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PubMed1991

A history of Oregon's Basic Health Services Act: an insider's account.

The state of Oregon has led the nation in creating legislation to guarantee universal access by establishing medical and funding priorities in a basic health care package. A preliminary prioritization project--known as the Oregon Medicaid Priority-Setting Project or the Golenski project--served as a "dry run" for Oregon's Basic Health Services Act passed in 1989. A list of 15 public policy principles developed from data gathered from citizen surveys was used as guide for participants in setting priorities. Oregon's pioneering attempt at creating a health care package using prioritization must be seen in the context of the state's particular democratic traditions.

Health Care Rationing↗
PubMed2004

Euthanasia and physician-assisted suicide policy in The Netherlands and Oregon: a comparative analysis.

This article presents a comparative analysis of euthanasia and physician-assisted suicide policy in The Netherlands and the state of Oregon in the United States. The topics of euthanasia and physician-assisted suicide are discussed in the context of the historical setting of The Netherlands and the United States with special emphasis placed on public opinion, role of the courts and the legislative bodies, and opinions of physicians. Major similarities and differences in the laws of The Netherlands and Oregon are discussed. The article examines whether the passage of the law has led to a slide down the slippery slope in The Netherlands and Oregon as had been suggested by the opponents of the law. The article concludes that the empirical evidence does not support the contention of the opponents. However, the author argues that the potential for this happening is much greater in The Netherlands than in Oregon.

Empirical Research↗
PubMed2000

Oregon's first year: the medicalization of control.

The results of Oregon's first year with physician-assisted suicide raise two questions. First, how will it be possible to evaluate what is actually going on in Oregon if there is no public access to the records and if physicians are shielded by patient confidentiality rules? The second question is whether the public understood that many, if not most, of those who want physician-assisted suicide want it not to relieve suffering as ordinarily understood but to maintain control over their dying, something that may not correlate at all with suffering from illness and disease. This commentary reviews the existing evidence from the Netherlands and suggests that abuse of the vulnerable will likely occur in Oregon over time. It also reviews the insufficiency of the data emerging from Oregon. Finally, it addresses the various issues raised by other commentators to the main article.

Confidentiality↗
PubMed2000

Therapeutic death: a look at Oregon's law.

Oregon voters approved the first American statute authorizing physician-assisted suicide, the Oregon Death With Dignity Act, in 1994. The authors of this article identify some positive and negative psychological effects of laws such as Oregon's on patients. Generally, they conclude, on the basis of psychological theory and the available data, that laws such as Oregon's benefit patients psychologically. Undoubtedly, however, there exist important possible antitherapeutic effects on patients, and the authors hope that discussion of both therapeutic and antitherapeutic consequences will stimulate future research by social scientists in this area.

Coercion↗
PubMed1991

Setting health care priorities in Oregon. Cost-effectiveness meets the rule of rescue.

The Oregon Health Services Commission recently completed work on its principal charge: creation of a prioritized list of health care services, ranging from the most important to the least important. Oregon's draft priority list was criticized because it seemed to favor minor treatments over lifesaving ones. This reaction reflects a fundamental and irreconcilable conflict between cost-effectiveness analysis and the powerful human proclivity to rescue endangered life: the "Rule of Rescue." Oregon's final priority list was generated without reference to costs and is, therefore, more intuitively sensible than the initial list. However, the utility of the final list is limited by its lack of specificity with regard to conditions and treatments. An alternative approach for setting health care priorities would circumvent the Rule of Rescue by carefully defining necessary indications for treatment. Such an approach might be applied to Oregon's final list in order to achieve better specificity.

Cost-Benefit Analysis↗
PubMed1992

Prioritizing Oregon's hospital resources. An example based on variations in discretionary medical utilization.

OBJECTIVE: To provide an alternative to Oregon's treatment-specific approach to rationing, we propose a prioritization based on the local hospital resources invested in discretionary medical admissions. DESIGN: We used 1988 Oregon hospital discharge data to determine age- and sex-adjusted per-capita rates of inpatient days for discretionary medical admissions (for high-variation medical conditions) in each of 33 hospital service areas. Potential ceiling rates were defined based on prevailing utilization rates for discretionary medical admissions in each hospital service area. Savings were calculated under the assumption that resources allocated for inpatient treatment of these conditions in areas that exceed the ceiling rates were reduced accordingly. SETTING: Nonfederal, acute-care hospitals used by Oregon residents. STUDY POPULATION: Oregon residents. MAIN OUTCOME MEASURES: Savings were defined in terms of patient days, hospital beds, hospital charges, and average costs. RESULTS: Among the 16 largest hospital service areas, patient-day rates for discretionary medical admissions ranged from 188 to 335 patient days per thousand. Potential savings from applying different ceiling rates ranged from $0.4 million to $94.7 million per year. If the rate in the state capital (Salem) were used as the ceiling (218 days per thousand), then 238 beds could be closed in 20 hospital service areas, for an estimated cost savings of $47.3 million. CONCLUSIONS: Hospital resources invested in discretionary admissions in high-rate areas represent an important potential source of funds for reallocation to meet other defined health care needs. Setting limits based on units of health care supply (eg, beds, capital equipment, and physicians) should be considered as an option for resource reallocation within health care.

Bed Occupancy↗
PubMed1999

Epidemic serogroup B meningococcal disease in Oregon: the evolving epidemiology of the ET-5 strain.

CONTEXT: In 1993, Oregon's incidence of serogroup B meningococcal disease began to rise because of a highly clonal group of strains designated enzyme type 5 (ET-5), the first such increase observed in the United States. OBJECTIVE: To evaluate the impact that the ET-5 strain has had on the epidemiology of meningococcal disease in Oregon. DESIGN AND SETTING: Epidemiologic analysis of surveillance data on Oregon meningococcal disease cases from 1987 through 1996 and multilocus enzyme electrophoresis typing of serogroup B isolates from June 1993 through April 1995 and from April through June 1996. PATIENTS: A total of 836 persons with invasive meningococcal disease. MAIN OUTCOME MEASURES: Disease frequency and clonality of strains. RESULTS: Serogroup B disease incidence rates more than doubled from the preepidemic period in 1987-1992 (1.0 case per 100000 population) to the recent epidemic period in 1995-1996 (2.2 cases per 100000). The age-specific incidence rate of serogroup B disease among those 15 through 19 years old increased 13-fold between the preepidemic period (0.5 case per 100000) and 1995-1996 (6.4 cases per 100000). However, the proportion of cases with meningococcemia and the case-fatality rate did not change. Of 99 Neisseria meningitidis isolates obtained from 1993-1995, 88 (89%) belonged to the ET-5 complex. Of these, 69 (78%) were a single clone, designated 301. Of 20 serogroup B isolates from 1996, 18 (90%) belonged to the ET-5 complex; 17 (94%) were the 301 clone. CONCLUSION: Serogroup B meningococcal disease incidence continues at high levels in Oregon with increasing predominance of the ET-5 clonal strains.

Adolescent↗
PubMed2000

Access to substance abuse treatment services under the Oregon Health Plan.

CONTEXT: The shift to Medicaid managed care has raised numerous concerns about access to publicly funded substance abuse treatment. The implementation of a capitated chemical dependency benefit within the Oregon Health Plan in 1995 provided an opportunity to study the impact of funding mechanisms on access. OBJECTIVES: To determine to what extent access to publicly funded substance abuse treatment changed following the shift to managed care in Oregon and to examine factors associated with that change. DESIGN: Analysis of statewide treatment and Medicaid eligibility data. SETTING AND PATIENTS: All Medicaid-eligible persons aged 12 to 64 years who were enrolled in the Oregon Health Plan during 1994 (88,320), 1996 (170,387), 1997 (160,929), or 1998 (149,877). MAIN OUTCOME MEASURES: Access rates (the number of unique individuals admitted to treatment during a calendar year divided by the average number of enrolled members) computed before (1994) and after (1997) implementation of the capitated benefit. Analyses were replicated with data for 1996 and 1998. RESULTS: The percentage of Medicaid-eligible persons admitted to substance abuse treatment programs during a calendar year increased from 5.5% of the average number of enrolled members per month in 1994 to 7.7% in 1997, following the shift to managed care. For 1996 and 1998, the rates were 6.9% and 7.7%, respectively. Access rates varied considerably among the 7 largest prepaid health plans after adjusting for case mix. Operating characteristics of these prepaid health plans, such as the method of reimbursing treatment providers, were significant predictors of access after controlling for member characteristics. CONCLUSION: According to our analyses, Medicaid-eligible persons in Oregon observed an increase in access to substance abuse treatment after a shift to managed care. JAMA. 2000;284:2093-2099.

Adolescent↗
PubMed2001

Evaluating microbial indicators of environmental condition in Oregon rivers.

Traditional bacterial indicators used in public health to assess water quality and the Biolog system were evaluated to compare their response to biological, chemical, and physical habitat indicators of stream condition both within the state of Oregon and among ecoregion aggregates (Coast Range, Willamette Valley, Cascades, and eastern Oregon). Forty-three randomly selected Oregon river sites were sampled during the summer in 1997 and 1998. The public health indicators included heterotrophic plate counts (HPC), total coliforms (TC), fecal coliforms (FC) and Escherichia coli (EC). Statewide, HPC correlated strongly with physical habitat (elevation, riparian complexity, % canopy presence, and indices of agriculture, pavement, road, pasture, and total disturbance) and chemistry (pH, dissolved O2, specific conductance, acid-neutralizing capacity, dissolved organic carbon, total N, total P, SiO2, and SO4). FC and EC were significantly correlated generally with the river chemistry indicators. TC bacteria significantly correlated with riparian complexity, road disturbance, dissolved O2, and SiO2 and FC. Analyzing the sites by ecoregion, eastern Oregon was characterized by high HPC, FC, EC, nutrient loads, and indices of human disturbance, whereas the Cascades ecoregion had correspondingly low counts of these indicators. The Coast Range and Willamette Valley presented inconsistent indicator patterns that are more difficult to characterize. Attempts to distinguish between ecoregions with the Biolog system were not successful, nor did a statistical pattern emerge between the first five principle components and the other environmental indicators. Our research suggests that some traditional public health microbial indicators may be useful in measuring the environmental condition of lotic systems.

Bacteria↗
PubMed2000

Derivation of shellfish harvest reopening criteria following the New Carissa oil spill in Coos Bay, Oregon.

Oil spills in Alaska, California, Maine, and other states have raised concerns regarding potential contamination of fish and shellfish, and have led to temporary closures of seafood harvests while health risks are assessed. Lacking standardized protocols, these assessments are generally ad hoc, site-specific efforts, with significant differences in risk evaluation criteria. This article describes the response of a state health agency to shellfish contamination following an oil spill on the Oregon coast, and discusses some of the factors that can complicate the evaluation of potential health risks from consumption of oil-contaminated shellfish. On 4 February 1999, the Japanese-owned cargo ship M/V New Carissa, carrying an estimated 400,000 gallons of light diesel and heavy fuel oil, ran aground 2 miles north of Coos Bay, Oregon. Damage to the ship's hull from the grounding and pounding surf caused the release of an estimated 25,000 to 70,000 gallons of oil. Concern for potential contamination of local recreational shellfish and commercial oyster beds prompted the Oregon Department of Agriculture (ODA) to close shellfish harvesting in Coos and Douglas counties. ODA requested assistance from the Oregon Health Division in the derivation of risk-based criteria for reopening the shellfish harvest. Criteria were developed for the primary contaminants of concern, polycyclic aromatic hydrocarbons (PAHs) expressed as total benzo[a]-pyrene (BaP) equivalents. "Safe" (<10 microg/kg) and "unsafe" (>45 microg/kg) BaP equivalent levels were derived based on upper end (32.5 g/d) and average (7.5 g/d) estimates of shellfish consumption, respectively. Composite samples of oysters, clams, and mussels (15-20 per composite) were collected from target areas and analyzed for PAHs by gas chromatography/mass spectroscopy (GC/MS). Carcinogenic PAHs were converted to total BaP equivalents (wet weight) and compared with criteria. Two oyster samples, collected from a slough off of Coos Bay, contained 33.9 and 34.5 microg/kg BaP equivalents; all other samples had less than 10 microg/kg BaP equivalents. An evaluation of the PAH profiles in the two higher oyster samples indicated a primary source other than the New Carissa oil. Because shellfish sample BaP equivalents attributable to the New Carissa oil spill did not exceed 10 microg/kg, shellfish harvesting was reopened on 4 March 1999. This study revealed some of the inherent difficulties in attempting to quantify health risks from contaminated shellfish following an oil spill and demonstrated the clear need for standardized protocols for responding to such events.

Animals↗
PubMed1992

Occupational exposure to 1,6-hexamethylene diisocyanate-based polyisocyanates in the state of Oregon, 1980-1990.

Monitoring of exposure to 1,6-hexamethylene (HDI) monomers and HDI polyisocyanates in Oregon was initiated in 1980 and covered primarily spray painting and related activities. A total of 562 air samples were collected from 60 workplaces during the years 1980-1990 and analyzed for HDI and HDI polyisocyanate content. Of the total, only a small fraction (6%) of the samples exceeded the state of Oregon permissible exposure limit (PEL) of 0.02 ppm for HDI monomer; however, a much higher number (42%) of the samples exceeded the Oregon PEL of 1 mg/m3 for HDI polyisocyanates. Spray finishing operations were divided into three categories: continuous industrial spraying, auto body repair shops, and intermittent spray operations of large objects. The highest exposures among all three categories for both HDI and HDI polyisocyanates were measured during spray finishing. The geometric mean for HDI in the industrial spray operations was 0.001 ppm and for HDI polyisocyanates was 3.78 mg/m3. Frequently, the peak exposures exceeded the Oregon PEL for polyisocyanates, reaching as high as 12.2 mg/m3. In auto body shops, the mean for HDI was 0.002 ppm and for HDI polyisocyanates was 1.60 mg/m3 with peak concentrations of 0.049 ppm for HDI and 18.4 mg/m3 for HDI polyisocyanates. In the third category of spray finishing of large objects, the geometric means for three subcategories ranged from 0.001 to 0.017 ppm for HDI with a peak concentration of 0.069 ppm. The geometric means for HDI polyisocyanates ranged from 2.09 to 15.9 mg/m3 with a peak of 29.5 mg/m3. In all the surveys, the ventilation facilities and personal protective equipment were evaluated.(ABSTRACT TRUNCATED AT 250 WORDS)

Cyanates↗
PubMed1992

The descriptive epidemiology of unnatural deaths in Oregon's state institutions: a 25-year (1963-1987) study. III. A 25-year overview of unnatural deaths in the mental and correctional facilities.

I document 25 consecutive years (1963-1987) of unnatural deaths within the State of Oregon's mental and correctional institutions in Marion County. This study includes 93 unnatural deaths in the Oregon State Hospital, 18 in the Forensic Psychiatric Program, 52 in the Fairview Training Center, and 45 in the Corrections Department facilities. These institutional unnatural deaths are compared with the 2,618 unnatural deaths that occurred during this same period in Marion County (exclusive of these state facilities). Death rates are shown in five 5-year blocks of time to illustrate death trends. Accidents and suicides were the predominant types of unnatural death in the Oregon State Hospital; suicides predominated in the Forensic Psychiatric Program and the corrections facilities; and accidents predominated in the Fairview Training Center. Extremely high total unnatural death rates were found in the Oregon State Hospital (approximately 520/100,000 or 8.46 times that found in Marion County) and the Forensic Psychiatric Program (approximately 561/100,000 or 9.13 times that found in Marion County). The overall accident death rate for the Fairview Training Center was approximately 119/100,000 or 2.84 times that found in Marion County. The overall total unnatural death rate for the corrections facilities was approximately 75/100,000 or 1.23 times that found in Marion County. I compare these data with those of other investigators in the United States, Canada, and western Europe. The total unnatural death rate appears to represent a valid criterion of violent death within a community.

Commitment of Persons with Psychiatric Disorders↗
PubMed1987

Impact of routine inquiry legislation in Oregon on eye donations.

Routine inquiry legislation can significantly affect procurement of donor eye tissues. Oregon Revised Statute (ORS) 97.268 was the first legislation of this type passed in the United States. In the first 12 months under this legislation, the Oregon Lions Eye Bank obtained, 2,312 eyes, sustaining a 135% increase in donor eye procurement over the yearly average for 1984-1985. During the first 12 months of routine inquiry, 484 corneas suitable for penetrating keratoplasty were obtained versus an annual average of 291 corneas for 1984-1985. Tissues for other transplant purposes and for research have similarly become more available. Age of donor tissue appears to be increasing slightly due to the disproportionate increase of donor eyes from the 70-or-over population. The Oregon Donor Program, the public and professional education coalition of the transplant programs in the state of Oregon, has played an invaluable role in making this penalty-free law a success.

Corneal Transplantation↗
PubMed1994

Value judgment in the Oregon Medicaid experiment.

Oregon proposed a unique social experiment in which combinations of medical conditions and treatments were prioritized. Under the proposed program, providers would not be reimbursed for services relevant to 17% of the condition-treatment pairs. The program was designed to expand access and allow significantly more residents to qualify for Medicaid. The original Oregon proposal used four levels of human judgment: community values assessed in town meetings; ratings of the desirability of health states; medical judgment of treatment efficacy; and subjective reordering of the list by Oregon Health Services Commissioners. In August 1992, the Department of Health and Human Services rejected Oregon's application to proceed with the experiment, objecting to the use of one of the four types of subjective data: ratings of the desirability of health states. A revised application that eliminated this one subjective component was approved in March 1993. This paper demonstrates that among the four levels of judgment, the ratings of health states were supported by the most evidence of reliability and validity. Implications for future prioritization experiments are discussed.

Community Participation↗
PubMed1998

Oregon emergency medical technicians' attitudes toward physician-assisted suicide.

OBJECTIVES: To determine Oregon intermediate and advanced emergency medical technicians' (EMTs') attitudes toward physician-assisted suicide (PAS) and factors associated with those attitudes. METHODS: An anonymous survey was sent to a random sample of 498 EMTs registered in Oregon. RESULTS: Surveys were delivered to 498 EMTs and 343 completed surveys were returned, for a response rate of 69%. The mean age of the respondents was 37.5 years (+/-8.73) and 79% were male. 232 (68%) agreed that PAS should be legal, 263 (77%) agreed that terminally ill people have a right to decide to commit suicide, while 57 (17%) thought not attempting resuscitation would be immoral. 251 (73%) reported seeing attempted suicide in terminally ill patients at least once, with 117 (34%) experiencing such calls >5 times. Only 22 (6%) stated that they would be unable to work in a system that directed them to withhold resuscitation after a PAS attempt, and 277 (81%) agreed that treatment protocols should direct EMTs to withhold resuscitation. 105 (31%) thought EMTs should participate in the decision to withhold resuscitation. 206 (60%) thought the law should allow lethal injection for terminally ill patients. 201 (59%) agreed there were circumstances under which they might personally consider PAS. If PAS were legal, EMTs stated they would withhold treatment from a terminally ill patient following attempted suicide in the following circumstances: based on standing orders, 78%; with on-line medical direction, 67%; after speaking with the primary physician, 53%; if the patient had decision-making capacity, 45%; with written documentation from the patient's physician, 68%; and never, 6%. CONCLUSIONS: A majority of Oregon EMTs responding to this survey expressed support for PAS, think treatment protocols should direct paramedics to withhold resuscitation in such cases, and would feel comfortable withholding resuscitation given appropriate protocols. Nearly 3 out of 4 Oregon EMTs report seeing at least 1 terminally ill patient who had attempted suicide.

Adult↗
PubMed1999

The passage and initial implementation of Oregon's Measure 44.

OBJECTIVE: To prepare a history of the passage and early implementation of Ballot Measure 44, "An Act to Support the Oregon Health Plan", and tobacco control policymaking in Oregon. Measure 44 raised cigarette taxes in Oregon by US$0.30 per pack, and dedicated 10% of the revenues to tobacco control. METHODS: Data were gathered from interviews with members of the Committee to Support the Oregon Health Plan, Measure 44's campaign committee, as well as with state and local officials, and tobacco control advocates. Additional information was obtained from public documents, internal memoranda, and news reports. RESULTS: Although the tobacco industry outspent Measure 44's supporters 7 to 1, the initiative passed with 56% of the vote. Even before the election, tobacco control advocates were working to develop an implementation plan for the tobacco control programme. They mounted a successful lobbying campaign to see that the legislature did not divert tobacco control funds to other uses. They also stopped industry efforts to limit the scope of the programme. The one shortcoming of the tobacco control forces was not getting involved in planning the initiative early enough to influence the amount of money that was devoted to tobacco control. Although public health groups provided 37% of the money it cost to pass Measure 44, only 10% of revenues were devoted to tobacco control. CONCLUSIONS: Proactive planning and aggressive implementation can secure passage of tobacco control initiatives and see that the associated implementing legislation follows good public health practice.

Health Promotion↗
PubMed1994

The Oregon Health Plan and public health.

The Oregon Health Plan would provide all Oregonians with health insurance through a combination of Medicaid expansion, employer mandates and high-risk coverage, with services delivered largely through managed care. The role of public health in a managed care environment is an important national issue, and one which has received much attention in Oregon. "Cultural" differences between Medicaid and public health have arisen over issues such as whether eligibility assures access, whether the private medical model will provide integrated care, the potential for exploitation of vulnerable populations in a capitated system, and the loss of cost-based Medicaid reimbursement to public clinics. In 1991, legislation required that Oregon's Medicaid managed care plans enter agreements with local health departments to assure their continued participation in providing certain public health services; these agreements are now being implemented. Oregon's experience suggests that any national health system will require a continuum of community and individual health services, with an important role for public health departments.

Health Benefit Plans, Employee↗
PubMed2003

Impact of patient placement criteria on substance abuse treatment under the Oregon Health Plan.

When Oregon shifted to managed care for Medicaid-funded substance abuse treatment, standardized patient placement and discharge criteria were rapidly implemented statewide. This prospective, naturalistic study examines the validity and impact of placement criteria with a sample of 240 adults presenting for treatment compared to a sample of 287 in Washington state, where implementation was phased in slowly. Baseline profile analysis suggested better differentiation between Level II and Level III clients for the Oregon sample and better implementation than with the Washington sample, presumably because Oregon clinicians received more training and had more experience with the criteria. A majority of the Oregon sample was placed in intensive outpatient programs, consistent with the recommended level of care. In this study, placement criteria showed good potential for changing treatment planning behavior, increasing individualization, and improving utilization of new levels of care.

Adolescent↗