Confucian bioethics and cross-cultural considerations in health care decision-making

This article discusses the similarities and differences between Beauchamp and Childress's principlism and Confucian bioethics in terms of autonomy, beneficence, nonmaleficence, and justice. The author presents sensitive approaches for culturally diverse groups in health care areas and cautions against dichotomy in cross-cultural studies, which ignores the dynamic nature and intravariations of cultures. As a way of health care providers to become engaged in cultural diversity in nursing practice and research, the author suggests that they do not only have a general knowledge about the theoretical differences among groups through "normative analysis" but also learn to appreciate each individual's particular beliefs and values through narratives of morality. Health care providers as well as legal professionals need to cultivate "cultural humility," which is the willingness to explore the similarities and differences between their own and each client's priorities and values and to develop courses of action with patients.     

Special report on health care delivery systems. Trends in the integrated delivery of health care and the corporate practice of medicine

The prospects for federal legislation preempting state corporate practice restrictions are unclear. The health care reform bill originally introduced by President Clinton contained a provision that would have preempted "any state law related to the corporate practice of medicine" insofar as it applied to the arrangements between non-fee-for-service health plans and their participating providers. H.R. 3600/S. 1757, 103d Cong., 1st Sess. 1407(b) (1993). Whether and in what form a preemption provision may survive the legislative process and see a Presidential signature remains to be seen. The particular fate of the federal legislation notwithstanding, however, health care executives can nevertheless remain confident that the legal treatment of the "corporate practice" of medicine will continue to be of vital concern as the various forms of health care organizations evolve in the ongoing struggle to deliver quality medicine at affordable prices.     

Real reform begins within: an organizational approach to health care reform

Health care systems are under pressure to control their increasing costs, to better adapt to evolving demands, to improve the quality and safety of care, and ultimately to ameliorate the health of their populations. This article looks at a battery of organizational options aimed at transforming health care systems and argues that more attention must be paid to reforming the delivery mechanisms that are so crucial for health care systems' overall performance. To support improvement, policies can rely on organizational assets in two ways. First, reforms can promote the creation of new organizational forms; second, they can employ organizational levers (e.g., capacity development, team-based organizations, evidence-informed practices) to achieve specific policy goals. In both cases organizational assets are mobilized with a view to creating complete health care organizations -- that is to say, organizations that have the capacity to function as high-performing systems. The challenges confronting the development of more complete health care organizations are significant. Real health care system reforms may likewise require implementing ecologies of complex innovation at the clinical, organizational, and policy levels. Policies play a determining role in shaping these new spaces for action so that day-to-day practices may change.     

The new institutionalist approaches to health care reform: lessons from reform experiences in Central Europe

This article discusses the applicability of the new institutionalism to the politics of health care reform in postcommunist Central Europe. The transition to a market economy and democracy after the fall of communism has apparently strengthened the institutional approaches. The differences in performance of transition economies have been critical to the growing understanding of the importance of institutions that foster democracy, provide security of property rights, help enforce contracts, and stimulate entrepreneurship. From a theoretical perspective, however, applying the new institutionalist approaches has been problematic. The transitional health care reform exposes very well some inherent weaknesses of existing analytic frameworks for explaining the nature and mechanisms of institutional change. The postcommunist era in Central Europe has been marked by spectacular and unprecedented radical changes, in which the capitalist system was rebuilt in a short span of time and the institutions of democracy became consolidated. Broad changes to welfare state programs were instituted as well. However, the actual results of the reform processes represent a mix of change and continuity, which is a challenge for the theories of institutional change.     

Methods for developing relative need criteria to accompany a health care capital expenditure limit

In recent years capital spending in the health care industry has escalated tremendously, and most forecasters agree that needs will increase at an even faster rate throughout the 1990s. As a result of this trend, there is a dire need to develop effective and equitable controls on capital spending in health care. One of the capital payment options under consideration is the establishment of a lid on capital expenditures and the concomitant allocation of capital to health care providers whose applications are the most meritorious. The purpose of this article is to present some ideas and methods for the development of a relative need system to accompany a capital expenditure limit and to supplement and expand the absolute need determinations of the typical CON process.     

推进欠发达地区电子政务发展的几点思考

本文结合欠发达地区电子政务开发实际阐述了在这些地区发展电子政务过程中应该坚持的主要原则,以及在电子政务发展过程中存在的问题,并提出了在电子政务发展过程中应采取的对策。     

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.     

The unintended consequences of New Zealand's primary health care reforms

In 2001, the New Zealand government commenced a program to reform the organization of publicly funded primary care services. While there have been several positive results of this reform, including the reduction of patient co-payments and the extension of the range of primary care services, the government's program was a hastily implemented attempt to place primary care, the delivery of which is dominated by private doctors, under firm state control. It was also an attempt to override preexisting arrangements. As such, the government succeeded in its goal of establishing new primary health organizations (PHOs), but there were also significant unintended consequences. As detailed in this article, these consequences include (1) the creation of a labyrinthine funding and organizational system with a variable capacity to deliver on the government's reform objectives, (2) an increase in the power and scope of preexisting doctor organizations combined with a government unable to wrest control over the setting of patient co-payment levels, and (3) an emerging lack of clarity about future directions for the primary health care sector.