HEALTHCARE REFORM
Ethics in a Changing System
The American public and healthcare experts agree that improving access should be the highest priority of healthcare system reform, according to a national study sponsored by Mercy Healthcare Arizona, Phoenix.
Conducted between March and August by the McLean, VA-based Wirthlin Group, the Delphi study polled the public and medical professionals on ethical issues related to access, cost, rationing, reform, and social versus individual rights. The group also performed second- and third-round polls of medical experts to follow up on concerns raised earlier to gauge their response to the push for healthcare reform.
In addition to agreeing on the importance of universal access, the public and healthcare experts polled believed illness prevention measures are the most important elements of a standard benefits package. But 81 percent of the public and only 54 percent of the experts thought persons should be able to choose alternative or natural therapies. They did agree that it is ethically appropriate to require people who engage in unhealthy life-styles to pay more toward the cost of their healthcare. Finally, 82 percent of experts and 65 percent of the public said it is appropriate to give or withhold treatment based on a patient's chance of survival.
One major difference between the public and medical experts was in the relative importance each group assigned to individual rights and the social good. Whereas experts said that social good should prevail, the American public believed the new healthcare system should emphasize individual rights. Healthcare experts did, however, believe that the reformed system should encourage individuals to take greater responsibility for their healthcare.
Although 44 percent of the public said they are unfamiliar with healthcare reform issues, 77 percent believed they should have input into the reform process. Healthcare experts were optimistic about the possibility of educating the public in this area and said the public and the healthcare community should share responsibility for that education.
Experts were divided on whether the Clinton administration's healthcare task force has approached healthcare system redesign ethically. In addition, half the experts polled predicted that the legislative process will result in a less ethical reform package. As the poll moved into its later stages, experts became more pessimistic about whether healthcare reform was on the right track.
INTEGRATED DELIVERY
Linking Hospitals and Physicians
The critical question regarding hospital-physician integration is not if or when it will occur, but how it will occur, according to a recent "best practices" study by the Dallas-based Arthur Andersen consulting firm.
Trust and equality among all partners is one of the key factors to successful physician-hospital integration, according to the study. Governance—which includes issues such as credentialing, compensation, overall decision making, and utilization management—is another critical area of concern. Smooth integration also requires a conflict resolution process to facilitate communication. And partners should address compensation and benefits issues early in the process to ensure these issue do not become a source of distrust.
Effective management of change is another success factor in physician-hospital integration. Leaders should work constantly to foster consensus and build teams. They should also promote understanding through ongoing education and discussion, make sure changes are phased in, anchor changes to specific processes, and create incentives that match strategic goals.
Study organizers found that integration efforts often have a dual focus. Before they can establish links with hospitals, often physicians must integrate with one another by developing common visions and goals and fostering a group culture. Moreover, hospitals frequently have multiple integration structures developing at the same time.
Physician-hospital integration is a continuous process rather than a destination, the study emphasizes. The blending of cultures required by such efforts takes time to nurture and develop.
Finally, the study notes that the increasing dominance of managed care and competitive payment arrangement has been a significant catalyst for integration in many markets. Although the legal structures for integration are often determined by regulatory restraints and barriers, the parties' business purposes should always be the main consideration.
IMMIGRATION
The Productive Melting Pot
Sixty-one percent of Americans think the United States' immigration policy should be tightened, according to a June poll by the New York Times and CBS News. But the fears that lead Americans to oppose open immigration—such as the belief that immigrants steal jobs from U.S. citizens—are largely unfounded, according to experts.
"There's no economic case for trimming back the current target of roughly 700,000 authorized immigrants a year," writes Jaclyn Fierman in Fortune. "If anything, the U.S. should welcome more newcomers from especially desirable groups—namely, the gifted, the ambitious, and the rich."
According to the Urban Institute, legal immigrants have done well in the United States. About 74 percent of immigrant men hold jobs, compared with 72 percent of the general male population. And economics professor George Borjas from the University of California at San Diego estimates that even though the nation's 20 million immigrants receive $1.1 billion more in welfare than they pay back in taxes, their working and spending contribute $5 billion a year to the economy, netting the nation almost $4 billion annually.
Immigrants do on occasion displace low-skilled workers, but in most cases they compete for jobs with other immigrants rather than with Americans. And in a study of the 400 largest U.S. counties, the Urban Institute found that for every 100 adult immigrants entering the population, the number of new jobs increased by 46, compared with a rise of just 25 jobs for every 100 new native-born Americans.
Despite these long-term benefits, short-term costs fall heavily on some American cities, especially Los Angeles, New York, Chicago, Houston, Washington, DC, and Miami. The educational system and public hospitals, in particular, are overburdened by record inflows of immigrants to these areas.
Additional impact grants to these cities are one step the government could take to help the nation assimilate its immigrants. Other tactics include revising the immigration policy limiting visas for unskilled workers to reduce their waiting time and increase the number of immigrants with needed talents, such as childcare workers and home health aides; reducing the red tape that makes it hard for entrepreneurs and investors to obtain U.S. visas; and doubling what Washington spends on English programs for children and adults.
CONSUMERS
Health and The Media
Health and medical reports in the media have had a significant effect on Americans' health-related behaviors, according to a recent Gallup poll conducted for Merck Media Minutes. Of more than 1,000 adults surveyed, 77 percent said they had made life-style changes—such as exercising more, eating specific foods, or using specific home remedies—as a result of a health or medical report.
However, the majority of consumers rarely (32 percent) or never (39 percent) visited a doctor as a result of a report in the media. And they rarely (26 percent) or never (39 percent) asked for a treatment mentioned.
Respondents said they are most interested in reports about disease prevention (29 percent), healthcare costs (28 percent), and new treatments (24 percent). When asked which three topics they were most interested in, those surveyed indicated cancer (62 percent), heart disease (48 percent), AIDS (38 percent), and women's health issues (33 percent).
Eighty-seven percent of respondents said they were more knowledgeable about health as a result of reports in the media. But 74 percent said they had read contradictory health or medical reports. In such cases, 35 percent said they would believe the new report, 18 percent would believe the earlier report, 17 percent would be confused, and 17 percent would not believe either report.
Copyright © 1993 by the Catholic Health Association of the United States.
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