Providing Hand Surgery Care to Vulnerably Uninsured Patients.

Economically vulnerable US patients are at risk for undertreatment of hand-related conditions as well as poorer outcomes. The cost of indigent care can be substantial to both the patients and their communities. Caring for these patients in a system that depends on inconsistent coverage requires a network of safety-net hospitals. To ensure that patients have access to care, the protection of safety-net hospitals should be prioritized when discussing federal and state funding allocation. On an individual scale, surgeons can also make changes in their practices to help find sustainable ways to care for indigent patients.

Habitantes de calle: entre el mito y la exclusión / Homeless people: between myth and exclusion

Al hablar del habitante de calle, resulta importante mencionar que es un fenómeno que ha tenido presencia milenaria, y que ha estado siempre permeado por las lógicas sociales de gobernanza, religión, cultura y economía. Han sido tan diversas las representaciones que se han tenido de esta población, que hoy inclusive sobreviven algunas de esas ideas que han hecho difícil su abordaje y comprensión. El objetivo de este texto es dar a conocer las reflexiones que han surgido de un ejercicio inicial de formación investigativa, en cuanto al fenómeno habitante de calle en Medellín. Para esta acción se revisaron algunos artículos sobre esta población, y se realizó una pequeña pasantía por el sistema de Atención al Habitante de Calle de Medellín, de donde surgieron algunas ideas referentes al concepto, historia y estrategias de intervención que se han implementado desde las diferentes administraciones para intentar dar solución a dicho fenómeno.

It is important to mention that homeless people is a phenomenon that has had a millennial presence, and that has always been permeated by the social logics of governance, religion, culture and economy. There had been so diverse representations about this population, that even today survive some of those ideas that have made it difficult to approach and understand them. The main objective of this text is to make known the reflections that have arisen from an initial exercise of investigative training, regarding that phenomenon of the homeless people in Medellin. Some articles on this specific population were reviewed, and a small internship was carried out by the Medellin homeless people Care System, emerging some ideas about the concept, history and intervention strategies that have been implemented since the different Governmental Administrations to try to solve this phenomenon.

Dialysis for undocumented immigrants in the United States.

The United States offers near-universal coverage for treatment of ESRD. Undocumented immigrants with ESRD are the only subset of patients not covered under a national strategy. There are 2 divergent dialysis treatment strategies offered to undocumented immigrants in the United States, emergent dialysis and chronic outpatient dialysis. Emergent dialysis, offering dialysis only when urgent indications exist, is the treatment strategy in certain states. Differing interpretations of Emergency Medicaid statute by the courts and state and federal government have resulted in the geographic disparity in treatment strategies for undocumented immigrants with ESRD. The Patient Protection and Affordable Care Act of 2010 ignored the health care of undocumented immigrants and will not provide relief to undocumented patients with catastrophic illness like ESRD, cancer, or traumatic brain injuries. The difficult patient and provider decisions are explored in this review. The Renal Physicians Association Position Statement on uncompensated renal-related care for noncitizens is an excellent starting point for a framework to address this ethical dilemma. The practice of "emergent dialysis" will hopefully be found unacceptable in the future because of the fact that it is not cost effective, ethical, or humane.

Dental school volunteerism.

Student Community Outreach for Public Education, SCOPE, is a student-led community outreach program at the University of the Pacific that provides leadership opportunities, service experiences, and a chance to understand the oral needs of all Americans. The organization and activities of the program are detailed, along with a description of the type of individuals served. The complex range of motives for community service and the relationship between the private system and the safety-net system are explored.

The ethics of charity dental clinics.

The Ben Massell Dental Clinic is part of the Jewish Family & Career Services in Atlanta, Georgia, which provides a wide range of health and social services on a sliding-fee basis. A fixed location, comprehensive service, and a clinic with full regular hours is an obvious benefit to patients. This structure also provides advantages to dentists who wish to donate their professional expertise without disrupting their offices and without the need to create a new logistic and management structure. Such a regular clinic also provides continuity of care in a charity setting.

Dental ethics case 6. Stalled payment for ongoing orthodontic treatment--balancing responsibilities.

It is not always easy for an orthodontist to strike the right balance between a caring, supportive and patient-centered approach, and the need to make a living and to run a profitable business in order to achieve this. Striving to act ethically and professionally at all times will help find this elusive balance and ultimately it will be more rewarding and professionally satisfying. Especially when dealing with children whose lives may be dramatically affected by the interruption or cessation of treatment, orthodontists have a duty to reassure themselves about the financial stability of their contractual relationships with patients or parents. Having consistent financial policies and flexible payment options may assist in this regard. Even in the face of non-payment of fees, treatments that have begun must in some form continue if their cessation would compromise the best interests of patients.

When the patient does not pay: a survey of primary care physicians.

OBJECTIVE: Despite ethical implications, there are anecdotal reports of health practitioners withholding services from patients who do not pay their bills. We surveyed physicians about their attitudes and experiences regarding nonpaying patients. DESIGN: A cross-sectional mailed survey. PARTICIPANTS: Three hundred seventy-nine of 1000 surveyed primary care physicians participated. MEASUREMENTS AND MAIN RESULTS: We studied how likely participants were to withhold 13 services from hypothetical patients who did not pay the physician's bills based on a 4-point Likert scale. Respondents were asked whether they had actually ever withheld such services from patients. The effects of demographic data on the number of services withheld from hypothetical and actual patients were analyzed by analysis of variance and multiple logistic regression. Most respondents (84%) would have withheld at least 1 item of service from the hypothetical patient, with 41% having ever withheld care from their actual patients. Most services involved administrative actions, but many respondents would be willing to forego other types of medical care. Being younger (P = 0.003), believing that patients are not always entitled to medical care (P = 0.002) and being in an urban practice (P = 0.03) were associated with withholding medical care from patients. CONCLUSIONS: A majority of primary care practitioners responding to our survey would be willing to withhold medical care from patients who do not pay their bills; some have actually done so despite ethical and legal mandates to the contrary. Physicians should be educated about the importance of the patient-physician relationship and their ethical obligations to patients.

[The development of the public health system between an increasing market orientation (commercialisation) and social responsibility]. / Die Entwicklung des Gesundheitssystems zwischen Okonomisierung und sozialer Gerechtigkeit.

The development of the public health system between an increasing market orientation (commercialisation) and social responsibility is critically reflected by examining the medical care of those who are deprived. Poverty in Germany is dramatically increasing. There are confirmed findings on the correlation of being poor and being ill. Poverty leads to an increased number of cases of illness and a higher mortality rate. And vice versa, chronic illnesses very often cause impoverishment. This correlation has largely been ignored not only by the public but also by experts, especially when public health-care issues are on the political agenda. With reference to the current discussion about public health-care and the widespread disregard of the living conditions of the poor, the categories of "reasonable behaviour" (Kant) and "communicative behaviour" (Habermas) are reflected on in a philosophical excursion. Further interest groups affecting the political sphere, such as the pharmaceutical industry, the medical profession, patients and scientists are also examined with regard to public health-care. What are the premises of a health-care discussion that is controlled by economic considerations, particularly when keeping in mind the humanistic and Christian ethics of our society? And what does this mean for our responsibility for those who are handicapped and are in need of our help? Do decision makers and participants of the health-care discussion satisfy these ethical challenges? And what are the effects of the so-called "social peace" on social cooperation and economic power of a country? The increasing market orientation (commercialisation) of the public health sector can only be accepted on the basis of practiced humanity and social responsibility. In the light of a human public health-care, deprived people are in need of our solidarity.

Kant's assessment of motivation in the fulfillment of social obligations.

This paper explores the motivations of physicians who promote the health of their communities through the fulfillment of social obligations beyond the boundaries of their own patients. Based on the assumption that physicians do not have social obligations, this paper looks at the normative, motivational question, namely "How should physicians be motivated to fulfill social obligations?" The paper traces the Kantian view of morality and motivation. The distinctions between required, merely permissible, and forbidden actions is drawn. Furthermore, Kant's view that required actions done in accordance with duty are of no moral worth is critiqued from three stand points. First, it is argued that just because motivations outside of Kantian-based duty are not as good, it does not follow that these motivations are of no moral worth. Second, it is argued that there are some motivations behind required actions that are clearly better than other motivations. Third, it is argued that required actions done in accordance with duty are clearly better than those actions done without relevance to duty. The paper concludes that many required actions done in accordance with duty are performed from motivations that do have moral worth.

Caring for the new uninsured: Hospital charity care for older people without coverage.

Despite near-universal coverage through Medicare, a number of elderly residents in the United States do not have health insurance coverage. To the author's knowledge, this study is the first to document trends in the use of hospital charity care by uninsured older people. Data from the New Jersey Charity Care Program, which subsidizes hospitals for services provided to low-income uninsured people, were used to analyze trends in charity care utilization by older people from 1999 to 2004. Charity care charges are standardized to uniform Medicaid reimbursement rates and inflation adjusted using the Medical Care Consumer Price Index. From 1999 to 2004, use of charity care by older people grew much faster than it did for younger patients. As a result, older people now account for a greater share of hospital charity care in New Jersey than children. Elderly users of charity care generated higher costs per patient than their younger counterparts. Cost differences were especially salient at the upper end of the distribution, where high-cost elderly patients used significantly more resources than high-cost patients in other age groups. These results highlight an emerging source of strain on the healthcare safety net and point to a growing population of uninsured residents who have costly and complex medical needs. Similar experiences are likely to be found in other states, especially those that have growing populations of elderly immigrants who are likely to lack health insurance.