Narratives and gatekeeping: making sense of triage nurses' practice

It is well documented that emergency service staff consider some patients to be 'inappropriate attenders'. A central example is 'trivia', denoting patients with medical problems considered too 'trivial' to warrant attention. Although research has repeatedly shown that frontline staff violate guidelines in turning away 'trivial' patients, existing research has paid insufficient attention to why staff are willing to engage in guideline-violating gatekeeping, which may put both themselves and 'trivial' patients at risk. To address this issue, the present article explores nurses' narratives about 'trivial' patients - referred to in this context as 'GP patients' - drawing on fieldwork data from a Norwegian emergency service. The article reconstructs three narrative clusters, showing that nurses' gatekeeping is motivated by concerns for the patient being turned away, for nurses and more critically ill patients, and for the service they work for. Some of the issues embedded in these narratives have been under-analysed in previous research - most importantly, the role of identity and emotion in nurses' gatekeeping, and how patient narratives can function as 'social prognoses' in nurses' assessments. Analysis of these narratives also reveals an antagonistic relationship between nurses and 'trivial' patients that contradicts nurses' ethical guidelines and indicates a need for healthcare reform.

Aetna's California Case Puts New Focus on Prior Authorization

The CNN story once again puts controversy about prior authorization into the spotlight. But is it necessary to review a patient's entire medical record?

Gatekeeping and the utilization of community health services in Shenzhen, China: A cross-sectional study

To assess the effects of the gatekeeper policy implemented in Shenzhen, China, in conjunction with a labor health insurance program, on channeling patients toward community health centers (CHCs).Eight thousand patients who visited 8 CHCs in Shenzhen were surveyed between May 1, 2013 and July 28, 2013. Half of the patients were subject to gatekeeper policy and the other half of them were not. Structured questionnaire was used to collect patients' choices of initial medical institution, use of CHCs and their satisfaction with health care. Bivariate and regression analyses were used to compare patient's choice, utilization, and satisfaction of CHCs.Compared with patients who were free to seek medical care at any place, patients with gatekeepers were 1.77 (95% CI 1.37-2.30) times more likely to choose CHCs first when seeking care. In the past year, the group with gatekeeper made 0.88 more visits to CHCs in the past year than the group without gatekeeper (P < .01), controlling for influencing factors. The 2 groups were equally satisfied with all satisfaction measures except for "waiting time," which was higher among patients without gatekeepers (P < .01).Our study indicates that, as repeatedly proven in other parts of the world, gatekeeping is effective in orienting patients toward primary care system. Along with increased efforts in rebuilding China's primary care network and expanding health insurance coverage, implementation of gatekeeper policy may help increase access to care, reduce inappropriate use of health resources, and strengthen primary care institutions.

Termination of pregnancy: a case for a change in the law

In recent months there has been renewed public and parliamentary debate on whether the abortion law in the United Kingdom should be reformed. Parliament has debated the issue on three occasions and now the House of Commons Select Committee on Science and Technology are calling for evidence in support of their inquiry into reform of the Abortion Act 1967. The inquiry gives district nurses the opportunity to inform the debate and ensure that their voices are heard given that topics for reform include nurse-led abortions and home abortions. In this article Richard Griffith and Cassam Tengnah review the development of the law relating to abortion and highlight the areas of reform to be considered by the select committee.

Admissibility of neuropsychological testimony after Daubert and Kumho

Neuropsychological testing has been used in court cases all over the United States, as testimony to provide evidence of whether or not a person has a traumatic brain injury. It has, however, been scrutinized for its admissibility in court, but recognized for objectivity in successfully documenting and proving deficits in people with traumatic brain injuries. The trial court is used as a gatekeeper, and may chose to perform assessments of the tests themselves, for validity of sensitivity, specificity, reliability and validity in determining whether a neuropsychological test may be used as testimony in a court case.

The role of the health care ombudsman

Beginning in the 1990s, with increased attention focused on the alleged abuses and arbitrary decision making by MCOs, several states began enacting legislation to establish health care ombudsmen. A variety of states, including the District of Columbia, are now considering health care ombudsman legislation. This article focuses on the varying role, functions, and duties of the health care ombudsman in each of these states and their benefit to the health care environment.

Finance issue brief: direct access: year end report-2003

Consumer demand for a less restrictive referral system has urged legislators, as well as the managed care industry and those in the medical field, to seek the best solution to the problem. The point of service (POS) plan was an early attempt by managed care plans to provide more freedom for enrollees. But POS plans are not always available or cost effective. Several of the larger managed care organizations, in an effort to improve enrollee and provider satisfaction, have eliminated or streamlined their referral processes. The American Medical Association has recommended that primary care and other medical specialty organizations collaborate in developing guidelines for specialty referrals, urging health plans to allow direct access in network without financial penalty as long as the access conforms with the established guidelines. In the meantime, legislators have responded to constituents by enacting measures that mandate direct access for specific types of care or standing referrals for ongoing treatment.

Finance issue brief: direct access: year end report-2002

Consumer demand for a less restrictive referral system has urged legislators, as well as the managed care industry and those in the medical field, to seek the best solution to the problem. The point of service (POS) plan was an early attempt by managed care plans to provide more freedom for enrollees. But POS plans are not always available or cost effective. Several of the larger managed care organizations, in an effort to improve enrollee and provider satisfaction, have eliminated or streamlined their referral processes. The American Medical Association has recommended that primary care and other medical specialty organizations collaborate in developing guidelines for specialty referrals, urging health plans to allow direct access in network without financial penalty as long as the access conforms with the established guidelines. In the meantime, legislators have responded to constituents by enacting measures that mandate direct access for specific types of care or standing referrals for ongoing treatment.

Criminal prosecution for HMO treatment denial

A child is seriously ill. She will not live much longer if steps are not promptly taken. However, her parents' HMO has denied approval for the treatment that she needs. According to her doctor, the treatment has a good chance of helping. It could extend her life by months or even years. The treatment is, however, expensive, more than her parents can pay. Also, the initial cost is just the beginning. As long as the child lives she will need expensive care. It is a burden that the HMO does not want to take. So, a few days from now--maybe less--she will lapse into unconsciousness and, soon after, she will pass away. Her parents ponder this and think: "We've paid premiums to that HMO for years. If she dies now, because of this denial, somebody ought to pay; the law should make somebody pay for letting our daughter die."

The physician as gatekeeper to the use of genetic information in the criminal justice system

The discovery of the molecular structure of deoxyribonucleic acid (DNA) and the science of molecular biology have profoundly changed medicine’s diagnostic capability and promise to transform the therapeutic realm. When some genetic disorders are diagnosed, physicians can intervene for prevention or treatment. While the basic structure of DNA is the same for all human beings, no two individuals, other than identical twins (or cloned individuals), have the same DNA sequence. This discovery has had important repercussions in the criminal justice system, where DNA can serve as an identification tool.

At the crossroads of these different uses of DNA, there are great concerns about potential misuses of genetic information. Preventing disease, curing illness, and convicting criminals are all seen as worthwhile uses of the technology, but concerns of potential misuse in medicine or in the criminal justice system are not unfounded. A 1998 American Medical Association (AMA) study showed that 68 percent of patients had fears that their genetic test results would be used against them by their employers or insurers. Others, pointing to racial profiling, have suggested that we may now face genetic profiling.

System effects of the Kansas Mental Health Reform Act of 1991

This paper analyzes the impact of the Kansas Mental Health Reform Act on client outcomes. The Act is of general interest because it reflects a trial of greater accountability without major changes in financial incentives. It made Community Mental Health Centers [CMHCs] gatekeepers that were accountable for services for adults with severe and persistent mental illnesses. The Act sought reductions in hospitalizations rates, expanded use of community support services, and increased independent living. The structure of the Act and Client Status Reports allow rigorous examination of these outcomes. The number of clients served increased significantly. Even though hospital days fell by 23%, there is no clear evidence that the Act itself reduced hospital days per client. The proportion of community support program clients residing independently rose significantly; the proportion participating meaningfully in the labor market fell. The goals of the Act were realized overall, but the performance of CMHCs varied considerably.

Resolving conflicts between EMTALA and managed care requirements

The Emergency Medical Treatment and Active Labor Act (EMTALA) requires a hospital to provide services to persons who come to the emergency department (ED) for emergency treatment without regard for their ability to pay. Yet some managed care plans require that the hospital obtain authorization before rendering emergency medical treatment, with the result that hospitals risk either nonpayment for services or violation of EMTALA. Hospitals can improve their payment rates for ED care by amending or challenging preauthorization requirements and insisting that plans apply a uniform standard of care to treatment of ED patients.