Search

BACKGROUND A multidisciplinary panel representing various stakeholders in the health care delivery and oncology services marketplace was convened to develop specific criteria for healthcare purchasers to consider when evaluating the structures and processes of health plans. These rank ordered criteria also can be used by oncologic service providers and health plan designers as a yardstick for the services they offer. METHODS A multidisciplinary 31-member Task Force was assembled by the Kerr L. White Institute and the American Cancer Society in March 1997. Task Force members were selected for their ability to offer expert insight as purchasers, suppliers, policymakers, consumers, or stakeholders in the health care marketplace. A preference-weighted majority voting rule was used to identify the three most important recommendations of the 10 that were generated through a modified Delphi technique. To test the practicality of the top three recommendations, leaders of large managed care organizations (MCOs) were surveyed; the results of this survey then were compared with the results of the Task Force survey. RESULTS The three most important recommendations from the Task Force were that health plans provide access to: 1) comprehensive cancer care, 2) preventive and screening services, and 3) second opinions and treatment options supported by scientific evidence. The difference between the responses of the Task Force and the MCOs was that MCOs placed the highest importance on evidence-based decision-making, with their next three rankings coinciding with those identified by the Task Force. CONCLUSIONS The value of these summary recommendations will be realized through their use by both purchasers and suppliers to influence the structure and content of the delivery of oncologic services.

In support of the Department's ongoing transformation efforts, and at the request of the Under Secretary of Defense (Personnel and Readiness), and the endorsement of the Under Secretary of Defense (Comptroller), the Defense Business Board (DBB) formed a Task Group to assess and make recommendations to the Department of Defense on how to manage DoD's rising obligation for providing healthcare for retired military personnel and their dependents. Specifically, the Task Group evaluated and provided this report on strategies and considerations for retiree healthcare obligations. The Task Group focused on eligibility, benefits provided, co-payments and deductibles, premiums, funding and management, and interaction with healthcare benefits provided by private employers. Terms of Reference for this Task Group provided for: 1. An assessment of the Department's current design and management strategy of its healthcare program(s) for military retirees and their dependents; 2. Examples and recommendations of successful public or private sector transitions in the ways retiree healthcare benefits are funded, managed and operated; and 3. options and recommendations that the Department of Defense should consider with respect to the future management and funding of its program(s).

To gain insight into the variation in physicians' clinical decisions and further understand the factors that influence physicians' thresholds for testing and treating.Written clinical scenarios were mailed to two groups of physicians who were asked to provide probability estimates of syphilis, how these estimates might change with new information, and when a diagnostic test would be ordered or treatment begun. A model was then used to calculate the probabilities at which physicians ordered tests or initiated treatment.Group 1 comprised 126 board-certified internists from metropolitan Philadelphia responding from a sample of 360 such physicians randomly selected from a directory. Group 2 consisted of 31 experts in sexually transmitted disease responding from a sample of 50 experts selected by the authors.Experts were willing to obtain a serologic screening test at a lower likelihood of syphilis (0.013%) than were internists (0.034%), and they were willing to obtain a lumbar puncture at a lower likelihood of neurosyphilis (0.165%) than were internists (0.393%). The difference in the groups' thresholds to begin neurosyphilis treatment was not significant. A multivariate model showed that group differences were created by individual characteristics (years in practice, subspecialty board certification, and full-time nonacademic practice) that were associated with higher thresholds for serologic screening.There are differences in the diagnostic testing practices for syphilis between national experts and internists. Although status in one of these groups alone did not predict the threshold for obtaining syphilis tests, certain individual characteristics were predictive. Examination of physician characteristics helps to explain the variation observed in their practice patterns, and determination of physicians' thresholds aids in analyzing these variations.

Context The United States recently implemented smallpox vaccination of selected military personnel in a national program of preparedness against use of smallpox as a biological weapon. The resumption of smallpox vaccinations raises important questions regarding implementation and safety. Objective To describe the US military smallpox vaccination program. Design Descriptive study of the vaccination program from its inception on December 13, 2002, through May 28, 2003. Setting US Department of Defense (DoD) fixed and field medical treatment facilities on multiple continents and ships at sea. Subjects US service members and DoD civilian workers eligible for smallpox vaccination. Main outcome measures Numbers of vaccinations and rates of vaccination exemptions, symptoms, and adverse events. Data were collected via reports to headquarters and rigorous surveillance for sentinel events. Results In 5.5 months, the DoD administered 450 293 smallpox vaccinations (70.5% primary vaccinees and 29.5% revaccinees). In 2 settings, 0.5% and 3.0% of vaccine recipients needed short-term sick leave. Most adverse events occurred at rates below historical rates. One case of encephalitis and 37 cases of acute myopericarditis developed after vaccination; all cases recovered. Among 19 461 worker-months of clinical contact, there were no cases of transmission of vaccinia from worker to patient, no cases of eczema vaccinatum or progressive vaccinia, and no attributed deaths. Conclusions Mass smallpox vaccinations can be conducted safely with very low rates of serious adverse events. Program implementation emphasized human factors: careful staff training, contraindication screening, recipient education, and attention to bandaging. Our experience suggests that broad smallpox vaccination programs may be implemented with fewer serious adverse events than previously believed.

ALTHOUGH modern medicine provides great benefits to large numbers of people, medical professionals and clinical researchers have expressed concern about the effectiveness and appropriateness of many current and emerging medical practices. For example, the evidence substantiating the effectiveness of many such practices is frequently questionable and in many instances entirely lacking.1 Research on medical interventions is often poorly designed and methodologically flawed.2 , 3 Many physicians lack the skills to interpret and critically evaluate medical literature,4 and they approach the same clinical problem with different theoretical assumptions, contributing to wide variations in practice patterns.5 , 6 Furthermore, physicians have difficulty incorporating information about probabilities . . .

Industrialization, the development of corporately managed systems, and the growing role of government in American health care have important implications for many groups and individuals, but for no...

Is the federal government devoting sufficient resources to fighting the epidemic of human immunodeficiency virus (HIV) infection, and are these resources being spent appropriately? Some observers contend that the amounts have been inadequate, but until now there has been no overall accounting of federal activities and spending to combat the epidemic. We report expenditure data collected from federal agencies for the years 1982 to 1989. In all, $5.5 billion will have been spent on HIV-related illness during this period by the federal government, nearly 60 percent of it by the U.S. Public Health Service. Federal spending on HIV-related illness in 1989 will reach $2.2 billion, representing over one third of all estimated national (public and private) HIV expenditures, and tripling state expenditures. In 1992, federal spending on the epidemic will reach an estimated $4.3 billion. Although sizable, this will be just 1.8 percent of all 1992 federal health dollars. Similarly, in 1992, national (public and private) spending on HIV-related illness will consume roughly 1.6 percent of all health-related costs in the United States. Federal spending for HIV research and prevention is similar to funding for other major diseases, including some conditions, such as cancer and heart disease, that now have a greater impact on mortality.

The roles described are not all-inclusive, since a small proportion of physicians, as in times past, will continue to pursue diverse careers outside of an tangential to health care. Neither are the roles mutually exclusive, as physician-managers are also organizational employees, as independently contracting professionals may also be partly fee for service, as physician entrepreneurs may be fee for service practitioners or contracting professionals, and so forth. The point is, that as the delivery of health care becomes a more complex and formalized process, and as large organizations delivering and insuring health care become more predominant, the various roles of physicians are becoming more distinctly obvious. What are the implications of this trend toward greater internal segmentation of the medical profession? At this juncture, they are not entirely clear. It could mean that some groups of physicians will achieve higher status and more rewards than other groups, which might result in greater conflicts within the medical profession. Undoubtedly, the emergence of corporately managed health care and the development of new (and possibly divergent) roles for physicians confronts the medical profession and its members with the gnawing questions of who they really are and what do they really want to be? Ultimately, the greatest challenge may be in finding a common set of commitments and values which transcend our many different roles, and which provide physicians with a clear and continuing sense of ourselves as medical professionals.

In Reply.— I agree strongly with the comments of Drs Forrow, Arnold, and Cassel and Ms Blank. There are major deficiencies in graduate medical training programs regarding ethical dimensions of clinical care, and the residency training period would be the best time to have an impact on physicians' behavior. However, there are obstacles in addressing this problem. Many attending physicians are not prepared to discuss, much less teach, ethical problems in patient care. Such activities are not rewarded. There is little consensus about how to teach approaches for dealing with complex ethical dilemmas. Residents already feel over-whelmed with their current load of educational demands. Nonetheless, efforts must be made, and I am gratified by the obvious interest of the American Board of Internal Medicine and others in seeking better ways to prepare physicians for ethical dimensions of clinical care. It can be done. I share Dr Light's belief that time

THE LIFE-SUSTAINING capability of modern medicine, coupled with its difficult ethical choices, has become the physician's most challenging moral dilemma 1-5 ( US News and World Report , Dec 6, 1982, p 53; Time , April 9, 1984, p 68). Caring for critically ill and dying patients is a difficult task that often vacillates between the rational and the absurd, the uplifting and the morbid. Conflicts in values among caretakers are frequently present, and uncertainty is pervasive. This article addresses the issue of distinctive ethical dilemmas faced by residents in caring for critically ill and dying patients, a problem that springs from the increasing capabilities of medicine and the peculiar role of residents in our medical hierarchy. Residents are fully licensed to practice medicine, but they are not totally autonomous. They have heavy responsibilities in patients' care, but they are not independent in making many decisions. They are usually the primary caretakers, but