Analysis of agency relationships in the design and implementation process of the equity fund in Madagascar.

BACKGROUND: There are large gaps in the literature relating to the implementation of user fee policy and fee exemption measures for the poor, particularly on how such schemes are implemented and why many have not produced expected outcomes. In October 2003, Madagascar instituted a user fee exemption policy which established "equity funds" at public health centres, and used medicine sales revenue to subsidise the cost of medicine for the poor. This study examines the policy design and implementation process of the equity fund in Madagascar in an attempt to explore factors influencing the poor equity outcomes of the scheme. METHODS: This study applied an agency-incentive framework to investigate the equity fund policy design and implementation practices. It analysed agency relationships established during implementation; examined incentive structures given to the agency relationships in the policy design; and considered how incentive structures were shaped and how agents responded in practice. The study employed a case-study approach with in-depth analysis of three equity fund cases in Madagascar's Boeny region. RESULTS: Policy design problems, triggering implementation problems, caused poor equity performance. These problems were compounded by the re-direction of policy objectives by health administrators and strong involvement of the administrators in the implementation of policy. The source of the policy design and implementation failure was identified as a set of principal-agent problems concerning: monitoring mechanisms; facility-based fund management; and the nature and level of community participation. These factors all contributed to the financial performance of the fund receiving greater attention than its ability to financially protect the poor. CONCLUSION: The ability of exemption policies to protect the poor from user fees can be found in the details of the policy design and implementation; and implications of the policy design and implementation in a specific context determine whether a policy can realise its objectives. The equity fund experience in Madagascar, which illustrates the challenges of beneficiary identification, casts doubts on the application of the 'targeting' approach in health financing and raises issues to be considered in universal health policy formulation. The agency framework provides a useful lens through which to examine policy process issues.

Risk-sharing or refund programs in assisted reproduction: a committee opinion.

Risk-sharing fee structures in assisted reproduction programs charge patients a higher initial fee but provide a partial refund if treatment fails. This opinion of the ASRM Ethics Committee analyzes the ethical issues raised by these fee structures, including patient selection criteria, conflicts of interest, and patient-informed consent. This document replaces the document of the same name, last published in 2004 (Fertil Steril 2004;82:S249-50).

Análise comparativa entre os códigos de ética odontológica e médica brasileiros / Comparative analysis of Brazilian medical and dental ethics codes / Análisis comparativo de los códigos brasileros de ética médica y dental

Os códigos de ética profissional são normas jurídicas (resoluções de autarquias federais) elaboradas pelos membros das mais diversas categorias de trabalhadores com o intuito de orientar a condutas desses profissionais no que diz respeito à ética na relação com os pacientes, com seus pares e com a sociedade. O objetivo deste estudo foi realizar uma análise comparativa entre os Códigos de Ética Odontológica e Médica. Observou-se que as diferenças entre estes documentos deontológicos surgem muito mais em virtude das particularidades de cada profissão do que por abordagens distintas frente a problemas similares. Concluiu-se que os Códigos de Ética Odontológica e Médica apresentam muito mais pontos em comum do que diferenças, mas seria interessante que os Conselhos de classe ao propor atualizações e modificações dos seus atuais códigos observassem o que as outras profissões da saúde contemplam em suas normas deontológicas, com o intuito de levar em consideração aspectos que também poderiam ser importantes para sua classe profissional de modo a engrandecer os códigos tornando um pouco mais fácil para os médicos e cirurgiões-dentistas a tomada de decisões éticas no seu trabalho diário em benefício da saúde do ser humano e da coletividade.

Los códigos de ética profesional son normas (resoluciones de autoridades federales) preparadas por los miembros de las diferentes categorías de trabajadores con el fin de orientar la conducta ética de estos profesionales en la relación con pacientes, colegas y la sociedad. El objetivo de este estudio fue realizar un análisis comparativo de los códigos de ética en Odontología y Medicina. Se observó que las diferencias entre estos documentos se deben más a las particularidades de cada profesión que a enfoques distintos frente a problemas similares. Se concluyó que los códigos de ética en Odontología y Medicina presentan más puntos en común que diferencias, pero sería interesante que los Consejos de Clase, al proponer actualizaciones y cambios a sus actuales códigos, observaran lo que otras profesiones de la salud contemplan en sus normas deontológicas, con fin de tener en cuenta aspectos que también podrían ser importantes para su clase profesional, de modo de ampliar los códigos y hacer un poco más fácil para los médicos y cirujanos dentistas la toma de decisiones éticas en su trabajo diario en beneficio de la salud del ser humano y la comunidad.

Professional ethics codes are norms (federal authority resolutions) prepared by members of the different categories of workers with the goal to guide the ethical conduct of these professionals in relation to patients, colleagues and society. The aim of this study was to carry out a comparative analysis of ethical codes in Dentistry and Medicine. It was observed that differences between these documents were due more to the particularities of each profession than to different focus, facing similar problems. It was concluded that Dentistry and Medicine ethical codes have more points in common than differences, but it would be interesting that Class Advisory Committees, when proposing actualizations and changes to their current codes, they will look what other health care professions view as deontological norms, with the end to have into account aspects which may be important also for their professional class, in order to extend the codes and facilitate to physicians and dentists ethical decision making in their daily task in benefit to the health of human beings and community.

[Ethical aspirations and the reality of medical practice at the end of the Ancien Regime]. / Aspirations ethiques et réalité de la pratique médicale a la fin de l'Ancien Régime.

At the end of the 18th century, economic survival was difficult for physicians. The medical market was crowded and to build (and seduce) a clientele, they had to pay particular attention to their appearance. Being well dressed and travelling by horse or in a carriage was necessary to demonstrate that they had a good reputation and were a "good" doctor. However, this still did not guarantee financial security for the doctor and his family. In an era when medical fees were only just beginning to be discussed, it was difficult to know how to bill patients and how to get paid. At the same time, the first texts on medical ethics appeared, insisting on modesty, authenticity, delicacy, and sincerity. In this article, by exploring personal archives and printed moral prescriptions, I will suggest that there were tensions between the everyday difficulties of medical practice and the recommendations on medical ethics, tensions that had consequences for the patient-doctor relationship.

Medical ethics and the payment of fees before treatment.

Whether it is ethically acceptable for doctors to require payment of fees before treatment depends on interpretation of the ethical rules of the profession, the circumstances of the doctor-patient relationship, the urgency of the patient's need for treatment, and whether refusal to treat before payment represents abandonment of a patient.

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.

Remuneraciones profesionales médicas / Medical remunerations

Desde que Aristóteles en su Etica a Nicomaco expresaba que "el fin que persigue el arte de la medicina es la salud" la profesión y la condigna remuneración de los médicos fueron consideradas en alta estima por parte de todos cuantos requerían de los servicios asistenciales médicos. Era sin lugar a dudas la del médico una de las profesiones más elogiosamente reconocidas y mejor remuneradas dentro de las variadas disciplinas humanas. En el presente trabajo se procura recrear la variable historia de las remuneraciones médicas y el particular destrato que ellas merecen en la actualidad en la República Argentina. Se hacen las consideraciones éticas, morales, laborales y legales sobre los conceptos remunerativos del médico y su discriminación cuando son considerados "honorarios" y cuando son considerados simplemente "salarios". Se concluye necesariamente que la histórica y merecida buena imagen del médico como agente de la salud se ha deteriorado y devaluado paulatinamente hasta llegar al presente en muchas comunidades a revestir el carácter de irrisoria, particularmente en lo atinente a su remuneración. Se toma en cuenta que en la actualidad la actividad médica depende no ya de sus pacientes asistidos, sino de terceros que ofician como pagadores de las prestaciones, preocupándose las más de las veces por el superávit económico que por el superávit de la salud. La labor médica se ha convertido en un mero objeto de intercambio y contienda económica, abandonando el espíritu de solidaridad individual y social de la atención para la salud. La medicina pasó a tomar parte integral de un "complejo comercial ¹ industrial" para la salud y todo ello sin considerar la formación humana y profesional del médico, su permanente incentivo en estudiar y agregar conocimientos a su arte y sin verificarlo como una entidad esencial como soporte natural en la salud de la comunidad...(AU)

Since Aristoteles wrote in his "Etica a Nicomaco" was expressing that "the end that chases the art of the medicine is the healthO", the profession and the deserved doctors remuneration were high esteem and consideration on the part for all those were needing of the welfare medical services. It was no doubt that the doctor, one of the professions more eulogistically recognized and best remunerated inside the varied human disciplines. In the present work one gets to recreate the changeable history of the medical remunerations and the individual mistreatment that they deserve at present in the Argentine Republic. Therere done the ethical, moral, labour and legal considerations on the remunerative of the doctor and his discrimination among when its considered to be "honorarium" and when are considered simply "wages". It concludes necessarily in that the historical and welldeserved good image of the doctor as a healths agent, has deteriorated and gradually devaluated, up to managing to the present in many communities to re-dress the character of derisory, particularly in the relating thing to his remuneration. It born in mind that at present the medical activity depends not already on his assisted patients, but of third that officiate as payers presentations, worrying more of the times for the economic surplus that for the healths surplus. The medical labor has turned into a mere exchanges object and economic contest, leaving the spirit of individual and social solidarity for the healths attention. The medicine passed to take integral report of a "commercial complex-industrially"for the health and all this without considering the doctors human and professional training, his art and withoutchecking it as an essential entity as natural support in the communitys health...(AU)

Remuneraciones profesionales médicas / Medical remunerations

Desde que Aristóteles en su Ética a Nicomaco expresaba que "el fin que persigue el arte de la medicina es la salud" la profesión y la condigna remuneración de los médicos fueron consideradas en alta estima por parte de todos cuantos requerían de los servicios asistenciales médicos. Era sin lugar a dudas la del médico una de las profesiones más elogiosamente reconocidas y mejor remuneradas dentro de las variadas disciplinas humanas. En el presente trabajo se procura recrear la variable historia de las remuneraciones médicas y el particular destrato que ellas merecen en la actualidad en la República Argentina. Se hacen las consideraciones éticas, morales, laborales y legales sobre los conceptos remunerativos del médico y su discriminación cuando son considerados "honorarios" y cuando son considerados simplemente "salarios". Se concluye necesariamente que la histórica y merecida buena imagen del médico como agente de la salud se ha deteriorado y devaluado paulatinamente hasta llegar al presente en muchas comunidades a revestir el carácter de irrisoria, particularmente en lo atinente a su remuneración. Se toma en cuenta que en la actualidad la actividad médica depende no ya de sus pacientes asistidos, sino de terceros que ofician como pagadores de las prestaciones, preocupándose las más de las veces por el superávit económico que por el superávit de la salud. La labor médica se ha convertido en un mero objeto de intercambio y contienda económica, abandonando el espíritu de solidaridad individual y social de la atención para la salud. La medicina pasó a tomar parte integral de un "complejo comercial – industrial" para la salud y todo ello sin considerar la formación humana y profesional del médico, su permanente incentivo en estudiar y agregar conocimientos a su arte y sin verificarlo como una entidad esencial como soporte natural en la salud de la comunidad...

Since Aristoteles wrote in his "Etica a Nicomaco" was expressing that "the end that chases the art of the medicine is the health…", the profession and the deserved doctor’s remuneration were high esteem and consideration on the part for all those were needing of the welfare medical services. It was no doubt that the doctor, one of the professions more eulogistically recognized and best remunerated inside the varied human disciplines. In the present work one gets to recreate the changeable history of the medical remunerations and the individual mistreatment that they deserve at present in the Argentine Republic. There’re done the ethical, moral, labour and legal considerations on the remunerative of the doctor and his discrimination among when it’s considered to be "honorarium" and when are considered simply "wages". It concludes necessarily in that the historical and welldeserved good image of the doctor as a health’s agent, has deteriorated and gradually devaluated, up to managing to the present in many communities to re-dress the character of derisory, particularly in the relating thing to his remuneration. It born in mind that at present the medical activity depends not already on his assisted patients, but of third that officiate as payers presentations, worrying more of the times for the economic surplus that for the health’s surplus. The medical labor has turned into a mere exchange’s object and economic contest, leaving the spirit of individual and social solidarity for the health’s attention. The medicine passed to take integral report of a "commercial complex-industrially"for the health and all this without considering the doctor’s human and professional training, his art and withoutchecking it as an essential entity as natural support in the community’s health...

Learning from the legal history of billing for medical fees.

INTRODUCTION: When patients pay for care out-of-pocket, physicians must balance their professional obligations to serve with the commercial demands of medical practice. Consumer-directed health care makes this problem newly pressing, but law and ethics have thought for millennia about how doctors should bill patients. HISTORICAL BACKGROUND: At various points in European history, the law restricted doctors' ability to bill for their services, but this legal aversion to commercializing medicine did not take root in the American colonies. Rather, US law has always treated selling medical services the way it treats other sales. Yet doctors acted differently in a crucial way. Driven by the economics of medical practice before the spread of health insurance, doctors charged patients according to what they thought each patient could afford. The use of sliding fee scales persisted until widespread health insurance drove a standardization of fees. CURRENT PRACTICE: Today, encouraged by Medicare rules and managed care discounts, providers use a perverse form of a sliding scale that charges the most to patients who can afford the least. Primary care physicians typically charge uninsured patients one third to one half more than they receive from insurers for basic office or hospital visits, and markups are substantially higher (2 to 2.5 times) for high-tech tests and specialists' invasive procedures. CONCLUSION: Ethical and professional principles might require providers to return to discounting fees for patients in straitened circumstances, but imposing such a duty formally (by law or by ethical code) on doctors would be harder both in principle and in practice than to impose such a duty on hospitals. Still, professional ethics should encourage physicians to give patients in economic trouble at least the benefit of the lowest rate they accept from an established payer.