Health care for older persons in England and the United States: a contrast of systems and values

This article extends previous comparisons of access to health care for older persons in England and the United States by comparing rates of avoidable hospital conditions as a proxy for primary care access and by examining the distribution of care within these older populations. Drawing on hospital data from the two countries, we find that older persons in the United States, particularly those over the age of seventy-five, receive far more revascularizations than do older persons in England. Differences in the use of lower-joint replacement are not as great, but we are unable to assess differences in the need for these procedures. Although older persons have greater access to specialty care in the United States, there appears to be much better access to primary care in England. We are unable to draw comparisons on the extent of inequalities in access to health care, although in the United States there is evidence of inequalities in access by race, and in England we confirm earlier studies that find inequalities by level of deprivation. These findings are discussed in the context of the political debates over access to care and rationing in the two countries.     

From clinical integration to accountable care

Four key challenges to reforming health care organizations can be addressed by a clinical integration model patterned after Advocate Physician Partners (APP). These challenges are: predominance of small group practices, dominant fee-for-service reimbursement methods, weaknesses of the traditional hospital medical staff structure and a need to partner with commercial insurance companies. APP has demonstrated teamwork between 3800 physicians and hospitals to improve quality, patient safety and cost-effectiveness. Building on this model, an innovative contract with Blue Cross Blue Shield of Illinois serves as a prototype for a commercial Accountable Care Organization. For this contract to succeed, APP must outperform the market competition. To accomplish this, APP has implemented strategies to reduce readmissions, avoid unnecessary admissions and emergency room visits, expand primary care access, and enhance quality and patient safety.     

Working to Death: The Regulation of Working Hours in Health Care

Recent research highlights significant risks associated with health professionals working long hours—risks to their health and safety, to the safety and quality of care provided to patients, and to public safety. This article undertakes a review of the various instruments used to regulate working hours in health systems, using six countries (Australia, Canada, Denmark, New Zealand, the United Kingdom, and the United States) and the European Union as primary comparators. The review demonstrates differences in the instruments used to regulate the issue in these countries and in the economic, social, and cultural factors that limit instrument choice and moderate instrument effectiveness.     

Eligibility for health care benefits for certain Filipino veterans in the United States. Final rule

Department of Veterans Affairs (VA) medical regulations describe veterans who are eligible to receive health care from VA in the United States. This document amends VA medical regulations to provide eligibility for VA hospital care, nursing home care, and outpatient services for any Filipino Commonwealth Army veteran, including those recognized by authority of the U.S. Army as belonging to organized Filipino guerilla forces, and for any veteran of the new Philippine Scouts, provided that any such veteran resides in the U.S. and is either a citizen of the U.S. or is lawfully admitted to the United States for permanent residence. Under this regulatory provision, these certain veterans are eligible for VA hospital care, nursing home care, and outpatient medical services in the United States in the same manner and subject to the same terms and conditions as apply to U.S. veterans.     

The national residency exchange: a proposal to restore primary care in an age of microspecialization

Healthcare deficiencies in the United States have long been perpetuated by a shortage of primary care providers. A core purpose of the Patient Protection and Affordable Care Act (PPACA) is to provide health insurance for America's approximately fifty million uninsured. Implementation of universal health insurance, however, does not mean sufficient healthcare access for all, since the supply of physicians does not and will not meet demand. For reasons reviewed in this Article, the current physician shortage mainly impacts primary care providers. This shortage is particularly troubling because increased provision of primary care relative to specialty care has been associated with improvement in health outcomes, disease prevention, cost effectiveness, and coordination of care. This Article highlights provisions in the PPACA that impact primary care physicians. Finally, this Article proposes the creation of a universal primary care loan repayment program and a national residency exchange designed to alleviate the U.S. primary care crisis by facilitating optimal distribution of resident physicians in each medical specialty based on community need.     

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.     

Nurse practitioner challenges to the orthodox structure of health care delivery: regulation and restraints on trade

Until recently, physicians have been the primary health care providers in the United States. In response to the rising health care costs and public demand of the past decade, allied health care providers have challenged this orthodox structure of health care delivery. Among these allied health care providers are nurse practitioners, who have attempted to expand traditional roles of the registered nurse. This article focuses on the legal issues raised by several major obstacles to the expansion of nurse practitioner services: licensing restrictions, third party reimbursement policies, and denial of access to medical facilities and physician back-up services. The successful judicial challenges to discriminatory practices against other allied health care providers will be explored as a solution to the nurse practitioners' dilemma.     

Public capabilities and health care effectiveness: implications from a comparative perspective

This article examines inter-relationship between "centers" and "peripheries" within political, professional and health care systems. It seeks to determine which conditions tend to improve the capacity of public authorities to further such measures of effectiveness as access to, quality of, and complementarity of health care delivery. Examples are selected from the experience of the United States and West European countries.     

Legal considerations of sleep deprivation among resident physicians

Medical training in the United States often takes the form of a grueling endurance test in which patients are often those most at risk. This Article discusses sleep deprivation among resident physicians in the United States with an eye towards resolving the problem through legal channels. It analyzes the effects of sleep deprivation on resident physicians, with subsequent discussion of the implications for patient care and medical training. Next, it makes comparisons to medical training in other developed nations, as well as regulations that exist in the airline and trucking industries, where public safety is a principal concern. Furthermore, this Article discusses proposals to mend the dilemmas created by sleep-deprived resident physicians through statutory and regulatory reform, deterrence by way of tort law, and unionization or collective bargaining.     

The production of the "battered immigrant" in public policy and domestic violence advocacy

In the context of U.S. public policy, battered immigrant signifies a person who is eligible to adjust his or her status under immigration law if he or she can demonstrate they have suffered domestic violence in the United States perpetrated by a U.S. citizen or legal permanent resident. Among community organizers, the term battered immigrant signifies a broader range of people for whom legal immigration status plays a role in their options for safety planning and/or leaving an abuser, the potential threat of deportation, and the eligibility for public benefits. Based on an ethnographic study of domestic violence advocacy with South Asian immigrants in Seattle and around the United States, this article examines how the difference in signification has direct social and political consequences with regard to who may access the benefits and protection offered to victims of domestic violence in the United States.     

Physicians' conflicts of interest in Japan and the United States: lessons for the United States

Japanese health policy shows that even with physician ownership and the absence of for-profit, investor-owned health care, physicians' conflicts of interest thrive. Physician dispensing of drugs and ownership of hospitals and clinics were justified in Japan as ways to avoid commercialization of medicine. Instead, they create physicians' conflicts and fuel patient overuse of services. Japan's Ministry of Health and Welfare (MHW) has responded by introducing per-diem payment, thereby creating incentives to decrease services in ways similar to those of American managed care organizations, but with none of their benefits, such as coordination of care, oversight of physicians practices, and quality assurance. Although the United States and Japanese health care systems are organized and financed differently there is convergence in the source of their physicians' conflicts and the way they are addressed. The United States is starting to integrate institutional and physician payment and align their incentives, in a traditional Japanese way. In so doing, the United States creates new physicians' conflicts and reduces the role of countervailing incentives and power, an advantage of previous policy. Japan, in turn, has combined incentives to increase and decrease services, thus moving closer to the U.S. policy.     

Rationing psychosocial treatments in the United States

This paper briefly reviews the recent history of psychosocial treatment for adults with severe mental illnesses in the United States. It examines the current sources and financing of such care, revealing the planned and unplanned reclassification of entitled beneficiaries and eligible patients, appropriate treatment, acceptable outcomes, and levels and sources of payment. One illustration of this phenomenon is seen in current efforts to identify and deliver only those public services that are covered by Medicaid, so as to allocate state resources only when they can be matched by federal monies. Another is the reliance on private health insurance, tied in the U.S. almost exclusively to employment, for medical care delivered under an acute, rather than a chronic care model. These analyses conclude with a discussion of the implicit and explicit mechanisms used to ration access to psychosocial treatment in the United States. The implications for individuals with serious mental illnesses, their families, and the general public are placed in historical and current policy contexts, recognizing the economic, social, and clinical variables that can moderate outcomes.     

美国管理式医疗的发展历程及对国内医保的借鉴

从理论和实证的研究表明,管理式医疗曾被当作美国医疗保险改革的典范,甚至有人尊其为有效降低医疗费用和成本的灵丹妙药。在有效控制节节攀升的医疗服务费用方面,管理式医疗确实达到了非常好的效果。但是,医疗服务需要关注的不仅是费用,还有医疗服务的质量、服务的可及性以及临床医疗的长远发展等方面。而美国管理式医疗的发展历程生动地诠释了普通民众需要的不仅仅是"廉价"的医疗服务这一现实。     

Quality assurance and hospital structure: how the physician-hospital relationship affects quality measures

Mr. Spaeth writes about the relationship between hospital administration and the physician, and how that relationship affects the quality of medical care delivered to the patient. The article focuses on the differences between the employment structure in an academic teaching hospital, and the open, independent contractor medical staff typical of a traditionally smaller community hospitals. The individual traits and nuances of these structures and how they can be distinguished from one another create dynamic differences in the approach for quality care. Peer review, credentialing, and management of adverse outcomes are just a few of the ways in which hospitals continue to strive to provide higher quality care, but the way these methods are implemented and performed in different hospital structures are dramatically different, yielding distinct results. Mr. Spaeth argues that the challenges faced by community hospitals in their effort to provide higher quality care and eliminate medical error are exacerbated because of their unique structure and the particular relationship physicians share with the hospital and its administration.     

Bundaberg and beyond: duty to disclose adverse events to patients

Although much excellent work has been done in Australia and elsewhere to improve the safety and quality of health care provision, the practice of medicine is inherently risky--adverse events sometimes occur. In Australia, practical guidelines for the open disclosure of adverse events to patients have been developed and are being implemented. State and Territory medical boards have recently adopted Codes of Conduct which include disclosure provisions, although the Australian Medical Association's Code of Ethics does not yet contain express patient disclosure provisions. There is a dearth of authority concerning legal obligations to disclose known or suspected adverse events. Although many Australian jurisdictions have introduced statutory protection for those who apologise or express regret to patients following an adverse event, there is no corresponding express statutory disclosure obligation, unlike in some parts of the United States. The Bundaberg experience illustrates the complex ethical, practical and legal issues which arise in this area.     

Product Liability in the European Union: Compensation and Deterrence Issues

In Europe a common standard of strict liability has been introduced with the European directive 85/374. The implementation of this Directive has not led to an expansion of product liability cases. Moreover neither the product nor the insurance market has been dislocated as in the United States. Both the fact that most liability cases continue to be discussed under national legislation—even when it is based on liability with fault—and the different price of insurance in Eurpean Countries show that the directive did not reach its harmonisation goals. We discuss the optional provisions that limit strict liability under the directive, but claim that the scarce impact of liability laws—in spite of increasing concerns for product safety—may be due to compensation provided by the Welfare State and to the cost of access to justice in Europe. Compensation by the Welfare State is inadequate with respect to the internalisation of the cost of accidents especially when public institutions do not file claims against liable producers. Product safety regulation should have performed the deterrence function. However we also point out that the threat of reputation losses is a powerful incentive for firms to carefully control product safety, when consumers increasingly care about product quality and accidents are heavily advertised by media.JEL Classification: K13, K41     

Using law to fight a silent epidemic: the role of health literacy in health care access, quality, & cost

The dominant rhetoric in the health care policy debate about cost has assumed an inherent tension between access and quality on the one hand, and cost effectiveness on the other; but an emerging discourse has challenged this narrative by presenting a more nuanced relationship between access, quality, and cost. This is reflected in the discourse surrounding health literacy, which is viewed as an important tool for achieving all three goals. Health literacy refers to one's ability to obtain, understand and use health information to make appropriate health decisions. Research shows that improving patients' health literacy can help overcome access barriers and empower patients to be better health care partners, which should lead to better health outcomes. Promoting health literacy can also reduce expenditures for unnecessary or inappropriate treatment. This explains why, as a policy matter, improving health literacy is an objective that has been embraced by almost every sector of the health care system. As a legal matter, however, the role of health literacy in ensuring quality and access is not as prominent. Although the health literacy movement is relatively young, it has roots in longstanding bioethical principles of patient autonomy, beneficence, and justice as well as the corresponding legal principles of informed consent, the right to quality care, and antidiscrimination. Assumptions and concerns about health literacy seem to do important, yet subtle work in these legal doctrines--influencing conclusions about patient understanding in informed consent cases, animating decisions about patient responsibility in malpractice cases, and underlying regulatory guidance concerning the quality of language assistance services that are necessary for meaningful access to care. Nonetheless, health literacy is not explicitly treated as a legally relevant factor in these doctrines. Moreover, there is no coherent legal framework for incorporating health literacy research that challenges traditional assumptions about patient comprehension and decision-making, and that emphasizes the need for providers to improve communication and take affirmative steps to assess patient understanding. The absence of a clear and robust consideration of health literacy in these doctrines undermines core access and quality aims, and it means that such laws are of limited efficacy in promoting health literacy. Returning to the theme that the health literacy problem reflects a complementary view of access, quality and cost, it is likely that the cost implications of this problem (and not concerns about quality and access) will motivate the kind of health literacy reform that may ultimately strengthen existing quality and access standards. One recent example of this can be seen in reforms linked to government, insurer and provider attempts to reduce costly medication errors.     

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); mental health services--DoD. Final rule

This final rule is to reform CHAMPUS quality of care standards and reimbursement methods for inpatient mental health services. The rule updates existing standards for residential treatment centers (RTCs) and establishes new standards for approval as CHAMPUS-authorized providers for substance use disorder rehabilitation facilities (SUDRFs) and partial hospitalization programs (PHPs); implements recommendations of the Comptroller General of the United States that DoD establish cost-based reimbursement methods for psychiatric hospitals and residential treatment facilities; adopts another Comptroller General recommendation that DoD remove the current incentive for the use of inpatient mental health care; and eliminates payments to residential treatment centers for days in which the patient is on a leave of absence.     

Condliff v North Staffordshire Primary Care Trust: can human rights redress inequities in United Kingdom and Australian cost-containment-driven health care reforms?

A recent case from the English Court of Appeal (R (on the application of Condliff) v North Staffordshire Primary Care Trust [2011] EWCA Civ 910, concerning denial by a regional health care rationing committee of laparoscopic gastric bypass surgery for morbid obesity) demonstrates the problems of attempting to rely post hoc on human rights protections to ameliorate inequities in health care reforms that emphasise institutional budgets rather than universal access. This column analyses the complexities of such an approach in relation to recent policy debates and legislative reform of the health systems in the United Kingdom and Australia. Enforceable human rights, such as those available in the United Kingdom to the patient Tom Condliff, appear insufficient to adequately redress issues of inequity promoted by such "reforms". Equity may fare even worse under Australian cost-containment health care reforms, given the absence of relevant enforceable human rights in that jurisdiction.     

Whistleblower protection for nurses and other health care professionals

Because most employees in the United States, including health care professionals, are employed "at will" (which means their employment can be terminated for any reason or no reason, as long as the reason isn't illegal), retaliatory actions by employers toward employees who speak out (i.e., blow the whistle) are not uncommon. Additionally, the law protecting whistleblowing employees varies greatly depending on the state where the employee works or if he or she works for the federal government. This article examines when and under what conditions a nurse or other health care professional may be protected from having an adverse employment action taken against him or her for reporting such issues as patient safety violations or health care fraud. The authors offer issues a nurse or other health care professional should consider before making the decision to blow the whistle. Finally, the authors also discuss the remedies such as reinstatement, back pay, or other compensatory mechanisms that may be available to employees terminated for reporting wrongdoing.