Practical allocation system for the distribution of specialised care during cellular therapy access scarcity.

Novel cellular therapy techniques promise to cure many haematology patients refractory to other treatment modalities. These therapies are intensive and require referral to and care from specialised providers. In the USA, this pool of providers is not expanding at a rate necessary to meet expected demand; therefore, access scarcity appears forthcoming and is likely to be widespread. To maintain fair access to these scarce and curative therapies, we must prospectively create a just and practical system to distribute care. In this article, we first review previously implemented medical product and personnel allocation systems, examining their applicability to cellular therapy provider shortages to demonstrate that this problem requires a novel approach. We then present an innovative system for allocating cellular therapy access, which accounts for the constraints of distribution during real-world oncology practice by using a combination of the following principles: (1) maximising life-years per personnel time, (2) youngest and robust first, (3) sickest first, (4) first come/first served and (5) instrumental value. We conclude with justifications for the incorporation of these principles and the omission of others, discuss how access can be distributed using this combination, consider cost and review fundamental factors necessary for the practical implementation and maintenance of this system.

Medicine for the City: Perspective and Solidarity as Tools for Making Urban Health.

The United States has pursued policies of urban upheaval that have undermined social organization, dispersed people, particularly African Americans, and increased rates of disease and disorder. Healthcare institutions have been, and can be, a part of this problem or a part of the solution. This essay addresses two tools that healthcare providers can use to repair the urban ecosystem-perspective and solidarity. Perspective addresses both our ability to envision solutions and our ability to see in the space in which we move. Solidarity is our ability to appreciate our fellowship with other people, a mindset that is at the heart of medical practice. These two tools lay the foundation for structurally competent healthcare providers to act in a restorative manner to create a health-giving built environment.

[Living a good live with e-health: anticipating ethical consequences and monitoring them]. / Goed leven met e-health: morele gevolgen van e-health-toepassingen.

E-health incorporates a range of digital techniques that are interlinked because they promise to improve people's health and quality of life. The question of how these techniques actually contribute to "living a good live" is not so easy to answer, because scientific, commercial and patients' perspectives all come into play. Research on the unintended consequences of e-health applications clearly shows that it is necessary to anticipate social consequences as early as in the design phase. However, because it is not possible to predict some outcomes, it is also necessary to properly monitor how these techniques affect daily life. It is crucial to pay attention to how these techniques affect people with different educational backgrounds.. Digital techniques have a great capacity to democratise healthcare, but may also unintentionally increase health inequalities. The ethical consequences of e-health applications need to be anticipated and monitored in order to prevent this happening as much as possible.

[Integrative and person-centred health care from a health system perspective]. / Integrative und personenzentrierte Gesundheitsversorgung aus der Perspektive des Gesundheitssystems.

OBJECTIVE: Many health-care systems are confronted on the one hand side with the challenge to meet care demands of a continuously aging population that suffers from multiple and chronic diseases and, on the other hand side, to adapt health-care services to the preferences of the population. We analyse whether the German health-care system already pursues the objective to deliver integrated, person-centred, interdisciplinary and interprofessional health-care services and which prospects 'integrated and person-centred health care' offers. METHOD: We performed a selective literature analysis. RESULTS: Different from the World Health Organisation or the Institute of Medicine, the German Social Code Book V does not pursue the objective of delivering person-centred health care. However, the introduction of integrated health-care services is explicitly enabled. Yet until now, only 10% of the population are encompassed by such health-care delivery concepts. Clear chances for integrated and person-centred health care exist, e. g., in reducing repeat diagnostic procedures, overcoming failures in communication and information exchange, and encouraging interprofessional health care delivery that up to now often encounter resistance of physicians. CONCLUSION: Legal provisions to reform the German health-care system in the direction of more integrative and person-centred health-care services are already partly in place. What is lacking is a broad implementation and evaluation of such a concept of health-care delivery that is advantageous for the system and preferred by the population.

[Challenges of an integrative and personalised health care for health economics and the insurance system]. / Herausforderungen einer integrativen und personalisierten Gesundheitsversorgung für die Gesundheitsökonomie und das Versicherungssystem.

OBJECTIVES: "Stratifying medicine" is a topic of increasing importance in the public health system. There are several questions related to "stratifying medicine". This paper reconsiders definitions, opportunities and risks related to "stratifying medicine" as well as the main challenges of "stratifying medicine" from the perspective of a public health insurance. DEFINITION: The application of the term and the definition are important points to discuss. Terms such as "stratified medicine", "personalised medicine" or "individualised medicine" are used. The Techniker Krankenkasse prefers "stratifying medicine", because it usually means a medicine that tailors therapy to specific groups of patients by biomarkers. OPPORTUNITIES AND RISKS: "Stratifying medicine" is associated with various hopes, e. g., the avoidance of ineffective therapies and early detection of diseases. But "stratifying medicine" also carries risks, such as an increase in the number of cases by treatment of disease risks, a duty for health and the weakening of the criteria of evidence-based medicine. CHALLENGES: The complexity of "stratifying medicine" is a big challenge for all involved parties in the health system. A lot of interrelations are still not completely understood. So the statutory health insurance faces the challenge of making innovative therapy concepts accessible in a timely manner to all insured on the one hand but on the other hand also to protect the community from harmful therapies. Information and advice to patients related to "stratifying medicine" is of particular importance. The equitable distribution of fees for diagnosis and counselling presents a particular challenge. The solidarity principle of public health insurance may be challenged by social and ethical issues of "stratifying medicine". CONCLUSION: "Stratifying medicine" offers great potential to improve medical care. However, false hopes must be avoided. Providers and payers should measure chances and risks of "stratifying medicine" together for the welfare of the patients.

Hospital-physician relationships: implications from the professional service firms literature.

PURPOSE: The hospital-physician relationship (HPR) has been the focus of many scholars given the potential impact of this relationship on hospitals' ability to achieve socially and organizationally desirable health care outcomes. Hospitals are dominated by professionals and share many commonalities with professional service firms (PSFs). In this chapter, we explore an alternative HPR based on the governance models prevalent in PSFs. DESIGN/METHODOLOGY APPROACH: We summarize the issues presented by current HPRs and discuss the governance models dominant in PSFs. FINDINGS: We identify the non-equity partnership model as a governance archetype for hospitals; this model accounts for both the professional dominance in health care decisions and the increasing demand for higher accountability and efficiency. RESEARCH LIMITATIONS: There should be careful consideration of existing regulations such as the Stark law and the antikickback statue before the proposed governance model and the compensation structure for physician partners is adopted. RESEARCH IMPLICATIONS: While our governance archetype is based on a review of the literature on HPRs and PSFs, further research is needed to test our model. PRACTICAL IMPLICATIONS: Given the dominance of not-for-profit (NFP) ownership in the hospital industry, we believe the non-equity partnership model can help align physician incentives with those of the hospital, and strengthen HPRs to meet the demands of the changing health care environment. ORIGINALITY/VALUE: This is the first chapter to explore an alternative hospital-physician integration strategy by examining the governance models in PSFs, which similar to hospitals have a high reliance on a predominantly professional staff.

The role of ethical banks in health care policy and financing in Spain.

OBJECTIVES: Ethical, social, or civic banks, constitute a secondary source of financing, which is particularly relevant in Southern and Central Europe. However there is no information on the scientific literature on this source of health care financing. METHOD: We review the characteristics of saving banks in Spain and illustrate the contribution of one institution "Obra Social Caixa Catalunya" (OS-CC) to the health care financing in Spain. RESULTS: Savings bank health care funding was equivalent to 3 percent of the public health expenditure for 2008. The programs developed by OS-CC illustrate the complex role of savings banks in health financing, provision, training, and policy, particularly in the fields of integrated care and innovation. CONCLUSIONS: Financing is a basic tool for health policy. However, the role of social banking in the development of integrated care networks has been largely disregarded, in spite of its significant contribution to complementary health and social care in Southern and Central Europe. Decision makers both at the public health agencies and at the social welfare departments of savings banks should become aware of the policy implications and impact of savings bank activities in the long-term care system.

[Bioethics and pharmacoeconomics: a difficult balance]. / Bioetica e farmacoeconomia: un difficile equilibrio.

While economic resources continue to decrease, there is a growing demand for health treatment. This faces health workers with an ethical dilemma. They are caught between, on the one hand, their responsibility to the individual patient and, on the other hand, the obvious need to make new treatments available to the largest number of patients. This clearly highlights the need for a regulated system of allocation of resources, whose rules must be agreed to by all operators in the field.

Coordinating the norms and values of medical research, medical practice and patient worlds-the ethics of evidence based medicine in orphaned fields of medicine.

Evidence based medicine is rightly at the core of current medicine. If patients and society put trust in medical professional competency, and on the basis of that competency delegate all kinds of responsibilities to the medical profession, medical professionals had better make sure their competency is state of the art medical science. What goes for the ethics of clinical trials goes for the ethics of medicine as a whole: anything that is scientifically doubtful is, other things being equal, ethically unacceptable. This particularly applies to so called orphaned fields of medicine, those areas where medical research is weak and diverse, where financial incentives are lacking, and where the evidence regarding the aetiology and treatment of disease is much less clear than in laboratory and hospital based medicine. Examples of such orphaned fields are physiotherapy, psychotherapy, medical psychology, and occupational health, which investigate complex syndromes such as RSI, whiplash, chronic low back pain, and chronic fatigue syndrome. It appears that the primary ethical problem in this context is the lack of attention to the orphaned fields. Although we agree that this issue deserves more attention as a matter of potential injustice, we want to argue that, in order to do justice to the interplay of heterogeneous factors that is so typical of the orphaned fields, other ethical models than justice are required. We propose the coordination model as a window through which to view the important ethical issues which relate to the communication and interaction of scientists, health care workers, and patients.

Traditional medicines in modern societies: an exploration of integrationist options through East Asian experience.

Modern scientific medicine is increasingly challenged by complementary and alternative therapies. Reviewing policy options for contemporary healthcare development, the World Health Organization's first global strategy on traditional and alternative medicine, released in May 2002, advocates integration. However, experience in East Asia, the only part of the world where state of the art modern scientific facilities are commonly found alongside thriving traditional practices, reveals that medical integration can take several forms. To clarify the available policy options, this article categorizes those forms, identifying three types of integration (unification, equalization and subjugation), plus one type of non-integration (marginalization). It marks out a zone of balanced healthcare development that cuts across two of the integrationist types, and comprises non-discriminatory state treatment of separate but linked sectors of traditional and modern medicine. The article closes by exploring arguments for and against locating state policy in this zone, and holds that policy should be situated here for medical practices that can meet broadly acceptable professional standards, demonstrate an existing social demand, and generate an adequate supply of medical practitioners, possibly through some state subsidy.

Fulfilling institutional responsibilities in health care: organizational ethics and the role of mission discernment.

In this paper we highlight the emergence of organizational ethics issues in health care as an important outcome of the changing structure of health care delivery. We emphasize three core themes related to business ethics and health care ethics: integrity, responsibility, and choice. These themes are brought together in a discussion of the process of Mission Discernment as it has been developed and implemented within an integrated health care system. Through this discussion we highlight how processes of institutional reflection, such as Mission Discernment, can help health care organizations, as well as corporations, make critical choices in turbulent environments that further the core mission and values and fulfill institutional responsibilities to a broad range of stakeholders.