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Indigenous peoples in the United States experience many health disparities and barriers to accessing health care services. In addition, Indigenous communities experience poor social drivers of health, including disproportionately high rates of food insecurity, violence, and poverty, among others. These challenges are unsurprising, given historical societal discrimination toward Indigenous peoples and government policies of violence, forced relocation with loss of ancestral home, and erasure of cultures and traditions. Indigenous peoples have displayed resilience that has sustained their communities through these hardships. Through treaties between the federal government and Indigenous nations, the federal government has assumed a trust responsibility to provide for the health and well-being of Indigenous populations through the direct provision of health care services and financial support of tribally operated health systems. However, despite serving a population that has endured substantial historical trauma and subsequent health issues, federal programs serving Indigenous peoples receive inadequate federal funding and substantially fewer resources compared with other federal health care programs. Access to care is further challenged by geographic isolation and health care workforce vacancies. Given the history of Indigenous peoples in the United States and their treatment by the federal government and society, the American College of Physicians (ACP) asserts the federal government must faithfully execute its trust responsibility through increased funding and resources directed toward Indigenous communities and the undertaking of concerted policy efforts to support the health and well-being of Indigenous people. ACP believes that these efforts must be community-driven, Indigenous-led, and culturally appropriate and accepted, and center values of respect and self-determination. [ABSTRACT FROM AUTHOR]

The U.S. health care system is undergoing a shift from individual clinical practice toward team-based care. This move toward team-based care requires fresh thinking about clinical leadership and responsibilities to ensure that the unique skills of each clinician are used to provide the best care for the patient as the patient's needs dictate, while the team as a whole must work together to ensure that all aspects of a patient's care are coordinated for the benefit of the patient. In this position paper, the American College of Physicians offers principles, definitions, and examples to dissolve barriers that prevent movement toward dynamic clinical care teams. These principles offer a framework for an evolving, updated approach to health care delivery, providing policy guidance that can be useful to clinical teams in organizing the care processes and clinician responsibilities consistent with professionalism. [ABSTRACT FROM AUTHOR]

This article reports on the coverage of the U.S. healthcare crisis by newspapers in 2006. The crisis received a little attention from the press. The reasons for this observation are indicated. Moreover, this article states the position of physicians on the crisis and some actions they are taking to address it.

Managed care and organized systems of care are restructuring the delivery of care in the United States. As care is reorganized, physician practice styles, autonomy, and compensation are undergoing profound changes. To successfully integrate physicians into the new managed systems of care, their organizational relationship to and their compensation within these systems must be carefully considered. This paper first explores physician motivation as it is related to compensation. The paper then describes a variety of emerging organizational designs aimed at aligning the interests of physicians and hospitals. The author considers fully integrated, physician-hospital organizations with target income compensation arrangements to be most suitable to the collective success of professionals and organized systems of care. The paper concludes with a discussion of the many dilemmas and challenges posed by the intertwining of managed care, organized networks of care, and professional compensation. [ABSTRACT FROM AUTHOR]

Secure messaging, or "e-visits," between patients and providers has sharply increased in recent years, and many hope they will help improve healthcare quality, while increasing provider capacity. Using a panel data set from a large healthcare system in the United States, we find that e-visits trigger about 6% more office visits, with mixed results on phone visits and patient health. These additional visits come at the sacrifice of new patients: physicians accept 15% fewer new patients each month following e-visit adoption. Our data set on nearly 100,000 patients spans from 2008 to 2013, which includes the rollout and diffusion of e-visits in the health system we study. Identification comes from difference-in-differences estimates leveraging variation in the timing of e-visit adoption by both patients and providers. We conduct several robustness checks, including matching analyses and an instrumental variable analysis to account for possible time-varying characteristics among patient e-visit adopters. This paper was accepted by Chris Forman, information systems. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 545-551 Context Most US medical schools have instituted cultural competence education in the undergraduate curriculum. This training is intended to improve the quality of care that doctors, the majority of whom are White, deliver to ethnic and racial minority patients. Research into the outcomes of cultural competence training programmes reveals that they have been largely ineffective in improving doctors' skills. In varied curricular formats, programmes tend to teach group-specific cultural knowledge, despite the vast heterogeneity of racial and ethnic groups. This cultural essentialism diminishes training effectiveness. Methods This paper proposes key curriculum content changes and suggests the inclusion of an intersectional framework in the cultural competence curriculum. This framework maintains that racial and ethnic minority groups hold multiple social statuses, called social locations, which interact with one another to uniquely shape the health views, needs and experiences of the individuals within the groups. Social locations include those defined by race, ethnicity, gender, social class and sexuality, which are experienced multiplicatively, not additively, within a particular social context. Cultural competence education must go beyond simplified cultural understandings to explore these more complex meanings. Doctors' ability to understand, communicate with and treat diverse groups can be vastly improved by applying an intersectional framework in academic research, self-awareness exercises and clinical training. Results Integrating an intersectional framework into cultural competency education can better prepare doctors for caring for racial and ethnic minority patients. This paper recommends curriculum elements for the classroom and clinical training that can improve doctor knowledge and skills for caring for diverse groups. Medical schools can use the proposed model to facilitate the development of new educational strategies and learning experiences. These improvements can lead to more equitable care and ultimately diminish disparities in health care. Although these recommendations are designed with US schools in mind, they may improve doctor understanding and care of marginal populations across the world. [ABSTRACT FROM AUTHOR]

As clinicians, educators, and researchers, our ability to provide the best possible care to our patients who are sexual and gender minority (SGM) people of color is increasingly challenged. Relative to the general population, SGM patients often have worse health outcomes, and among SGM patients, racial and ethnic minorities are particularly vulnerable. Healthcare policies proposed by the current administration, along with an increasingly hostile and dangerous social climate, have the potential to seriously harm SGM patients of color. In this paper, we discuss these key policy issues impacting the health of SGM patients of color. We then suggest questions for clinicians to consider to help them decide which advocacy activities are right for them, recommending self-examination, skills development, and political action. We end by outlining concrete, actionable steps to advocate for SGM patients of color in patient care, healthcare organizations, medical education, research, and public policy. [ABSTRACT FROM AUTHOR]

Aim This article describes the foundation of an emerging care delivery model based on partnership. It also reflects on and synthesizes the findings of earlier concept analyses of its core concept. Background Changes in the delivery of health care services in the United States have been driven significantly by cost containment over the last 20 years. This has resulted in an unprecedented pace of work, fragmentation of care, and medical errors. Fundamental changes are needed to meet the needs of today's health care environment. Methods A literature search was done in electronic data bases. Concept analysis papers were reviewed and synthesized. Results The antecedents, attributes and consequences of partnership are described and linked to the supporting literature and theoretical models. Conclusions Engaging and empowering the patient through partnership seem to be crucial to developing a cohesive and effective model of care delivery. Partnerships among patients, their families, physicians, nurses and other clinicians positively impact on safety, quality of care, satisfaction, outcomes and job fulfillment. Implications for nursing management Managers need to foster an environment that allows for stronger reciprocal relationships. They need to facilitate changes in practice that support the development of partnerships among patients, their families and all care providers. [ABSTRACT FROM AUTHOR]

Background: This paper presents a case study that demonstrates the evolution of a project entitled "Enhancing QUality-of-care In Psychosis" (EQUIP) that began approximately when the U.S. Department of Veterans Affairs' Quality Enhancement Research Initiative (QUERI), and implementation science were emerging. EQUIP developed methods and tools to implement chronic illness care principles in the treatment of schizophrenia, and evaluated this implementation using a small-scale controlled trial. The next iteration of the project, EQUIP-2, was further informed by implementation science and the use of QUERI tools. Methods: This paper reports the background, development, results and implications of EQUIP, and also describes ongoing work in the second phase of the project (EQUIP-2). The EQUIP intervention uses implementation strategies and tools to increase the adoption and implementation of chronic illness care principles. In EQUIP-2, these strategies and tools are conceptually grounded in a stages-of-change model, and include clinical and delivery system interventions and adoption/implementation tools. Formative evaluation occurs in conjunction with the intervention, and includes developmental, progress-focused, implementation-focused, and interpretive evaluation. Results: Evaluation of EQUIP provided an understanding of quality gaps and how to address related problems in schizophrenia. EQUIP showed that solutions to quality problems in schizophrenia differ by treatment domain and are exacerbated by a lack of awareness of evidence-based practices. EQUIP also showed that improving care requires creating resources for physicians to help them easily implement practice changes, plus intensive education as well as product champions who help physicians use these resources. Organizational changes, such as the addition of care managers and informatics systems, were shown to help physicians with identifying problems, making referrals, and monitoring follow-up. In EQUIP-2, which is currently in progress, these initial findings were used to develop a more comprehensive approach to implementing and evaluating the chronic illness care model. Discussion: In QUERI, small-scale projects contribute to the development and enhancement of hands-on, action-oriented service-directed projects that are grounded in current implementation science. This project supports the concept that QUERI tools can be useful in implementing complex care models oriented toward evidence-based improvement of clinical care. [ABSTRACT FROM AUTHOR]

This article focuses on quality improvement in medical care in the U.S. Efforts, particularly in the last decade or so that have been undertaken to improve the quality and efficiency of medical care. Changing the behavior of physicians and other health care workers is at the crux of many of these efforts. Clinical pathways and computerized decision support have been advocated to improve adherence with practice guidelines, and Quality Improvement Organizations have been charged with assisting providers in quality improvement activities. Clinical pathways, structured care plans that note the essential elements of care by hospital day, have been widely used by hospitals in efforts to improve the quality and efficiency of care.

With the rise of clinical management, new skills of medical doctors stand out, including leadership skills. Medical doctors organize medical work and improve patient care. The training of frontline leadership skills, however, is weakly developed in residency programmes. Medical professional cultures tend to resist organizational techniques and values. This paper analyses cultural interventions in health-care organizations, aimed at overcoming ‘clashes’ between professional and organizational logics in frontline domains. These interventions do not work against, but ‘use’ professional traditions, styles and customs as cultural resources. We use one particular project to illustrate this, a project in which internal medicine residents are invited to join quality improvement sessions, during which they identify critical (organizational) experiences with care provision and realize change. We show how residents feel enabled to establish results and cooperate with other professionals. We also show how this project links organizational responsibilities and medical professionalism – how complementarity (instead of conflict) is established. This is done in practical ways, which commit instead of alienate medical professionals. [ABSTRACT FROM PUBLISHER]

Background: Medical diaspora options, including the engagement of expatriate physicians in development efforts within their home country, are being called for to reverse the effects of brain drain from developing countries. This paper presents the results of a study exploring the potential contributions for the Sudanese Medial Diaspora Options to the healthcare delivery system (HCDS) in Sudan, focusing on the options of temporal and permanent returns and the likely obstacles faced in their implementation.Methods: This was a cross-sectional study using a mixed methods design including quantitative and qualitative approaches. For the quantitative approach, the study, which focused on the possible contribution of the diaspora to healthcare delivery in Sudan, was based on an online survey using random purposive and snowballing sampling techniques involving 153 Sudanese physicians working in Saudi Arabia and other Gulf States, the United Kingdom, the Republic of Ireland, and the United States of America. The qualitative approach involved in-depth interviews with returnee physicians and key informants in Sudan, focusing on the return experiences, the barriers for return, and the options to improve future contributions.Results: Despite contributions of the Sudanese medical diaspora being of a small scale considering the size of the phenomenon, as well as infrequent and not appropriately organized, their inputs to academia and the links built with overseas institutions and specialist clinical services were nevertheless remarkable. The main barrier to temporal return was inappropriate organization by the local counterparts, while those for permanent return of physicians were poor work environment, insufficient financial payment, unsecured accommodation, and offspring education. The study identified short-term return as a feasible option considering the country's current conditions. Proper coordination mechanisms for short-term returns and facilitation of permanent return through stakeholders' collaboration were proposed to improve diaspora contributions.Conclusions: The potentials of Sudanese medial diaspora contributions to the HCDS in Sudan are promising. Short-term contributions were observed as the best option for the current country situation. Creation of a coordinating body from within the healthcare sector in Sudan to effectively coordinate diaspora contributions is recommended. [ABSTRACT FROM AUTHOR]

Background: There is increased interest in the capacity of US immigrants to contribute to their homelands via entrepreneurship and philanthropy. However, there has been little research examining how immigrant physicians may support health systems and what factors facilitate or raise barriers to increased support.Methods: This study used an observational design with paper questionnaire and interview components. Our sample was drawn from attendees of a 2011 conference for US Based Nigerian physicians; respondents who were not US residents, physicians, and of Nigerian birth or parentage were excluded from further analysis. Respondents were randomly selected to complete a follow-up interview with separate scripts for those having made past financial contributions or medical service trips to support Nigerian healthcare (Group A) and those who had done neither (Group B). Survey results were analyzed using Fischer exact tests and interviews were coded in pairs using thematic content analysis.Results: Seventy-five of 156 (48 %) individuals who attended the conference met inclusion criteria and completed the survey, and 13 follow-up interviews were completed. In surveys, 65 % percent of respondents indicated a donation to an agency providing healthcare in Nigeria the previous year, 57 % indicated having gone on medical service trips in the prior 10 years and 45 % indicated it was "very likely" or "likely" that they would return to Nigeria to practice medicine. In interviews, respondents tended to favor gifts in kind and financial gifts as modes of contribution, with medical education facilities as the most popular target. Personal connections, often forged in medical school, tended to facilitate contributions. Individuals desiring to return permanently focused on their potential impact and worried about health system under-preparedness; those not desiring permanent return centered on how safety, financial security and health systems issues presented barriers.Conclusions: This study demonstrates several mechanisms by which health systems may benefit from expatriate engagement. Greater identification of reliable local partners for diaspora, deeper collaboration with those partners and a focus on sustainable interventions might improve the quantity and impact of contributions. Ethnic medical associations have a unique role in organizing and facilitating diaspora response. Public-private partnerships may help diaspora negotiate the challenges of repatriation. [ABSTRACT FROM AUTHOR]

Maldistribution of physicians is the norm in much of the USA. This paper explores the effect that the integration of telemedicine into the health system could have on physician workforce requirements in the USA. The analysis is based on preliminary evidence suggesting that telemedicine is an effective and efficient means of delivering a broad spectrum of health services to medically under-served rural and inner-city communities. While the emphasis here is on interactive, videobased telemedicine services, other telemedicine modalities, such as store-and-forward techniques and remote monitoring, are likely to have a parallel effect. As these new technologies become a normal part of health care, they will reshape the medical workforce and exert a profound influence on physician workforce requirements in the USA. This paper presents a potential model for this reshaped workforce that emphasizes an expanded role for mid-level health-care providers. [ABSTRACT FROM AUTHOR]

This paper examines the uses of some health status indices in measuring equity of access to medical care. Empirical examples are provided using data from national surveys of the U.S. population conducted from 1964 through 1976. A simple indicator, mean number of physician visits, suggests that between 1963 and 1976 the poor improved their position relative to the rest of the population and, indeed, currently enjoy the highest level of access. However, a second measure, the use-disability ratio indicates that the poor may still receive less care relative to their need. A third measure, the symptoms-response ratio suggests how norms of appropriate behavior might be incorporated into an access measure. [ABSTRACT FROM AUTHOR]

Medical anthropology has long appreciated the clinical encounter as a rich source of data and a key site for critical inquiry. It is no surprise, then, that a number of physician-anthropologists have used their clinical insights to make important contributions to the field. How does this duality challenge and enhance the moral practice and ethics of care inherent both to ethnography and to medicine? How do bureaucratic and professional obligations of HIPAA and the IRB intersect with aspirations of anthropology to understand human experience and of medicine to heal with compassion? In this paper, I describe my simultaneous fieldwork and clinical practice at an urban women's jail in the United States. In this setting, being a physician facilitates privileged access to people and spaces within, garners easy trust, and enables an insider perspective more akin to observant participation than participant observation. Through experiences of delivering the infants of incarcerated pregnant women and of being with the mothers as they navigate drug addiction, child custody battles, and re-incarceration, the roles of doctor and anthropologist become mutually constitutive and transformative. Moreover, the dual practice reveals congruities and cracks in each discipline's ethics of care. Being an anthropologist among informants who may have been patients reworks expectations of care and necessitates ethical practice informed by the dual roles. [ABSTRACT FROM AUTHOR]

Background: In 2007, the National Cancer Institute (NCI) launched the NCI Community Cancer Centers Program (NCCCP) as a public-private partnership with community hospitals with a goal of advancing cancer care and research. In order to leverage federal dollars in a time of limited resources, matching funds from each participating hospital were required. The purpose of this paper is to examine hospitals' level of and rationale for co-investment in this partnership, and whether there is an association between hospitals' co-investment and achievement of strategic goals.Methods: Analysis using a comparative case study and micro-cost data was conducted as part of a comprehensive evaluation of the NCCCP pilot to determine the level of co-investment made in support of NCI's goals. In-person or telephone interviews with key informants were conducted at 10 participating hospital and system sites during the first and final years of implementation. Micro-cost data were collected annually from each site from 2007 to 2010. Self-reported data from each awardee are presented on patient volume and physician counts, while secondary data are used to examine the local Medicare market share.Results: The rationale expressed by interviewees for participation in a public-private partnership with NCI included expectations of increased market share, higher patient volumes, and enhanced opportunities for cancer physician recruitment as a result of affiliation with the NCI. On average, hospitals invested resources into the NCCCP at a level exceeding $3 for every $1 of federal funds. Six sites experienced a statistically significant change in their Medicare market share. Cancer patient volume increased by as much as one-third from Year 1 to Year 3 for eight of the sites. Nine sites reported an increase in key cancer physician recruitment.Conclusions: Demonstrated investments in cancer care and research were associated with increases in cancer patient volume and perhaps in recruitment of key cancer physicians, but not in increased Medicare market share. Although the results reflect a small sample of hospitals, findings suggest that hospital executives believe there to be a strategic case for a public-private partnership as demonstrated through the NCCCP, which leveraged federal funds to support mutual goals for advancing cancer care and research. [ABSTRACT FROM AUTHOR]

The effects of malpractice law and financial incentives on physicians are typically studied independently. This paper shows that to make both positive and normative statements about medical malpractice liability, one must consider physicians' legal and financial incentives jointly. I develop a simple model to show that when treatment is unprofitable at the margin, mitigation of liability lowers treatment levels; conversely, when treatment is profitable, mitigation of liability raises them. Motivated by this simple theoretical framework, I analyze the impact of a tort reform in Texas that mitigated malpractice liability. Consistent with the theory, the rate of cesarean sections among commercially insured mothers, for whom the procedure is considered profitable, increased by 2 percentage points relative to the rate of cesarean sections among mothers covered by Medicaid, for whom the procedure is thought to be unprofitable. [ABSTRACT FROM AUTHOR]

The article reports on the call of family physicians to develop medical homes in the U.S. It states that U.S. President Barack Obama has shown interest to fund a medical home to oversee the conditions of chronically ill patients in the country. It cites that joining the agenda is the College of Family Physicians of Canada (CFPC) that released a discussion paper and called on governments to establish a medical home. The move of CFPC is not only intended for ill patients but for every Canadian.

Comments on a study by R. M. Werner and colleagues, which examined issues relating to the use of deception by physicians to get an insurance company to pay for a medical procedure. Percentage of physicians in the U.S. who had supported misrepresentation of facts given to insurance companies; Ethical implications of the deceptive approach to health insurance; Arguments concerning the health care system in the U.S.

The objectives of any healthcare system are multifaceted and complex in today's everchanging world. This paper will focus on healthcare delivery as it relates to the concepts of funding, patient-centered care and physician shortages within the systems of Canada, the United Kingdom (UK) and France. Of great concern in the United States is the fact that healthcare is not universal. There are currently more than 43 million Americans who are uninsured. Poor funding affects patient access to care and the patient-centered focus of the U.S. healthcare delivery system. Collaborative patient-centered practice is a method that facilitates health care professionals working together and with their patients. Suggestions for reform in the United States will be discussed as they relate to the most successful aspects of each of the healthcare delivery systems in Canada, France, and the United Kingdom. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to address why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home, and the relevance of such payment reforms as pay-for-performance and episodes/bundling. The review illustrates why prevalent physician payment mechanisms in the US have failed to adequately support primary care and why innovative approaches to primary care payment play such a prominent role in the PCMH discussion. FFS payment for office visits has never effectively rewarded all the activities that comprise prototypical primary care and may contribute to the "hamster on a treadmill" problems in current medical practice. Capitation payments are associated with risk adjustment challenges and, perhaps, public perceptions of conflict with patients' best interests. Most payers don't employ and therefore cannot generally place physicians on salary; while in theory such salary payments might neutralize incentives, operationally, "time is money;" extra effort devoted to meeting the needs of a more complex patient will likely reduce the services available to others. Fee-for-service, the predominant physician payment scheme, has contributed to both the continuing decline in the primary care workforce and the capability to serve patients well. Yet, the conceptual alternative payment approaches, modified fee-for-service (including fee bundles), capitation, and salary, each have their own problems. Accordingly, new payment models will likely be required to support restoration of primary care to its proper role in the US health care system, and to promote and sustain the development of patient-centered medical homes. [ABSTRACT FROM AUTHOR]

The United States faces tremendous challenges with its healthcare system. By any standard, it is expensive and performs poorly in most measures of health and thus, is in great need of reform. But how do we reform things without making the situation worse? Some of the more fundamental problems arise from the combination of a fee-for-service payment system for physicians with insurance-based financing care. This combination results in conflicts among the interests of patients, physicians and payers. This paper examines this issue from a decision analytic perspective, starting with a definition of the patient-centered view, and an assessment of the practicality of controlling costs by making healthcare more patient-centric. It then illustrates how fee-for-service models corrupt decision-making and other solutions designed to reign in the abuses of the fee-for-service model and also negatively impacts the quality of decision making for individual patients. Whatever the strategies for health reform, the degree of patient-centeredness of care is a benchmark that allows policy makers to understand how far they have had to deviate from optimal to achieve the desired ends of cost control. [ABSTRACT FROM AUTHOR]

Research Objective. This paper tests for differences in the effect of State Children's Health Insurance Program (SCHIP) on children's insurance coverage and physician visits across three age groups: pre-elementary school-aged children (pre-ESA), ESA children, and post-ESA children. Data Source. The study uses two cross sections of the Survey of Income and Program Participation (SIPP) from the 1996 and 2001 panels. Study Design. A difference-in-differences approach is used to estimate the effect of SCHIP on coverage and physician visits of newly eligible children of different age groups. Data Collection. Demographic, insurance, and physician visit information for children in families with income below 300 percent of federal poverty line were extracted from the SIPP. Principal Findings. Uninsurance rates for post-ESA children declined due to SCHIP while public coverage and the likelihood of visiting a physician increased. Estimates of cross-age differences show that post-ESA children experienced a larger decline in uninsurance rates compared with pre-ESA and ESA children and a larger increase in physician visits compared with ESA children. Conclusions. The higher rate of physician visits for post-ESA children due to SCHIP demonstrates the importance of extending insurance coverage to teens as well as young children. [ABSTRACT FROM AUTHOR]

This paper describes (1) the design, methods and baseline data of the first smoking cessation clinical trial for Chinese Americans with medical conditions - Chinese Community Smoking Cessation Project (CCSCP); (2) the collaborative process between researchers and the Chinese community; and (3) the barriers and facilitators of implementing the study. CCSCP was a culturally tailored, randomized, smoking cessation trial testing the efficacy of an intensive (physician advice, in-person counseling with nicotine replacement therapy, 5 telephone calls) compared to a minimal (physician advice and self-help manual) intervention. The study applied a community-sensitive research method involving community members in all phases of the research process in San Francisco Bay Area during 2001–2007. CCSCP recruited 464 smokers from health care facilities (79%) located in Chinese neighborhoods and through Chinese language media (21%). Baseline assessments and interventions were conducted in-person using translated and tested questionnaire and intervention materials. The majority of the participants were men (91%) with a mean age of 58.3 years, foreign born (98%), with less than high school education (58%), spoke no English (42%) and in non-skilled or semi-skilled occupations (60%) with <$20,000 household income (51%). Participants smoked regularly on an average 38.6 ± 17 years, smoked 9.1 ± 8 cigarettes per day and 85% smoked daily. Cultural tailoring of recruitment methods and intervention design led to successful enrollment and retention of participants, overcoming barriers faced by the participants. Community sensitive collaborative process facilitated implementation of study protocol in community health care settings. [ABSTRACT FROM AUTHOR]

In two prior papers, "Properly Documenting a File and Forensic Examination of IME Doctors" and "Qualifications and Paradigms for the Independent Examiner," we first explained how field practitioners can better document case files to withstand challenges, including those made by Independent Examiners (IEs, a.k.a. IMEs, ICE, DME, QME), and addressed forensically examining the IE, as well. The second paper sought to establish reasonable standards and protocols to which IEs should be held. It is thought that, in this way, the examiner's credibility can be established, to say nothing of actuating fair and accurate examinations. Still, despite nationwide protest and outrage among practicing doctors and angry patients, the reality is that in a vast majority of jurisdictions in the U.S., any doctor can become an IE merely by making application with an insurance company or intermediary; for most states, there are simply no standards or guidelines to organize this process. We have always spoken out against this. The previous two papers represent two of the few published works on this subject. This paper will demonstrate the excesses some IEs go to in cutting claims. While we hasten to add that this is not an indictment against all Independent Examiners, these are stories that need to be told because they shed light on what is becoming alarmingly commonplace in health care: IEs who ignore patients, ignore factual medical realities, and ignore sworn testimony, downgrading real injuries under the fiction of being "independent." When called to task, the IE has only to say, "That's my opinion," without threat of lawsuit, discipline, or any form of sanction. We consider such scenarios a moral outrage and an injustice to patients who suffer as the result of biased "independent" examinations. Many IEs do "reviews" and "independent examinations" full time and do not actually treat patients anymore. Although business is booming, it's the patients who lose out. [ABSTRACT FROM AUTHOR]

American physicians are increasingly concerned that they are losing professional control. Other analysts of medical power argue that physicians have too much power. This essay argues that current analyses are grounded in a structuralist reading of power. Deploying Michel Foucault's "care of the self" and rhetorician Raymie McKerrow's "critical rhetoric," this essay claims that medical power is better understood as a way that medical actors take on power through rhetoric rather than a force that has power over medical actors. Through a close reading of an essay by Senator Bill Frist, this paper argues that physicians experience a process of "subjection" wherein they are both agents of and objects of medical power as it is combined with state and corporate power in the American "war on terror." This alternative mode of analyzing medical power has implications for our collective understanding of its operations and the means by which we propose alternative enactments of medical power. [ABSTRACT FROM AUTHOR]

The U.S. health care system is one of the world's most advanced systems. Yet, the health care system suffers from unexplained practice variations, major gaps between evidence and practice, and suboptimal quality. Although information processing, communication, and management are key to health care delivery and considerable evidence links information/communication technology (IT) to improvements in patient safety and quality of care, the health care system has a longstanding gap in its investment. In the Crossing the Quality Chasm and Building a Better Delivery System reports, The Institute of Medicine and National Academy of Engineering identified IT integration as critical to improving health care delivery systems. This paper reviews the state of IT use in the U.S. health care system, its role in facilitating evidence-based practices, and identifies key attributes of an ideal IT infrastructure and issues surrounding IT implementation. We also examine structural, financial, policy-related, cultural, and organizational barriers to IT implementation for evidence-based practice and strategies to overcome them. [ABSTRACT FROM AUTHOR]

The US health care system has changed dramatically over the past forty years or so. This paper analyzes its potential transformation into a consumer-driven health care system (with the newly enacted HSAs and the increased popularity of employer defined contributions). The emphasis in the first part is the evolution of the role of providers (mostly physicians) into bearers of financial risk and gatekeepers. The second part discusses the new consumer-driven health care proposals and its potential impact on the future of health care as it pertains to putting consumers under financial risk and gives them a perceived sense of control over health care decisions. [ABSTRACT FROM AUTHOR]

This paper examines the impact of changes in the medical marketplace on medicalization in U S. society. Using four cases (Viagra, Paxil, human growth hormone and in vitro fertilization), we focus on two aspects of the changing medical marketplace: the role of direct-to-consumer advertising of prescription drugs and the emergence of private medical markets. We demonstrate how consumers and pharmaceutical corporations contribute to medicalization, with physicians, insurance coverage, and changes in regulatory practices playing facilitating roles. In some cases, insurers attempt to counteract medicalization by restricting access. We distinguish mediated and private medical markets, each characterized by differing relationships with corporations, insurers, consumers, and physicians. In the changing medical environment, with medical markets as intervening factors, corporations and insurers are becoming more significant determinants in the medicalization process. [ABSTRACT FROM AUTHOR]

The prescribing of pharmaceuticals by health care providers is influenced by many factors. The significance of these factors is an important consideration to public health advocates and government agencies, health insurance companies, pharmaceutical firms, physician and provider associations, medical ethics researchers, patient consumers, and other stakeholders in health care. Better understanding the factors that motivate physician prescribing can bring about more efficient use of health care resources through the improved dissemination of information and more informed decision making. This paper attempts to provide a sound and inclusive review of the influences upon physician prescribing patterns in the extant literature. This review identifies several factors as being highly influential upon physician prescribing: peer influence, financial and managed care considerations, pharmaceutical representatives and drug samples, and direct-to-consumer advertising. To date, several key areas have not been well researched; these include the perceived price of a drug, the role of new technology, and the impact of physician experience. Based upon the literature review, a theoretical model of individual physician prescribing in the outpatient setting is proposed. Further research might be directed toward determining the influence of each factor upon physician prescribing and testing the overall model and interactions among its individual components. [ABSTRACT FROM PUBLISHER]

Health care consumers often need information about the quality of health services provided by specific facilities and health professionals. A growing number of Web sites are meeting consumers' needs for quality-related information. These sites offer a wide array of information, ranging from traditional directory information to comparative data and records of personal experiences. This paper provides a selective review of Web sites that offer information on the quality of health services delivered by specific physicians and facilities in the United States. [ABSTRACT FROM PUBLISHER]

In this paper, I examine the notion of accountability and its historical evolution in health care. Using medical mistakes and adverse patient outcomes as my focus, I examine the interests served by particular models of accountability and argue for a model of collective fiduciary responsibility in U.S. health care today. [ABSTRACT FROM AUTHOR]

As some preventive medicine physicians have been denied medical licenses for not engaging in direct patient care, this paper attempts to answer the question, "Do preventive medicine physicians practice medicine?" by exploring the requirements of licensure, the definition of "practice" in the context of modern medicine, and by comparing the specialty of preventive medicine to other specialties which should invite similar scrutiny. The authors could find no explicit licensure requirement for either a certain amount of time in patient care or a number of patients seen. No physicians board certified in Public Health and General Preventive Medicine sit on any state medical boards. The authors propose that state medical boards accept a broad standard of medical practice, which includes the practice of preventive medicine specialists, for licensing purposes. [ABSTRACT FROM AUTHOR]

Shared decision making is a process in which patients are involved as active partners with the clinician in clarifying acceptable medical options and in choosing a preferred course of clinical care. Shared decision making offers a way of individualizing recommendations, according to patients'' special needs and preferences, when some patients may benefit from an intervention but others may not. This paper clarifies how the U.S. Preventive Services Task Force (USPSTF) envisions the application of shared decision making in the execution of screening and chemoprevention. Unlike conventional USPSTF reports, this paper is neither a systematic review nor a formal recommendation. Instead, it is a concept paper that includes a commentary on the current thinking and evidence regarding shared decision making.Although the USPSTF does not endorse a specific style of decision making, it does encourage informed and joint decisions. This means that patients should be informed about preventive services before they are performed, and that the patient–clinician partnership is central to decision making. The USPSTF suggests that clinicians inform patients about preventive services for which there is clear evidence of net benefit, and, if time permits, about other services with high visibility or special individual importance. Clinicians should make sure that balanced, evidence-based information about the service (including the potential benefits and harms, alternatives, and uncertainties) is available to the patient if needed. For preventive services for which the balance of potential benefits and harms is a close call, or for which the evidence is insufficient to guide a decision for or against screening, clinicians should additionally assist patients in determining whether individual characteristics and personal preferences favor performing or not performing the preventive service.The USPSTF believes that clinicians generally have no obligation to initiate discussion about services that have either no benefit or net harm. Nonetheless, clinicians should be prepared to explain why these services are discouraged and should consider a proactive discussion for services with high visibility or special individual importance or for services for which new evidence has prompted withdrawal of previous recommendations. [Copyright &y& Elsevier]

This paper examines the feasibility of achieving U.S. health care reform and prognosis for success. In order to accomplish the task, this paper provides a check list of major problems which emerge continually in the field. In compiling a list of major problems, a tentative list of eight are presented. These problems include the following: unnecessary administrative costs; other major industrial countries can provide adequate health care at a lower rate of the national budget than does the U.S.; increase in malpractice insurance; shortage of primary care physicians in the rural and inner city areas; failure of health insurance; abundance of technology; distribution of care; and increase in health care costs. According to the author, these eight major problems give some indication to the complexity of the issues involved in the health care reform. These problems should be viewed in the context of the five major participant groups in health care: consumers, politicians, physicians and other health care providers, employers, and insurance companies. This paper briefly discusses the affected participants. It also provides a brief review of the proposed solutions to the problem of health care reform.

The fundamental problems that beset the U.S. health care system--cost, quality, and access--differ in scope and intensity in inner cities. Current trends in health care are systemwide but are more difficult to accommodate in inner cities because of scarce resources and stresses to the health care system. In this position paper, the American College of PhysiCians seeks to highlight directions and innovations in public policy for inner-city health care with renewed determination that health care problems in the United States must be solved, especially in cities, where they are most extreme. Many persons in inner cities experience an urban health penalty because of the concentration of economic decline, job loss, and major health problems. Because the problems originate in a complex interaction of socioeconomic factors, behavior, environment, and disease that is related to race and ethnicity, multifaceted approaches that extend beyond the medical model are needed to improve health status. The College argues for tackling health problems of the inner city in the context of a comprehensive urban policy that addresses the root: causes of poverty. In addition, this position paper contains more specific recommendations to improve health care delivery to inner cities. The College calls for a comprehenSiVe urban partnership initiative to address all aspects of the urban penalty-social, economic, and health-related--and recommends solutions through public and private collaborations that can be adapted to the circumstances of each Community in addition, policy recommendations address health care coverage, providers, public hearth initiatives, community involvement, and short-term improvements to such existing programs as Medicaid. [ABSTRACT FROM AUTHOR]

This article focuses on problems in the delivery of health care services in the United States. The two problems are: the difficulty of access to primary care physicians and long patient waiting times in the office or clinic. Long waiting times are dependent primarily upon poor functioning of the appointment system and secondarily on patient flow in the office or clinics. A health care facility that recognizes these problem areas and is interested in taking steps to reduce patient waiting time and to better utilize its professionals is still faced with the question of how to measure the changes. The purpose of this paper is to present two techniques--work sampling and patient flow analysis, which can serve as tools to accomplish this task.

Health care practitioners are encouraged to "know the cultures" of the multicultural client population they are serving in the United States. The premise behind this injunction is that the use of culturally sensitive techniques that are tailored to the cultural background of the client would result in effective therapy and produce positive outcomes. However, as reflected in the plethora of terms used to describe the application of this knowledge, it is not made explicit why culture would make a difference in therapy nor how it makes a difference, ultimately, in the outcome. The intern of this paper is to highlight one of the fundamental sources of variation in cultural beliefs that affect individual mental health. We propose a model that penetrates to the core of why culture makes a difference in how problems are perceived and appropriate responses defined. Humans have three basic needs: safety and security, integrity, and a sense of belonging. Yet each culture uniquely frames each of these needs and prescribes the sanctioned means to achieve them. In our struggle to define culturally competent or culturally based care, this fundamental aspect is often overlooked. Instead, the Western worldview, structure, and definitions are used as the template to assess dysfunction, diagnose a disorder, and prescribe appropriate care. The theoretical underpinnings of indigenous concepts of self and symbolic interactionism are integrated to clarify these cultural misconceptions and to construct a new paradigm for providing effective and acceptable mental health care. [ABSTRACT FROM AUTHOR]

This paper presents a cohort analysis of the use of health services by elderly Americans. Standard cohort tables are constructed using data on approximately 50,000 individuals from the 1972, 1976, and 1980 Health Interview Surveys. Six 4-year age cohorts are tracked: the youngest, 56-59 years old in 1972: the oldest, 84-87 years old in 1980. Significant age and period effects on physician and hospital contact have been detected; for example the aging effect reflects an increase in the percentage of individuals who either saw a physician on an outpatient basis or were hospitalized in the previous year. Analysis of the volume of physician visits reveals an inverse J-curve relationship with age, with the pivotal point occurring at or about age 80. Consideration of nine alternative explanations of the J-curve phenomenon shows that three are plausible on either conceptual or empirical grounds. Two of these explanations suggest the substitution of either (1) hospital-based services for ambulatory-based services or (2) social supports (especially in the form of older children as care givers) for physicians' services: the third explanation focuses on the involuntary severance of patient-practitioner relationships. resulting from the retirement or death of longstanding family physicians. Finally, competing policy implications of these explanations are discussed. [ABSTRACT FROM AUTHOR]

This paper addresses the problem of the effects of a total institution (Goffman, 1961) environment on the use of medical services. The empirical focus is on a midwestern United Slates penitentiary for men. Three components of the problem are identified: the difference between the incidence of physician visits as compared with a "free" population, variations in the use of medical services among different groups of inmates, and discussion of possible reasons for differences found. For the first two component's, evidence is presented; for reasons that are discussed, however, explanation of differences found remains speculative. [ABSTRACT FROM AUTHOR]

Abstract: The hours worked by physicians are affected by changes in a number of factor, including attitudes rewards labor-leisure tradeoffs, the characteristics of the physician workforce, and the level of demand for medical services. This paper analyzes changes in the hours worked per week by office-base physicians over the decade 1970-80. Overall. there has been a statistically significant decline in hours of approximately 3 per ¢ or 1.5 hours per week. This decline was fairly uniform across most physician characteristics, although the decline was greater for those in primary care specialties. Female physicians increased their average hours worked, although this increase was not statistically significant. In terms of the delivery of killed medical services, the decline in total hours was largely offset by an increase in the percentage of total hours devoted to patient care. The question of whether these trends will continue has important implications for the validity of projections of a physician surplus, in the near future. [ABSTRACT FROM AUTHOR]

Abstract: This paper presents analyses of recent natioanl survey data on access to medical care. In particular, information on major access indicators and special problems associated with the economic and political climate of the 1980s collected in a 1982 national telephone survey of 6.610 United Scales adults and children, representing some 4.802 families, is compared with previous national stirrers for kef population subgroups--by age. place of residence, income, race, insurance coverage, and type of regular source of care In general, the findings show that favorable progress has been made, but some inequities continue to persist. Some traditionally disadvantaged groups are more likely to have a regular family doctor, private insurance coverage, have been to a doctor, or had certain preventive tests and procedures than was true for them in the past. On the other hand, compared to the more economically and/or socially advantaged groups in 1982, they have still not "caught up" entirely. There also is evidence that they may be hardest hit by the exacerbation of the financial barriers to care thai result from unemployment, inflation, and cutbacks in health program eligibility and benefits that have characterized the decade of the 1980s. [ABSTRACT FROM AUTHOR]

This article examines the history and effect of the Consensus Development Program (CDP) at the National Institutes of Health (NIH). Introduced at a time when the relationship between the U.S. public and the medical profession was at a nadir, the CDP frequently placed the NIH in the middle of broader debates in medical practice and health policy during the last quarter of the 20th century. Drawing on published and archival sources, this paper sheds light on the challenges associated with collecting, assessing, and communicating evidence to medical professionals and convincing them to act on it in the name of improved health care. Administrators at the NIH sought a middle ground between changing medical practice and respecting professional autonomy, with varying degrees of success. This debate has continued implications today as tensions persist between scientific guidelines and the clinical medicine practiced by physicians and expected by patients. [ABSTRACT FROM AUTHOR]

Background: The many challenges in health care today create a special need for great leadership. However, traditional criteria for physicians' advancement to leadership positions often regard academic and/or clinical accomplishments rather than the distinctive competencies needed to lead. Furthermore, physicians' training can handicap their developing leadership skills. In this context, an emerging trend is for health-care institutions to offer physician-leadership programs.Methods and Results: This paper reviews the rationale for developing physician-leaders. Factors that underscore this need include: (1) physicians may lack inclinations to collaborate and to follow, (2) health-care organizations pose challenging environments in which to lead (e.g., because of silo-based structures, etc.), (3) traditional criteria for advancement in medicine regard clinical and/or academic skills rather than leadership competencies, and (4) little attention is currently given to training physicians regarding leadership competencies.Conclusion: Definition of these competencies of ideal physician-leaders will inform the curricula and format of emerging physician leadership development programs. [ABSTRACT FROM AUTHOR]