National health care spending, 1989

Markets, Medicare, and making do: business strategies after national health care reform

This essay examines the role of business health care purchasers in keeping market solutions at the center of the health system. One might assume that employers would have a clear ideological preference for market solutions, but big business managers are ambivalent about market interventions at both the firm and public policy levels. Although currently enthusiastic about market-oriented managed care, large employers have been periodically disappointed by firm-level market experiments during the past two decades. They viewed with skepticism the Republican proposal to apply private-sector market cures to the public Medicare and Medicaid, fearing that the proposals would accelerate cost-shifting to private business payers. Big business objections have been muted, however, by the organizational weakness so vividly illustrated during the national health reform debate.

Clinical radiopharmacy: principles and practices

On the average, radiopharmacists spend about 17.2% of their time in clinical activities if their practice setting is in an institution, and about 8.5% of their time if their practice setting is in a centralized nuclear pharmacy. A recent survey of radiopharmacists was conducted to determine: (1) the percentage of time they spend engaged in selected activities, and (2) the specific clinical activities in which they are involved. A few radiopharmacists spend as much as 50% of their time in clinical activities, but most spend only 5% to 20% of their time. Some of the clinical activities involve direct interactions with patients, such as explaining the reasons for administering the radioactive material or actually administering the dose. Other clinical activities are indirect, such as reviewing charts before or after studies and making recommendations to other health care professionals. About half of the pharmacists surveyed see a need for increasing their clinical activities. The need to maximize the time involved in providing pharmaceutical care is discussed and several patient-care activities/responsibilities are proposed.

Perinatal nurse practitioners and health care reform

Health care delivery for pregnant women at high risk is changing in response to the nation's need to contain costs and improve care. Perinatal nurse practitioners can provide specialized care to women at high risk in a wide variety of settings. They provide quality, cost-effective care and can improve access to prenatal care for families at risk for untoward pregnancy outcomes.

A sociodemographic comparison of families of very low-birthweight infants: 1982-1991

Social and demographic characteristics were investigated in families who had very low birthweight infants between 1982 and 1984 (historical cohort). Since those data were collected, the number of women using drugs during pregnancy has increased significantly. Therefore, between 1989 and 1991 (current cohort) we continued to document sociodemographic characteristics of families of very low-birthweight infants (144 mothers, 156 infants). Data were collected from review of hospital charts and outpatient health records, and monthly interviews. The two cohorts were similar demographically. Changes in family composition occurred more frequently in the current cohort. There was a startling increase in illicit drug use between the two groups of women 3% in the historic cohort and 20% in the current cohort. In the historical cohort all infants went home to their mothers; however, in the current cohort 7.8% of infants were placed with other family caretakers. Infant health outcomes for the first six months after hospital discharge were similar in both groups. From 1982 to 1991 the increases in substance abuse, nonmaternal caretakers, family moves, and changes in family composition have implications for health care providers involved in infant follow-up care.

The United States' health care system: problems and solutions

The problems facing the U.S. health care system are not new; they have been discussed for the last 60 years. The problems have not been solved because, due to fears of government involvement, we have been reluctant to impose central planning and management on the system. Reliance on the free market and fee-for-service reimbursement to allocate health resources, to contain costs and to determine who has health insurance has failed. The result is that the U.S. spends more per capita on health services than any other country in the world, but lags behind many other countries on such health indicators as life expectancy and infant mortality. Several criteria for evaluating proposals for health reform are offered and ten such proposals are discussed. It is likely that, in the short run, the U.S. will adopt reforms that require the least change in the current system. However, these changes will not address adequately the fundamental problems with the system and, ultimately, major changes will have to be undertaken. [This article is followed by an editorial by Dr. Jonathan Trobe relating its concepts to the objectives set forth in the recently proposed Clinton Health Plan.]

Perspectives on functional assessment: its use for policy making

Functional assessment has the power to decide who receives care, for how much and by whom. Yet, despite its perceived value for setting public policy, these tools are often described as either flawed or formative in their development. Thus, policy-making using functional assessment could be considered premature during a time when cost and quality controls are overdue. Such a dilemma pits consumers, practitioners and researchers against policy-makers and payers as health-care decisions hang in the balance. This article presents the views of key constituencies on the readiness of functional assessment for policy-making. The discussion, focused primarily on setting health-care policy in the United States, is framed against a profile of health-care trends, within the context of the World Health Organization's International Classification of Impairments, Disabilities, and Handicaps, and with reference to the characteristics of selected tools in widespread use. These perspectives may shed light on ways to proceed for building confidence in the tools' viability for policy-making.

Together again: business, government, and the quest for cost control

Corporate America leads the pack in the collective anxiety attack over health care costs. But will the business community add its considerable political power to the movement for national health reform? Conventional wisdom suggests not: businessmen seldom rally for collective concerns, have traditionally been biased against government action, and have diverse interests. This article guardedly offers grounds for greater optimism about corporate participation, arguing that the proper institutional context can help businessmen to see their preferences as consistent with health reform. Business groups have already proven critical to the issue development stage, where a dedicated group of corporate health reformists were key to getting reform on the national agenda. Business may also respond to strong leadership from President Clinton and assist in the legislation of national health reform. Yet the price of this corporate support is a decidedly conservative slant to the proposed legislation.

Developments in alcoholism treatment

Alcohol treatment systems expanded and diversified considerably over the past decade. This reflects adaptation to a variety of forces, including developments in national health care financing and policy, changes in other health care systems with which alcohol treatment had strong ties, the more diffuse effects of social movements and a "drying trend" in American public opinion, as well as agitation by advocacy and provider groups within the alcohol field. Drawing on national monitoring data, this chapter reviews developments at the levels of financing policy, organizations, client populations, and treatment modalities, documenting expansion in private sector alcohol treatment units, a growing emphasis on providing outpatient treatment, a merger between services for alcohol and drugs at the organizational and conceptual levels, increases in service delivery to coerced populations, as well as demographic change in alcohol treatment caseloads during the 1980s.

Health policy dilemmas related to high technology infertility services

As cost containment in health care becomes an important concern, the costs and benefits of specific health care services will be more closely examined. The costs and benefits of one type of health care, high technology infertility services, are explored in this paper. These services may be particularly susceptible to cost containment since they are costly, raise ethical issues, and because they currently are provided to healthy individuals not experiencing life-threatening illness who can afford them.

Problems of health insurance coverage and health care in the United States: public and private solution strategies

A nearly universal consensus has developed in the United States that the current health care financing system is a failure. The system has been unable to control the continuing rapid rise in health care costs (by far, the highest in the world), and it has been unable to stem the growing population that has no health insurance coverage (at least 36 million people). There is nearly universal political agreement that government must provide health insurance to a far greater share of the population than ever before. The political debate now focuses on whether this expanded government role should supplement the private insurance system with an enlarged public program covering those left out of private insurance coverage, or replace private insurance with a universal government health insurance program covering the entire population.