RESUMO
Physicians' advocacy obligations are best understood as going beyond advocacy on behalf of individual patients, which I call the "individualistic view," to include advocacy for intelligent research-based allocation schemes that promote good outcomes and cost-effective care for all patients, which I call the "systemic view." This systemic view includes moving beyond self-interest to promote less-wasteful and more cost-conscious allocation decisions and the setting of priorities at all levels to expand health care access. It includes physician involvement in discussions with patients in the context of clinical care, involvement in the formulation and administration of benefit structures and other allocation policies, and, finally, involvement in promoting public dialogue about health care priorities. This involvement is based on a concept of a deliberative process that can result in "just enough" decisions within systems for the preservation and promotion of health care and other societal goods.
Assuntos
Alocação de Recursos para a Atenção à Saúde/ética , Acessibilidade aos Serviços de Saúde/ética , Defesa do Paciente/ética , Papel do Médico , Alocação de Recursos/ética , Justiça Social/ética , Alocação de Custos/ética , Tomada de Decisões , Custos de Cuidados de Saúde/ética , Alocação de Recursos para a Atenção à Saúde/economia , Prioridades em Saúde/economia , Prioridades em Saúde/ética , Promoção da Saúde/economia , Promoção da Saúde/ética , Acessibilidade aos Serviços de Saúde/economia , Humanos , Consentimento Livre e Esclarecido/ética , Benefícios do Seguro/economia , Benefícios do Seguro/ética , Reembolso de Seguro de Saúde/ética , Defesa do Paciente/economia , Alocação de Recursos/economiaAssuntos
Custos de Medicamentos/ética , Acessibilidade aos Serviços de Saúde , Insulina/economia , Insulina/uso terapêutico , Benefícios do Seguro , Adulto , África/epidemiologia , Fatores Etários , Canadá/epidemiologia , Indústria Farmacêutica/economia , Indústria Farmacêutica/ética , Indústria Farmacêutica/organização & administração , Feminino , Saúde Global/economia , Saúde Global/normas , Acessibilidade aos Serviços de Saúde/economia , Acessibilidade aos Serviços de Saúde/organização & administração , Acessibilidade aos Serviços de Saúde/normas , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/ética , Disparidades em Assistência à Saúde/organização & administração , Humanos , Benefícios do Seguro/economia , Benefícios do Seguro/ética , Benefícios do Seguro/estatística & dados numéricos , Benefícios do Seguro/tendências , Masculino , Relações Pais-Filho , Estados Unidos/epidemiologia , Cobertura Universal do Seguro de Saúde/economia , Cobertura Universal do Seguro de Saúde/organização & administração , Cobertura Universal do Seguro de Saúde/normas , Organização Mundial da Saúde/economia , Organização Mundial da Saúde/organização & administraçãoAssuntos
Consumo de Bebidas Alcoólicas/efeitos adversos , Consumo de Bebidas Alcoólicas/tendências , Doença de Alzheimer/etiologia , Benefícios do Seguro/ética , Consumo de Bebidas Alcoólicas/epidemiologia , Doença da Artéria Coronariana/epidemiologia , França/epidemiologia , Humanos , Incidência , Benefícios do Seguro/estatística & dados numéricos , Estudos Observacionais como AssuntoRESUMO
Fee for services (FFS) is the prevailing method of payment in most Chinese public hospitals. Under this retrospective payment system, medical care providers are paid based on medical services and tend to over-treat to maximize their income, thereby contributing to rising medical costs and uncontrollable health expenditures to a large extent. Payment reform needs to be promptly implemented to move to a prospective payment plan. The diagnosis-related group (DRG)-based case-mix payment system, with its superior efficiency and containment of costs, has garnered increased attention and it represents a promising alternative. This article briefly describes the DRG-based case-mix payment system, it comparatively analyzes differences between FFS and case-mix funding systems, and it describes the implementation of DRGs in China. China's social and economic conditions differ across regions, so establishment of a national payment standard will take time and involve difficulties. No single method of provider payment is perfect. Measures to monitor and minimize the negative ethical implications and unintended effects of a DRG-based case-mix payment system are essential to ensuring the lasting social benefits of payment reform in Chinese public hospitals.
Assuntos
Sistemas de Apoio a Decisões Administrativas/economia , Grupos Diagnósticos Relacionados/economia , Planos de Pagamento por Serviço Prestado/economia , Reforma dos Serviços de Saúde/economia , Hospitais Públicos/economia , China , Sistemas de Apoio a Decisões Administrativas/ética , Grupos Diagnósticos Relacionados/ética , Planos de Pagamento por Serviço Prestado/ética , Financiamento Governamental/economia , Reforma dos Serviços de Saúde/ética , Gastos em Saúde/ética , Benefícios do Seguro/economia , Benefícios do Seguro/ética , Tempo de InternaçãoRESUMO
The economic pressure on German hospitals has increased considerably over the last years, mainly because of the introduction of a flat-rate payment system, and it will most likely further increase under the current demographic and political conditions. The growing dominance of economics in the inpatient sector increases the pressure on hospital staff and results in an increased volume of care (with sometimes inappropriate overtreatment) and uncontrolled rationing and a continuous struggle to maintain the quality of patient care. This development is not only alarming from an ethical perspective, but also impairs the hospital's economic performance. To counter the increasing economic pressure with "more ethics" does--according to the line of reasoning adopted in this article--not appear to be very successful. Rather, central ethical values in inpatient care have to become an integral part of hospital management. This value management first requires a clear definition of the normative standards, e.g. within a mission statement. Second, the realisation of the normative standards in routine inpatient care has to be systematically assessed, evaluated and managed. Since normative standards are difficult to measure objectively and on a quantitative scale, (repeated) surveys among hospital staff are the central instrument to secure the "internal quality" of the hospital. It appears very likely that more ethics in the hospital will pay off by improving its economic performance. The empirical proof for this conceptually extremely plausible hypothesis has yet to be provided.
Assuntos
Ética Institucional , Benefícios do Seguro/ética , Programas Nacionais de Saúde/ética , Qualidade de Vida , Doença Crônica/economia , Doença Crônica/terapia , Análise Custo-Benefício , Custos de Medicamentos , Alemanha , Alocação de Recursos para a Atenção à Saúde/economia , Alocação de Recursos para a Atenção à Saúde/ética , Humanos , Benefícios do Seguro/economia , Programas Nacionais de Saúde/economia , Neoplasias/economia , Neoplasias/terapiaAssuntos
Assistência Odontológica/ética , Odontólogos/ética , Ética Odontológica , Planejamento de Assistência ao Paciente/ética , Aposentadoria , Beneficência , Humanos , Benefícios do Seguro/ética , Seguro Odontológico/ética , Autonomia Pessoal , Justiça Social , Revelação da Verdade , Procedimentos Desnecessários/éticaRESUMO
There has been an explosion of interest in the concept of 'universal health coverage', fuelled by publication of the World Health Report 2010. This paper argues that the system of user charges for health services is a fundamental determinant of levels of coverage. A charge can lead to a loss of utility in two ways. Citizens who are deterred from using services by the charge will suffer an adverse health impact. And citizens who use the service will suffer a loss of wealth. The role of social health insurance is threefold: to reduce households' financial risk associated with sickness; to promote enhanced access to needed health services; and to contribute to societal equity objectives, through an implicit financial transfer from rich to poor and healthy to sick. In principle, an optimal user charge policy can ensure that the social health insurance funds are used to best effect in pursuit of these objectives. This paper calls for a fundamental rethink of attitudes and policy towards user charges.
Assuntos
Honorários e Preços/ética , Reforma dos Serviços de Saúde/economia , Acessibilidade aos Serviços de Saúde/economia , Benefícios do Seguro/economia , Seguro Saúde/economia , Cobertura Universal do Seguro de Saúde/economia , Reforma dos Serviços de Saúde/ética , Acessibilidade aos Serviços de Saúde/ética , Humanos , Benefícios do Seguro/ética , Seguro Saúde/ética , Cobertura Universal do Seguro de Saúde/éticaAssuntos
Anticoncepção , Planos de Assistência de Saúde para Empregados/legislação & jurisprudência , Benefícios do Seguro/legislação & jurisprudência , Patient Protection and Affordable Care Act , Anticoncepção/economia , Anticoncepção/ética , Planos de Assistência de Saúde para Empregados/economia , Planos de Assistência de Saúde para Empregados/ética , Humanos , Benefícios do Seguro/economia , Benefícios do Seguro/ética , Patient Protection and Affordable Care Act/economia , Patient Protection and Affordable Care Act/ética , Patient Protection and Affordable Care Act/legislação & jurisprudência , Religião , Estados UnidosRESUMO
BACKGROUND: Poverty due to illness has become a substantial social problem in rural China since the collapse of the rural Cooperative Medical System in the early 1980s. Although the Chinese government introduced the New Rural Cooperative Medical Schemes (NRCMS) in 2003, the associations between different health insurance benefit package designs and healthcare utilization remain largely unknown. Accordingly, we sought to examine the impact of health insurance benefit design on health care utilization. METHODS AND FINDINGS: We conducted a cross-sectional study using data from a household survey of 15,698 members of 4,209 randomly-selected households in 7 provinces, which were representative of the provinces along the north side of the Yellow River. Interviews were conducted face-to-face and in Mandarin. Our analytic sample included 9,762 respondents from 2,642 households. In each household, respondents indicated the type of health insurance benefit that the household had (coverage for inpatient care only or coverage for both inpatient and outpatient care) and the number of outpatient visits in the 30 days preceding the interview and the number of hospitalizations in the 365 days preceding the household interview. People who had both outpatient and inpatient coverage compared with inpatient coverage only had significantly more village-level outpatient visits, township-level outpatient visits, and total outpatient visits. Furthermore, the increased utilization of township and village-level outpatient care was experienced disproportionately by people who were poorer, whereas the increased inpatient utilization overall and at the county level was experienced disproportionately by people who were richer. CONCLUSION: The evidence from this study indicates that the design of health insurance benefits is an important policy tool that can affect the health services utilization and socioeconomic equity in service use at different levels. Without careful design, health insurance may not benefit those who are most in need of financial protection from health services expenses.
Assuntos
Necessidades e Demandas de Serviços de Saúde/economia , Benefícios do Seguro/economia , Seguro Saúde/economia , Serviços de Saúde Rural/organização & administração , Adolescente , Adulto , China , Estudos Transversais , Feminino , Necessidades e Demandas de Serviços de Saúde/ética , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Benefícios do Seguro/ética , Seguro Saúde/ética , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pobreza , Serviços de Saúde Rural/estatística & dados numéricos , População RuralRESUMO
In recent decades, prevention policies--i.e., insurance policies constructed to give incentives to investments in prevention and thereby reduce reliance on insurance--have been much discussed both with regard to different kinds of market insurance and, albeit primarily within a European context and in relation to an ongoing discussion about the need for a shift towards an "active" welfare state, with regard to social insurance. The present contribution identifies normative issues that deserve attention in relation to a general introduction of prevention policies in market insurance and social insurance. It is argued that the importance of these normative issues suggests that arguments and distinctions drawn from moral and political philosophy should play a more prominent role both in the debate on the shift towards an active welfare state and the use of prevention policies in market insurance.
Assuntos
Saúde Ambiental/ética , Comportamentos Relacionados com a Saúde , Política de Saúde , Seguro Saúde/ética , Serviços Preventivos de Saúde/ética , Comparação Transcultural , Saúde Ambiental/economia , Saúde Ambiental/métodos , Europa (Continente) , Humanos , Benefícios do Seguro/economia , Benefícios do Seguro/ética , Benefícios do Seguro/normas , Seguro Saúde/normas , Motivação , Serviços Preventivos de Saúde/economia , Serviços Preventivos de Saúde/métodos , Previdência Social/ética , Previdência Social/normas , Estados UnidosRESUMO
In societal priority setting between health programs for different patient groups, many people are reluctant to discriminate too strongly between those who can benefit much from treatment and those who can benefit moderately. We suggest that this view of distributive fairness has a counterpart in personal valuations of gains in health. Such valuations may be influenced by psychological reference points and diminishing marginal utility such that the individual utility of care in patient groups with different potentials may be more similar than what conventional QALY estimates suggest. In interviews in three convenience samples, there is some support for the hypothesis. Most respondents do not think that desire for treatment is significantly less in those who stand to gain only moderately compared with those who stand to gain much - even when the treatment is associated with a mortality risk. When stating insurance preferences, a majority of subjects express a greater concern for avoiding the worst states in question than for maximising expected value for money in terms of treatment effects. The tendency applies to outcomes in terms of both quality and quantity of life. Choices between prefixed response options fit well with oral explanations of these choices.
Assuntos
Alocação de Recursos para a Atenção à Saúde/economia , Prioridades em Saúde/economia , Seguro Saúde/economia , Anos de Vida Ajustados por Qualidade de Vida , Análise Custo-Benefício , Alocação de Recursos para a Atenção à Saúde/ética , Prioridades em Saúde/ética , Necessidades e Demandas de Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/ética , Humanos , Benefícios do Seguro/economia , Benefícios do Seguro/ética , Seguro Saúde/ética , Noruega , Preferência do Paciente/economia , Preferência do Paciente/estatística & dados numéricos , Índice de Gravidade de Doença , Medicina Estatal/economia , Medicina Estatal/normasRESUMO
This article adopts an institutional approach to describe the changing secondary market for life insurance in the United States. Since the 1990s, this market, in which investors buy strangers' life insurance policies, has grown in the face of considerable moral ambivalence. The author uses news reports and interviews to identify and describe three conceptions of this market: sacred revulsion, consumerist consolation, and rationalized reconciliation. Differences among the conceptions are considered in view of the institutional legacy of life insurance and its success in organizing practices, perceptions, and understandings about markets and death. From this case, the author draws implications for analyses of morals in markets, an important and emergent topic within economic sociology.
Assuntos
Atitude Frente a Morte , Comércio/ética , Seguro de Vida/ética , Princípios Morais , Ética Institucional , Humanos , Benefícios do Seguro/ética , Seguro de Vida/economia , Estados UnidosRESUMO
Patients, providers, and policy leaders need a new moral compass to guide them in the turbulent U.S. health care system. Task forces have proposed excellent ethical codes, but these have been seen as too abstract to provide guidance at the front lines. Harvard Pilgrim Health Care's ten-year experience with an organizational ethics program suggests ways in which health care organizations can strengthen transparency, consumer focus, and overall ethical performance and contribute to the national health policy dialogue.
Assuntos
Alocação de Recursos para a Atenção à Saúde/ética , Sistemas Pré-Pagos de Saúde/ética , Associações de Prática Independente/ética , Participação da Comunidade , Tomada de Decisões Gerenciais , Ética Institucional , Administração Financeira/ética , Controle de Acesso/economia , Controle de Acesso/ética , Alocação de Recursos para a Atenção à Saúde/economia , Sistemas Pré-Pagos de Saúde/economia , Humanos , Associações de Prática Independente/economia , Benefícios do Seguro/economia , Benefícios do Seguro/ética , Maine , Massachusetts , New Hampshire , Estudos de Casos Organizacionais , Piperazinas/economia , Piperazinas/provisão & distribuição , Purinas/economia , Purinas/provisão & distribuição , Qualidade da Assistência à Saúde/economia , Qualidade da Assistência à Saúde/ética , Citrato de Sildenafila , Sulfonas/economia , Sulfonas/provisão & distribuiçãoAssuntos
American Medical Association/organização & administração , Benefícios do Seguro/ética , Cobertura do Seguro/ética , Seguro Saúde/ética , Programas de Assistência Gerenciada/normas , Assistência Farmacêutica/ética , Tomada de Decisões , Custos de Medicamentos , Benefícios do Seguro/economia , Cobertura do Seguro/economia , Seguro Saúde/economia , Assistência Farmacêutica/economia , Assistência Farmacêutica/normas , Honorários por Prescrição de Medicamentos/ética , Estados UnidosRESUMO
Patients and physicians often perceive the current health care system to be unfair, in part because of the ways in which coverage decisions appear to be made. To address this problem the Ethical Force Program, a collaborative effort to create quality improvement tools for ethics in health care, has developed five content areas specifying ethical criteria for fair health care benefits design and administration. Each content area includes concrete recommendations and measurable expectations for performance improvement, which can be used by those organizations involved in the design and administration of health benefits packages, such as purchasers, health plans, benefits consultants, and practitioner groups.