Managed care regulations: impact on quality?

Over the last decade, the general public and providers have become increasingly concerned about the quality of care provided by managed care organizations. This article focuses on state and federal legislative proposals to protect quality, and the potential tradeoffs involved with increased regulatory oversight of managed care proposals. In enacting managed care legislation, policy makers should balance the costs potential with the extent to which proposed policies will protect consumers from harm, enhance the operation of the market, or affect quality of care, access to services or choice of providers.     

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.     

Caring: the neglected health outcome? or input?

In most forms of evaluation of health care--and it is certainly true of economic evaluation--and is considering the outcomes of such care, caring tends to be omitted, or simply forgotten. It is often the case that little more than lip service is paid to the inclusion of caring as an input. This paper takes a closer look at caring, the neglected outcome of health care. The perspective starts from that of economics but other disciplines are examined briefly along the way to determine whether they deal better with caring than does the dismal science of economics. It is concluded that there is a need for greater consideration of caring as both an outcome and an input in evaluation of health care and that in the specific context of economic evaluation, when considering caring, economists might usefully look to other disciplines to broaden and deepen their conceptualisation of both benefits and costs in their economic evaluation studies.     

Home care for the elderly: problem or solution?

Home care for the elderly has become an important health care tool in both developed and developing countries. However, several ethical, social, and operational concerns have received insufficient attention, and the Brazilian literature on this theme is limited. Starting with a bibliographic review on home care, this paper takes a bioethical approach to potential problems arising from this growing and important patient care modality. A broader ethical approach is needed to implement home care for the elderly, with policies to protect the patient, family, and caregiver, aimed at improving the quality of this program format.     

How to promote prevention--economic incentives or legal regulations or both?

Legal regulations of the work environment are probably regarded as the main tools for promoting prevention at the workplace. Legal regulations are expressed as occupational exposure limits, bans, and taxes. Taxes can be regarded as economic incentives as well, and other economic incentives are insurance systems for employers' and consumers' actions. The latter have been found to have profound effects regarding environmental issues and may also, in the future, be a powerful tool for workplace-related prevention. The research in this area is rather limited, but there are some research results that can be obtained from the area of environmental economics. This paper discusses some examples in which legal regulations, economic incentives, or both have been used. Legal regulations and market-based economic incentives may produce similar results, but the economic cost and political feasibility typically differ. This situation makes the selection and design of instruments an important field for future research.     

Caring and researching: complementary or exclusionary practices?

The conception of empirical nursing has been disseminated, based on "doing", updated according to professional practice, impairing the interdisciplinarity between care, research and the building of a specific knowledge able to provide scientificity to its actions. Thus, authors aimed at understanding nurses' conceptions on care and research, analyzing their practices and verifying if they are complementary or exclusionary. They used participant observation and semi-structured interviews with nurses working at a University Hospital located in the state of Rio de Janeiro, Brazil. Results showed different discourses on care and research as well as the difficulties to associate these activities that, for nurses, are theoretically complementary but practically exclusionary.     

Community care for long-stay psychiatric patients: need- or policy-driven?

This paper describes an economic analysis undertaken as part of an evaluation of mental health services in Clwyd. This project was conducted in response to the decision to close the North Wales Hospital, Denbigh; a long-stay psychiatric hospital. Cost data were collected in both the hospital setting and subsequent community care settings. These data are compared with effectiveness data developed in other parts of the overall project in order to place the discussion in a cost effectiveness framework. Little significant difference in care effectiveness between hospital and community settings is identified, although minor improvements in some aspects for some patients are noted. However, there are considerable changes in the care costs. The cost estimates show that old long-stay patients cost more to care for in the community than the new long-stay patients, whilst in hospital they had cost less. In addition, the results highlight the significant influence of pay scales and capital funding on cost of care. The paper concludes that the cost of care is substantially affected by non-needs-driven policy decisions as well as by direct patient needs.     

An office or a bedroom? Challenges for family-centered care in the pediatric intensive care unit

Although the modern pediatric intensive care unit (PICU) has followed general pediatrics and adopted the family-centered care model, little is known about how families prospectively experience PICU care. The authors' goal was to better understand the experiences of families whose child was hospitalized in a PICU. They conducted a 12-month prospective ethnographic study in a PICU in a tertiary care hospital in a large North American urban center. Data were obtained via participant-observation and formal and informal interviews with 18 families and staff key informants. Findings revealed a disconnect between the espoused model of family-centered care and quotidian professional practices. This divergence emerged in the authors' analysis as a heuristic that contrasts a professional "office" to a sick child's "bedroom." PICU practices and protocols transformed the child into a patient and parents into visitors; issues such as noise, visitation, turf, and privacy could favor staff comfort and convenience over that of the child and family. The authors' discussion highlights suggestions to overcome this divergence in order to truly make the PICU family centered.     

Fee-for-service or donation? Hungarian perspectives on informal payment for health care

Informal payments are known to be widespread in the post-communist health care systems of Central and Eastern Europe. However, their role and nature remains contentious with the debate characterized by much polemic. This paper aims to make sense of this debate by reviewing and summarizing the main arguments of the theoretical debate in Hungary. The review examines the possible causes of informal payment, the motivation of the actors involved and the impact of informal payment on system performance, focusing on efficiency and equity. The lines of arguments are summarized in two contrasting hypotheses, which envisage informal payment as either a donation or a fee-for-service. Evidence pertaining to the scale of informal payments and the motivation of patients are reviewed, but found to be inconclusive to verify the hypotheses. Although focused on Hungary, accounts from other countries facing informal payments show similar threads of discussion and dilemmas. These theories should be tested further using evidence from existing studies and new empirical research, since the validity of the gratitude payment concept is a central dilemma of effective policy making in the area. To orient future research, a possible agenda is outlined, which links evidence to be obtained to the defining features of gratitude payments.     

Psychosocial care for cancer patients in primary care? Recognition of opportunities for cancer care

The paper outlines psychosocial problems experienced by cancer patients and the current barriers to service delivery. New models of psychosocial service provision are put forward, emphasizing information, communication and technology aids in an attempt to improve co-ordination of care. The management of cancer patients has evolved greatly over the past decades, and patients are well placed to benefit from the experiences of primary care professionals in the delivery of chronic illness disease management strategies.