Physician strikes.

Throughout medical history, physicians have rarely formed unions and/or carried out strikes. In a profession faced with the turmoil of health reform and increasing pressure to change their practices and lifestyles, will physicians resort to unionization for collective bargaining, and will a strike weapon be used to fight back against the array of corporate and government powers involved in the transformation of the American health-care system? This article examines the question of whether there could be such a thing as an ethical physician strike. Although physicians have not historically used collective bargaining or the strike weapon, the rapidly changing practice environment in the United States might push physicians and other health-care professionals toward unionization. This article considers the ethical questions that would arise if physicians started taking advantage of labor laws, and it lays out criteria for an ethical strike.

Development of a medicare beneficiary comprehension test: assessing medicare part d beneficiaries' comprehension of their benefits.

BACKGROUND: Medicare Part D, the senior prescription drug benefit plan, was introduced through the Medicare Modernization Act of 2003. Medicare beneficiaries receive information about plan options through multiple sources, and it is often assumed by consumer health plans and healthcare providers that beneficiaries can understand and compare plan information. Medicare beneficiaries are older, may have cognitive problems, and may not have a true understanding of managed care. They are more likely than younger persons to have inadequate health literacy, thereby demonstrating significant gaps in knowledge and information about healthcare. OBJECTIVE: To develop a Medicare Beneficiary Comprehension Test (MBCT) to evaluate Medicare beneficiaries' understanding of Part D plan concepts, as presented in the 2008 Medicare & You handbook. METHODS: A 10-question MBCT was developed using a case-vignette approach that required beneficiaries to read portions of the Medicare & You handbook and answer Part D-related questions associated with healthcare decision-making. The test was divided into 2 sections: (I) insurance concepts and (II) utilization management/appeals and grievances to cover standard terminology, as well as newer utilization management and appeals and grievances procedures that are unique to Part D. The test was administered to 100 beneficiaries at 2 sites-a university geriatrics clinic and a private retirement facility. Beneficiaries were tested for cognition and health literacy before being administered the test. RESULTS: The mean score on the MBCT was 3.5 of a maximum of 5, with no statistical difference found between both sites. Ten faculty members and 4 graduate students assessed the content validity of the instrument using a 4-point Likert rating rubric. The construct validity of the instrument was assessed using a principal components analysis with varimax rotation. The principal components analysis yielded 4 factors that were labeled as "Plan D concepts," "managed care/utilization management," "cost-sharing," and "plan comparisons." The factor analysis indicated that the test is multidimensional and did measure the construct. CONCLUSIONS: Medicare beneficiaries' understanding of Part D may play a key role in the management of their drug use and health and the associated outcomes. The MBCT and its pending revisions can be administered to beneficiaries with differing health outcomes. Medicare beneficiaries are often faced with several pieces of information involving a complex array of choices amidst bewildering plan options. It is crucial that beneficiaries and/or their family members involved in the decision-making process understand the plan benefits to truly make an informed decision. As the number of Medicare beneficiaries increases over the coming years with the baby boomers, it becomes even more imperative that the elderly have improved access to treatments that can achieve desirable outcomes. Measuring comprehension by Medicare beneficiaries may be an initial step toward understanding more complex issues, such as treatment adherence, decision-making, and, ultimately, trends in healthcare utilization and outcomes.

E-prescribing: history, issues, and potentials.

Electronic-Prescribing, Computerized Prescribing, or E-RX has increased dramatically of late in the American health care system, a long overdue alternative to the written form for the almost five billion drug treatments annually. This paper examines the history and selected issues in the rise of E-RX by a review of salient literature, interviews, and field observations in Pharmacy. Pharmacies were early adopters of computerization for a variety of factors. The profession in its new corporate forms of chain drug stores and pharmacy benefits firms has sought efficiencies, profit enhancements, and clinical improvements through managed care strategies that rely upon data automation. E-RX seems to be a leading factor in overall physician acceptance of Electronic Medical Records (EMRs), although the Centers for Medicare and Medicaid (CMS) incentives seem to be the propelling force in acceptance. We conclude that greater research should be conducted by public health professionals to focus on resolutions to pharmaceutical use, safety, and cost escalation, which persist and remain dire following health reform.

The Colombian health insurance system and its effect on access to health care.

In 1993, the Colombian government sought to reform its health care system under the guidance of international financial institutions (the World Bank and International Monetary Fund). These institutions maintain that individual private health insurance systems are more appropriate than previously established national public health structures for overcoming inequities in health care in developing countries. The reforms carried out following international financial institution guidelines are known as "neoliberal reforms." This qualitative study explores consumer health choices and associated factors, based on interviews with citizens living in Medellin, Colombia, in 2005-2006. The results show that most study participants belonging to low-income and middle-income strata, even with medical expense subsidies, faced significant barriers to accessing health care. Only upper-income participants reported a selection of different options without barriers, such as complementary and alternative medicines, along with private Western biomedicine. This study is unique in that the informal health system is linked to overall neo-liberal policy change.

Does supply influence mammography screening?

OBJECTIVE: To explain rural-urban differences in mammography screening by supply of health care services. METHODS: Logistic regression models were used to assess whether variation in the supply of health care services related to mammography screening explained rural-urban differences in mammography screening rates. RESULTS: Women living in small (thinly populated) rural areas not adjacent to a metro area were less likely to obtain a mammogram (OR = 0.682, CI: 0.62-0.75) compared to women in large metro counties. This difference was reduced after adjusting for predisposing and enabling factors (OR = 0.843, CI: 0.76-0.93). CONCLUSIONS: Contextual-level enabling factors mediated the rural-urban difference in mammography screening.

Assessment of medicare part d communications to beneficiaries.

BACKGROUND: Older Americans receive healthcare benefits through the federal Medicare program. The Centers for Medicare & Medicaid Services provides comprehensive information to Medicare beneficiaries regarding benefits, plan options, and enrollment policies primarily through the annual Medicare & You handbook and the Medicare website. Few studies have assessed the overall readability and, therefore, the usefulness of this handbook for adequately educating beneficiaries. Healthcare communications written at higher levels than the readers' comprehension levels cannot be well understood. OBJECTIVE: To measure the readability of the 2008 Medicare & You handbook provided to all Medicare beneficiaries. METHOD: For our analysis, the 2008 version of the Medicare & You handbook was downloaded from the Centers for Medicare & Medicaid Services website. Passages of ≥250 words were saved individually in Windows Notepad as text files. Shorter passages (ie, <250 words) were combined with the next continuing passage. Each file was then uploaded into the Internet-based Lexile analyzer (the Lexile Framework for Reading). Figures, pictures, and tables were not included in the analysis. RESULTS: Approximately 70% of analyzed passages were written at approximately the 5th- to 12th-grade levels (Lexile scores: 790L-1290L), whereas 30% of the passages were written at levels above grade 12 (Lexile scores: 1310L-1910L). CONCLUSION: Medicare beneficiaries who have less than a high-school level education may find the passages analyzed in this study difficult to read and comprehend as discussed, indicating the need for simplified communication. Our study provides recommendations to improve the handbook for better comprehension by beneficiaries.

Neighborhood geographical factors and the presence of advanced community pharmacy practice sites in Greater Chicago.

OBJECTIVES: To determine the availability of experiential learning opportunities in culturally diverse areas and to identify opportunities and barriers to attract and sustain sites for the University of Illinois at Chicago College of Pharmacy. METHODS: Utilizing variables of census tract income, racial/ethnicity composition and crime index, data analyses included descriptive statistics and multivariate logistic regression. Faculty members involved in experiential education were interviewed to identify other factors influencing site placement and selection for community-based advanced pharmacy practice experiences (APPEs). RESULTS: Median family income and Asian population were significantly higher and black population was significantly lower in census tracts with community APPE sites than in census tracts without APPE sites (p < 0.05). No significant differences were found in the population variables of white and Latino populations and crime index. The Asian population variable was the only significant predictor of an APPE site (p = 0.0148) when controlling for other variables. Distance from the College, pharmacy staffing issues, goodwill, influence of district and corporate managers, and strategic initiatives were critical considerations in site establishment and overall sustainability. CONCLUSION: Advanced community pharmacy practice sites were fairly well distributed across metropolitan Chicago, indicating that exposure to diverse populations during the advanced community practice experiences parallels with strategic College objectives of expanding and diversifying experiential sites to enhance pharmacy students' abilities to meet emerging patient care challenges and opportunities.

Factors associated with long-stay nursing home admissions among the U.S. elderly population: comparison of logistic regression and the Cox proportional hazards model with policy implications for social work.

Two statistical methods were compared to identify key factors associated with long-stay nursing home (LSNH) admission among the U.S. elderly population. Social Work's interest in services to the elderly makes this research critical to the profession. Effectively transitioning the "baby boomer" population into appropriate long-term care will be a great societal challenge. It remains a challenge paramount to the practice of social work. Secondary data analyses using four waves (1995, 1998, 2000, and 2002) of the Health Retirement Study (HRS) coupled with the Assets and Health Dynamics among the Oldest Old (AHEAD) surveys were conducted. Multivariable logistic regression and Cox proportional hazards model were performed and compared. Older age, lower self-perceived health, worse instrumental activities of daily living (IADL), psychiatric problems, and living alone were found significantly associated with increased risk of LSNH admission. In contrast, being female, African American, or Hispanic; owning a home; and having lower level of cognitive impairment reduced the admission risk. Home ownership showed a significant effect in logistic regression, but a marginal effect in the Cox model. The Cox model generally provided more precise parameter estimates than logistic regression. Logistic regression, used frequently in analyses, can provide a good approximation to the Cox model in identifying factors of LSNH admission. However, the Cox model gives more information on how soon the LSNH admission may happen. Our analyses, based on two models, dually identified the factors associated with LSNH admission; therefore, results discussed confidently provide implications for both public and private long-term care policies, as well as improving the assessment capabilities of social work practitioners for development of screening programs among at-risk elderly. Given the predicted surge in this population, significant factors found from this study can be utilized in a strengths-based empowerment approach by social workers to aid in avoiding LSNH utilization.

Medication adherence and persistence in the last year of life in COPD patients.

OBJECTIVE: To examine medication adherence and persistence among COPD patients during their last year of life. DATA SOURCE: National VA databases were used to identify patients who had COPD and died between 1999 and 2003. STUDY DESIGN: We examined use of inhaled corticosteroids (ICS), long acting beta(2) agonists (LABA), methylxanthines (MTX), and anticholinergics (AC), alone and in combination. Medication possession ratios (MPR) were compared between regimens by quarterly periods using General Estimating Equations (GEE). Medication persistence was examined in monotherapy users with Kaplan-Meier survival analysis and extended Cox proportional hazard models. PRINCIPAL FINDINGS: Only half of the identified patients in the COPD cohort (5913 of 11,376) used any medications. Among 5913 patients, overall mean (SD) MPR was 0.44 (0.32) during the last year of life. A positive linear trend in MPR was observed across quarterly periods in AC users (beta=0.014, p<0.0001), and was highest for MTX users (beta=0.11, p<0.0001). Of 3436 on monotherapy only, 40% discontinued medication within 30 days, and 70% discontinued within 90 days. MTX users were less likely to discontinue (HR=0.714, p=0.012) than reference (AC) group. CONCLUSION: COPD patients in their last year of life tended to use respiratory medications sporadically. Further research is needed to qualify whether minor differences in MPR between regimens reflect behavioral differences related to regimen or reflect refill policy and MPR calculation technique.

Iatrogenic disease management: moderating medication errors and risks in a pharmacy benefit management environment.

Disease Management (DM) programs have advanced to address costly chronic disease patterns in populations. This is in part due to the programs' significant clinical and economical value, coupled with interest by pharmaceutical manufacturers, managed care organizations, and pharmacy benefit management firms. While cost containment realizations for many such interventions have been less than anticipated, this article explores potentials in marrying Medication Error Risk Reduction into DM programs within managed care environments. Medication errors are an emergent serious problem now gaining attention in US health policy. They represent a failure within population-based health programs because they remain significant cost drivers. Therefore, medication errors should be addressed in an organized fashion, with DM being a worthy candidate for piggybacking such programs to achieve the best synergistic effects.

Strikes by physicians: a historical perspective toward an ethical evaluation.

Current conditions surrounding the house of medicine-including corporate and government cost-containment strategies, increasing market-penetration schemes in health care, along with clinical scrutiny and the administrative control imposed under privatization by managed care firms, insurance companies, and governments-have spurred an upsurge in physician unionization, which requires a revisiting of the issue of physician strikes. Strikes by physicians have been relatively rare events in medical history. When they have occurred, they have aroused intense debate over their ethical justification among professionals and the public alike, notwithstanding what caused the strikes. As physicians and other health care providers increasingly find employment within organizations as wage-contract employees and their work becomes more highly rationalized, more physicians will join labor organizations to protect both their economic and their professional interests. As a result, these physicians will have to come to terms with the use of the strike weapon. On the surface, many health care strikes may not ever seem justifiable, but in certain defined situations a strike would be not only permissible but an ethical imperative. With an exacerbation of labor strife in the health sector in many nations, it is crucial to explore the question of what constitutes an ethical physician strike.

The impact of urinary incontinence on quality of life of the elderly.

OBJECTIVES: To investigate the impact of urinary incontinence (UI) on health-related quality of life (QOL), as measured by the Medical Outcomes Study Short Form-36 (SF-36) and to compare UI and non-UI elderly Medicare beneficiaries enrolled in managed care plans on the prevalence of depression and self-rated health. METHODS: After excluding beneficiaries younger than 65 years old, a total of 141 815 completed surveys were used for analysis. The survey included 1 question on difficulty in controlling urination, 3 questions on depression, 3 questions on health, a series of questions regarding comorbid medical conditions, and the SF-36. Self-rated health, prevalence of depression, and scores in each domain of QOL were compared between UI and non-UI groups. RESULTS: Overall, the prevalence of UI was 24.7% (20.9% in men, 27.5% in women). The UI group was about twice as likely to feel depressed as the non-UI group. The UI group also rated their health more negatively. Compared with continent respondents, those who were incontinent had lower standardized scores on all 8 subscales of SF-36 as well as 2 summary scores. Results from multiple regressions indicated that UI had a significantly negative impact on all aspects of QOL after adjusting for comorbidities and demographic differences. CONCLUSION: Findings indicate that elderly patients with UI are more depressed and have worse perceived health. On certain domains of QOL, the negative impact of UI even surpasses that of other severe comorbidities.

Cost-effectiveness analysis and the formulary decision-making process.

BACKGROUND: Faced with high drug expenditures in an environment of cost containment, drug formulary systems, particularly in managed care, have become more dependent on pharmacoeconomic evaluations to assess the value of new products. Within pharmacoeconomics (PE), cost-effectiveness analysis (CEA) is the most commonly used method. However, current methodological concerns about CEA have limited its practical contribution to the formulary process. Advances in analysis are likely to improve the relevance of CEA over time. OBJECTIVE: The purpose of this paper is to review CEA, its limitations, and its applications in formulary decision making in order to promote greater utility of CEA for managed care pharmacists. SUMMARY: Enhancements to CEA, such as the development of modeling software, rank-order stability analysis, cost-consequence analysis (CCA), and budget impact analysis are discussed. A combined method of CCA-CEA and standardized guidelines are suggested to improve the impact of CEA in the drug formulary process. CONCLUSION: Along with advances in its methodology and relevant standardized guidelines, CEA will gain increased importance in formulary decision making, helping to assure the goal of cost containment while ensuring quality of care.

Physician collective bargaining in a U.S. public hospital.

In a study to investigate the factors that would drive attending physicians employed in a public hospital to seek collective bargaining with their employer, the authors developed an instrument to determine which variables and which hypotheses were predictive of union proneness. The findings reveal that a desire for voice was the number one reason for physicians' wanting to join a union. Union-prone physicians had a lower salary on average, were more dissatisfied with their income, were more likely to feel the effects of work "speed up" (too many patients and too little time), were less likely to have administrative functions (thus a larger patient care role), had a strong sense of entitlement to collective bargaining, believed that unions improve participation in decisions affecting their jobs (reinforcing their desire for voice), and had a sense that a union would improve their treatment by supervisors (reinforcing their desire for due process and equity).