The hospice movement: institutionalizing innovation

The early leaders of the hospice movement shared a number of attitudes with the founders of the alternative institutions of the 1960s and early 1970s: nostalgia for simple, old fashioned ways, dissatisfaction with bureaucratic and authoritarian institutions, faith in the power of nature, a determination to avoid domination by experts, and a desire to improve the quality of personal relationships. However, as hospices have become better established, they gradually have been incorporated into the dominant health care system and have lost their uniqueness. Some have affiliated with hospitals or home health agencies. Even autonomous organizations are subject to pressures for accommodation because they rely on the established order for resources, personnel, and political acceptance. Organizations receiving payment under the new Medicare benefit must adhere to a set of regulations that may distort the movement. Though creation of this benefit may have been facilitated by increased support for hospice ideals, the government views hospices primarily as a way to save money. Paradoxically, as hospices have grown in popularity, the critical force of the movement has been blunted.     

Better together: Coexistence of for-profit and nonprofit firms with an application to the U.S. hospice industry

Many markets maintain a nontrivial mix of both nonprofit and for-profit firms, particularly in health care industries such as hospice, nursing homes, and home health. What are the effects of coexistence vs. dominance of one ownership type? We show how the presence of both ownership types can lead to greater diversity in consumer types served, even if both firms merely profit-maximize. This is the case where firms serve consumers for multiple consumption durations, but where donations are part of a nonprofit firm objective function and happen after services have been provided. This finding is strengthened if the good or service has value beyond immediate consumption or the direct consumer. We show these predictions empirically in the hospice industry, using data containing over 90 percent of freestanding U.S. hospices, 2000–2008. Nonprofit and for-profit providers split the patient market according to length of stay, leading to a wider range of patients being served than in the absence of this coexistence.     

Foreign medical graduates and U.S. physician supply: old issues and new questions

Recent increases in the number of foreign medical graduates (FMGs) in U.S. hospital-training positions raise new questions about the future role of FMGs in U.S. medicine. Despite an historical surplus of physicians, forces such as greater demand for resident house officers, stabilization in undergraduate medical education enrollment, increase in demand for medical services, growth in both the number of women in medicine and physician employment in group practices, and continuing imbalances in the distribution of physicians favor FMG migration to the United States. Health system reform must be sensitive to the historical, current, and future role FMGs play in medical care delivery, especially in regard to service in underserved areas, specialties, and employment settings.     

The hospitalist movement: ten issues to consider

The rapidly growing hospitalist model appears to be living up its promise to improve the efficiency and perhaps the quality of hospital care. The important issues no longer relate to its continued existence--even skeptics concede that it is here to stay. Instead, concern surrounds the myriad organizational and clinical issues that inevitably appear whenever there is a major change in the health care system.     

Population growth and economic development: two new U.S. perspectives

This report compares the research paths of economic development reports by the US National Academy of Sciences (NAS) and the American Assembly of Columbia University. The NAS group, made up principally of economists and demographers, refrained from recommending population reduction targets, in contrast to the stronger terms of its 1971 report. A 1965 report by the Assembly spoke of population as a serious negative influence for economic development, political stability, and world peace, while the new report speaks of negative socioeconomic effects, and of the limiting of a person's right to control family size. The NAS agenda was established before the US delegation to the UN population conference in Mexico City retreated from declaring population growth to be a necessarily negative influencer of socioeconomic progress. The Assembly took the position that possible benefits of population growth would be far outweighed by factors such as resource depletion and women's health. The NAS maintained that growth might provide incentives for institutional adjustments (market development, investment in education) and control of growth should not be considered a substitute for such interventions. Both reports agree that control of fertility is a human right, but the NAS report examined the question of the acceptable degree of compulsion to be used to encourage couples. The Assembly objected to limiting access to family planning by defunding abortion programs oversease. Differences exist between the 2 reports in questins such as the negative impact of 1950's population growth, the synergistic effect of growth on many areas of human activity, the extent to which welfare of future generations is considered relevant today, and the adequacy of pure economic analysis in assessing need. Much study of population/development linkages is still required.     

Nutrition in Space: Evidence from the U.S. and the U.S.S.R.

Space flight exposes humans to a hostile, stressful environment as well as to the weightlessness associated with microgravity. The stresses of space travel affect nutritional balance, as evidenced by interrelated changes in body composition, energy utilization, and endocrine function. The limited data gathered thus far suggest that space flight incurs acute decreases in fluid mass and chronic, ongoing changes in muscle and bone mass. Concurrent with these changes is an increase in energy used per unit body mass. Other preliminary data suggest that bed rest and space flight may incur increased sensitivity to insulin. Further research is needed to determine the human energy and protein requirements for space, as well as a means of quantifying changes in body composition during extended-duration space flight.     

The broken covenant in U.S. healthcare

There has been a long-established covenant in healthcare existing between physicians and society. This agreement, steadfast for decades, has been abrogated by society beginning in the 1990s with the arrival of managed care. Among other things, the broken covenant has resulted in the early retirement of physicians, thereby exacerbating the projected shortage of physicians for the U.S. healthcare system. Executive business coaching of physicians to increase their career satisfaction is presented as a solution to abate physicians retiring prematurely and thus meet society's growing demand for medical practitioners.     

Role of U.S. military research programs in the development of U.S.-licensed vaccines for naturally occurring infectious diseases

U.S. military physicians and researchers have collaborated in the development of eight U.S.-licensed vaccines since 1934, when product efficacy requirements were added to product safety requirements mandated in 1902. These vaccines include influenza (1945), rubella (1969), adenovirus types 4 and 7 (1980), meningococcus A, C, Y, W-135 (1981), hepatitis B (1981), oral typhoid (1989), Japanese encephalitis (1992), and hepatitis A (1995). Current efforts include new adenovirus and Japanese encephalitis vaccines, and vaccines to prevent dengue, diarrhea due to enterotoxigenic E. coli, Campylobacter, and Shigella, malaria, hemorrhagic fever with renal syndrome, scrub typhus, meningococcus type B, and HIV infection. All vaccines currently administered to U.S. military forces must be licensed by the U.S. Food and Drug Administration (FDA).     

Environmental health and hazardous waste issues related to the U.S.-Mexico border.

Environmental health and environmental quality issues along the U.S.-Mexico border have been of concern for several years. The enactment of the North American Free Trade Agreement and the presence of the maquiladoras (foreign-owned industries using imported raw materials) have intensified those concerns recently. Efforts to assess these issues are complicated by the fact that many of the issues affecting the border region are within federal jurisdiction, but the problems are regional and local in nature. Thus, state and local governments become involved with public concerns about real and potential problems. One major problem is that environmental health data from this region are lacking, particularly from Mexico. Some new agencies such as the Border Environment Cooperation Commission, the United States-Mexico Border Health Commission, and the North American Commission on Environmental Cooperation have joined several existing agencies at the federal and state level to address environmental quality and health. Several studies have been initiated to determine air and water quality, but little is being done in the areas of hazardous waste and health assessment. Several problems are anticipated in the generation of such data, such as its format and accessibility. Data gaps and research needs are discussed.