Third-party Payment Research Articles

Professionalism and Conflict of Interest

You have accessThe ASHA LeaderMake it Work1 Aug 2003Professionalism and Conflict of Interest Allan O. Diefendorf Allan O. Diefendorf Google Scholar More articles by this author https://doi.org/10.1044/leader.MIW.08142003.25 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In One of the most important assets of an audiologist is reputation in the community he or she serves. This reputation is based not only upon the quality of care provided to patients, but also upon the community’s perception of the integrity of the audiologist’s business operations. Therefore, a guiding principle for audiologists is that they shall avoid personal interests that conflict with the best interest of the patients they serve. That is, when potential for conflict of interest exists, the interests of the patient must come before those of the audiologist. A conflict of interest may exist when an audiologist or immediate family member engages in business practices or relationships that provide the audiologist with financial incentives. This involvement could result in a loss of objectivity and may affect how services are delivered to a patient who is seeking care and recommendations from the audiologist. Moreover, although the appearance of a conflict of interest may not actually be a legal or ethical violation, appearances can damage the reputation of an individual, his or her practice, and profession. In ASHA’s Code of Ethics, Principle of Ethics III advocates, “Individuals shall honor their responsibility to the public by promoting public understanding of the professions, by supporting the development of services designed to fulfill the unmet needs of the public, and by providing accurate information in all communications involving any aspect of the professions.” Rule of Ethics III-B states, “Individuals shall not participate in professional activities that constitute a conflict of interest.” As the profession of audiology has continued to evolve, product dispensing has become a significant part of service delivery. Increasingly, alliances between audiologists and hearing instrument manufacturers have become a significant factor in service delivery. As such, professionals are faced with decisions that may result in ethical dilemmas between their patient’s best interest and their own financial interests. As these relationships become more common and complex, there are more and more possibilities for conflicts of interest. Examples of potential conflicts of interest include, but are not limited to, any investment, financial interest, or commercial interest in a company with which an audiologist does business; any employment or consulting with a company with which an audiologist does business, without disclosing the relationship to a patient; accepting gifts, material goods, entertainment, incentive travel, or education expenses from a company with which an audiologist does business; and participating in any industry-sponsored social functions that give rise to the appearance of biasing or influencing professional judgment or practice. Health care professionals are distinguished by the type of services they provide to the public and for complying with strict legal regulations and ethical guidelines regarding reimbursement. As audiologists achieve greater autonomy, receive more third-party payment, and gain more direct access to Medicare reimbursement, our business practices will receive greater scrutiny by the public. As such, audiologists will be held accountable to the same anti-kickback prohibitions and federal laws (Stark Laws) that prohibit physicians from referring patients to an entity for the furnishing of services if the physician or an immediate family member has a direct or indirect financial interest in the entity providing such services. Doctoring professions, to which audiology aspires to become, assume similar values, attitudes, and beliefs concerning patient care. Serving patients’ interests is the first and primary mission, and this mission must always come before personal financial interests. And conflicts of interest, even if by appearance only, must be eliminated entirely from the professional’s practice. Author Notes Allan O. Diefendorf, directs audiology and speech-language pathology at the Indiana University Medical Center. He is on the faculties of the department of otolaryngology, head & neck surgery at the Indiana University School of Medicine, and the department of audiology and speech sciences at Purdue University. Contact him by e-mail at [email protected]. Additional Resources FiguresSourcesRelatedDetails Volume 8Issue 14August 2003 Get Permissions Add to your Mendeley library History Published in print: Aug 1, 2003 Metrics Downloaded 848 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2003 American Speech-Language-Hearing AssociationLoading ...

American Society of Clinical Oncology policy statement update: tobacco control--reducing cancer incidence and saving lives. 2003.

As an international medical society dedicated to cancer prevention, the American Society of Clinical Oncology (ASCO) advocates a fundamental reform of United States and international policy toward addictive tobacco products. ASCO's goal is the immediate reduction of tobacco use and ultimate achievement of a tobacco-free world. The centerpiece of ASCO's policy is the recommendation for an independent commission to study the tobacco problem in all of its dimensions: social, medical, legal, and economic (both domestically and globally). The commission membership should include broad-based representation and expertise on tobacco issues. In ASCO's view, tobacco control efforts to date have been less than successful because they are too fragmented and incremental, leaving many important issues unaddressed. A more comprehensive solution could flow from this study, including input from a variety of government agencies involved with public health, agriculture, First Amendment and other legal considerations, and international trade. The study, within defined time limits, should culminate in a report that outlines a strategy for achieving immediate reduction of tobacco use and ultimate achievement of a tobacco-free world, including explicit plans and a timetable for implementation. Although this comprehensive approach to tobacco control will take many years to implement even under the best of circumstances, there are certain measures that could be undertaken immediately with meaningful impact on tobacco usage. These include: Increasing efforts to discourage tobacco use, particularly among the young Raising federal excise taxes by at least $2 per pack and encouraging states to consider tobacco taxes as a first resort in revenue enhancement Ensuring that tobacco settlement funds be devoted only to health-related projects, including medical treatment, biomedical research, and tobacco prevention efforts Requiring disclosure of all ingredients in tobacco products Comprehensively reforming third-party payment for tobacco cessation efforts Additional restriction of secondhand smoke in any places where the public may congregate Supporting necessary research into tobacco addiction, toxicities, and prevention strategies Enhancing global tobacco control, including a halt of United States government promotion of tobacco products

Online credit card processing models: Critical issues to consider by small merchants

Electronic commerce is continuing as a thriving business for those companies that streamlined their online business processes; however, making payments over the Internet is still fearsome to customers. Although a variety of payment mechanisms have been developed, payment by credit cards remain the leading mechanism for online payments. For real-time online credit card processing, a merchant needs to install a third-party proprietary software in the merchant e-commerce server. However, many issues need to be resolved before integrating a third-party payment solution to a merchant e-commerce system. In this paper, we attempt to address the current state of the online credit card processing system, especially we discuss the available models of online real-time credit card processing systems. We also discuss several factors such as cost, complexity and security issues related to implementing such a system. The results can be extremely valuable to small businesses that are venturing into Internet commerce.

Does gatekeeping control costs for privately insured children? Findings from the 1996 medical expenditure panel survey.

Gatekeeping requirements were widely adopted by health insurers in an attempt to control costs in the mid-1990s, but empirical evidence demonstrating decreased health expenditures for children enrolled in such plans is lacking. We analyzed data from 3254 children with private health insurance sampled in the 1996 Medical Expenditure Panel Survey (MEPS) to compare total per capita health expenditures among gatekeeping versus indemnity plan enrollees. This sample represents 40.4 million privately insured American children. Total expenditures were defined as payments from all sources, including third-party and out-of-pocket payments, but excluding administrative costs. MEPS data are based on information provided by patients, health care providers, and hospitals. Gatekeeping plans included all children enrolled in health maintenance organizations or other plans requiring a primary care gatekeeper. All others were considered indemnity plan enrollees. Mean total per capita annual expenditures for children in gatekeeping versus indemnity plans differed by <1% (887 dollars vs 881 dollars, respectively). Third-party payments by gatekeeping plans on behalf of their beneficiaries were 636 dollars versus 595 dollars by indemnity plans. Out-of-pocket payments were on average 62 dollars less for gatekeeping enrollees than for indemnity enrollees. After multivariate adjustment, mean per capita expenditures were approximately 4% lower for gatekeeping enrollees than for indemnity enrollees. In 1996, total per capita annual health expenditures for children in gatekeeping plans were approximately 8 dollars less than for those in indemnity plans. These data indicate that gatekeeping is not an effective cost-containment method for children.

Recent dietary guidelines to prevent and treat cardiovascular disease, diabetes, and obesity.

Nutrition guidelines are emphasizing dietary patterns as primary and secondary prevention trials provide increasing evidence of the importance of lifestyle changes to prevent/control cardiovascular disease (CVD) risk factors such as diabetes and hypertension. Despite the increasing evidence that weight loss and modified dietary patterns are effective, there is considerable debate about the level of carbohydrate that will be most beneficial. Epidemiologic studies indicate that certain ethnic and racial minority groups have increased CVD risk with higher rates of obesity, hypertension, diabetes, and stroke. Immigrant and Native American populations have had a dramatic rise in obesity, diabetes, and ultimately CVD with acculturation, accompanied by a higher fat intake and decreased physical activity. Culturally tailored intervention approaches are being used to reduce risk. The lack of third-party payment still limits the availability of nutrition services. However, medical nutrition therapy is covered by Medicare for diabetes and pending legislation will extend coverage to CVD. Medical education researchers have developed tools such as the WAVE (Weight, Activity, Variety and Excess) pocket guide as a quick method to facilitate addressing referral for medical nutrition therapy that can be readily incorporated into practice settings.

Databases for Research on Nonprofit Health Care Organizations

As tax-exempt entities that compete in commercial markets with for-profit organizations, nonprofit health care organizations present stimulating intellectual challenges to the theorist and the empiricist alike. Because of third-party payment and policy intensiveness of health care, much information is available to researchers. Most research has focused on comparisons with for-profits and on public policy issues. This article describes the major streams of research on health care delivery organizations and the main sources and types of data that are available to researchers. We suggest criteria for evaluating data sources and identify some limitations and barriers that now exist. We conclude by identifying and assessing the data problems that could confront researchers interested in ownership issues in health care and by offering suggestions on how the more serious ones might be addressed to facilitate improved research.

Decision making in social work practice

Decision making in social work is high-stakes work. Regardless of practice setting, client population, and role, practitioners confront the challenge of both making and facilitating good decisions. Decisions are defined as intentional choices made from a number of alternative possibilities that will result in some effect (Van Bemmel & Helder, 1997). In the course of a day, social workers make countless decisions. Clinicians assess problems and determine treatments of choice. Policymakers and administrators determine program priorities. Purchasers must choose between alternative providers and benefit packages. Agencies decide service eligibility rules. Child protection workers determine whether children are at risk, whether courts should be petitioned, and whether out-of-home placements are necessary. In yet other cases, the very problem presented by a client is one of choice, and the social worker's task is to strengthen the client's decision-making skills. Women facing choices among adoption, abortion, and keeping their babies; women in abusive domestic situations planning how to be safe; troubled couples contemplating divorce; and families considering when and if to seek institutional care for an elderly loved one--these are but a few of the many practice situations that can be conceptualized as counseling in decision making. In decision counseling, the shared tasks of social worker and client are assessing and improving the client's decision-making efforts. Social workers' decisions determine efficiencies, effectiveness, and even fates. Services are delivered or denied. Children stay in foster care or return to once-abusive parents. Couples choose counseling or divorce. Elderly people live alone or enter nursing homes. Families are housed or not. Troubled teenagers are sent to counselors or to court. Professional decision making is recognized as a matter of public policy, given its impact on client access to care, type and quality of care received, third-party payment, and outcomes (Chapman & Sonnenberg, 2000; Matchar & Samsa, 2000; Rosen, Proctor, & Livne, 1985). Whereas our practice necessitates that we make decisions, our professionalism demands that we do so in an informed and rational manner. Society expects that professionals, by virtue of their knowledge and skill, to make decisions carefully and well. Yet evidence from the burgeoning field of decision-making research warns us that decision quality may be compromised by factors such as time pressure, emotions, cultural differences, lack of information, and a wide range of alternatives for choice. These factors are the rule, rather than the exception, for many contexts in which social workers make decisions. Social workers' decisions are increasingly subject to scrutiny for purposes of payment authorization or quality assurance. External reviewers want to know why treatment decisions are made, and increasingly practitioners are asked to articulate their clinical rationale for the recommended treatment and to provide the evidence that is the basis for treatment decisions (Goodman, Brown, & Deitz, 1992). Implicit in the requirement that providers prepare treatment plans and in the use of such plans for quality monitoring is the assumption that the plans are a product of careful, deliberate decision making. How, then, can we strengthen social workers' capacity for making critical decisions? How do we ensure that decisions are made on the basis of the best information available? How can social workers, ever pressed for time and resources, make decisions efficiently? How do we structure the decision-making process to ensure the inclusion of critical stakeholders--families, clients, purchasers, advocacy groups--in decisions about choice of intervention? How can we use information and choice to help empower clients (Jimison & Sher, 1999)? …

American Indians and the private health care sector: the growing use of private care by Indians has implications for patients, providers, and policymakers.

American Indians and the private health care sector: the growing use of private care by Indians has implications for patients, providers, and policymakers.

Dental Work Force Strategies During a Period of Change and Uncertainty

Both supply and demand influence the ability of the dental work force to adequately and efficiently provide dental care to a U.S. population growing in size and diversity. Major changes are occurring on both sides of the dental care market. Among factors shaping the demand for dental care are changing disease patterns, shifting population demographics, the extent and features of third-party payment, and growth of the economy and the population. The capacity of the dental work force to provide care is influenced by enhancements of productivity and numbers of dental health personnel, as well as their demographic and practice characteristics. The full impact of these changes is difficult to predict. The dentist-to-population ratio does not reflect all the factors that must be considered to develop an effective dental work force policy. Nationally, the dental work force is likely to be adequate for the next several years, but regional work force imbalances appear to exist and may get worse. Against this backdrop of change and uncertainty, future dental work force strategies should strive for short-term responsiveness while avoiding long-term inflexibility. Trends in the work force must be continually monitored. Thorough analysis is required, and action should be taken when necessary.

The end of asymmetric information.

JHPPL 26.5 13 Robinson 4:34 PM Page 1045 The End of Asymmetric Information James C. Robinson University of California, Berkeley The most pernicious doctrine in health services research, the greatest impediment to clear thought and successful action, is that health care is different. Of course the medical sector has features not found elsewhere in the economy and polity, but then there is a uniqueness to every other industry. Each of the salient characteristics of health care, including pro- fessionalism, licensure, nonprofit organization, third-party payment, and heavy government regulation, can be found in other sectors, albeit not bundled in quite the same distinct and dysfunctional manner. The unique- ness doctrine hence proves too much. More importantly, the principle serves as a two-way barrier to entry between the health and nonhealth sectors. In one direction it discourages mainstream economists from importing the principles of industrial organization, game theory, and transactions costs to health care issues by raising a wall of acronyms and institutional trivia that impedes dialogue. In the other direction it fosters a complacency among the virtuosi of health policy analysis, allowing us to achieve fame and fortune in our small pond without fear of competi- tion from denizens of the scholarly shark tank. To some within the health care community, the uniqueness doctrine is self-evident and needs no justification. After all, health care is essential to health. That food and shelter are even more vital and seem to be pro- duced without professional licensure, nonprofit organization, compulsory insurance, class action lawsuits, and 133,000 pages of regulatory pre- scription in the Federal Register does not shake the faith of the orthodox. Journal of Health Politics, Policy and Law, Vol. 26, No. 5, October 2001. Copyright © 2001 by Duke University Press.

Diagnosis and Management of Dental Caries Throughout Life

To provide health care providers, patients, and the general public with a responsible assessment of currently available data regarding the diagnosis and management of dental caries throughout life.A non-Federal, non-advocate, 13-member panel representing the fields of dentistry, epidemiology, genetics, medicine, oral biology, oral radiology, pathology, periodontics, public health, statistics, surgery, and including a public representative. In addition, 31 experts in these same fields presented data to the panel and to a conference audience of approximately 700.Presentations by experts; a systematic review of the dental research literature provided by the Agency for Healthcare Research and Quality; and an extensive bibliography of dental caries research papers, prepared by the National Library of Medicine. Scientific evidence was given precedence over clinical anecdotal experience.Answering predefined questions, the panel drafted a statement based on the scientific evidence presented in open forum and the scientific literature. The draft statement was read in its entirety on the final day of the conference and circulated to the experts and the audience for comment. The panel then met in executive session to consider these comments and released a revised statement at the end of the conference. The statement was made available on the World Wide Web at http://consensus.nih.gov immediately after the conference. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.This Consensus Development Conference, the first sponsored by the NIH on dental caries, provided an excellent venue to describe the great success that has been achieved in reducing caries prevalence. More importantly, it provided a public forum to review both the strengths and weaknesses of current dental caries research and clinical procedures. Effective preventive practices, such as the use of fluoride, sugarless products, and dental sealants were reconfirmed and clinical studies to identify more conservative but more effective nonsurgical and surgical approaches are to be applauded. However, it was evident that current diagnostic practices are inadequate to achieve the next level of caries management in which noncavitated lesions are identified early so that they can be managed by nonsurgical methods. Some new and sensitive diagnostic approaches were presented to the panel, but concern was raised about the use of histological confirmation of caries presence as an appropriate gold standard. The resolution of these issues requires that surrogate markers, validated by histological confirmation, be developed. Once these surrogate markers of dental caries activity are validated, rapid advances in our understanding of the caries. In spite of optimism about the future, the panel was disappointed in the overall quality of the clinical data set that it reviewed. Far too many studies used weak research designs or were small or poorly described, and consequently had questionable validity. There was a clear impression that clinical caries research is underfunded, if not undervalued. Moreover, incomplete information on the natural history of dental caries, the inability to accurately identify early lesions and/or lesions that are actively progressing, and the absence of objective diagnostic methods are troubling. Several systematic reviews of the literature presented at the Consensus Development Conference concluded that the majority of the studies were inadequate, and it is clear that a major investment of research and training funds is required to seize the current opportunities. This is not to say that the diagnostic, preventive, and treatment techniques currently used do not work, but rather that earlier studies to support their efficacy do not meet current scientific standards. Indeed, given the dramatic improvements in reducing dental caries prevalence in the past 30 years, both consumers and health professionals should not depart from the practices which are likely to have contributed to this oral health improvement, including the use of a variety of fluoride products, dietary modification, pit and fissure sealant, improved oral hygiene, and regular professional care. In addition, pending new data, clinicians should apply both preventive and therapeutic interventions in the manner in which they have been studied. When solid confirmation of the effectiveness of promising new diagnostic techniques, nonsurgical treatments of noncavitated lesions, and conservative surgical interventions for cavitated lesions are obtained, dental health professionals and the public should embrace them rapidly in anticipation of attaining still higher levels of oral health. None of these anticipated advances will be achieved, however, in the absence of a progressive, third-party payment system that acknowledges its responsibility to compensate providers adequately to ensure that the next generation of conservative therapy can be enjoyed by the American people.

Dissemination of educational classes for families of adults with schizophrenia.

Despite the well-documented efficacy of psychoeducational and behavioral approaches in family interventions for persons with serious mental illness (1), clinicians have rarely included these methods in their professional repertoires (2). Journal publications, books, continuing education courses, and advocacy by the National Alliance for the Mentally Ill and its local affiliates have induced few professionals to provide family psychoeducation. Mental health professionals adopt new services primarily for the same reason that employees of any firm change their work practices-namely, because the authority structure and contingencies of reinforcement that impinge on their daily activities are altered in a direction favoring change. Therefore, administrative clout must be brought to bear to mandate the inclusion of family psychoeducation in the spectrum of services provided by a clinic, mental health center, community support program, hospital, or independent provider (3). In addition, the consequences of clinicians' services must differentially reward the use of these methods of involving families in services for the seriously mentally ill (4). Differential rewards could come from performance standards and evaluations, performance-based pay, third-party payments, positive feedback from clients and families, public recognition, and increased self-efficacy. Use of in-service training or workshops to persuade clinicians to adopt innovations such as family psychoeducation and family management techniques has a checkered and unremarkable track record. For example, brief training has failed completely in efforts to bring about adoption of family interventions. On the other hand, more extended efforts to train staff, including organizational consultation, have been more successful (5). In one study, two days of staff training produced no change, whereas intensive training over several months resulted in the implementation of new family programs at the majority of study sites (6). Staff from sites that received extensive training but did not adopt the interventions rated family interventions as less consistent with their professional philosophy and agency norms and identified more obstacles to intervention, notably intense work pressure, uncertainty about financing the intervention, agency bureaucracy, lack of leadership, skepticism about the interventions, problems with confidentiality, and inability to provide services in the evenings or on weekends (6). In this Rehab Rounds column, Amenson and Liberman describe a three-phase, multilevel dissemination effort designed to overcome the above-mentioned barriers to the incorporation of family psychoeducation into the routine care provided at community mental health centers in an ethnically diverse urban setting. Moreover, Amenson and Liberman demonstrate the need for continued support and nurturance of the project to ensure that the original enthusiasm associated with a novel intervention is not lost once it becomes a standard part of treatment.

Recent developments in home total parenteral nutrition.

Home parenteral nutrition (HPN) support has been an advancing therapy in the past 30 years. Patients who previously had no options to sustain their lives are now able to live at home, maintain employment, and continue with most daily activities. Although this therapy has been innovative and successful, it requires great financial and professional resources. The expense of HPN makes most patients dependent on third-party payment, and the complications can result in frequent hospitalizations and may be life-threatening. For these reasons, extensive training of the patient and caregivers is necessary. Thorough and time-consuming monitoring by a multidisciplinary team of professionals is also essential. Home care and supply companies offer services that make the process of home TPN easier for the patient and the healthcare team. Advances in the area of home nutrition support are expected to continue as the demand for this therapy rises.

Economic grand rounds: what is psychiatric "medical necessity?.

Economic grand rounds: what is psychiatric "medical necessity?.

Cost-effective infertility care.

Cost-effective healthcare has become a principal paradigm in all areas of medicine. In order to establish cost-effective care, clinical outcomes under various cost conditions have to be examined. Such a process cannot be static since it has to consider ever evolving treatments and outcome results. In infertility, the evaluation of cost-effective care should be simpler than in most other areas of medicine since treatment end-points are easily defined. Nevertheless, the field is lagging in the establishment of cost-effective treatment algorithms. In this review, an effort is made to define the current state of the art of cost effective infertility care, to suggest steps that can be taken to drive the process forward and to encourage the introduction of even limited processes to further the concept of outcome-dependent cost assessment within a practice setting. The limited availability of resources mandates their judicious use throughout medicine. In a field like infertility, by many (rightly or wrongly) perceived as 'elective', the judicious use of resources seems even more necessary since it would permit the treatment of larger patient populations than have currently access to care without further expense to third-party payments.

Review of Working it out: Using exercise in psychotherapy.

KATE F. HAYS Working It Out: Using Exercise in Psychotherapy Washington, DC: American Association, 1999, xxii + 281 pp. (ISBN 1-55798-592-8, US$39.95, Hardcover) In this well-organized book, Kate Hays presents exercise as a important component of a multi-modal approach to therapy. The overall content is differentiated into four major sections, in the first of which Hays establishes the value of exercise. She defines her terms and lays the foundations of her rationale within the context of empirical research demonstrating the body-mind connection. The reader is then walked through various theoretical and philosophical perspectives on both therapy and exercise, and is asked to reflect upon his or her own beliefs and views. The second section moves from theory to the use of exercise as a therapeutic tool. Describing therapists as agents for change, (p. 37) Hays provides a model outlining the stages of change and assumptions therein. It is in this section that she points out the challenges encountered in using exercise in psychotherapy and defines the myriad issues related to using this approach with non-exercising clients. These involve the issues of helping clients begin an exercise program within a therapeutic context, the type and amount of exercise, and factors affecting beliefs about the efficacy of exercise (e.g., personal, social, cultural, interpersonal). Outlined in the third section are the Psychological Benefits of Exercise with Specific Populations, overviewing many common clinical populations and specific exercise-based treatment recommendations. Populations include those individuals suffering from depression, anxiety, post-traumatic stress disorder, eating disorders, and substance abuse, as well as less commonly clinical populations, such as those dealing with lifestyle issues, lifespan issues, and issues idiosyncratic to athletes. Each chapter includes Practitioner Recommendations that direct the therapist on the appropriate use of psychological techniques for that population, specific issues that may be encountered, options for application of treatment, and anticipated effects of exercise as treatment. The fourth section, Caveats and Boundaries, is just that, an important collection of chapters that did not find a place elsewhere in the book (though chapter 18 might fit in the previous section). The construct of boundaries is stretched to include boundaries on the physical limits of exercise, boundaries on the interpersonal and ethical limits of therapists and clients, and the boundaries of the professional disciplines involved in the ongoing integration of exercise and therapy. The first chapter in this section speaks to issues of moderation versus overuse of exercise, provides an excellent overview of models of overuse, and introduces the reader to constructs such as exercise deprivation and exercise degradation. The next chapter covers ethical issues and competency, including confidentiality, dual-- role relationships, self-disclosure, non-erotic physical contact, and the different traditions' perspectives on the ethics of sexual contact with present or former clients. Issues of diagnosis and third-party payments are also addressed. Hays wraps up this section with the steps a practitioner might take in order to further explore the field of sport psychology. The final section of the book constitutes a glossary of exercise and sport psychology terms and a number of appendixes. These include an outline for the development and expansion of a therapy practice that involves exercise, the history of exercise and sport psychology, and an exercise-related intake assessment. There is no major notion in the book that is not supported by a wealth of references to the literature of sport psychology or to the general field of psychology itself. As an author, Hays is very objective in her willingness to state clearly what empirical evidence does or does not exist for her assertions, acknowledging self report for its qualitative value. …

The growth of school-based health centers and the role of state policies: results of a national survey.

To document recent growth among school-based health centers across the United States and identify state policies that may be facilitating that growth, using a nationwide survey. This was the fourth in a series of surveys undertaken by the Making the Grade office, Washington, DC. During the period from July to September 1998, a written survey instrument was sent to 50 state governments plus the District of Columbia requesting data on numbers of school-based health centers as well as their basic characteristics and a description of state funding and other policies as they relate to the centers. Follow-up telephone calls and additional mailings secured a 100% completion rate. The numbers of centers by state and region, basic health center characteristics, levels of state financial support, and numbers of states implementing specific policies to sustain and replicate the centers. School-based health centers increased from 900 during school year 1995-1996 to 1157 in 1997-1998, a 29% gain. Mid-Atlantic and New England states continue to lead the regions with 37% of the total. The fastest growth occurred in the Midwest and the Southwestern/Rocky Mountain states. State grant funding of centers decreased slightly during this period. Other policies, including support from Medicaid and the State Child Health Insurance Program, are increasing third-party revenues. The spread of school-based health centers into the Southwest and Rocky Mountain states is increasing the importance of the centers to rural communities. Because these areas are generally more conservative than either coast, these developments suggest a continued migration of school-based health centers from the political margins into the mainstream. The growth of the centers during a period of stagnation in state grant funding may also suggest that other sources of support, including third-party payments and support from private institutions, are becoming more significant.

The future for third-party payment in veterinary medicine

The future for third-party payment in veterinary medicine

Health Care Reform and Postgraduate Psychiatric Education

Psychiatric educators must prepare to teach in an era in which funding for education is more difficult to obtain, all forms of treatment are shorter, patients are discharged from the hospital while they are still acutely ill, the burden of paperwork and other administrative tasks is greater, psychiatrists provide less psychotherapy, and residents are no longer able to play a primary role in the treatment of patients covered by third-party payment schemes. A surcharge on a national insurance plan could make up for funding deficits, but this is not likely to occur in the near future. A more realistic model involves billing for services of faculty who integrate direct participation in patient care with teaching and better definitions of the role that residents can play in modern patient care. Overage from clinical activities driven by faculty may provide sufficient funding for resident services that provide an opportunity for longitudinal patient experiences. Strategies for political action and for better collaborations with primary care faculty are discussed.

Quality Improvement in Health Care: A Framework for Price and Output Measurement

The durability of health care treatment, the substantial technical change in health care treatment, and the prevalence of third-party payment interact to create substantial difficulty in measuring the price and output of health care. This paper provides a framework for analyzing the demand for health care taking into account these difficulties. It then suggests how this framework might be used to improve measurement of health care prices and output.