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PubMedDate not supplied

Designing a Medicare prescription drug benefit: issues, obstacles, and opportunities.

We review the policy concerns underlying some of the most contentious issues that must be resolved prior to the enactment of a Medicare drug benefit. We consider critical issues both in benefit design-targeted versus universal eligibility, benefit subsidies, and benefit comprehensiveness--and in benefit administration, focusing especially on issues involving the administration of the drug benefit in traditional Medicare. Despite the apparent contentiousness of the drug benefit debate, alternative proposals may not be so far apart on these issues.

Aged↗
PubMedDate not supplied

Obstacles to employers' pursuit of health care quality.

Large employers' roles in improving health care quality are shifting away from value-based purchasing toward direct efforts to improve health care delivery within local markets. Although most large employers adopted the tools required for value-based purchasing, inadequate information on quality has frustrated employers and limited their ability to make choices based on quality. More recent quality initiatives aimed at directly improving local health delivery systems may be limited to specific markets where the largest employers can exert substantial influence.

Competitive Bidding↗
PubMed2000

Agreeableness as obstacle.

The author discusses excessive agreeableness as it appears in the analytic situation, the patient agreeing with all interpretations, accepting all the analyst suggests in such a way as to keep the treatment apparently ongoing and peaceful but actually semi-paralysed. This type of agreeableness is linked with what has been described in the literature under the rubric of compliance. The author aims to show the various ways in which this agreeableness is enacted in the relationship with the analyst, and then to explore further the kind of anxieties that this defensive structure tries to ward off. Material from an adolescent patient is used to describe the slow unravelling of very powerful anxieties about being invaded and taken over by her object, anxieties that lead to her having no life and no mind of her own. It is suggested that such deeply paranoid anxieties may unconsciously be present in other patients of this compliant, 'agreeable' type.

Adolescent↗
PubMed2003

Obstacles facing the psychoanalyst when interpreting narcissistic pathologies: characteristics of the authoritarian patient.

This paper explores the unconscious agreements between patient and analyst that promote some aspects of conflict to be excluded from the content of the interpretations. This generates an experience of exerting omnipotent control over the analyst, which subsequently consolidates a narcissistic phantasy. A stagnation of the analytic process is established in the course of the analysis but this remains hidden by areas of partial progress in the patient. Clinical material is provided in order to show the vicissitudes of the interrelationship between patient and analyst. It also demonstrates the working through by the analyst of a situation of both transferential and countertransferential conflict. This leads to an inhibition on the part of the analyst in his interpreting function. The use of projective identifications, which are mutually contradictory and incompatible, is also under discussion. This, as a result of being expressed simultaneously, constitutes a paradox, which may lead the analyst to confusion and an experience of paralysis. The subsequent confusional anxieties are considered. Additionally, authoritarianism is discussed, including its attendant difficulties of establishing boundaries between the self and the object. Finally, under consideration is the risk one takes in formulating authoritarian interpretations, which, in certain cases, can impose criteria on the patient.

Adult↗
PubMed2001

Genetically modified tumour vaccines: an obstacle race to break host tolerance to cancer.

The development of genetically modified tumour vaccines (GMTV) has been prompted by a better understanding of antitumour immune responses and genetic engineering technologies, as well as the identification of numerous tumour antigens (TA) in several malignancies which occasionally induce spontaneous tumour regressions. Cellular vaccines are based on autologous or allogeneic tumour cells genetically engineered to secrete different cytokines, co-stimulatory molecules, or allogeneic HLA molecules in order to provide a strong stimulatory signal together with the presented TA. Another promising approach that is targeted towards breaking immune tolerance to TA, exploits dendritic cells (DC) loaded or genetically modified with TA (and sometimes cytokines). Effective nonviral and viral gene delivery systems have been constructed including a third generation of adenoviral, lentiviral and hybrid vectors. Studies in mice demonstrated that therapeutic, curative immune responses might be elicited by GMTV. Promising results from animal studies are rarely seen in human trials. Several reasons, such as numerous escape mechanisms of slowly evolving spontaneous tumours and immune incompetence of advanced patients, are major concerns. Improved monitoring of immune responses to GMTV is essential to distinguish between responders and non-responders in order to tailor immune therapy strategy to the individual patient.

Animals↗
PubMed2004

A model for the mediation of processivity of DNA-targeting proteins by nonspecific binding: dependence on DNA length and presence of obstacles.

A physical and mathematical model is presented to explain processivity of proteins on DNA. In this model, a DNA-targeting protein such as a restriction enzyme can diffuse to the DNA surface and nonspecifically bind to it. Once on the DNA surface it will either move along the DNA or equilibrate with the surrounding region. Owing to the nonspecific binding, the search for a specific site on the DNA occurs in a reduced dimensionality, and the protein appears processive when moving from one specific site to another. The simplest version of this nonspecific-binding-facilitated diffusion model is solved and the results quantitatively explain experimentally observed dependence of the processivity ratio on the intervening DNA length between two specific sites.

Binding Sites↗
PubMed2004

Overcoming obstacles: collaboration for change.

Effective diabetes care requires a partnership between prepared, proactive practice teams and informed, activated patients. Diabetes education helps to overcome many of the barriers to effective self-management by enabling people with diabetes to make informed decisions about their day-to-day self-care. Both psychosocial and health outcomes have been improved through a variety of training programmes; however, education must be coupled with ongoing self-management support if these benefits are to be sustained. The principal goal of diabetes education has undergone a major shift over the past few years--evolving from primarily didactic interventions, focused on encouraging patients to adhere to the prescribed therapy, towards more interactive learning that supports people in making informed, self-directed decisions.

Cooperative Behavior↗
PubMed2004

Overcoming obstacles: new management options.

The outlook for patients with type 2 diabetes looks set to improve with the availability of new diabetes management options that provide more comprehensive control of blood glucose levels and/or encourage better patient compliance than previous alternatives. New insulin analogues, such as insulin lispro, aspart and glargine, allow more physiological insulin replacement and greater freedom in the timing and content of meals, compared with regular insulin preparations. The development of novel non-invasive routes of insulin administration promises to further improve diabetes management. Many barriers to initiating insulin relate to the need for frequent insulin injections, fears that insulin injections will be painful and difficult to administer, and concerns about hypoglycaemia and weight gain. Thus, each measure that reduces these barriers will help to prevent inappropriate delays in starting insulin therapy as well as to promote better compliance with therapy. The output from continuous glucose monitoring devices will assist accurate insulin replacement, which is difficult using point-estimates of blood glucose. Such devices will hopefully also circumvent the need for finger stick tests. There are several novel therapies in development that will further expand the portfolio of treatment options for patients with type 2 diabetes. Improved quality and choice of diabetes management options will provide doctors with the tools they require to develop tailored treatment plans, increase the probability that treatment goals are achieved and thereby reduce the risk of patients developing late-stage diabetes-related complications.

Blood Glucose Self-Monitoring↗