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Throughout this century, as in many other countries, the proportion of the British population in the older age groups has increased. The effect this has on the economy is discussed. Topics covered include the determinants of the economic status of old people; the reasons for the choice of retirement ages; the burden of the aged on younger generations; the costs of pension schemes; the disincentive effects of pensions on savings; and poverty in old age.
Medical publications contain numerous references to obstacles or disincentives confronting patients who wish to return to work after illness or injury. Current developments of importance to this aspect of medical practice and four recent studies, conducted in Edinburgh, that may contribute to the continuing debate about how best to deal with such problems are reviewed. The studies concern measurement of rehabilitation status, identification of potential to benefit from rehabilitation, medical contributions to occupational assessment of accident victims, and patients' patterns of involvement with medical and vocational rehabilitation services. It is concluded that coordination between services is still a major problem and is likely to remain so if more effective bridging between medical and vocational aspects of rehabilitation is not achieved.
The uptake of hepatitis B vaccine was assessed amongst 100 medical and 100 nursing staff in a teaching hospital with a policy of recommending to those at risk that they should seek immunization from their general practitioners. Sixteen per cent of nurses and 31% of doctors had completed a course of immunization with confirmation of seroconversion. An additional 9% and 18% respectively had been immunized without post-immunization serology. Ninety three per cent of nurses and 61% of doctors who had not been immunized would like to receive the vaccine. The commonest reasons for non-immunization amongst nurses were fear of vaccine and lack of advice, and amongst doctors, apathy and difficulty in obtaining the vaccine. Eighty seven per cent of medical staff and 57% of nurses had a history of needle stick injury. The low rates of vaccine uptake in this study combined with the high incidence of needle stick injury calls for a reappraisal of present hepatitis B vaccination programmes in hospitals. In particular the abrogation of responsibility for immunization to general practitioners is probably a major disincentive to potential vaccines.
BACKGROUND: It is important for healthcare providers to report safety related events, but little attention has been paid to how the definition and classification of events affects a hospital's ability to learn from its experience. OBJECTIVES: To examine how the definition and classification of safety related events influences key organizational routines for gathering information, allocating incentives, and analyzing event reporting data. METHODS: In semi-structured interviews, professional staff and administrators in a tertiary care teaching hospital and its pharmacy were asked to describe the existing programs designed to monitor medication safety, including the reporting systems. With a focus primarily on the pharmacy staff, interviews were audio recorded, transcribed, and analyzed using qualitative research methods. RESULTS: Eighty six interviews were conducted, including 36 in the hospital pharmacy. Examples are presented which show that: (1) the definition of an event could lead to under-reporting; (2) the classification of a medication error into alternative categories can influence the perceived incentives and disincentives for incident reporting; (3) event classification can enhance or impede organizational routines for data analysis and learning; and (4) routines that promote organizational learning within the pharmacy can reduce the flow of medication error data to the hospital. DISCUSSION: These findings from one hospital raise important practical and research questions about how reporting systems are influenced by the definition and classification of safety related events. By understanding more clearly how hospitals define and classify their experience, we may improve our capacity to learn and ultimately improve patient safety.
The volume of milk for manufacture has more than doubled since 1970 and now exceeds that taken by the liquid market. To match producer payments more closely to market realities the MMB will, from April 1984, replace the fat and solids-non-fat compositional quality payment scheme with one based on fat, protein and lactose. In the last 10 years the seasonal trough of production has moved from December to August/September. In an attempt to slow this trend and also provide a disincentive to additional supplies at peak, the MMB is altering its seasonal price adjustments. Milk prices will be increased in August and September and decreased in May and June. The changes in themselves will not affect the total sum of money available to producers, hence most of them will see little difference to their annual income. The exception will be those producers supplying milk of either especially low or high protein and, to a lesser extent, fat content. The change in seasonal adjustments will however cause a noticeable disruption in the cash flow to all producers. The price changes are not likely to produce an immediate management response but should encourage producers to consider critically their existing feeding, breeding and calving policies.
The physical status of 137 chronic dialysis patients was assessed by both objective and subjective measures; education and employment statuses were also determined. Below normal grip strength characterized the majority of patients; slowed nerve conduction and subjective fatigue were also observed among a subset of patients. However, patients demonstrated good to normal muscle strength and relatively normal pinch strength, and activities of daily living presented no problems for the large majority of patients. Employment probability was directly related to educational status. Despite dialysis requirements and other employment disincentives, 42% of non-diabetic men aged 21-59 were employed.
The physicians in charge of 15 German hemodialysis units furnished data on 713 dialysis patients. Data relating to the vocational status were examined for 612 patients aged 60 years or below. It was found that the current working status varies with psychological and social factors. The data show that the vocational status is importantly influenced by the premorbid profession, the level of schooling and by the conditions of the local labor market. With the exception of severe complications or secondary diseases, no relation existed between the somatic state and the current working status. As assessed by the physicians in charge, most dialysis patients were able to work part time, but unable to work full time. Lack of facilities for, or financial disincentives against, part time employment are felt to be the single most important obstacle to vocational rehabilitation of dialysis patients.
This study analyzed hospital resource consumption for 5,065 Medicare patients in 90 noncancer designated medical diagnosis-related groups (DRGs) by whether or not patients had a diagnosis of a malignancy (i.e. cancer). Patients with cancer had greater hospital resource utilization than noncancer patients in these medical DRGs. Cancer patients had a greater percentage of outliers (p less than 0.02), twice the financial loss under DRGs, more diagnoses (p less than 0.001) and procedures (p less than 0.0001) per patient, and a greater mortality (p less than 0.0001) than noncancer patients. These findings raise the question of the equity of DRG payment vis-à-vis medical cancer patients in many medical DRGs, and whether the DRG scheme may provide disincentives to treat some elderly Americans with cancer.
Cigarette smoking remains the primary cause of preventable death and morbidity in the United States. Smoking causes lung cancer, COPD, and CHD and contributes significantly to mortality from other conditions such as stroke. Maternal smoking during pregnancy causes low birthweight and perinatal mortality, and it may have lasting impact on the child's physical and cognitive growth. Passive exposure to ETS causes lung cancer and poses particular danger to the respiratory health of young children. Smoking cessation strategies are important, but the should be supplemented by community and policy-level interventions. Workplace or community smoking bans, statewide taxes on tobacco, and antismoking media campaigns may be effective adjuncts to individual cessation strategies. These strategies may be an even more important disincentive to smoking initiation. The expanding horizon of health consequences of smoking and its costs to American society should again challenge public health agencies to develop and implement effective strategies to prevent smoking acquisition by young people. These health effects should also motivate health professionals in other countries where smoking prevalence is increasing, rather than decreasing, to initiate more effective efforts to reverse this trend and minimize the excess morbidity and death that accompany this dangerous habit.
We are in the midst of an era of plummeting pay lines at the NIH. History shows that when the federal deficit is high, NIH pay lines tend to fall, and the impact on biomedical research can be disastrous. Equally bad is the disincentive for the future generations of biomedical researchers who observe their mentors struggling to get adequate funding. How many bright young people will be turned away from careers in biomedical research? How much innovative science will be delayed or never initiated, how many new cures never realized? At a time of unprecedented challenges and remarkable technological advances that enable us to address those challenges, lack of funding is a threat to our society.
Lack of third-party reimbursement is frequently cited as a cause of underutilization of partial hospitalization. The authors contacted a sample of health maintenance organizations (HMOs) and public and private payers to obtain information about their payment policies. They conclude that in the private sector, reimbursement barriers are diminishing but that clinicians frequently must obtain an extracontractual agreement for coverage. Partial hospitalization is particularly attractive to HMOs and others that pay on a capitated basis and can strictly control utilization. A recent clarification of Medicare guidelines may facilitate reimbursement for hospital-based programs, but there remain significant disincentives under the Medicare statute for widespread utilization of partial hospitalization.
During the past 15 years, federal regulations, survey and inspection programs, and payment policies have presented conflicting incentives and disincentives for the provision of mental health services in nursing homes in the United States. Policies and regulatory measures have reflected the concern that many patients in nursing homes are not receiving the mental health care they need, and, more prominently, the concern that some of the services that are provided seem to be inappropriate or medically unnecessary. Despite evidence that payment policy and regulatory oversight can be used effectively to promote quality improvement, the need for improved access and quality of mental health services in long-term care remains substantial. Recent reports issued by the Surgeon General and by the Institute of Medicine identify a need for refinements in the assessment process, the use of outcomes-based quality measures, and payment policies designed to improve access and quality. These elements must be coordinated to promote humane treatment in nursing homes, including access to medically necessary psychiatric care.
A major public policy problem is the extremely low labor force participation of people with severe mental illness coupled with their overrepresentation on the public disability rolls. This situation is especially troubling given the existence of evidence-based practices designed to return them to the labor force. This article reviews research from the fields of disability, economics, health care, and labor studies to describe the nature of barriers to paid work and economic security for people with disabling mental disorders. These barriers include low educational attainment, unfavorable labor market dynamics, low productivity, lack of appropriate vocational and clinical services, labor force discrimination, failure of protective legislation, work disincentives caused by state and federal policies, poverty-level income, linkage of health care access to disability beneficiary status, and ineffective work incentive programs. The article concludes with a discussion of current policy initiatives in health care, mental health, and disability. Recommendations for a comprehensive system of services and supports to address multiple barriers are presented. These include access to affordable health care, including mental health treatment and prescription drug coverage; integrated clinical and vocational services; safe and stable housing that is not threatened by changes in earned income; remedial and postsecondary education and vocational training; benefits counseling and financial literacy education; economic security through asset development; legal aid for dealing with employment discrimination; peer support and self-help to enhance vocational self-image and encourage labor force attachment; and active involvement of U.S. business and employer communities.
OBJECTIVE: The Ticket to Work and Work Incentives Improvement Act of 1999 removes work disincentives and promotes access to vocational services for people with disabilities. This study calculated the amount of payments that would have been made to employment service providers if study participants had been enrolled in the Ticket program. METHODS: Data were from 450 Social Security Disability Insurance beneficiaries with psychiatric disabilities enrolled in a multisite study of supported employment. Earnings over two years were used to calculate provider payments under two reimbursement formulas used in the Ticket program. RESULTS: Only a quarter of service recipients (26 percent) reached earnings levels that would have triggered provider payments under the first reimbursement formula. Only 4 percent would have completed their trial work period and left the rolls, generating payments under the second formula. CONCLUSIONS: The current provider payment systems of the Ticket to Work program do not reflect the reality of rehabilitation for individuals with severe mental illness. Reforms should take into account outcomes of return-to-work services for this population.
Recent evaluations by the U.S. General Accounting Office and the National Alliance for the Mentally Ill of reemployment efforts of the federal-state vocational rehabilitation program found that services offered by state vocational rehabilitation agencies do not produce long-term earnings for clients with emotional or physical disabilities. This paper examines reasons for these poor outcomes and the implications of recent policy reform recommendations. Congress must decide whether to take action at the federal level to upgrade programs affecting persons with severe mental illnesses or to continue to rely on state decision making. The federal-state program largely wastes an estimated $490 million annually on time-limited services to consumers with mental illnesses. Rechanneled into a variety of innovative and more appropriate integrated services models, the money could buy stable annual vocational rehabilitation funding for 62,000 to 90,000 consumers with severe mental illnesses. Larger macrosystem problems involve the dynamics of the labor market that limit job opportunities and the powerful work disincentives for consumers with severe disabilities now inherent in Social Security Disability Insurance, Supplemental Security Income, Medicare, and Medicaid.
Many scientific discussions, especially in the past 8 yr, have focused on definition of criteria for the optimal assessment of the preclinical toxicity of pharmaceuticals. With the current overlap of responsibility among centers within the Food and Drug Administration (FDA), uniformity of testing standards, when appropriate, would be desirable. These discussions have extended beyond the boundaries of the FDA and have culminated in the acceptance of formalized, internationally recognized guidances. The work of the International Committee on Harmonisation (ICH) and the initiatives developed by the FDA are important because they (a) represent a consensus scientific opinion, (b) promote consistency, (c) improve the quality of the studies performed, (d) assist the public sector in determining what may be generally acceptable to prepare product development plans, and (e) provide guidance for the sponsors in the design of preclinical toxicity studies. Disadvantages associated with such initiatives include (a) the establishment of a historical database that is difficult to relinquish, (b) the promotion of a check-the-box approach, i.e., a tendancy to perform only the minimum evaluation required by the guidelines, (c) the creation of a disincentive for industry to develop and validate new models, and (d) the creation of state-of-the-art guidances that may not allow for appropriate evaluation of novel therapies. The introduction of biotechnology-derived pharmaceuticals for clinical use has often required the application of unique approaches to assessing their safety in preclinical studies. There is much diversity among these products, which include the gene and cellular therapies, monoclonal antibodies, human-derived recombinant regulatory proteins, blood products, and vaccines. For many of the biological therapies, there will be unique product issues that may require specific modifications to protocol design and may raise additional safety concerns (e.g., immunogenicity). Guidances concerning the design of preclinical studies for such therapies are generally based on the clinical indication. Risk versus benefit decisions are made with an understanding of the nature of the patient population, the severity of disease, and the availability of alternative therapies. Key components of protocol design for preclinical studies addressing the risks of these agents include (a) a safe starting dose in humans, (b) identification of potential target organs, (c) identification of clinical parameters that should be monitored in humans, and (d) identification of at-risk populations. One of the distinct aspects of the safety evaluation of biotechnology-derived pharmaceuticals is the use of relevant and often nontraditional species and the use of animal models of disease in preclinical safety evaluation. Extensive contributions were made by the Center for Biologics Evaluation and Research to the ICH document on the safety of biotherapeutics, which is intended to provide worldwide guidance for a framework approach to the design and review of preclinical programs. Rational, scientifically sound study design and early identification of the potential safety concerns that may be anticipated in the clinical trial can result in preclinical data that facilitate use of these novel therapies for use in humans without duplication of effort or the unnecessary use of animals.
OBJECTIVES: To determine how Medicaid prescription drug policies differ by state, and to assess how these policies affect pharmacies and the drug therapies available to Medicaid patients with HIV infection or tuberculosis. EVALUATION PROCESS: The state affiliates of the American Pharmaceutical Association (APhA) were surveyed to learn how state Medicaid policies impact the provision of prescription drugs to Medicaid patients within their state. The survey focused on Medicaid payment level incentives, Medicaid payments compared with private payments, Medicaid utilization policies, and incentives and disincentives in each state's Medicaid payment system. RESULTS: Approximately two-thirds of the APhA affiliates reported that the Medicaid payment levels in their states for drugs used to treat HIV-related illnesses were at least moderately below private payment levels; in 11 states these Medicaid payments were substantially below those of private payers. Many APhA affiliates responding to the survey stated that the Medicaid program in their state limited the number of reimbursed drugs that Medicaid patients can receive. Eight APhA affiliates reporting that these utilization limits created restrictions on the ability of Medicaid patients with AIDS and HIV-related infections to receive needed medications. CONCLUSIONS: With Medicaid programs becoming the major payers of AIDS-related healthcare, federal policies should standardize Medicaid coverage, payment, and utilization policies for prescription drugs needed by Medicaid recipients with HIV-related conditions. This would enable Medicaid patients to receive necessary and adequate drug therapies regardless of their state of residence. These federally mandated policies also would require an increased federal role in financing this expanded Medicaid drug coverage.
This study was designed to investigate anabolic steroid users' experiences of, and motivations for, use. Five men and six women users took part in in-depth interviews. Four themes emerged: Steroid Use vs Abuse; Side-effects; Trusted Information Sources; and Social Pressure. Many users believed that steroids used in moderation were safe. Serious side-effects (liver and kidney damage, hypertension) were not significant disincentives. Information from health professionals tended to be mistrusted because it was not based on first-hand experience of use. Social support, especially from within the body building community, was an important motivator. It is concluded that intervention programmes need the support of the body building community in order to be effective.