A larger perspective on the Flexner report.

This paper is an attempt to place the Flexner Report of 1910 in the larger perspective of dynamics of American society in the years surrounding the turn of the 19th century. It looks at medicine as an integral part of society affected by the contradictions affecting the larger society. The Flexner Report is viewed as an attempt by the capitalist class to ameliorate those contradictions affecting medicine. The events preceding the publication of the Flexner Report are described in detail, and some problems with conventional accounts of the origins of the Flexner Report are discussed. In addition, the paradigm of medicine that was institutionalized with the acceptance and implementation of the Flexnerian recommendations is discussed.

The holistic alternative to scientific medicine: history and analysis.

The resurgence of the holistic health movement in the 1970s can be in part attributed to increasing consumer dissatisfaction with the present system of medical care delivery. This article traces the rise and decline of modern medicine by analyzing the assumption of hegemony by scientific medicine and its practitioners. Then it describes the challenges that holistic medicine's theories and therapies currently pose to scientific medicine's organizational form and practical content. Holistic medicine is assessed in terms of its organizational and conceptual basis, and the relationship between holistic medicine and the needs of advanced capitalist society is discussed.

Proprietary hospital chains and academic medical centers.

This article examines the reasons why proprietary hospital chains have become interested in buying or managing academic health center hospitals. Among the explanations that are discussed are such factors as vertical integration of health care, chain legitimation, integration of finance and delivery systems, and short-term profit potential. These factors are further examined through the use of a structured analysis of the interpenetration of proprietary chain hospitals and academic medical centers. We also discuss the consequences of these linkages in terms of such issues as continued educational mission, types of sponsored research programs, degree of indigent care provision, and changes in the nature of physician and other health worker training. The larger social implications of the movement of proprietary chains into tertiary medical care are evaluated.

The walk-in chains: the proprietarization of ambulatory care.

In this article we examine the previously little-studied development in U.S. health care--the growth of a proprietary ambulatory care system composed of health maintenance organization, urgent care centers, ambulatory surgicenters, ambulatory diagnostic centers, large group practices, and other delivery modalities. The growth of this system as a result of the ease of access to capital, limited or nonexistent regulation through Certificate of Need or other mechanisms, the growing surplus of physicians, decreases in the use of hospitals as a result of changed insurance benefits and inpatient utilization review, new developments in biotechnology, and computerization and miniaturization of new technological advances is discussed. The reasons for the expanded growth of proprietary chains over nonprofit systems of ambulatory care are also discussed. The article concludes with a discussion of the negative consequences for individual health and the health care system that may be generated by the continued growth of proprietary ambulatory care.

Health care workers' unions and health insurance: the 1199 story.

Labor unions that represent health care workers encounter unique circumstances. This study focuses on 1199--the largest health care workers' union in the United States, based in New York City--and describes how the union and its National Benefit Fund have structured a managed indemnity health insurance program that provides extensive benefits for its members. The authors detail the workings of the National Benefit Fund and the ways in which it can improve the health care of its members through its union structure. The Fund represents a model for improving the provision of health care to Americans.

Whither public health?

This paper examines the future of Schools of Public Health in the United States. The history of Schools of Public Health is developed by tracing the history of the philanthropies which supported scientific medicine and public health in the early decades of the twentieth century. The role of the theory of disease in shifting the focus of public health from the community to the laboratory is explored. This paper argues that Schools of Public Health have lost their legitimacy and no longer have any content area or discipline for which they alone are responsible. The declining public image of public health is explored in light of the recent swine flu and legionnaire disease episodes. The current tendencies of Schools of Public Health as miniature business schools or as departments of medical schools are explored and criticized and a revitalized curriculum for Schools of Public Health is posited.

The rise and fall of New Jersey's uncompensated care fund.

Since 1982, acute care hospitals in New Jersey have been reimbursed on a diagnosis-related group (DRG) basis along with a provision for 100 percent reimbursement of uncompensated care (bad debts and charity care). Initially, that system was based on a hospital-specific surcharge. Eventually, that was replaced with a uniform charge for all hospitals, including reimbursement by Medicare. But the growth in the number of uninsured, an inequitable financing system, increases in bad debts, and the elimination of Medicare payments led to the program's demise. An extended legislative stalemate has resulted in a pair of temporary extensions--aided by an infusion of federal Medicaid dollars--but the state still must find a permanent solution.

Health policy implications of the holistic health movement.

A forthright rebellion against the philosophical and clinical orientations of scientific medicine has occurred in the United States during the 1970s. This rebellion includes a growing number of people engaged in self-care practices in attempts to alter their health status through "lifestyle" adjustments, as well as a diverse amalgamation of practitioners (both medical and otherwise), who offer a wide range of therapies outside the mainstream of modern medical practice. Holistic health care has lately become the rubric under which these therapies are grouped. Scientific medicine is the term commonly used to refer to procedures officially sanctioned by the organized medical profession. In the late 19th century, scientific medicine emerged as an advance beyond allopathic medicine after germ theory provided an explanation and, later treatment for infectious diseases. Financial support by private philantropic foundations came in the wake of the Flexner Report on medical education, which provoked a reorganization of medical education in the United States. The subsequent hegemony of scientific medicine thus became assured. To date, few policy analysts have attempted to assess holism and its health policy implications. This article delineates several of the more important policy issues raised by the holistic movement, a phenomenon that represents a challenge to the present organization of health care institutions as well as to scientific medicine.

From DRGs to deregulation: New Jersey takes the road less traveled.

Following a 1992 court ruling that declared New Jersey's system of financing uncompensated care unconstitutional, the state radically changed its 12-year-old hospital payment system that pioneered the use of diagnostic-related groups (DRGs). In its place, New Jersey lawmakers approved a package of reforms that lets hospitals set their own charges and collect bad debts, uses the state's unemployment insurance trust fund to pay for charity care, and reforms the individual and small group insurance markets. Immediate results of the law include new subsidies for inner-city hospitals, lower bond ratings, and hospital layoffs.

Multinational operations of US for-profit hospital chains: trends and implications.

The expansion of United States for-profit hospital chains into the international arena is a new and important development. Experiences with contract management of middle eastern hospitals in the early 1970s gave the American firms impetus to pursue ownership of health facilities in other parts of the world. US companies now operate over 95 foreign hospitals. The reasons for this involvement include the political receptivity of the government of the host nation; the potential for rapid growth and profits; the lack of indigenous competition; and the ability to occupy a distinct niche within the extant health services organization. The political and ideological implications of the growth of private medicine, particularly in the United Kingdom, in terms of its effects on the National Health Service are discussed. Questions for future research are posed.

Are international patients the answer to American hospitals' problems?

American hospitals hoping to capitalize on the lucrative market for international patients may be in for some surprises. Not only is this market limited, but also the drawbacks may outweigh the potential benefits for hospitals seeking to enter this business.