Caring for the infirm: a task for the individual or for a social insurance programme?

In West Germany, seventy per cent of all nursing home patients receive only a pocket-money, for social health insurances are responsible only for the care of "sick" people, but not of those needing only "care". The infirm individual, however, rarely can pay for the costs of nursing homes out of his own revenue. Despite general agreement that guarding against the financial risks of becoming dependent on nursing is insufficient there is little consensus on what a new concept should look like. Some proposals are more concerned with avoiding cost-expansion than with effective health care. On the one hand, the implementation of a new branch in the social insurance system, called "nursing insurance", is demanded, which would pay for the stay in nursing homes. On the other hand, it is emphasized that the capacity for voluntary individual provision should be strengthened as well as the families' means to care for their bedridden members. This paper presents the discussion and outlines implications for health care of the various proposals.     

Is a QALY still a QALY at the end of life?

Recent research into end of life and palliative care has focused on the development of a replacement for the quality adjusted life year (QALY) as an outcome measure. Reasons given range from the lack of anticipated survival benefit from treatment to the inappropriateness of death as an anchor for valuing health states, or the increased value of time to the individual at the end of life. The Palliative Care Yardstick, has been proposed as an alternative. In this paper, I argue that the QALY should not be abandoned as an outcome measure in end of life and palliative care populations and suggest possible methods for generating empirical data to support or refute this. I show why the arguments made for replacement of the QALY are not supported by current evidence and how in some cases the abandonment of the QALY framework would lead to an unjustifiable inequitable distribution of resources.     

Is there a doctor in the house?

Unless employees can readily access your physician network, even the best physicians won't do them much good. Here is a state-of-the-art system for measuring access to care.