The paradoxical politics of provider reempowerment

The recent decline, indeed perhaps dismantling, of managed care is sometimes treated as both consequence and cause of the political reempowerment of medical providers, whose professional dominance managed care had challenged. Drawing evidence from Round III of the Community Tracking Study of the Center for Studying Health System Change, this article reviews the politics of four "arenas" of managed care regulation--prompt payment, mandated benefits, external appeals, and financial solvency--and concludes that the power of providers is contingent on patterns of coalition and conflict that differ across the discrete arenas. The zero-sum connotations of the "de" and "re" empowerment of providers under managed care fail to capture the subtlety of providers' search for fresh cultural, economic, and political resources in shifting policy contexts.     

Sexual and nonsexual offenders with intellectual and learning disabilities: a comparison of characteristics, referral patterns, and outcome

This article reports an evaluation of a community intellectual disability offender service over the period from 1990 to 2001. Men who committed sex offenses or sexually abusive incidents (n = 106) and men who committed other types of offenses and serious incidents (n = 78) are compared on personal characteristics, referral sources, forensic details, and outcome up to 7 years after referral. The cohorts are older than one would expect from the criminology literature, and, at about 33%, the incidence of mental illness is consistent with some previous studies. A greater proportion of sex offenders had criminal justice involvement and a formal disposal from court. Fire raising was not overly represented as an offense. There was a higher rate of reoffending in the nonsexual cohort, which persisted up to 7 years. Investigating only reoffenders, there was a considerable amount of harm reduction recorded up to 7 years, statistically significant up to 5 years following initial referral.     

The epidemiology of female rape victims who seek immediate medical care: temporal trends in the incidence of sexual assault and acquaintance rape

Women who seek medical care following sexual assault are usually evaluated and treated in an emergency department (ED). Therefore, EDs can be an important source of sexual assault surveillance data. The authors compared the incidence of sexual assault presenting for emergency care in a single county during July to November of 1974 and 1991. Participants included all female sexual assault victims aged 14 and older who presented for ED evaluation. Treating physicians prospectively collected data using standardized forms. The z statistic was used to compare sexual assault incidence. There was a 60% increase in the incidence of sexual assault victims presenting for emergency care in 1991 compared to 1974, primarily due to an increase in the incidence of women presenting to the ED after rapes by known assailants. In contrast, the annual incidence of reported stranger assaults was similar in the two study years.     

"Just say no!": the right to refuse psychotropic medication in long-term care facilities

This article examines the rights of patients, particularly incompetent patients, in long-term care facilities to refuse psychotropic medication. In exploring this topic, the author focuses on the provisions of the Omnibus Budget Reconciliation Act of 1987 which was part of a Congressional solution to afford greater protection to residents of long-term care facilities. Because the legislation has not lived up to expectations, the author advocates for further legislative action to protect the dwindling bundle of rights of the elderly.     

Medicolegal aspects of witnessed suicide due to gunshot to the head. II. Legal medicine aspects and examination of the firing hand

The second part of the paper on suicides by gunshots to the head in the presence of witnesses focuses on relevant morphological autopsy findings such as entrance site, signs of close range or contact shots, bullet path etc. and also discusses selected aspects of ascertaining gunshot residues. For the identification of the shooter an integral medicolegal assessment of all the facts including the investigation results and the autopsy findings is essential. However, the morphological findings alone do not allow safe diagnosis, as for example in a homicide the temporal region, which was affected in all our cases, may have been deliberately chosen by the perpetrator as a localization typical of suicide. Thus methods to ascertain gunshot residues on the firing hand (by means of adhesive films and the polyvinyl-alcohol collection method--PVAL) are of great practical importance. In seven cases adhesive films and/or the polyvinyl-alcohol collection method were used. In one case the gunshot residues (GSR) were analysed by means of tape lifts and subsequent scanning electron microscopy (SEM). It was found that especially the combined application of topographical (adhesive tape/PVAL) and cumulative (SEM) methods allowed for the doubtless identification of the shooter, thus usually confirming the suicide. By the example of one case it is demonstrated that without the immediate collection of evidence at the scene objective reconstruction of the event becomes impossible. On the basis of the reported cases recommendations are finally given for a differentiated approach in the medicolegal evaluation of alleged witnessed suicide by gunshot (to the head).