David M. Frankford

Who should determine when health care is medically necessary

In the United States there has been a radical shift in the power to determine when health care is medically necessary and therefore covered by insurance. From the 1950s through the late 1970s, phys...

Responsive Medical Professionalism: Integrating Education, Practice, and Community in a Market-Driven Era.

Revolutionary changes in the nature and form of medical practice institutions are likely to reverberate backward into medical education as leaders of the new practice organizations demand that the educational mission be responsive to their needs, and as these demands are increasingly backed by market power. In the face of this pressure, medical educations traditional response--that it should have autonomy in defining its mission--is no longer viable. Instead, more explicit, formal, and systemic linkages between practice and educational institutions are inevitable. The crucial question is whether these linkages will reflect the values of the market, oriented by economic self-interest, or the values of medical professionalism, oriented by the obligation to sacrifice economic self-interest in the service of patients. The authors maintain that the realization of the normative ideal of professionalism in medical education within the emerging market environment requires that a vision be articulated that is distinct from that of either autonomy or the market, and that combined lay-professional institutions be established to integrate--and perhaps merge--education and practice, and to foster responsiveness to lay values and community needs. The authors conclude by briefly describing examples of current efforts in this direction.

The normative constitution of professional power.

This article concerns the manner in which we think and talk about power in health care policy and regulation, and the political and social practices allied with that discourse. I assert that in health care policy and practice we speak of and live within the era of countervailing power. In this language and practice power is a force exercised by one actor to enforce its will against another actor against whom power is exerted. I contend that this language inculcates an individual and social passivity in which citizens rely upon various types of representatives to constitute health care for them in a manner in which they do not and cannot participate. However, this language of power and the political and social practice with which it is associated is merely a contingent, historical product. I claim that an alternative discourse of power is possible, in which power consists of the social interactions in which all of us mutually participate but no one of us can control. Power in this sense is participatory by nature, and because no one is in control, it makes no sense to relegate tasks to specialized, nonparticipatory domains. This alternative discourse of power, therefore, might call forth participatory practices in health care and a concomitant diminution of specialization and expansion of the public sphere. The result would be to blur the lines separating politics from everyday interaction, politics from economy, professionals from patients, and insurers from insureds. Participation would mean much more than casting a vote or writing a check but would also include the mutual sharing of time and energy in the tasks that need to be done: long-term and short-term care, practices of prevention, caring for the chronically ill, and monitoring bureaucratic and professional activities.

The problems with punitive damages in lawsuits against managed-care organizations.

A byproduct of the aging of the population has been a dramatic rise in the rate of Alzheimers disease and other types of dementia. A conservative estimate is that there are currently 4 million people in the United States with dementia.1 In the final stage of dementia, patients are typically unable to walk or to feed themselves, they are incontinent and aphasic, and they have lost the capacity to have relationships with other people. Family members or other surrogate decision makers must make difficult and often painful decisions about limiting care.2 Should they authorize surgery, hospitalization, intravenous medication? Is a proposed treatment excessively burdensome to a patient who cannot understand its purpose and who is nearing the end of life?

Regulating Managed Care: Pulling the Tails to Wag the Dogs

The health-policy airwaves are currently filled with talk of regulating managed care to protect “consumers.” In the name of “consumer protection” numerous states have already passed legislation to regulate managed care and a multitude of proposed additional state legislation, as well as major bills in Congress, are pending. In this essay I question much or most of this enterprise, concluding that little public good is likely to be attained from regulation of managed care within the confines of our current market-based, competitive private insurance system (including the spillover effects on major public programs like Medicare and Medicaid and the patchwork of public programs aimed at smaller populations, such as the Children’s Health Insurance Program). The allied culture and institutions of dog-eat-dog are simply too deeply entrenched. The essay concludes by noting briefly that the same may be true in a compulsory, universal system in the United States and by noting that scholars like me who are sympathetic to “consumer protection” are put into a real dilemma because we must be concerned that managed care regulation serves to legitimate and reinforce a system that is inequitable and prudentially flawed.1 We can divide actual and proposed managed care regulation into two groups, one termed procedural and the other substantive. By “pro-

Book Review Editor's Introduction

The issues presented by euthanasia and physician-assisted suicide (PAS) have become increasingly divisive in recent years, and for good reason. For one thing, only in modernity (at least since the Stoics) have we entertained the notion that an individual can be the master of his or her life, and perhaps only the past half century has brought us the notion that the individual can be the master of death as well. For another, human wisdom is usually the accretion of centuries of experience. No such development has been possible in this domain because infectious diseases relieved most generations of the dilemmas we now face posed by aging and the possibility of lingering death. While we have experienced the terrors of state-sponsored euthanasia in Nazi Germany, we have had little experience with euthanasia or PAS that is relatively “private” and occurs in an era in which most individuals will die in processes that are relatively long-term. One can see this lack of experience in many of the arguments that have been raised for and against euthanasia or PAS. Proponents have often argued strongly from the position of absolute, inalienable rights, which are neither derived from nor dependent on experience, and are therefore neither undercut by the lack of prior experience nor defeated by the possibility of future (good or bad) experience. By contrast, opponents have often stood firm on the absolute absence of experience. They point out that we have never before experimented in this area, and argue that to do

Unchanging New Leadership

Each of these fine articles discusses the possibility that the twenty-first century might witness new leadership in health care.1 Any such discussion of new leadership, necessarily, carries within it an implicit concept of change. Leadership is new because it moves the world in a direction that is different than the previous path taken. I want to tease out the possibilities of change raised by these essays. The bottom line is that change, to be significant, would have to be multifactorial or multisectorial such that I am even more pessimistic than most of the authors seem to be. Out of an abundance of caution, I should say that I do not offer a theory of change, or even a typology of change. More modestly, I just build upon the very scientific observations that change involves more than rearranging the deck chairs on the Titanic and that there are framing issues in deciding when change occurs. Definitions of change have longitudinal or temporal aspects, as well as latitudinal ones, involving issues concerning breadth of change. Each of these involves different degrees of abstraction. For example, most people would characterize the passage of U.S. Medicare as rather significant change because the legislation was, as Ted Marmor (2000) describes, a rare legislative moment for the U.S. Congress. However, at a different level, the change was not so vast because the legislation left intact the extant understanding of how health care was to be delivered, the relationship between a finance system and providers, and the relation-

The ethical obligations of compassionate supply

and have a slightly less clear-cut risk/benefit ratio. Then there are drugs available only on prescription. In these latter two instances--availability from a pharmacy on a restricted basis or on the prescription of a doctor--it should be the potency and complexity of the preparation that governs the extent of professional supervision required (pharmacist in the one case, medical practitioner in the other).