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N Goldfield

Publications and source records attributed to N Goldfield.

50 records · Page 3Linked to original sources
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Efforts to implement national health reform in the United States.

Beginning in this issue and carrying forth during the year, the author will trace the history of the development of a national health policy in the United States. In beginning this new feature, Physician Executive recognizes the potential impact of national health reform on physician executives and the need to contribute to informed discussion on the current national health reform debate. In this first article, the authors sets the stage for the series, establishing the historical precedents for national health care reform and some of the groundrules for the articles to follow.

Consumer Behavior↗
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The paradoxes of national health reform during the Wilson era.

The current debate over health care reform may represent yet another opportunity to establish a national health policy. A similar level of activity occurred during the presidency of Woodrow Wilson. In many ways, the failure to enact national health reform (NHR) in the early 20th Century represents a paradigm for subsequent failed attempts to enact NHR.

Health Policy↗
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The high point of efforts to improve access to health care by "documentation".

The set of articles of which this article is a part has documented the tension between the advocates and the opponents of government intervention in the American health care system. This article will focus on a chapter of American health care history that is almost forgotten and has still never been told in its entirety. The story of the Committee on the Costs of Medical Care (CCMC), which existed from 1927 to 1933, represents the apogee of the factual approach effort to changing health care delivery in America.

Delivery of Health Care↗
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The protocol solution: a mildly acidic commentary.

Protocols have captured the imagination of American's health care guru's. These self-proclaimed experts promise decreases in health care expenses of up to 25 percent if protocols for the appropriate use of expensive procedures are adopted throughout the country. With the establishment of several proprietary protocol companies and the push to develop national clinical guidelines, protocols have appeared on the health care scene with a vengeance. However, protocols will have dramatically different effects, depending on how and where they are implemented. This article will concentrate on the challenges of implementing protocols in a single health care institution, typically a hospital or a managed care institution.

Algorithms↗
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The AMA faces down FDR and wins.

There are two types of change that can occur via federal health care legislation: expansion in access and cost containment. Without passing judgment on the advisability of legislative change, I will argue that federal legislation is unlikely to occur unless both the executive and the legislative branches of government are controlled by the Democratic party. I am not suggesting that the change is necessarily an "improvement," only that Democratic Party control is necessary, particularly as the change pertains to access.

American Medical Association↗
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Why we cannot agree on the direction of health reform: an exploration of American values.

Most of the articles in this series examine historical forces that have shaped American health care policy. This article will ask the reader to step back from the swirl of events that have led to a health care system that provides excellent care to many and minimal services to a substantial minority. The purpose of this article is to place often contradictory health policies within their philosophical context. Such an analysis can lead to an understanding of the reasons for the simultaneous appearance of both competitive and regulatory features in the American health care system.

American Medical Association↗
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Medicare and Medicaid: the first successful effort to increase access to health care.

The passage of Lyndon Johnson's health care legacy, Medicare and Medicaid, in 1965 represents the last time that health reform legislation expanding access to care was successfully proposed and implemented in the United States. Access, of course, represents only half the pie in health reform, the other part being the organization of the health care system. There has never been any major legislation passed through both houses of Congress and signed by a President that changed the organization and delivery of health services. It seems certain that President Clinton will propose legislation dealing with both access to and organization of our health care system. Though it may not have seemed so at the time, President Johnson had it easy compared to the challenges confronting President Clinton.

Health Policy↗
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Truman and the medical profession: replay or lesson for the nineties.

This article describes the first serious effort on the part of an American president to enact national health insurance (NHI). President Truman considered his inability to enact NHI the single most important defeat during his presidency. While a variety of factors led to the demise of NHI, three are most notable. The dynamic interplay of these factors, integrated with references to the current accelerating debate over national health reform, will serve as the focus for this seventh article in a series on historical efforts to enact national health reform in the United States.

American Medical Association↗
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A guide to the upcoming health reform debate.

AT the 1992 ACPE National Institute, several hundred physician executives actively participated in a debate on three competing visions for the health care system in the United States. This new column in the journal attempts to further this process by providing information on policy positions of relevance to College members. While the College does not advocate a particular position, the College encourages individual members to contact the interest group of their choice and get involved in the health policy debate. In this first column, one of the proposals currently being discussed is summarized.

Competitive Medical Plans↗
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National health reform advocates retrench and prepare for Medicare.

With the failure of President Truman's efforts to pass compulsory health insurance for all, national health reform (NHR) advocates began to redirect their political attention to a politically powerful group of Americans who were simultaneously vulnerable from a health care point of view--the elderly. This effort culminated in the passage of Medicare under President Johnson. This article will focus on antecedents to passage of Medicare that can be found in the Eisenhower and Kennedy administrations. It will also discuss other facets of health reform proposals from the Eisenhower administration. While most proposals never became law, the legislative intent of many of them--outlawing cancellation of policies, a minimum standard health benefit package, establishment of regional health authorities, preference for prepayment plans, and establishment of a reinsurance pool administered by the federal government--is currently under active discussion by the Clinton health reform task forces.

Aged↗
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What will future historians say about the Clinton health reform act.

In a series of articles that began in the March-April 1992 issue of Physician Executive, the author has provided historical background on the debate that currently rages on the nature and course of national health reform. In addition to tracing past efforts to expand access to health care for Americans, Dr. Goldfield has provided unique insights into the American political process and into the American psyche. In this final article in the series, Dr. Goldfield provides his personal assessment of what the chances for real reform of the health care delivery system are and his views on what that reform will ultimately look like. He calls himself a skeptic, not a cynic, saying that the likelihood of meaningful change is small, given the numerous proponents of the status quo.

Competitive Medical Plans↗
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Physicians' responses to diagnostic test guidelines.

Internists (IM), subspecialty internists (SS), and family practitioners (FP) were surveyed regarding their opinions of ten of the Blue Cross Blue Shield Association/American College of Physicians diagnostic test use guidelines applied to the asymptomatic periodic health exam. The majority of 390 respondents agreed with the guidelines (59% of all responses). There was at least 40% disagreement with seven of ten guidelines. Board certification was associated with agreement. Internists and family practitioners were more likely to agree than subspecialty internists. The number of years in practice had a negative correlation with agreement for five guidelines. HMO physicians tended to agree with guidelines that discouraged test ordering. Results indicate that these guidelines for test use, based on research data and developed cooperatively by physicians, are a starting point for guidelines to testing during the periodic health examination.

Attitude of Health Personnel↗
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Payment and provider profiling of episodes of illness of clinical illnesses involving rehabilitation.

The prevailing trend in American health care finance for the last two decades and likely for the forseeable future, is the movement from a system based on fee for service payments to one dominated by capitation arragements. At the core of this change is a shifting of risk from payers to providers. Such a fundamental transition is not without its difficulties. This is exemplified by some of the problems experienced by the Health Care Financing Administration (HCFA) as it has begun to encourage beneficiaries to move from traditional fee for service Medicare to capitated HMOs. The most recently published regulations involving risk adjustment of rates of payment for managed care organizations (MCOs) did not find much favor as the statistical power was poor and the clinical meaningfulness of the risk adjustment was highly problematic. Specifically, the risk adjustment explained less than 10% of the variation in costs (compared to approximately 30% when DRGs were first implemented). From a clinical perspective, the methodology only used hospitalization data for adjustment of capitation rates; that is, anyone who was not hospitalized was assumed to be healthy! It is known that payment for rehabilitation services is among the most difficult to understand and predict of all medical care. This article will summarize the development of a new risk adjustment methodology which should be particularly useful for payment and monitoring of episodes of clinical conditions that involve rehabilitation. The article will conclude with directions for future research.

Capitation Fee↗