National health insurance and the new health occupations: nurse practitioners and physicians' assistants

This article considers a number of issues which might arise in formulating policy for new health occupations. Its particular focus is on nurse practitioners and physicians' assistants and their treatment under potential national health insurance arrangements. The development and expansion of these occupations are described, as is the evidence on their performance with respect to the quality of medical care provided, the impact on the cost of such care, and changes in access to care. We then discuss several issues which might arise in the context of national health insurance legislation, including reimbursement rates and methods, certification and licensure, training subsidies, deployment incentives, and compatibility with an increased supply of physicians.     

Training Parents Reported for or at Risk for Child Abuse and Neglect to Identify and Treat Their Children's Illnesses

Parents at-risk or reported for child abuse or neglect may demonstrate deficits in infant and child health care skills, placing their children at greater risk for health problems. Research assistants, caseworkers, and a nurse provided health care skills training to parents at risk or reported for child abuse or neglect. A health reference guide and other training materials were validated by health care professionals. Training involved teaching parents to follow a series of steps to identify symptoms, use reference and record-keeping materials, determine the best form of treatment, and either treat the illness at home, consult a physician, or seek emergency treatment. Skill acquisition was assessed through observations of parent behavior in simulated health care scenarios. A series of multiple baselines across parents demonstrated effectiveness of this training in the context of these scenarios. Six out of seven parents met the 100% mastery criterion. All parents provided positive ratings of the content of the training program, the training strategies, and the counselors who provided training.     

Grants for nurse practitioner traineeship programs--PHS. Interim final regulations

These regulations set forth requirements for grants to schools of nursing, medicine, and public health, to public or nonprofit private hospitals, and to other public or nonprofit private entities to meet the costs of traineeships for training nurse practitioners. A trainee must sign a commitment with the Secretary to practice full-time as a nurse practitioner in a primary medical care health manpower shortage area, designated under section 332 of the Public Health Service Act (the Act), for a period equal to 1 month for each month of traineeship support, after completion of the training. If this obligation is not fulfilled, a trainee must pay back traineeship support. The purpose of these regulations is to respond to the comments on the 1980 interim final regulations and to conform 42 CFR Part 57, Subpart AA, with the Paperwork Reduction Act of 1980, Pub. L. 96-511, and with the Omnibus Budget Reconciliation Act of 1981, Pub. L. 97-35, which requires, among other provisions, that the Secretary provide, by regulation, for the waiver or suspension of the repayment obligation under certain conditions. In addition, other minor changes have been made and Office of Management and Budget (OMB) numbers are cited in those sections which have approved reporting and recordkeeping requirements.     

Public Health Service--Grants for construction of teaching facilities, educational improvements, scholarships and student loans; grants for nurse practitioner traineeship programs. Interim-final regulations

These regulations set forth requirements for grants to schools of nursing, medicine, and public health, to public or nonprofit private hospitals, and to other nonprofit entities to meet the costs of traineeships for the training of nurse practitioners. Trainees must reside in health manpower shortage areas and sign a commitment with the Secretary to practice full-time as nurse practitioners in areas having shortages of primary medical care manpower.     

New health professions after a decade and a half: delegation, productivity and costs in primary care

Though knowledge about physician's assistants and nurse practitioners is far from conclusive, these new health practitioners (NHPs) appear to perform a large percentage of primary care services at a high level of quality and productivity. Moreover, the gap between the physician/NHP substitution ratio and the NHP/physician cost ratio seems wide enough to assure cost savings when NHPs are used well.     

Medicare program; allowing certifications and recertification by nurse practitioners and clinical nurse specialists for certain services--HCFA. Final rule with comment period

This final rule with comment period authorizes nurse practitioners and clinical nurse specialists, working in collaboration with a physician, to certify and recertify that extended care services are needed or continue to be needed. In addition, it sets forth the qualification requirements that a nurse practitioner or clinical nurse specialist must meet in order to sign certification or recertification statements. This final rule is necessary to implement section 6028 of the Omnibus Budget Reconciliation Act of 1989.     

Sudden unexpected death from cardiac concussion (commotio cordis) with unusual legal complications

Sudden and unexpected death may result from cardiac concussion following blunt force trauma to the thorax. Undiagnosed pathologic disease must be carefully evaluated as a possible contributory element. Legal complications may arise from any autopsy. It is recommended that a photograph be taken upon completion of the autopsy. This photograph and adequate records can be used to refute any charges against the pathologist or assistants for the poor condition of a body after its release.     

In the matter of Christine B. Biersach. In the Ohio Court of Appeals

HOLDING: Before withdrawal of tube feeding may be permitted, a guardian must establish, by clear and convincing evidence, the treating and consulting physicians' education, training, and experience; the physician's history and experience with the patient; the fact that the physician personally examined the patient; and the opinions required by statute. Each physician should also testify to his opinion that the other physician in the matter is qualified, by reason of advanced education or training, limited practice, experience, or certification as a specialist, to make the findings and provide the opinions about the patient which are required by the statute. The consulting physician's opinion should be more than a conclusory adoption of the attending physician's opinion. Rather, it should be independently stated and, ideally, should include the reasons upon which it is based.     

Considering the consequences of increased reliance on judicial assistants: a study on Dutch courts

Virtually all judicial systems employ judicial staff members to assist judges in their work. However, except for US Supreme Court law clerks the role of these judicial assistants in judicial decision-making is minimally understood. This observation also holds true for the Netherlands, where an increased focus on managerial issues, such as efficiency and effectiveness, seems to have resulted in a growing number of judicial duties being assigned to judicial assistants. This article provides an initial reflection on such reliance on assistants. The context in which this development occurred is clarified, and the manifestation of the role of judicial assistants within the judicial process is described. This article also discusses two factors that require consideration when reliance on assistants increases: (1) the mechanisms for safeguarding the profession of the judge and the judicial assistant; and (2) the position of the judicial assistant in the judicial decision-making process. The consideration demonstrates the advantages of employing judicial assistants and also sheds light on serious risks relating to an increased role of judicial assistants in judicial decision-making.     

刑事诉讼专家辅助人的倾向性及界限

刑事诉讼专家辅助人的倾向性,指专家辅助人帮助委托方参与刑事诉讼鉴定意见的质证、提出专家意见所体现的一种职业上的偏向。新《刑事诉讼法》及其司法解释并未明确专家辅助人的倾向性,不利于其属性的完整。因此,应当比较外国为平衡专家制度属性所进行的相关制度设计,定位我国刑事诉讼专家辅助人的＂相对二元化倾向性＂及其法律界限、科学界限、道德界限,以及这些界限的制度保障。     

Sickness benefits. Railroad Retirement Board. Final rule

The Railroad Retirement Board (Board) hereby amends its regulations under the Railroad Unemployment Insurance Act (RUIA) to permit a "nurse practitioner" to execute a statement of sickness in support of payments of sickness benefits under the RUIA. The Board does not currently accept statements executed by a nurse practitioner, which in some cases may delay payment of benefits.     

Remedies for Dishonest Assistance

The paper considers the nature of claims against dishonest assistants and the various money remedies those claims may evoke. Dishonest assistance is a form of civil secondary liability whereby the assistant is held jointly and severally liable along with the trustee whose misconduct he assisted. This is the sense in which dishonest assistants are said to be accountable as constructive trustees. In order to understand remedies available against dishonest assistants it is accordingly necessary to understand the corresponding remedies against defaulting trustees and what it means for them to be accountable. The paper examines the two different types of compensation that may be awarded against defaulting trustees—substitutive and reparative—and observes that the same two types of compensation may be given against dishonest assistants in appropriate cases. It also explores the circumstances in which trustees and dishonest assistants should be accountable for profits and whether they should ever be liable to pay exemplary damages. A strict application of the theory of civil secondary liability produces controversial results in connection with these latter remedies.     

Medicare and Medicaid programs; nurse aide training and competency evaluation programs--HCFA. Final rule

This rule amends the Medicare and Medicaid regulations pertaining to facilities to incorporate Federal requirements that States have training and competency evaluation by Medicare participating skilled nursing facilities and Medicaid participating nursing facilities and also have a nurse aide registry. The purpose of these provisions is to ensure that nurse aides have the education, practical knowledge, and skills needed to care for residents of facilities participating in the Medicare and Medicaid programs. These requirements implement, in part, sections 4201(a) and 4211(a) of the Omnibus Budget Reconciliation Act of 1987, section 6901(b) of the Omnibus Budget Reconciliation Act of 1989, and sections 4008 and 4801 of the Omnibus Budget Reconciliation Act of 1990.     

TRICARE Program; inclusion of anesthesiologist assistants as authorized providers; coverage of cardiac rehabilitation in freestanding cardiac rehabilitation facilities. Final rule

This final rule establishes a new category of provider as an authorized TRICARE provider and it increases the settings where cardiac rehabilitation can be covered as a TRICARE benefit. It recognizes anesthesiologist assistants (AAs) as authorized providers under certain circumstances. It also authorizes cardiac rehabilitation services, which are already a covered TRICARE benefit when provided by hospitals, to be provided in freestanding cardiac rehabilitation facilities.     

The forensic radiographer: a new member in the medicolegal team

Multidetector computed tomography is becoming more widespread in forensic medicine. In most services, autopsy assistants perform the radiological examination. We introduced professional radiographers into the legal medicine service and hypothesized they would also be able to take over duties currently reserved for other specialists. The aims of this study were to evaluate if radiographers could be trained as "forensic radiographers" by (1) integrating graduated medical radiographers into the legal medicine service, (2) investigating the advantages of this collaboration, and (3) defining the duties of the forensic radiographers.The study was performed prospectively on a group of 8 recruited radiographers who underwent a testing period with special training. They learned the basics of medicolegal case treatment, the autonomous execution of postmortem computed tomography angiography, and postprocessing of data. Seven of 8 radiographers finished the training and were integrated into our service. Although all radiographers were able to fulfill the duties demanded after the training period, some radiographers could not enter or complete the program because they were unable to work with dead bodies.Our study presents the advantages of integrating radiographers into the medicolegal team and proposes how to train the forensic radiographers. In addition, the duties and responsibilities of these new specialists are defined.     

The physician assistant as forensic investigator

Physician assistants are employed as forensic investigators at the Office of the Medical Examiner, Suffolk County, New York. We describe the educational qualifications of physician assistants and their valuable role in forensic medicine in Suffolk County.     

Medicare and Medicaid programs; requirements for long term care facilities; nursing services; posting of nurse staffing information. Final rule

In this rule, we finalize provisions specified in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) that establish new data collection, posting, and recordkeeping requirements for skilled nursing facilities (SNFs) and nursing facilities (NFs). It requires that on a daily basis for each shift, SNFs and NFs must post nurse staffing data for the licensed and unlicensed staff directly responsible for resident care in the facility. Facility census information must also be posted. This final rule is also part of a broader communication outreach initiative by CMS to provide beneficiaries, their families, and the public with access to updated data and other information that can assist them in making healthcare decisions.     

Teaching method: A basis for discussion

Skilled professionals such as lawyers are imperative for any society. Their training is even more critical, as it shapes their eventual role in transforming society. They play an important role since the law influences literally all aspects of our lives. My thesis here is that the “market” for lawyers in sub-Saharan Africa is dictated by the stage of societal development. Thus their training must be focused on the present and projected needs of the particular society. So, what role do academics play in realising this long-term goal? Academics must wear many hats as thinkers and scholars, teachers and mentors. They must influence philosophical paradigms of teaching for local relevance. They must deconstruct the “market” to decipher its meaning – are they training professionals for local service or for emigration? Thus, examining the place of the university academic in the training process, this paper investigates the situation, and makes policy-level remedial proposals.     

Bouvia v. County of Riverside

The plaintiff, a quadriplegic with cerebral palsy, had admitted herself voluntarily to the psychiatric department of Riverside General Hospital in September 1983. She then revealed her intention of starving herself to death, requested that hospital personnel administer only pain medication and hygienic care, and sought preliminary and permanent injunctions to prevent the hospital from either force feeding, transferring, or discharging her. The essence of her legal claim was that society was obliged to honor, and to assist her in carrying out, her privacy right to end her life. While the Superior Court recognized a patient's right to refuse life-sustaining care under some circumstances, it ruled that because Bouvia's condition was not terminal, her rights must yield to the interests of the state and other third parties in preserving life.