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N Daniels

Publications and source records attributed to N Daniels.

At least 19 recordsLinked to original sources
PubMed1997

Dialogue. Resource allocation: to those in the greatest need or those who will benefit most?

The behavioral healthcare community seeks universal coverage for mental health and addiction treatment services at parity with coverage for other medical conditions. To achieve this goal, our field must accept and work within realistic financial limits. The time has come to establish a framework for "rational rationing" of behavioral healthcare resources. What are the priorities? How should resources be equitably shared? Should we sacrifice people with mild and moderate disabilities and illness in order to spend most of our dollars on people who are severely impaired? Our first writer, Dr. Daniels, warns us that there are no moral tenets upon which we can easily or comfortably hang our hats, as he shares the current perspective of medical bio-ethics. Dr. Sabin is a practicing psychiatrist at Harvard Pilgrim Health Care. He highlights the Oregon health Plan as one example of political fortitude and wisdom in resolving healthcare resource allocation challenges. Mac Crawford, chairman of the board and chief operating officer of Magellan Health Services, is in one of the most influential positions in private sector integrated behavioral services delivery. He stresses the importance of managed care and clinical process standardization as fundamental requirements for the rational allocation of resources. One additional note: The lack of a consumer voice in this Dialogue is an unfortunate consequence of the mismatch between submissions received and our publication deadlines. It was our intention to present the perspective of a prominent individual from the growing field of consumer and family advocacy. We apologize for the lack of this perspective, which may have extended this discussion to the practical implications of this abstract question of resource allocation.

Cost-Benefit Analysis↗
PubMed1996

The role of cost-effectiveness analysis in health and medicine. Panel on Cost-Effectiveness in Health and Medicine.

OBJECTIVE: To develop consensus-based recommendations guiding the conduct of cost-effectiveness analysis (CEA) to improve the comparability and quality of studies. The recommendations apply to analyses intended to inform the allocation of health care resources across a broad range of conditions and interventions. This article, first in a 3-part series, discusses how this goal affects the conduct and use of analyses. The remaining articles will outline methodological and reporting recommendations, respectively. PARTICIPANTS: The Panel on Cost-Effectiveness in Health and Medicine, a nonfederal panel with expertise in CEA, clinical medicine, ethics, and health outcomes measurement, was convened by the US Public Health Service (PHS). EVIDENCE: The panel reviewed the theoretical foundations of CEA, current practices, and alternative procedures for measuring and assigning values to resource use and health outcomes. CONSENSUS PROCESS: The panel met 11 times during 2 1/2 years with PHS staff and methodologists from federal agencies. Working groups brought issues and preliminary recommendations to the full panel for discussion. Draft recommendations were circulated to outside experts and the federal agencies prior to finalization. CONCLUSIONS: The panel's recommendations define a "reference case" cost-effectiveness analysis, a standard set of methods to serve as a point of comparison across studies. The reference case analysis is conducted from the societal perspective and accounts for benefits, harms, and costs to all parties. Although CEA does not reflect every element of importance in health care decisions, the information it provides is critical to informing decisions about the allocation of health care resources.

Advisory Committees↗
PubMed1995

The yin and yang of health care system reform. Professional and political strategies for setting limits.

President Clinton's proposed Health Security Act would establish a National Health Board (NHB) with three key functions. The NHB would (1) decide which services are "medically necessary or appropriate" (Title I, Subtitle B, Section 1154), (2) "recommend ... appropriate revisions (to the benefit package) ... to reflect changes in technology, health care needs, health care costs, and methods of service delivery" (Title I, Subtitle F, Section 1503, [a] [2]), and (3) "determine a national per capita baseline premium target" (Title VI, Subtitle A, Section 6002, [a]), thereby establishing a national health care budget. To date, including the work of Mrs Clinton's Task Force on Health Care System Reform, there has been little discussion of how the NHB would carry out these responsibilities. Critics claim that a budget cap would require rationing. Advocates counter that eliminating waste would make rationing unnecessary. In the imagined "testimony" that follows, we recommend two strategies to the NHB for carrying out its three key functions and for addressing the controversy about whether it should consider rationing.

Cost Control↗
PubMed1994

The articulation of values and principles involved in health care reform.

The Ethics Working Group of Clinton's Health Care Task Force developed a list of principles and values that should govern health care reform. These principles and values are compatible with central moral and political traditions, as well as with more rigorous theoretical accounts of justice and health care, but they are "freestanding" points of agreement, not presupposing any particular theoretical background. Though imprecise and not ranked by priorities, the principles guide thinking about the fairness of alternative reform proposals. Their use is illustrated by comparing alternatives on universality of access, phase-in period, the creation of unequal tiers, and the provision for wise allocation and rationing.

Advisory Committees↗
PubMed1992

HIV-infected professionals, patient rights, and the 'switching dilemma'.

The ethical issues surrounding the Centers for Disease Control and American Medical Association guidelines for health professionals infected with the human immunodeficiency virus are examined and discussed. Although human immunodeficiency virus transmission risks during surgery are lower than many risks we routinely face, it is not irrational for a patient to want to switch from an infected professional to an uninfected one. The American Medical Association claim that physicians have a duty to avoid imposing any identifiable risks is implausible. Knowing the Centers for Disease Control estimate of risks gives us no way to decide whether the rights of patients or those of handicapped (infected) workers should be given priority. Granting priority to patient rights, either by giving patients the opportunity to know the risks they face and to switch to another provider, or by removing infected providers (compulsory switching), makes us all worse off. This gives us reason to reject these guidelines and emphasize other infection control measures.

American Medical Association↗
PubMed1992

HIV-infected health care professionals: public threat or public sacrifice?

The ethical controversy surrounding the Centers for Disease Control (CDC) and American Medical Association (AMA) guidelines for restricting the practice of HIV-infected health professionals appears to hinge on whether we give priority to the rights of infected workers or patients. We cannot simply dismiss the concerns of patients as irrational, despite the low risks of transmission. Nor can we avoid the dispute about rights by claiming with the AMA that professionals have obligations to refrain from imposing "identifiable risks," however low, on patients. Nevertheless, allowing the full exercise of patient rights, either by giving patients the opportunity to know the risks they face and to switch providers, or by removing infected providers (compulsory switching), would make each of us worse off. This gives us adequate reason to reject these guidelines and to emphasize other infection control measures.

American Medical Association↗
PubMed1992

Running economy of elite male and elite female runners.

Twenty female and 45 male middle and long-distance runners, in training for the U.S. Olympic Trials, served as subjects. Ninety percent of both men and women subjects reached the Trials; eight women and 12 men qualified for the Olympic Games and five won medals. Each subject completed a VO2max and a series of submax treadmill runs, for the purpose of comparing heart rate (HR), VO2, and blood lactate (HLa) among men and women and among runners of various event specialties. Results showed the men to be taller, heavier, to have a lower six-site skinfold sum and a higher VO2max, than the women (P less than 0.05); there was no difference in age. When compared in running economy, men used less oxygen (ml.min-1.kg-1) at common absolute velocities, but VO2 (ml.km-1.kg-1) was not different between men and women at equal relative intensities (%VO2max). When men and women of equal VO2max were compared, the men were significantly more economical, using any method of comparison. Also, when comparisons of men and women of equal economy were made, it was found that the men had an even greater advantage over the "matched" women subjects than the mean VO2max comparison using all subjects. In looking at the SD (800-/1500-m runners), MD (3-K/5-K/10-K runners) and LD (marathon runners), it was found that the SD runners used the least oxygen (ml.min-1.kg-1) at speeds of marathon race pace and faster, but not at slower speeds. Men and women responded similarly in this regard. Running economy data for speeds slower than typical race paces, tended to show the LD runners to be most economical, suggesting that the speeds over which runners are tested plays an important part in determining which subjects are the most economical. It was concluded that at absolute running velocities, men are more economical than women, but when expressed in ml.km-1.kg-1 there are no gender differences at similar relative intensities of running. Also, when men and women of equal VO2max or equal economy are matched, the men show a better aerobic profile. It is recommended that economy data be collected up to speeds equal to over 90% VO2max.

Adult↗