bluuebunny/crossref_metadata_2025 huggingface dataset:
Memory in Camouflage: Alberto Breccia and Guillermo Saccomanno's“ William Wilson” as Catalyst for Memory
Authors: Rommens Aarnoud
Published: December 2005

This article explores how a minor medium such as comics—specifically,Alberto Breccia's version of Edgar Allan Poe's “William Wilson”—used its counter-censorial potential to activate memory in a context stifled by harsh repression. Through the development of several reading hypotheses, the author demonstrates how Breccia's drawings allow for a decoding that runs counter to the signification imposed by the Argentina junta of 1976-83. By recontextualizing the transfer to comics and by detaching the images from Poe's source text, the analysis diverges from traditional adaptation studies, which privilege words (the “original”) over images (the adaptation itself). Instead, the analysis foregrounds the specificity of the Latin American cultural framework as one of camouflage, in which encryption and decoding are central and potentially empowering. This utopian thrust is located in the comic's appeal to memory, which runs directly counter to a censorial logic intent on erasing and forgetting.
Is Mimetic Theory in Literature and Art Universal?
Authors: Gu Ming Dong
Published: December 2005

Mimesis is one of the most fundamental ideas in Western poetics. Mimetic theories constitute a mainstream in Western aesthetics. In comparative studies of Chinese and Western poetics, however, there exists a widely accepted opinion that mimetic theory is a cultural invention unique to the Western tradition. And on this scholarly consensus has been constructed a fundamental dichotomy, ramifying into a series of binary oppositions: the metaphorical,figurative, transcendental nature of Western art, as against the metonymic,literal, immanentist nature of Chinese art. Critically reviewing the comparative studies of mimetic theory, this article argues against the accepted opinion. By examining various ontological and epistemological aspects of mimesis in the Chinese tradition in relation to the West, this article reestablishes imitation as a transcultural human instinct and mimetic theory in art as a universal idea across cultural traditions. It also examines how the artistic ideal is conceived of in Chinese and Western representation, how Chinese mimetic theory differs from its Western counterpart, and what implications an understanding of the differences may have for the comparative study of Western and non-Western literatures.
Physicians' Conflicts of Interest in Japan and the United States: Lessons for the United States
Authors: Rodwin Marc A. , Okamoto AtoZ (Etsuji)
Published: December 2005

Japanese health policy shows that even with physician ownership and the absence of for-profit, investor-owned health care, physicians' conflicts of interest thrive. Physician dispensing of drugs and ownership of hospitals and clinics were justified in Japan as ways to avoid commercialization of medicine. Instead, they create physicians' conflicts and fuel patient overuse of services. Japan's Ministry of Health and Welfare (MHW) has responded by introducing per-diem payment, thereby creating incentives to decrease services in ways similar to those of American managed care organizations, but with none of their benefits, such as coordination of care, oversight of physicians practices, and quality assurance.

Although the United States and Japanese health care systems are organized and financed differently there is convergence in the source of their physicians' conflicts and the way they are addressed. The United States is starting to integrate institutional and physician payment and align their incentives, in a traditional Japanese way. In so doing, the United States creates new physicians' conflicts and reduces the role of countervailing incentives and power, an advantage of previous policy. Japan, in turn, has combined incentives to increase and decrease services, thus moving closer to the U.S. policy.
Mass Screening in Low-Income Populations: The Challenges of Securing Diagnostic and Treatment Services in a National Cancer Screening Program
Authors: Lantz Paula M. , Richardson Lisa C. , Sever Lowell E. , Macklem Debra J. , Hare Martha L. , Orians Carlyn E. , Henson Rosemarie
Published: December 2005

Funding for many mass screening programs for low-income and uninsured populations provides resources for screening tests, yet only rarely does it provide coverage for necessary follow-up diagnostic and treatment services. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), a federally funded initiative that provides cancer screening to low-income uninsured and under-insured women, covers some diagnostic follow-up tests and no treatment services. We conducted in-depth case studies of seven state programs participating in the NBCCEDP to investigate the strategies and approaches being used to secure diagnostic and treatment services. The results suggest that the program relies on a patchwork of resources—at state and local levels—to provide diagnostic and treatment services. This includes a number of components of local safety nets, all of which are unstable and have uncertain futures. Public health disease-screening initiatives need to reconsider the feasibility of continued reliance on case-by-case appeals to the local safety net for diagnostic follow-up and treatment services.
Systemwide Effects of Medicaid Retrospective Drug Utilization Review Programs
Authors: Moore William J. , Gutermuth Karen , Pracht Etienne E.
Published: December 2005

Aggregate pooled cross-sectional and time-series annual state data for 1985 to 1992 were used to estimate the systemwide effects of retrospective drug utilization review programs (Retro-DUR) on Medicaid drug and nondrug outcomes. The results provide evidence that these programs produce significant cost savings in the drug budget without spillover effects (positive or negative) in other nondrug budgets within the Medicaid system. We also examine the influence of restricted formularies in this post-Retro-DUR era on drug and nondrug budgets in the Medicaid system; we find significant cost savings in the former but positive spillover effects in the latter.
Big Bang and the Policy Prescription: Health Care Meets the Market in New Zealand
Authors: Gauld Robin D. C.
Published: December 2005

This article discusses events that led up to and the aftermath of New Zealand's radical health sector restructuring of 1993. It suggests that“big bang” policy change facilitated the introduction of a set of market-oriented ideas describable as a policy prescription. In general, the new system performed poorly, in keeping with problems of market failure endemic in health care. The system was subsequently restructured, and elements of the 1993 structures were repackaged through a series of incremental changes. Based on the New Zealand experience, big bang produces change but not necessarily a predictive model, and the policy prescription has been oversold.
Technology Assessment and the Sociopolitics of Health Technologies
Authors: Lehoux Pascale , Blume Stuart
Published: December 2005

In a growing number of countries, health technology assessment (HTA) has come to be seen as a vital component in policy making. Even though the assessment of the social, political, and ethical aspects of health technology is listed as one of its main objectives, in practice, the integration of such dimensions into HTA remains limited. Recent social scientific research on the inherently political nature of technology strongly supports such a comprehensive approach. The growing claims by and on behalf of consumer groups also suggest that HTA should be informed by a broader set of perspectives. Using the example of the cochlear implant in children, this essay compares the professed objectives of HTA with typical practice and explores possible explanations for the discrepancies observed. A second example, home tele-monitoring for elderly persons, demonstrates how the types of evidence considered by HTA and the process through which assessments are produced may be reconsidered. We argue for the formal integration of the sociopolitical dimensions of health care technologies into assessments. The ability of HTA to more fully address important issues from a public policy point of view will increase by making explicit the sociopolitical nature of health care technologies.
Paying for Medicare: Benefits, Budgets, and Wilbur Mills's Policy Legacy
Authors: Patashnik Eric , Zelizer Julian
Published: December 2005

Medicare features an unusually complex financing design. The Hospital Insurance Trust Fund pays for Part A of Medicare (hospital stays), while the Supplementary Medical Insurance Trust Fund finances Part B (doctor visits,outpatient care, and certain home health services). At a time when Medicare policy is generating debate, this article takes a new analytical look at the origins and consequences of the program's peculiar bifurcated structure. Addressing historians of the U.S. welfare state as well as contemporary health policy reformers, the article focuses on the crucial role of legendary Ways and Means Committee chair Wilbur Mills in Medicare's enactment in 1965. The central theme of the article is that fiscal conservatism and a commitment to budgetary restraint constitute important elements of Medicare's original political understanding. Contrary to analysts who argue that Medicare's financing design has produced “perverse” effects, we argue that it has served a valuable social function by encouraging policy makers to confront periodically the costs of one of the largest and fastest-growing federal programs. An argument can be made that Medicare's original division requires modification in order to integrate health care delivery changes of the past few decades. It is crucial, however, for reformers not to lose sight of the policy goals, including fiscal rectitude, that motivated the adoption of Medicare's bifurcated structure in the first place.
The Medicare Cost Report and the Limits of Hospital Accountability: Improving Financial Accounting Data
Authors: Kane Nancy M. , Magnus Stephen A.
Published: December 2005

Health policy makers, legislators, providers, payers, and a broad range of other players in the health care market routinely seek information on hospital financial performance. Yet the data at their disposal are limited, especially since hospitals' audited financial statements—the “gold standard” in hospital financial reporting —are not publicly available in many states. As a result, the Medicare Cost Report (MCR), filed annually by most U.S. hospitals in order to receive payment for treating Medicare patients, has become the primary public source of hospital financial information. However, financial accounting elements in the MCR are unreliable,poorly defined, and lacking in critical detail. Comparative analyses of MCRs and matched, audited financial statements reveal long-standing problems with the MCR's data, including major differences in reported profits; variations in the reporting of both revenues and expenses; an absence of relevant details,such as charity care, bad debt, operating versus nonoperating income, and affiliate transactions; an inconsistent classification of changes in net assets; and a failure to provide cash flow statements. Because of these problems, MCR financial data give only a limited and often inaccurate picture of the financial position of hospitals. Audited financial statements provide a more complete perspective, enabling analysts to address important questions left unanswered by the MCR data. Regulatory action is needed to create a national database of financial information based upon audited statements.
Proof and Policy from Medical Research Evidence
Authors: Mulrow Cynthia D. , Lohr Kathleen N.
Published: December 2005

When judging the benefits and harms of health care and predicting patient prognosis, clinicians, researchers, and others must consider many types of evidence. Medical research evidence is part of the required knowledge base,and practitioners of evidence-based medicine must attempt to integrate the best available clinical evidence from systematic research with health professionals' expertise and patients' rights to be informed about diagnostic and therapeutic options available to them. Judging what constitutes sound evidence can be difficult because of, among other things, the sheer quantity,diversity, and complexity of medical evidence available today; the various scientific methods that have been advanced for assembling, evaluating, and interpreting such information; and the guides for applying medical research evidence to individual patients' situations. Recommendations based on sound research can then be brought forward as either guidelines or standards, and criteria exist by which valid guidelines and standards can be developed and promulgated. Nonetheless, gaps and deficiencies exist in current guidelines and in the methods for finding and synthesizing evidence. Interpreting and judging medical research involves subjective, not solely explicit, processes. Thus, developments in evidence-based medicine are an aid, but not a panacea,for definitively establishing benefits and harms of medical care, and the contributions that medical research evidence can make in any clinical or legal situation must be understood in a context in which judgment and values,understanding of probability, and tolerance for uncertainty all play a role.
Cost-Effectiveness Analysis in the Courts: Recent Trends and Future Prospects
Authors: Jacobson Peter D. , Kanna Matthew L.
Published: December 2005

This article provides an initial look at how managed care organizations(MCOs) might incorporate cost-effectiveness analysis (CEA) into their decision-making process and how the courts might respond. Because so few medical liability cases directly involve CEA, we must look at other areas of the law to assess potential MCO liability for applying CEA. In general negligence cases, courts rely on a risk-benefit test to determine customary practice. Likewise, in product liability cases, courts use a risk-utility calculus to determine liability for product design defects. And in challenges to government regulation, courts examine how agencies use CEA to set regulatory policy. The results have been mixed. In product liability cases,CEA has led to some punitive damage awards against automobile manufacturers. But courts have integrated it in negligence cases without generating juror antipathy, and generally defer to agency expertise in how to incorporate CEA. The article discusses the implications of these cases for MCO use of CEA and outlines various options for setting the standard of care in the managed care era.
Evidence-Based Medicine and the Law: The Courts Confront Clinical Practice Guidelines
Authors: Rosoff Arnold J.
Published: December 2005

This article examines how courts are likely to apply evidence-based medicine, and particularly clinical practice guidelines (CPGs), in healthcare litigation involving quality-of-care and entitlement-to-benefits (coverage)claims. Exploring the “politics” of the current situation, it observes that, just as clinicians have been reluctant to use CPGs in practice,courts have been, and likely will continue to be, slow to apply them in deciding cases., The article analyzes extant and proposed statutory approaches to legitimizing and promoting courts' use of CPGs. It concludes by renewing the author's earlier and controversial proposal to establish a voluntary federal program for certifying guidelines and directing courts to give certified CPGs greater weight in healthcare litigation.
HCFA and the States: Politics and Intergovernmental Leverage
Authors: Gormley William T. , Boccuti Cristina
Published: December 2005

In this article, we seek to explain variations in the Health Care Financing Administration's (HCFA) relationship to state governments. After reviewing several alternative models of the policy-making process, we argue that the utility of each model depends on certain issue characteristics, especially salience and conflict. We further argue that HCFA's choice of intergovernmental tools, rooted in a political setting, depends on the same issue characteristics. We illustrate our arguments by examining HCFA's behavior during the Clinton administration and by focusing on four cases: HMO performance measurement, nursing home regulation, lead screening for children,and the Children's Health Insurance Program (CHIP).
Health Insurance Expansion through States in a Pluralistic System
Authors: Gold Marsha R. , Mittler Jessica , Aizer Anna , Lyons Barbara , Schoen Cathy
Published: December 2005

The United States continues to stand almost alone among developed nations in its lack of universal health care coverage. In this essay, we argue that even though the debate over whether the federal government or states should lead the effort to expand health care coverage under the federal system is relevant in strategizing how to cover the uninsured; the more critical issues stem from the challenge of the mixed and fragmented mode of public-private financing of our pluralistic health care system.

We base this argument on (1) an in-depth review of Oregon's and Tennessee's five years of experience with broad coverage reform in the context of the United States health care system and on (2) a more abbreviated review of other state experiences in providing health care coverage.

We conclude from our review that when the will exists, states can substantially expand coverage. However, as one moves up the income scale,political support and resources are harder to come by. Further, concerns grow about the interface of public and private coverage, with issues of“crowd out” and other distributional questions dominating the discussion of coverage expansion as policy makers focus less on how to cover people than on how to make sure one kind of coverage doesn't preempt another. Concern for crowd out can then lead to policies that keep out some of the very people policy makers may want to cover. In this context the question whether states or the federal government is more likely to succeed in expanding coverage is eclipsed by the more fundamental challenges raised by pluralism. Neither federal norstate government is likely to be fully successful without first identifying ways of better coordinating public and private activities and resources to provide continuous and affordable coverage.
Pegram v. Herdrich: On Peritonitis, Preemption, and the Elusive Goal of Managed Care Accountability
Authors: Hammer Peter J.
Published: December 2005

Managed care presents the paradox of organizations having real power over people's lives without there being clear or consistent means of ensuring accountability. In Pegram v. Herdrich, the United States Supreme Court struggled with whether “fiduciary duties” under the federal Employee Retirement Income Security Act (ERISA) could be used to counterbalance the incentives that HMOs have to deny necessary care. Given press coverage of the case, however, it was easy to get the impression that the managed care industry itself was on trial in Pegram. This report examines the political and legal forces underlying the dispute and analyzes the Supreme Court's unanimous rejection of the notion of federally imposed duties for HMOs. In the absence of ERISA fiduciary obligations, attention must now shift to developments in state tort law, the scope of federal ERISA preemption, and the prospect of legislative reform. The report concludes with an exploration of how the elusive goal of managed care accountability might be pursued in the wake of Pegram.
Evaluating Partnerships for Community Health Improvement: Tracking the Footprints
Authors: Shortell Stephen M. , Zukoski Ann P. , Alexander Jeffrey A. , Bazzoli Gloria J. , Conrad Douglas A. , Hasnain-Wynia Romana , Sofaer Shoshanna , Chan Benjamin Y. , Casey Elizabeth , Margolin Frances S.
Published: December 2005

Private-public partnerships are increasingly seen as an important mechanism for improving community health. Despite their popularity, traditional evaluations of these efforts have produced negative or mixed results. This is often attributed to weak interventions or an insufficient period of time to observe an impact. This study examines two additional possibilities—the need for a well-articulated shared vision and the governance and management capabilities of the partnership itself. We conducted a midstream process evaluation of twenty-five community partnerships associated with the Community Care Network (CCN) Demonstration Program. We examined how the roles of a common shared vision, strong governance, and effective management influence a partnership's ability to achieve its objectives. The findings, based on both qualitative and quantitative analyses, underscore the importance of membership organizations' perceived benefits and costs of participation and management capabilities to the partnership's progress toward a vision. Based on the qualitative data, six key governance and management characteristics are identified that separate the top performing partnerships from the lowest performing ones. We explore the implications of this research for future evaluations of public-private community health partnerships.
Preventing Lethal Violence in Schools: The Case for Entry-Based Weapons Screening
Authors: Mawson Anthony R. , Lapsley Peter M. , Hoffman Allan M. , Guignard John C.
Published: December 2005

Violence-related behavior in schools has declined in recent years, but the perception of risk remains high. Disturbingly high percentages of students and teachers report staying home out of fear, and many students bring weapons to school for protection. Current proposals for preventing school violence include punishing the violence-prone, expulsion for weapon carriers, and creating a culture of nonviolence through various behavioral methods like conflict resolution. None of these proposals address the issue of lethal violence and hence personal safety. The risk of lethal violence in schools(related mainly to firearms) could be substantially reduced by creating an effective barrier between firearms and people. This could be achieved by using entry-based weapons detection systems similar to those now used in airports and courts. Decreasing the risk and fear of violence by converting schools into weapons-free zones would also be expected to increase attendance and improve scholastic performance. Randomized, controlled studies should be undertaken to evaluate the efficacy and cost-effectiveness of entry-based weapons detection systems for achieving these outcomes.
Foul Weather Friends: Big Business and Health Care Reform in the 1990s in Historical Perspective
Authors: Swenson Peter , Greer Scott
Published: December 2005

Existing accounts of the Clinton health reform efforts of the early 1990s neglect to examine how the change in big business reform interests during the short period between the late 1980s and 1994 might have altered the trajectory of compulsory health insurance legislation in Congress. This article explores evidence that big employers lost their early interest in reform because they believed their private remedies for bringing down health cost inflation were finally beginning to work. This had a discouraging effect on reform efforts. Historical analysis shows how hard times during the Great Depression also aligned big business interests with those of reformers seeking compulsory social insurance. Unlike the present case, however, the economic climate did not quickly improve, and the social insurance reform of the New Deal succeeded. The article speculates, therefore, that had employer health expenditures not flattened out, continuing and even growing big business support might have neutralized small business and other opposition that contributed heavily to the failure of reform. Thus in light of the Clinton administration's demonstrated willingness to compromise with business on details of its plan, some kind of major reform might have succeeded.
Risk, Response, and Mental Health Policy: Learning from the Experience of the United Kingdom
Authors: Wolff Nancy
Published: December 2005

Policy makers in the United States and the United Kingdom recognize that mentally disordered offenders present special challenges to law enforcement,mental health, and social service systems, as well as the community. Although various policy initiatives have advanced over the past twenty years to improve the management of mentally disordered offenders, mental health policy has chronically failed in both countries. Because safety concerns have emerged as the mental health system has been “deinstitutionalized,” debate is growing about whether the community-care approach works—for the community. This study argues that mental health policy fails because policy makers focus on the wrong risks and design policies that manage these risks in ways that increase the possibility of adverse clinical and economic outcomes. The argument made here uses the case of persons with severe mental illness in the United Kingdom as an example of the complex relationship between risk and policy making in democratic governance. Emphasis is on the nature of risk in mental health policy and how government responds to policy and political risks. Mental health policy in Britain is then analyzed in terms of its response to and management of risks. Mental health policy has historically mismanaged the risk issue in the United Kingdom and as such has set in motion the growing community-care backlash. The path to a better outcome lies in the responsible management of the right risks. Lessons from the United Kingdom experience can be usefully applied to mental health issues in many industrial democracies.
Interest Groups and State Medicaid Drug Programs
Authors: Pracht Etienne E. , Moore William J.
Published: December 2005

A simultaneous equations model is estimated to analyze the interaction between state Medicaid pharmaceutical drug reimbursement rates, drug recipients per capita, and expenditures per drug recipient. Interest groups are shown to have a strong positive impact on pharmacy reimbursement rates,which, in turn, have an impact on pharmacy participation rates and drug utilization and expenditure patterns. Finally, a strong inverse relationship exists between expenditures per recipient and program size. The results verify the existence of substantial variation in state Medicaid programs and point to potentially growing disparities as a result of current policies.
Is the Doctor In? The Evolving Role of Organized Medicine in Health Policy
Authors: Laugesen Miriam J. , Rice Thomas
Published: December 2005

Until recently, physicians were viewed as the dominant player in health policy. Now, however, they compete with many other effective interest groups. This article analyzes this changing role, and specifically how organized medicine has changed its approach to influencing health policy. The essay begins with a review of the reasons for the growth and subsequent decline of physicians' influence. This is followed by a case study of physician payment reform under Medicare, which illustrates the ways in which organized medicine chooses when and when not to cooperate with government. The article concludes with a discussion of where physicians are likely to continue to be influential in future health policy reform. Three such areas are noted: payment policy,quality and clinical innovation, and medical education and training.
Unfinished Business: How Litigation Relates to Health Care Regulation
Authors: Sage William M.
Published: December 2005

“Regulation by litigation” is a recently recognized trend in American legal governance that develops differently in each economic sector it affects. In health care, widespread litigation can be viewed as the product of three partial transformations: incomplete industrialization, incomplete consumerism, and incomplete social solidarity. One can argue that the public turns to the courts because other actors who might exercise judgment and authority to resolve problems appear unreliable. Because litigation has several features at odds with sound health policy—including its cost,its hindsight bias, and its adversarial character—it may be necessary to develop new discretionary institutions to address specific questions that regulators cannot or will not answer.
Implementing Health Care Reform in Israel: Organizational Response to Perceived Incentives
Authors: Gross Revital
Published: December 2005

Devising new incentives was a main element of health care reform in Israel,which created a regulated market that embodies many principles of managed competition. This study examined sick fund directors' perceptions of the new incentives and their strategic responses to these incentives, enabling the testing of how managed competition works in practice. The methodology used was a multiple case study of Israel's four sick funds. Data were gathered through in-depth interviews with 160 senior officials, analysis of national health insurance legislation, and analysis of published and unpublished archival documents, newspaper articles, public statements of senior managers, and other published data on the sick funds' behavior. The study revealed discrepancies between planned and perceived incentives and highlighted the effect of the latter on strategy formulation. Analysis of sick fund strategies showed that their responses to managed competition incentives deviated from theoretical expectations, compromising some of the objectives of the reform. The study also shows that contextual features account for the specific model of managed competition that was implemented and for the specific strategies employed by the sick funds. The study concludes by highlighting the need to build a process that will enable policy makers to consider local contextual factors when planning and implementing reform, involving health care providers in designing incentives, continuously monitoring processes and outcomes in the reformed system, and allowing for flexibility in policy making.
Mandating Insurance Offers for Low-Wage Workers: An Evaluation of Labor Market Effects
Authors: Wolaver Amy , McBride Timothy , Wolfe Barbara
Published: December 2005

Employing a simultaneous model of part-time status, health insurance offers, and wages, we examine the impacts on employment and health insurance coverage of nondiscrimination rules in the tax code governing employer-sponsored health insurance. Using 1988 and 1993 Employee Benefits Supplements to the Current Population Surveys and variations in health insurance premiums and minimum wages, we find that health insurance coverage among low-wage primary earners is increased by at most 31 percent by the policy, at a cost of an estimated 0.8–5.4-percentage-point decrease in full-time employment for low-wage workers.
Health News and the American Public, 1996–2002
Authors: Brodie Mollyann , Hamel Elizabeth C. , Altman Drew E. , Blendon Robert J. , Benson John M.
Published: December 2005

The Kaiser Family Foundation/Harvard School of Public Health Health News Index, a series of 39 surveys with a total of over 42,000 respondents from 1996 through 2002, measures how closely Americans follow major health stories in the news and what they understand about the issues covered in those stories. On average, four in ten adults reported following health news stories closely. The public reports paying the most attention to stories about public health, followed by health policy and disease-related stories. While knowledge about health news varies, individuals who follow health news stories closely are significantly more likely to give the correct answer to knowledge questions about those stories.
Monitoring the Uninsured: A State Policy Perspective
Authors: Blewett Lynn A. , Good Margaret Brown , Call Kathleen Thiede , Davern Michael
Published: December 2005

Because states have primary responsibility for the implementation of public health insurance programs, states need timely, good quality data to evaluate programs, monitor trends in the number and characteristics of the uninsured,and better understand the dynamics of health insurance coverage. This article provides a synthesis of the data sources available to states for monitoring rates of health insurance coverage. Information was collected through a comprehensive review of state and national health surveys and in-depth interviews with state analysts in all fifty states. Our findings suggest that national surveys do not meet states' needs for data, and in response, states have initiated their own household surveys. We provide information on thirty-six household surveys that are used to estimate state levels of health insurance coverage. We recommend that national and state efforts be better coordinated to facilitate efficient use of resources to achieve good state-level date.
The Impact of Litigation on Nursing Home Quality
Authors: Troyer Jennifer L. , Thompson Herbert G.
Published: December 2005

Government reports indicate that regulations have been ineffective in improving quality of care in many nursing homes. Some analysts feel that litigation against nursing homes may be the result of quality problems that are monitored during the inspection process, some contend litigation merely causes quality problems by diverting financial resources away from patient care, and some argue that litigation is duplicating the efforts of the inspection process. Given that the relationship between litigation and inspection-oriented measures of quality is not clear, this article explores the relationship empirically. When a significant relationship is found, the empirical results suggest that litigation is associated with a decline in inspection-oriented measured quality in the nursing home facing the legal claim. In contrast, litigation against a chain has a very different relationship to firm-level quality, where firms within a chain that is being sued have higher levels of inspection-oriented quality. Our results suggest that legal claims may result from quality problems that go unmeasured during the inspection process. However, more research in this area is warranted.
State Nursing Home Enforcement Systems
Authors: Harrington Charlene , Mullan Joseph T. , Carrillo Helen
Published: December 2005

This study presents interview and statistical data from a telephone and fax survey of state agency officials and statistical data from the Centers for Medicare & Medicaid Services' Online Survey Certification and Reporting(OSCAR) system. State survey activities for nursing facilities were reviewed and the number and types of intermediate sanctions issued by states in l999 were reported, along with barriers to the use of such sanctions. Using five selected enforcement measures to create a summary score, states were classified by quartiles based on the stringency of their nursing facility enforcement activities. Controlling for the number of complaints as a proxy for quality, the predictors of a summary of state enforcement actions were:percentage of population at age eighty-five and above, Democratic governors,higher percentages of chain facilities, and lower facility occupancy rates. Regional differences in enforcement patterns also were shown. Many federal policies and resource constraints were identified as barriers to effective regulation. The findings identified nursing facility survey and enforcement issues that need to be addressed by policy makers.
Voting with Their Feet: Patient Exit and Intergroup Differences in Propensity for Switching Usual Source of Care
Authors: Tai-Seale Ming
Published: December 2005

Many analysts advocate patient exit as a strategy for consumers who experience poor-quality care. Exit is believed to have the potential to improve patient welfare by having patients leave (or “exit”)poor-performing health care providers, thus signaling their dissatisfaction with the quality of care they have received and thereby admonishing those providers to improve. However, the validity of exit as a signal of consumer dissatisfaction hinges on how closely it reflects dissatisfaction. Intergroup differences in the propensity to exit could also result in unintended consequences. This article examines the association between consumer experience and the decision to change one's usual care providers. It also investigates if there are any intergroup differences in the propensity for changing providers according to insurance status, gender, and race or ethnicity. Data come from household surveys conducted by the Center for Studying Health System Change. Results show significant intergroup differences in propensity for switching usual source of care for voluntary or involuntary reasons related to insurance, rural residency, age, income, race, and ethnicity. Policy implications of the empirical results on exit, voice, and consumerism are discussed.
The Paradoxical Politics of Provider Reempowerment
Authors: Brown Lawrence D. , Eagan Elizabeth
Published: December 2005

The recent decline, indeed perhaps dismantling, of managed care is sometimes treated as both consequence and cause of the political reempowerment of medical providers, whose professional dominance managed care had challenged. Drawing evidence from Round III of the Community Tracking Study of the Center for Studying Health System Change, this article reviews the politics of four “arenas” of managed care regulation—prompt payment, mandated benefits, external appeals, and financial solvency—and concludes that the power of providers is contingent on patterns of coalition and conflict that differ across the discrete arenas. The zero-sum connotations of the “de” and “re” empowerment of providers under managed care fail to capture the subtlety of providers' search for fresh cultural, economic, and political resources in shifting policy contexts.
Reconsidering Risk: Adapting Public Policies to Intergenerational Determinants and Biosocial Interactions in Health-Related Needs
Authors: Strully Kate W. , Conley Dalton
Published: December 2005

According to recent research, interactions between infant health and environment can play crucial roles in clustering health and economic disadvantage among certain families. Researchers have provided a clear example of such intergenerational biosocial cycles when they document that interactions between parental low birth weight status and prenatal environment are associated with the risk of a low birth weight, and that interactions between a child's birth weight status and early childhood environment are associated with adult socioeconomic outcomes. In this article, we consider how existing policies may be revised to more effectively address such interactions between social and biological risk categories. We are particularly concerned in this discussion with revising risk categories so they can encompass biological risk, social risk, and developmental frameworks. A framework of biosocial risk is quite flexible and may be applied to a variety of issues and programs; however, in this article we focus on the single case of low birth weight to illustrate our argument. In considering specific applications, we further explore how attention to biosocial interactions may reshape Medicaid,special education, the Earned Income Tax Credit, and Temporary Assistance for Needy Families.
Nondecision Making and Inertia in Portuguese Health Policy
Authors: Oliveira Mónica D. , Magone José M. , Pereira João A.
Published: December 2005

Despite there having been a positive context for initiating health care reforms in Portugal in the past fi fteen years (accompanied by political consensus on the nature of the structural problems within the health care system), there has been a lack of reform initiatives. We use a process-based framework to show how institutional arrangements have infl uenced Portuguese health care reform. Evidence is presented to demonstrate inertia and nondecision making in three critical areas of Portuguese health policy:clarifying the public-private mix in coverage and provision, creating fi nancial incentives and motivation for human resources, and introducing changes in the pharmaceutical market. Several factors seem to explain these processes,namely, problems in the balance of power within the political system, which have contributed to a lack of proper policy discussion; a lack of pluralism in the formation of health care policies (with low participation from citizens and high mobilization among structural interest groups); and the low priority of health care in public sector reforms. Portuguese politicians should be aware of the pitfalls of the current political system that constrain participatory arrangements and pluralism in policy making. In order to pursue health care reform, future governments will need to counterbalance the strong influence of structural interest groups.
Renovating the Commons: Swedish Health Care Reforms in Perspective
Authors: Saltman Richard B. , Bergman Sven-Eric
Published: December 2005

Recent reform experience in Sweden supports the premise that key dimensions of a country's health care system reflect the core social norms and values held by its citizenry. The fundamental structure of the Swedish health system has remained notably consistent over the past half century, that is, tax-based fi nancing and publicly operated hospitals. Yet on other, nearly as important,parameters, there has been substantial change, for example, the persistent pursuit for thirty years of a stronger primary care framework and the effort to allow patient choice of doctor, health center, and hospital within the publicly operated system. This particular combination of continuity and change has occurred as traditional Swedish values of jamlikhet (equality)and trygghet (security) have been challenged in an environment shaped by an aging population, changing medical technology, and Sweden's integration into the European Single Market. This article explores the ongoing process of health system development in Sweden in the context of the country's broader social and cultural characteristics.
Health Policy in Denmark: Leaving the Decentralized Welfare Path?
Authors: Vrangbæk Karsten , Christiansen Terkel
Published: December 2005

In this article, we investigate developments in Danish health care policy. After a short presentation of its historical roots, we focus on the decades after the administrative reform of 1970, which shaped the current decentralized public health care system. Theories of path dependency and institutional inertia are used to explain the relative stability in the overall structure, and theories of policy process and reform are used to discuss gradual changes within the overall framework. Although comprehensive reforms have not taken place in Denmark, many gradual changes may pave the way for more radical changes in the future. The political climate currently seems to be more favorable toward structural reform than in the past.
Reform, Change, and Continuity in Finnish Health Care
Authors: Häkkinen Unto , Lehto Juhani
Published: December 2005

This article describes some essential aspects of the Finnish political and governmental system and the evolution of the basic institutional elements of the health care system. We examine the developments that gave rise to a series of health care reforms and reform proposals in the late 1980s and early 1990s and relate them to changes in health care expenditure, structure, and performance. Finally, we discuss the relationship between policy changes,reforms, and health system changes and the strength of neo-institutional theory in explaining both continuity and change. Much of the change in Finnish health care can be explained by institutional path dependency. The tradition of strong but small local authorities and the lack of legitimate democratic regional authorities as well as the coexistence of a dominant Beveridge-style health system with a marginal Bismarckian element explain the specific path of Finnish health care reform. Public responsibility for health care has been decentralized to smaller local authorities (known as municipalities) more than in any other country. Even an exceptionally deep economic recession in the early 1990s did not lead to systems change; rather, the economic imperative was met by the traditional centralized policy pattern. Some of the developments of the 1990s are, however, difficult to explain by institutional theory. Thus, there is a need for testing alternative theories as well.
When Health Policy Is the Problem: A Report from the Field
Authors: Spitz Bruce , Abramson John
Published: December 2005

We often think of health policy and health services research as offering solutions to cost, quality, and access problems. Many of us see health policy as simply ineffective. But any activity that has the power to cure can also do harm. Is it possible that the health policy enterprise has contributed to the very problems it has been attempting to eliminate? We argue that it has. Reasonable assumptions have led to a series of solutions that have provided political cover for those vested in the status quo. This process is nonpartisan, with those of us on the left and the right unintentionally and inadvertently contributing to the problems we are so committed to solving.
Determinants of States' Allocations of the Master Settlement Agreement Payments
Authors: Sloan Frank A. , Carlisle Emily Streyer , Rattliff John R. , Trogdon Justin
Published: December 2005

To determine which factors influence states' allocation decisions for the tobacco Master Settlement Agreement and the four individual settlements' annual payments, including the decision to securitize, we analyzed the effects of voter characteristics, political parties, interest groups, prior spending on public tobacco control programs, and state fiscal health on per capita settlement funds allocated to tobacco-control, health, and other programs. Tobacco-producing states and those with high proportions of conservative Democrats or elderly, black, Hispanic, or wealthy people tended to spend less on tobacco control. Education and medical lobbies had strong positive influences on per capita allocations for tobacco-control and health-related programs. State fiscal crises affected amounts spent by states from settlement funds as well as the probability of securitizing future cash flows from the settlements.
Assisting Altruism: Evaluating Legally Binding Consent in Organ Donation Policy
Authors: Mesich-Brant Jennifer L. , Grossback Lawrence J.
Published: December 2005

The growing need for organ and tissue transplants has led a number of states to enforce a policy that views a donor's declared intent to be an organ donor as legally binding. This allows health officials to harvest organs without the permission of the next of kin. Legally binding consent is controversial because of concerns that it may anger family members, lead to negative publicity, and discourage potential donors. We use interviews and a pooled time-series data set of cadaveric donation rates in U.S. states to evaluate the effectiveness of this policy. Our research indicates that enforcement of legally binding consent has marginally increased cadaveric donations while not significantly affecting donor registration. We also find evidence that the effect of the policy might be greater if it were more fully implemented and coordinated with efforts to improve public acceptance and awareness.
The Chronicling of Obesity: Growing Awareness of Its Social, Economic,and Political Contexts
Authors: Brownell Kelly D.
Published: December 2005

© 2005 by Duke University Press.
As Irrational As Bert and Bin Laden: The Production of Categories, Commodities, and Commensurability in the Era of Globalization
Authors: Pedersen David
Published: December 2005

David Pedersen teaches social and cultural theory at the University of Michigan, where he recently completed his Ph.D. in anthropology and history. He is the author of “The Storm We Call Dollars: Determining Value and Belief in El Salvador and the United States” (Cultural Anthropology, August 2002) and author (with Paul K. Eiss) of the introductory essay to that issue, “Values of Value.”