The Milbank Memorial Fund quarterly. Health and society最新文献

The uniquely parsimonious approach to treatment of end-stage renal disease patients in the U.K. was initially developed under the imprimatur of the nation's medical elite and sanctioned by the central government. Public value for public money and an equitable balance of scarce resources among many social and medical claims still guide the National Health Service. But these clinically dominated allocative decisions are imperfect, often counter-productive, and, ultimately, political. There is a marked dissonance between compassionate and bureaucratic themes.

Economic, demographic, and technological pressures have led at the same time to increased demands upon health services and the need to contain spending on health care. As the United States has focused singularly on an array of market mechanisms, Western European countries have each adopted a broader set of strategies along with limited de-insurance: innovative regulatory approaches and a move from compulsory health insurance models to flexible national health service models of providing health care. Pursuit of cost-containment in Western Europe has proceeded along with pursuit of quality and, above all else, equity.

The federal government considers all persons aged 65 and over a single beneficiary group, and data collectors consider them a single cohort. As a result, the very old (80 years and over) are virtually invisible; little is known about their specific income benefits and economic resources. Costs for the very old--a more economically diverse group than the nonaged--are likely to grow disproportionately. Recent proposals to share costs will affect the distribution of income and assets among the aged and between generations.

The National Center for Health Statistics is embarked on a major project to combine the respective strengths of cognitive psychologists and survey researchers in a common effort to improve the design of survey questionnaires. This methodological research is conducted within the framework of the National Health Interview Survey, the nation's main source of information on the health of civilians. Better quality of such information--from recall to response rates--can aid both scientific inquiry and public policy.

High technology--complex, expensive, restricted in availability, and requiring some form of explicit rationing--is bound to influence the medical task. Diagnosis, prognosis, decision, and management have all incorporated high technology, changing the hospital physician's role from one of private contractor to one of team member. Attitudes toward the balance between burden and benefit of high technology are as varied as are the conflicting vested interests among patients, professionals, society, industry, and government. Above all, it will take time for both patients and professionals to learn how to redefine expectations in a changing relationship.

Proposals to shift more of Medicare's costs to beneficiaries raise the question of whether the oldest old--the heaviest users--have the resources to bear these costs. Information on cash income, assets, other economic resources, and in-kind benefits provides an assessment of the economic status of the very old. When all factors and adjustments are considered, the oldest old, as a group, are shown to have substantially lower economic status than the young old.

A parliamentary committee of inquiry was convened in response to growing concern--among the general public and the scientific community--about new techniques in human fertilization and research in embryology. The committee had to enter that jurisprudential minefield, the theoretical relation between morality and the law. When issues arise in which there is no historical tradition, the voice of morality may be genuinely confused and uncertain. But the law, unlike moral opinion, cannot be contradictory; it must be definite, unambiguous, and universally applicable.