount of information to assist the physician or surgeon to select the most appropriate patient management, reduce treatment variation, reduce medical error and contain costs. They help the legal practitioner and courts determine the standard of care in medical negligence cases. However, they have numerous limitations. Their quality is highly variable and acceptance among the medical and legal professions is not universal. Good guidelines should be widely sourced, validly based on outcomes, widely accepted, updated regularly and include clear practice recommendations. Whatever their quality, they are not self-evident and do not cover precisely each and every clinical situation. They have rarely been incorporated into legislation and cannot be used in any court as the sole arbiter of a standard of practice. They must be supported by expert evidence and are themselves open to challenge. Adherence does not guarantee tortfeasor protection nor lack of adherence culpability.     

Do drug courts reduce the use of incarceration?: A meta-analysis

Purpose

The objective of this research was to synthesize the empirical evidence on the effectiveness of adult drug courts to serve as an alternative to incarceration, and to investigate which features of drug courts predict successful diversion.

Methods

We performed a series of meta-analyses of different incarceration outcomes, and performed meta-regression analyses investigating which features of drug courts predict successful diversion.

Results

Drug courts significantly reduced the incidence of incarceration on the precipitating offense, corresponding to a reduction in confinement from 50% to 42% for jail and 38% for prison incarceration. However, drug courts did not significantly reduce the average amount of time offenders spent behind bars, suggesting that any benefits realized from a lower incarceration rate are offset by the long sentences imposed on participants when they fail the program. Meta-regression results indicated that certain drug courts features (i.e., program intensity, in-program sanctions, risk profile of participants) are related to incarceration outcomes.

Conclusions

The evidence concerning drug courts impact on incarceration is mixed. Drug courts eliminate the experience of incarceration for many drug-involved offenders, but they also do not appear to reduce the aggregate, near-term burden placed upon correctional resources. More research is required to confirm these findings.     

Is there an acceptable answer to rising medical malpractice premiums?

This article explores the key issues involved in the attempts at reform of the present medical malpractice system. Investigating the effects that federal tort reform legislation would have on physicians, patients, lawyers, and the medical malpractice insurers, Dr. Gunnar succinctly outlines the issues surrounding the present "crisis in healthcare" and explores the separate interests involved. The article examines the economic forces influencing the medical malpractice insurance industry, reviews previous tort reform, and predicts the future of federal tort reform legislation. Dr. Gunnar concludes by proposing alternatives for malpractice reform.     

Aligning physician decision-making with the goals of health care organizations: are there any lessons from law firms?

In order to achieve efficiency in the delivery of health care services, it is essential to align more closely the behavior of physicians with the goals of the health care organization with which they are affiliated. Achieving alignment presents a number of challenges, including legal constraints, a long tradition of physician independence, a tendency for physicians to become involved in procurement decisions, and a scarcity of comparative effectiveness data that could serve as a basis for treatment protocols and purchasing decisions. The article discusses these challenges and suggests some partial solutions. In addition, it compares the incentives that affect physicians in health care organizations and partners in law firms and suggests that there may be some lessons that health care organizations can learn from the firms.     

The bones in the Abbey: are they the murdered princes? A review of the evidence

In 1674, the skeletons of two children were found in the Tower of London. They were believed to represent the remains of the "Princes in the Tower" (who had disappeared in 1483), and were reinterred as such in Westminster Abbey. Popular belief and conventional historical tradition held that the princes had been murdered by their uncle, King Richard III, to clear his path to the throne. In 1933, the bones in the Abbey were disinterred and examined, with the conclusion that they were indeed those of the princes. One skull was also thought to show evidence of death by suffocation, supporting another feature of popular legend. Later reviews of the investigation, however, revealed significant errors and omissions. This report summarizes the inconsistencies present in the scientific record and suggests that reexamination of the remains with improved techniques in both carbon dating and forensic science would provide a much more accurate analysis, thus helping to clarify the historical record.