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PubMed1993

Impact of the Catastrophic Coverage Act and new coverage guidelines on Medicare skilled nursing facility use.

The promulgation of new coverage guidelines and provisions of the 1988 Medicare Catastrophic Coverage Act indicated that Medicare's role in financing nursing home care could expand greatly. This paper presents a facility-level analysis addressing how the policy changes affected the payer mix of subgroups of Medicare-certified skilled nursing facilities (SNFs). Our analysis found that the new policies increased participation of nursing homes in the Medicare SNF program and suggested that the policies expanded both access to the Medicare SNF benefit and the role of public financing for nursing home care. Greater responsiveness to the policies was observed among proprietary SNFs and among those with more beds.

Catastrophic Illness↗
PubMedDate not supplied

Regulation of biotechnology products in the global pharmaceutical market: the case of the European community and the United States.

Biotechnology represents an opportunity for innovative products, new markets, or capital investments, depending on one's perspective. A primary consideration in regulating this industry is to ensure that innovation is not stifled yet the public is protected from potentially unsafe or ineffective products. We compared the regulatory requirements and procedures for obtaining marketing approval for biotechnology products in the European Community (EC) and the United States and identified key concerns of the biotechnology industry regarding the regulatory aspects of these products. The methodology consisted of a secondary literature review and mail survey. Biotechnology products are approved faster in the EC than the US. Both the EC and the US use advisory or expert committees in their respective approval procedures, although the EC does so more regularly. Market exclusivity provisions for biotechnology products range from 6 to 10 years in the EC compared with 7 years for "orphan" biotechnology products in the US. Regulatory affairs managers of the biotechnology industry were most concerned about application review time periods, communication with regulatory agencies, consistency in implementing regulations, and public policy changes. These concerns provide insight into the deficiencies that exist in regulatory processes and are valuable in identifying problems and implementing improvements.

Biotechnology↗
PubMed1995

Assessing the outcome of making it easier for patients to change general practitioner: practice characteristics associated with patient movements.

BACKGROUND: The government white paper, Promoting better health, suggested that primary health care services should be made more responsive to patient needs and that competition, brought about by the freer movement of patients between practices, could act as a mechanism for improving the quality of the services provided. Policy changes reflecting these aims were introduced with the 1990 contract for general practitioners. AIM: A study was carried out to estimate the volume of patient movement between practices not attributable to a patient's change of address or to a major change in the practice they had left, and to investigate which practice characteristics patients moved towards and which they moved away from when changing general practitioner. METHOD: Data on 2617 patient movements during June 1991 were collected from five family health services authorities. These patient movements were analysed in relation to data on practice characteristics obtained from family health services authority records. RESULTS: The estimated volume of movement of patients between practices was small (1.6% of the registered population per year). The majority of movements were between group practices; a quarter of the movements recorded were to single-handed general practitioners. However, the ratio of the number of movements from group practices to single-handed general practitioners compared with those from single-handed general practitioners to group practices was 1.37 (95% confidence interval 1.19 to 1.57). In choosing single-handed general practitioners these patients were willing to forgo access to a woman general practitioner, extended services and greater hours of general practitioner availability. Among the subset of movements between group practices, patients were more likely to gain access to a practice nurse, longer surgery hours and a woman general practitioner as a consequence of their move. CONCLUSION: The scale of patient movement observed did not indicate any substantial mechanism by which the new policy of encouraging consumerist behaviour on the part of primary care users could effect desired changes in primary care practice. Among the patient movements observed, the evidence suggests that when choosing a practice potential patients were not deterred by the fact that a practice was single-handed. The public's perception of the factors contributing to a high quality of service may conflict with the official characterization of good practice and high quality services in primary health care.

Adolescent↗
PubMed1996

Research ethics and the medical profession. Report of the Advisory Committee on Human Radiation Experiments.

The Advisory Committee on Human Radiation Experiments was convened by President Clinton in January 1994 in response to allegations of unethical practices in radiation experiments involving human subjects that were sponsored by the US government between 1944 and 1974. The committee's Final Report was released in October 1995. In addition to analyzing the history of the ethics of medical research involving human subjects, the committee reviewed current federal policies and procedures for protection of human subjects. In this article, the committee's findings are discussed as they relate to the patient-physician relationship, the issue of trust, and the specific role of the physician-investigator in all types of human experimentation. The committee found evidence of discussion of the conduct of human research at the highest levels of the government and within the medical profession, particularly with regard to risk, during the 1940s and 1950s. However, in both federal policy and professional practice, requirements for consent were more likely to apply to "healthy volunteers" than to patient-subjects (ie, those with disease or illness). Today, consensus exists that duties to obtain informed consent apply to all human subjects, whether healthy or sick, regardless of the risk or potential for medical benefit from participation in the research and regardless of the nature of sponsorship or funding (eg, federal, military, or private). Based on a finding of serious deficiencies in the current system of protections for human subjects, the committee offers a number of recommendations, including changes in institutional review boards; in the interpretation of ethics rules and policies; in oversight, accountability, and sanctions for ethics violations; and in compensation for research injuries. More than public policy changes, however, the committee recommends that the medical profession intensify its commitment to the ethics of research involving human subjects.

Advisory Committees↗
PubMed1996

Incidence of death and hospitalization from assault occurring in and around licensed premises: a comparative analysis.

The aim of the research was to: determine the incidence of serious assault in and around licensed premises in New Zealand, and to compare the circumstances of assault with those that occurred in other locations. For the period 1978-87, inclusive, 49 assault fatalities occurred in or around licensed premises representing 9.4% of all homicides and 12.9% where a place was specified. The comparable figures for assaults resulting in hospitalization in 1988 were: 251, 10.2% and 18.4%, respectively. Further analyses suggests that our estimate of the incidence rate is likely to be an underestimate due to changes over time in the large number of assault cases which have no specific place of occurrence identified. In comparison with homes homicides in licensed premises were more likely to involve: males; Maori, unarmed fights and brawls; unknown assailants; alcohol; occur during the evening and toward the end of the week; and result in head injury. For non-fatal events similar differences were found. In comparison with homes non-fatal assaults were more likely to involve: males; young adults, Maori, the unemployed, unarmed fights and brawls, and head injury. There have been a number of significant policy changes in New Zealand since 1988 which may have resulted in a change to the situation reported here.

Adolescent↗
PubMed1996

The effects of ownership and ownership change on nursing home industry costs.

OBJECTIVE: This study examines the effects of ownership type and ownership change on nursing home cost structures, differentiating patient care costs from plant costs. DATA SOURCES: Administrative data from the Michigan Department of Social Services, Medical Services Administration (Medicaid), and the Michigan Department of Public Health are used. Cost data are based on audited cost reports for 393 nursing care facilities in Michigan in 1989. Other facility characteristics are based on data from the 1989 annual licensing and certification survey conducted by the Michigan Department of Public Health. STUDY DESIGN: A series of ordinary least squares regressions is estimated, in which the dependent variable is either per diem patient costs or per diem plant costs. Ownership types are defined as chain, proprietary non-chain, freestanding non-profit, government-owned, and hospital-based facilities. Pooled estimation techniques, as well as separate regressions by ownership type, are presented to test for interaction effects. Key variables include whether a facility changed ownership in the preceding five years and whether chain facilities are in-state- or out-of-state-owned, in addition to size, payer mix, and case mix. PRINCIPAL FINDINGS: Behavioral differences among nursing home ownership types in respect to patient care costs tended to distinguish government-owned and hospital-based facilities from the freestanding homes rather than the usual distinction between for-profit and not-for-profit classes. Variables traditionally included in nursing home cost studies, such as size, occupancy, payer mix and case mix, were found to have similar effects on per diem patient care costs for freestanding non-profit homes as well as for chain proprietary facilities. With regard to the effects of ownership change on per diem plant and per diem patient costs, however, there are few differences among ownership types. Chain and non-chain for-profit facilities, non-profit homes, and hospital long-term care units that had changed ownership reported significantly higher per diem plant costs than facilities without a change of ownership, but did not spend more on patient-related costs. Michigan Medicaid plant reimbursement system policy changes instituted in 1985 to promote continued ownership of facilities were not entirely successful. CONCLUSIONS: Non-profit homes look increasingly like their for-profit counterparts with respect to spending on patient care costs. Increased competition for the more lucrative private-pay patients, coupled with declining state Medicaid reimbursement to nursing homes, may have blurred the historical distinctions between the non-profit and for-profit sectors in the nursing home industry. An exception to increasing homogeneity within the nursing home industry is the tendency of proprietary homes to experience more frequent changes of ownership, which results in higher capital costs passed on to state Medicaid programs. Findings from this study indicate that while facility sales increase per diem plant costs, they do not result in increased spending for direct patient care, suggesting that state Medicaid programs may be indirectly subsidizing facility sales with no accompanying increase in expenditures for patient care. To discourage frequent facility sales, state Medicaid programs may need to consider alternative methods of reimbursing nursing home owners for capital costs.

Capital Expenditures↗
PubMedDate not supplied

The case for breaking through ageism in mental health care.

This paper critically examines the recent policy in mental health nursing of refocusing care on people with severe and enduring mental health problems. It is argued that older people with severe and enduring mental illnesses such as dementia are excluded from this policy and that this amounts to a clear case of ageism. Various ways of addressing the problem of ageism in recent policy changes are explored.

Aged↗
PubMedDate not supplied

A combined community strategy to reduce cholesterol and other risk factors.

Our primary objective was to conduct an integrated program to reduce coronary risk factors in the population of an Israeli kibbutz. The population-based objective was to reduce the mean community total cholesterol level. The individual-based objective was to provide counseling and treatment for individuals at high risk and to reduce individual total and low-density lipoprotein cholesterol levels. The intervention included food policy changes in the central kibbutz kitchen, health education programs aimed at all age groups, and health counseling for individuals at risk. Evaluation was by questionnaire at baseline and at the end of two years, blood lipoproteins, and monitoring of all food purchased by the kibbutz. Fifty-three percent of the adult population (100 of 187) had borderline to high baseline total cholesterol levels. At one year, 27% of these were in the normal category. Egg consumption dropped by 6%, liquid oil by 7%, and red meat by close to 19%. Consumption of fish, chicken meat, and vegetarian patties increased. Consumption of 1% milk increased by almost 300%. We conclude that an integrated health education program targeting individuals and the community together can be effective in reducing risk factors for coronary artery disease.

Adult↗
PubMed1996

Deeming rules and the increase in the number of children with disabilities receiving SSI: evaluating the effects of a regulatory change.

This article examines a source of the growth in the SSI children's program: a relatively minor and little-noticed change in the financial eligibility rules. The way parental earnings were counted as income, or "deemed" to children (to use SSA language) was changed. The new, more generous financial eligibility rules added a small but significant number of recipients to the rolls after 1992 and also increased the benefit amounts for many of those already receiving SSI. Using SSA administrative data and a simulation technique, this article estimates how much the deeming policy change contributed to the expansion of the rolls and the cost of the program. We estimate that program costs of the deeming rule change were approximately $63 million annually in 1993 dollars. The change led to a 2-percent increase in the number of children on the rolls.

Age Factors↗
PubMed1996

Using research to change public policy: reflections on 20 years of effort to eliminate corporal punishment in schools.

In the past 20 years, over half of the states have abolished corporal punishment in schools. Without the use of ethically questionable, experimental studies in which students were randomly assigned to paddlings, advocacy researchers were able to integrate the literature and experimental research on reward, punishment, and motivation, and conduct enough studies to provide sufficient data for policy changes. Further, every popular school discipline training program promotes well-proven positive and preventive techniques and punishments that do not inflict physical pain. Research on alternatives, naturalistic evidence from schools that eliminated corporal punishment, and survey research prove that schools do not need to use corporal punishment. The movement to eliminate parental spanking is at a stage similar to the beginning of the school corporal punishment debate in 1976. Even though some studies may show that moderate parental spanking may do no short-term harm, there is little scientific evidence that it is necessary. There are no data to indicate that schools which eliminated corporal punishment became any worse. The same demographic factors and political polarizations that have kept about half of American school children from the protections against paddling afforded students in almost all other Western democracies also impede the movement to eliminate parental spanking. Since we know that corporal punishment too often leads to excesses, and since we have a multitude of effective positive approaches, what is the worst thing that would happen if all Americans stopped hitting children in any setting? The same children who are hit for misbehavior would continue that misbehavior and other ineffective punishments would be used. Most parents and teachers would discover what behavioral scientists already know. A combination of reward, positive motivational techniques and appropriate, nonphysical punishments would prevent most misbehavior. Other factors being equal, in the next generation, rates of childhood aggression and child abuse would drop dramatically, since corporal punishment would not be considered a viable and automatic reaction to misbehavior. Not a bad result for giving up something that has never been supported by the majority of those who study discipline in homes and schools. This is the message researchers and practitioners should actively convey to parents, policy makers and the media.

Child↗
PubMedDate not supplied

The art and science of the psychopharmacotherapy of African Americans.

Recent research and clinical experience has shown that African Americans may be at greater risk for inappropriate treatment. Such experiences can interact negatively with an existing distrust of the mental health system. Providers may show different prescribing patterns with racial and ethnic minorities: they may overuse antipsychotics, dispense higher dosages, and more commonly give involuntary treatment, which results in more side effects and a poorer outcome. Conversely, they may underuse other psychotropic medications, especially for anxiety and affective disorders, which are underdiagnosed in minorities. Recent research suggests that ethnic differences may exist in pharmacokinetics, and so different dosing strategies may be necessary. Not surprisingly African Americans in distress are more likely to seek initial treatment outside of the mental health system, seek treatment later in the course of the illness, complain more about side effects, and terminate treatment earlier. Cultural as well as socioeconomic factors must be considered. Newer pharmacological agents may be potentially more helpful for minorities because they are better tolerated, have better side effect profiles, and demonstrate better efficacy. However, African Americans have limited access to these agents. Education of providers and patients, policy changes in the public sector, wider implementation of research policies concerning inclusion of minorities, and different marketing strategies by pharmaceutical concerns are probably necessary to maximize pharmacotherapy of minorities.

Black or African American↗
PubMed1996

Media advocacy: lessons from community experiences.

Media advocacy is the strategic use of mass media and community organizing as a resource for advancing a social or public policy initiative. Across the United States, communities are using media advocacy to promote healthier public policies and environments. The U.S. Center for Substance Abuse Prevention commissioned numerous case studies of media advocacy on alcohol and tobacco issues in a diverse array of communities, including efforts in African-American and Latino communities or using computer-based electronic communication systems. The paper describes these efforts briefly, and summarizes lessons learned, including: media advocacy can lead to larger victories when used as a complement to community organizing in the context of a larger strategic vision for policy change; like policy advocacy, media advocacy is best done in the context of clear long-term goals; conscious framing, guiding the choice of spokespeople, visuals, and messages, can alter media coverage and public debate of health policies; advocates need to respect the media but also remember that they have power in relation to the media; and media advocacy is often controversial and not suited to every situation. The case studies show that media advocacy is a potent tool for public health workers, making an important contribution to campaigns to promote healthier public policies.

Alcoholism↗
PubMed1993

Restructuring federalism: the impact of Reagan policies on the family planning program.

Through fiscal cutbacks and structural changes, Reagan's federalism assaulted the ethos of public health. In assessing the effects of Reagan policies on a basic public health program, family planning services, we find a substantial decrease in spending for this program, a reduction in the numbers of patients served, and increased variation among the states in the provision of services to low-income women. These effects are comparable with findings from other studies on the impact of Reagan's federalism upon social programs and have manifold implications for public health.

Capital Financing↗
PubMed1983

Public policy and female sterilization in Costa Rica.

For 20 years, female sterilization has been increasing in popularity as a contraceptive method in Costa Rica. However, contraceptive sterilization has never been allowed explicitly under Costa Rican law. In 1976 the Costa Rican National Assembly instituted more stringent guidelines regarding medical sterilizations in order to eliminate contraceptive sterilizations, which had been occurring under relatively loose interpretations of national policy. Data from the 1976 National Fertility Survey and the 1981 Contraceptive Prevalence Survey indicate that the change in policy had only a short-term effect. Period sterilization rates fell substantially after 1976 but rebounded considerably by 1980, and the estimate of the proportion of married women who will ultimately be sterilized was approximately .5 for the periods both before and after 1976.

Adolescent↗
PubMed1995

A comparison of the determinants of safe injecting and condom use among injecting drug users.

A sample of 582 injecting drug users were interviewed as part of an evaluation of an AIDS prevention programme for drug users. This paper examines the biographic and predispositional determinants of five HIV preventive behaviours--equipment sharing (not receiving and not giving) and and condom use (with regular partners, casual partners and sex clients). A two-stage sequential approach was adopted for a logistic regression analysis. Initially, to model each of the five preventive behaviours, biographical and drug use variables were entered. In a second set of models, behavioural predisposition factors were included. Age, drug use and prison experience correlate with variables in both models, although not consistently in the same direction. While a predisposition to reject sharing correlates with safer rejecting and condom use, the predisposition to safer sex only correlates with condom use. Needle exchange programmes that only target the individual would seem to be inadequate. To enhance targeted interventions changes in public and agency policy that create a social environment conductive to behaviour change are required.

Acquired Immunodeficiency Syndrome↗
PubMed1989

Perinatal mortality in rural Tanzania.

Prolonged labour was the most frequent cause of perinatal death in a rural hospital in the south western highlands of Tanzania. After the introduction of an obstetric policy aiming to prevent prolonged labour by making use of the guidelines of the partogram, perinatal mortality was reduced from 71 to 39 per 1000 births. Baird's clinico-pathological classification is still considered a useful instrument for the discovery of avoidable factors in perinatal deaths. The concept of the partogram should be an integral part of the training of medical auxiliaries in the field of maternal and child health (MCH).

Delivery, Obstetric↗
PubMedDate not supplied

Fertility intentions and subsequent behavior: a longitudinal study in rural India.

This report compares fertility and family planning intentions of rural Indian women in 1975 with actual outcomes in 1987. Ninety-four of 103 respondents who had fewer children than they wanted in 1975 and had stated definite intentions with respect to future fertility and contraceptive use were reinterviewed in 1987. Overall, women had fewer children than desired and stopped childbearing when they reached or closely approximated their ideal number of sons. Since sons were clearly the determinant of "reproductive success," it is argued that only a significant change in the status of rural women can bring about widespread compliance with the official family planning program's two-child norm.

Adolescent↗