Abstract
This article says what it says primarily by way of illustration rather than demonstration. By extensively illustrating a case study of one community, it points to some of the complexities facing contemporary American society in its efforts to distribute health care. Because it is illustrative, the conclusions and recommendations found in this article are suggestive only. One would hardly want to draw any hard and fast conclusions from a sample of one (community). Nonetheless, the case study approach has some advantages. It avoids the error, commonly made by philosophers and theologians, of applying abstract and partisan principles to problems whose existence, seriousness, and nature have as yet to be determined. It also avoids the error commonly made by those who are more empirically oriented of studying one phenomenon (e.g., total health-care expenditures) in many communities and thereby missing out completely on how one fact on the healthcare scene impinges upon another.
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Notes and References
This name, the names of the hospitals in Grandview and other proper names used in this article are fictitious.
I carried out both the 1978 survey and the 1979 consulting work as a Research Associate with Jefferson Davis Associates of Cedar Rapids, Iowa and Atlanta, Georgia.
A more complete report of the events described in this article can be found in “A Report from a Community Health-Care Planner,” Health Care Management Review, (No. 4, Fall, 1981), 49–55 and “A Follow-up Report from a Community Health-Care Planner,” Health Care Management Review forthcoming.
This figure is probably a little high since it is based on information gathered from telephone interviews. Presumably those without telephones are more likely not to have hospital insurance than those with telephones. Government statistics show that (at about the same time period) almost 80% of the population is covered by private health insurance while 12% of the population is covered by Medicare: Statistical Abstracts of the United States, 1980, US Department of Commerce, Bureau of Census, Washington, DC, pp. 108, 347, 551. Because some people have both Medicare and private insurance, these figures cannot be added together. Also it should be kept in mind that many people without insurance can still receive “free” medical services through Medicaid, and so on.
H. Tristram Engelhardt, Jr. ,“Health Care Allocations: Responses to the Unjust, the Unfortunate, and the Undesirable,” In Earl E. Shelp (ed.), Justice and Health Care Dordrecht, Holland: D. Reidel Publishing Co., 1981). On pages 121–122 Professor Englehardt makes these distinctions as follows
Victor R. Fuchs argues against the centralized system. “Physician-centered approaches permit much greater flexibility in adjusting to the needs and preferences of patients at the local level, where the care is actually provided. Most important, they keep medical decision making where it belongs, in the hands of the physicians.” The New England Journal of Medicine 304 (No. 24, June 11, 1981), 1487–1490. He also argues that several factors are working to curtail medical expenditures (per physician), and although there will be more physicians around in the next few years, the overall effect will be to put a kind of ceiling on medical expenditures. If this is so, the need for the Federal Government to intervene to contain costs will lessen.
There are here not only the direct costs of governmental regulations, such as paper work, extra meetings needed to interpret regulations, travel expenses to attend hearings, and so on, but indirect expenses incurred because govern-mental decisions often take months and even years to be made.
Kim Carney, “Cost Containment and Justice,” in Earl E. Shelp (ed.), Justice and Health Care, Dordrecht, Holland: D. Reidel Publishing Co., (1981), 169–170. Carney lists other reasons as well, such as the inability of consumers to assess the quality of care they are receiving, the practice of third party payers to pay on a reasonable-cost basis (which practice gives physicians and hospitals no incentive to lower costs), the nonprofit status of certain hospitals (in which institutions the profit motive is by definition absent, as are the efficiencies that go with that motive), and the tradition in medicine that prevents physicians and hospitals from advertising their charges.
At present, philanthropy accounts for between one and two percent of medical expenditures (Statistical Abstracts of the United States, 1980, US Department of Commerce, Bureau of Census, Washington, DC, p. 106) It is hardly likely that this philanthropy could be expanded to pay the govern-ment’s share of medical costs which conservatively represents over 40% of the total.
It is interesting to note in this connection the on-going discussions in the New England Journal of Medicine that indicate that physicians generally are concerned with procedures that will help contain costs. The following articles and notes appeared in that journal in the span of a few months dealing directly with cost effectiveness: Richard H. Egdahl, “Physicians and the Containment of Health Care Costs,” 304 (April 9, 1981), 900–901; Brandon S. Centerwall, “Cost Benefit Analysis and Heart Transplantation,” 304 (April 9, 1981), 901–903; Jonathan A. Showstack and Ira D. Glick, “Cost and Efficacy of Ambulatory Versus Inpatient Care,” 304 (June 4, 1981), 1431; Russell Hull et al. ,“Cost Effectiveness of Clinical Diagnosis, Venography, and Noninvasive Testing in Patients with Symptomatic Deep-Vein Thrombo-sis,” 304 (June 25, 1981), 1561–1567; Harry A. Guess, “Bernoulli’s CostBenefit Analysis of Smallpox Immunization,” 305 (August 6, 1981), 341; David A. Haymes, “Physicians and Health-Care Costs,” 305 (August 6, 1981), 349
According to Letitia Cunningham, in “Nursing Shortage? Yes!”, American Journal of Nursing, 79 (March 1979), 469–480, the nursing shortage is nationwide in both urban and rural areas. What is worse, projections indicate that the demand for nurses will increase in the next few years.
"In Summary of Public Hearings of the National Commission on Nursing (July 1981, Chicago, pp. 37–43) it was argued that nurses should have more leadership roles than they do now (e.g., have membership on boards of hospitals). The general sense of the report is that nurses do not have the authority to make decisions commensurate with their training.
1'See footnote #8.
"As if to lend support to this point, James Stacey suggests that federal regulations aimed at cutting costs by putting restrictions on purchases of CT scanners have been all wrong since these scanners have proved to be the most useful of the big ticket items to appear on the medical scene in the past 20 years (the other ones being ESRD equipment and treatment and bypass surgery for patients suffering from angina). “Killed by the Cut,” American Medical News, Oct. 23, 1981, pp. 13–14.
C. Wayne Higgins and John G. Bruhn make similar suggestions in “Health Care Regulations and the Economics of Federal Health Care Policies,” Health Care Management Review 6 (No. 4, Fall, 1981), 41–47.
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Fotion, N. (1983). Distributing Health Care. In: Humber, J.M., Almeder, R.F. (eds) Biomedical Ethics Reviews · 1983. Biomedical Ethics Reviews. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-59259-439-9_6
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