Obstetrician-Gynecologists' Practices in Postpartum Sterilization Without a Valid Medicaid Consent Form.

OBJECTIVE: To explore the practices of obstetrician-gynecologists (ob-gyns) in the United States surrounding postpartum sterilization when the Medicaid consent form was not valid. METHODS: Using the American College of Obstetricians and Gynecologists' online directory, we conducted a qualitative study where we recruited ob-gyns practicing in 10 geographically diverse U.S. states for a qualitative study using semi-structured interviews conducted by telephone. We analyzed interview transcripts using the constant comparative method and principles of grounded theory. RESULTS: Thirty ob-gyns (63% women, 77% nonsubspecialized, and 53% academic setting) were interviewed. Although most physicians stated that they did not perform sterilizations without a valid Medicaid sterilization form, others noted that they sometimes did due to a sense of ethical obligation toward their patient's health, being in a role with more authority or seniority, interpreting the emergency justification section of the form more broadly, or backdating the form. The physicians who said that they never went ahead without a signed form tended to work at large institutions and were concerned with losing funding and engaging in potentially illegal or fraudulent behavior. CONCLUSION: Physicians' varied behaviors related to providing postpartum sterilization without a valid Medicaid consent form demonstrate that the policy is in need of revision. Unclear terminology and ramifications of the Medicaid sterilization policy need to be addressed to ensure equitable care.

Are Medicaid Closed Formularies Unethical?

State Medicaid programs have proposed closed formularies to limit spending on drugs. Closed formularies can be justified when they enable spending on other socially valuable aims. However, it is still necessary to justify guidelines informing formulary design, which can be done through a process of decision making that includes the public. This article examines criticisms that Medicaid closed formularies limit deliberation about decisions that affect drug access and unfairly disadvantage poor patients. Although unfairness to poor patients is a risk, it is not a problem unique to Medicaid, since private insurance programs have also implemented closed formularies.

Stratified reproduction, family planning care and the double edge of history.

PURPOSE OF REVIEW: There is a growing clinical consensus that Medicaid sterilization consent protections should be revisited because they impede desired care for many women. Here, we consider the broad social and ideological contexts for past sterilization abuses, beyond informed consent. RECENT FINDINGS: Throughout the US history, the fertility and childbearing of poor women and women of color were not valued equally to those of affluent white women. This is evident in a range of practices and policies, including black women's treatment during slavery, removal of Native children to off-reservation boarding schools and coercive sterilizations of poor white women and women of color. Thus, reproductive experiences throughout the US history were stratified. This ideology of stratified reproduction persists today in social welfare programs, drug policy and programs promoting long-acting reversible contraception. SUMMARY: At their core, sterilization abuses reflected an ideology of stratified reproduction, in which some women's fertility was devalued compared to other women's fertility. Revisiting Medicaid sterilization regulations must therefore put issues of race, ethnicity, class, power and resources - not just informed consent - at the center of analyses.

Legal and ethical implications of health care provider insurance risk assumption.

From bedside to boardroom, nurses deal with the consequences of health care provider insurance risk assumption. Professional caregiver insurance risk refers to insurance risks assumed through contracts with third parties, federal and state Medicare and Medicaid program mandates, and the diagnosis-related groups and Prospective Payment Systems. This article analyzes the financial, legal, and ethical implications of provider insurance risk assumption by focusing on the degree to which patient benefits are reduced.

Social justice considerations in neonatal care for nurse managers and executives.

This article presents the struggle between social justice and market justice within the current health care system, specifically issues affecting neonatal care. Community benefit is described and discussed as an aspect of social justice demonstrated by hospitals. The federal and state Children's Health Insurance Program also is discussed in relation to social justice and health care costs. Implications for managers and executives overseeing neonatal care are presented in relation to the economic and social issues.

Solving the problem of the uninsured.

Reform of the United States health care system is less complicated than at first might appear. The building blocks of an ideal system are already in place. The federal government already generously subsidizes private health insurance and safety net care. What is wrong with the current system is that there are too many perverse incentives. One could reasonably argue that government is doing more harm than good, and that a laissez faire policy is better than what is now in place. Nonetheless, if government is going to be involved in a major way in the health care system, perverse incentives should be replaced with neutral ones. At a minimum, government policy should be neutral between private insurance and the social safety net, never spending more on free care for the uninsured than it spends to encourage the purchase of private insurance. Careful application of this principle would go a long way toward creating an ideal health care system.

The inequity of Medicaid reimbursement in the United States.

The United States Medicaid programme aims to provide public health insurance to certain categories of the low-income population. Considerable non-uniformity exists within the programme because each of the 50 states, Washington, DC and 5 territories are individually responsible, within broad federal guidelines, for its administration. The non-uniformity shows up in different eligibility requirements, benefits and health care provider reimbursement rates. This paper examines reimbursement rate variations across individual programmes and discusses how these variations affect health care provider participation. Dual market theory suggests, and empirical results conclude that low reimbursement rates cause health care providers to participate less fully in the programme. Variations in access to medical care because of differences in reimbursement rates thereby create severe horizontal and vertical inequities across programmes. To reduce these inequities, the federal government might offer earmarked grants for the mandated purpose of raising reimbursement rates to a uniform percentage of private rates in all programmes.