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Mind, money, and morality: ethical dimensions of economic change in American psychiatry.

Mind, Money, and Morality: Ethical Dimensions of Economic Change in American Psychiatry

Certain general trends currently dominate health care delivery in America, trends shaped largely by economics and driven specifically by the need to contain rising costs. As throughout the health care system, there are pressures in psychiatry to restrain spiraling costs; mental health care costs of about $20 million currently represent some 14 percent of total expenditures for health care. [1]

At present, three alternatives for economic reform in health care delivery dominate attention. First, costs can be contained by the imposition of third-party payer price controls by replacing retrospective cost-based reimbursement with set-price prospective reimbursement. This is the solution offered by Medicare's Diagnosis-Related-Groups (DRG) system and by various other prospective payment schemes imposed by insurance carriers. Second, costs might be contained through market discipline, that is, by setting for-profit providers in a competitive environment and making consumers of care bear more of the real costs of their choices. Third, the traditionally solo practice fee-for-service (FFS) medicine might be replaced by prepaid group practices in which group members pay a fixed fee to providers in advance of the need for care and providers bear the financial risk of providing care without charge as it is needed. This is the strategy of the health maintenance organization (HMO). While each of these alternatives offers some promise, each also carries with it substantive ethical problems, problems that are generally more pressing in the area of mental health care.

DRGs: The Medicare Solution

Medicare's solution to escalating costs of hospitalization was the introduction in 1983 of DRGs, a system of prospective reimbursement based on 468 diagnoses. Except for a few additional variables, hospitals are reimbursed for Medicare patients with a preset amount determined by the average cost of treating the diagnostic group to which the patient is assigned. If the hospital can treat that patient for less, it makes money on the DRG; if treatment costs more, it loses money.

There are many problems raised by DRG reimbursement in general. [2] The complexity of individual patients' diseases and courses of treatment makes imposing uniform payment for hospital care overly simple at best. The financial pressures placed on hospitals under DRGs can lead them to create mechanisms to promote early discharge of all patients and to avoid admitting those likely to cost more to treat, namely, the very sick and, due to their generally less healthy conditions, the poor and the less educated. DRGs also provide incentives to seek out easy-to-treat patients and those in groups likely to make money for the hospital, to use the more profitable diagnosis in ambiguous cases, and to manage care on the basis of admission-discharge-readmission sequences rather than treating multiple problems during one admission.

The Psychiatric Exemption

For the immediate future much of psychiatric medicine has escaped the DRG price controls now widespread elsewhere in American health care. Because of the need to examine further the implications of prospective payment systems, psychiatric hospitals have been temporarily exempted from Medicare's DRG system. Distinct-part psychiatric units of general hospitals as well as alcohol and drug abuse hospitals and substance abuse units in general hospitals may also apply for exemption. [3] The best guess now is that Medicare's Health Care Finances Administration (HCFA) will not push for universal application of psychiatric DRGs before 1989 at the earliest.

Applied to the care of mental illness, DRGs would be particularly problematic. The specifically psychiatric DRGs developed by Medicare are not valid as predictors of either length of stay or intensity of resource utilization, and thus are unfair in that reimbursement levels will not adequately reflect the costs of treatment. The plurality of hospital psychiatric care settings--general hospitals with "scatter beds," general hospitals with distinct psychiatric units, private and public psychiatric hospitals, hospital-based substance abuse facilities--suggests that under some arrangements some hospitals may make money on DRGs while others lose. The biggest losers are likely to be psychiatric hospitals and general hospitals with distinct psychiatric units, especially if the hospital is large, urban, treats many severely ill patients, treats many Medicare patients, and is a significant teaching site. [4]

The financial impact of psychiatric DRGs might force some psychiatric hospitals to close and some general hospitals to close psychiatric units. [5] The closing of many such units would be an even more significant loss than it may appear, since their presence in general hospitals has contributed to enhanced respect for psychiatry, has allowed for more use of cost-offsetting liaison psychiatry, and has lessened the stigma attached to inpatient psychiatric treatment.

Given the underdetermined character of many psychiatric diagnoses and the lack of reliable external validation, there is great potential for "DRG creep," that is, use of more lucrative DRGs when diagnoses are in doubt. There is also clearly an incentive to seek these more profitable patients in the first place, "skimming the cream" and leaving the neediest patients for someone else, generally government sponsored inpatient facilities and state mental hospitals.

Psychiatric DRGs also provide an incentive toward early discharge of patients with mental disorders and can therefore lead to compromise of quality of care and multiple readmissions. [6] A study in Maryland has found that prospective payment for psychiatric patients reduces the cost of initial hospital stay by cutting the length of stay but increases the number of readmissions, and concludes that the cost of psychiatric inpatient care will be essentially the same over time as more frequent admissions become the pattern. [7]

Cuts in length of stay may be especially counterproductive in alcohol and drug treatment programs. [8] If hospital substance abuse units adopted the DRG scheme, care would change substantially. Given the dramatic cut in length of stay (LOS) called for by the DRGs one can only suppose that an increased rate of recidivism to alcohol dependence would follow. This would mean loss of the savings to be expected in other health care costs from successful treatment, confounding the very point of a prospective payment system.

Moreover, current DRGs make no allowance for multiple alcohol and drug dependency that may require sequential detoxifications. Many alcohol and drug addiction patients have secondary medical and psychiatric diagnoses such as cirrhosis or depression that may require extended treatment. Nor are multiple psychiatric diagnoses in the substance abuse population addressed by DRGs.

Finally, because the DRG system is designed to apply only to short-term patient care, cognitive methods of treatment that generally take longer may tend to be replaced by noncognitive methods. [9] Not only might this have a substantive impact on the future of psychotherapy in general, it might also mean circumventing patients' active and reflective participation in their psychiatric care in many cases where this alternative is otherwise promising. It may serve to move even more psychiatric care out of the office setting with its emphasis on exploration of experience and into the restrictive and rushed hospital environment where illness is the theme. [10]

The Mental Health Marketplace

If the cost spiral in health care is the result, at least in part, of "rich uncle" financing, "scout's honor" reimbursement, and lack of concerned and knowledgeable consumers, then one obvious road to reform is to draw health care delivery closer to the norms that prevail in the marketplace generally. If providers were forced to compete for cost-conscious consumers' health care dollars, so the argument goes, prices would be contained by the usual discipline of the market. Providers would market cheap, convenient, high quality services, and consumers would bear the real cost of their health care choices.

DRG exemption for most psychiatric services combined with these marketplace assumptions have made psychiatry, especially for-profit, multi-hospital corporate psychiatry, the boom town of contemporary American medicine. While the number of not-for-profit psychiatric hospitals has remained constant over the last several years, the number of for-profit hospitals has grown dramatically. [11] Adolescent and child psychiatry is a special focus for growth. [12]

Several factors beyond exemption from DRG price controls may help to account for this explosive growth: access of for-profit corporations to investment capital, lessening of the stigma of psychiatric care, and greater parental willingness to pay for professional treatment of their childrens' behavioral problems. But the most obvious explanation is economic. Profit margins for proprietary psychiatric hospitals average around 25 percent compared to the 13 to 17 percent typical for acute care hospitals, and adolescent and child psychiatric programs can yield margins of 30 percent. [13] Simply put, "health care corporations have included psychiatric in-patient facilities in their acquisitions because they view them as profitable." [14]

To attract patients, psychiatric hospitals and psychiatric units of general hospitals are marketing their services aggressively. This involves developing short-term in-patient treatment programs, advertising, cultivating referral networks, combining medical and psychiatric services into packages, and generally seeking new patient groups, especially among adolescents, women, and the elderly.

Perhaps this competitive environment will distribute high quality psychiatric services at affordable prices. And the increased public attention to psychiatry that advertising and other marketing ventures bring may promote further acceptance of mental health care. But there are several good reasons to be apprehensive about this boom in psychiatry and especially about for-profit psychiatry.

The Negative Side of Competition

Price constraint through competition generally works when it involves products or services that are sufficiently standard to allow for price and quality comparisons and a consuming public knowledgeable enough to effect intelligent comparisons. Both features are missing in psychiatry. How can the public compare the relative effectivness of a particular adolescent behavioral modification program with its competitors, for example? In fact, the inability to comparison shop is so thoroughgoing in some areas of mental health care that the very opposite of price constraint may occur. Competing providers may simply raise their prices to match the costliest, locally successful program to assert comparable quality through comparable charges. It is also becoming clear that for-profit acute care hospitals generally make their money, not by providing more efficient services, but by charging higher prices. [15] If this pattern repeats itself in psychiatric hospitalization, the nation is in for higher prices because of proprietary competition.

Moreover, increasing competitiveness in psychiatry will likely cause access problems. Plainly, one's competitive advantage is not enhanced by caring for patients who are unable to pay for their care or who are uninsured. This will likely lead to avoiding some categories of patients and to "dumping" them on the public system. Thus the poor, uninsured, and very sick have the most to lose in the new procompetitive psychiatric environment. The multi-hospital corporation's economic mandate to expand and to assure stockholder profits may mean more transitory management, the closing of unprofitable hospitals, and a generals loss of local orientation and community service. [16]

It is hard to be confident that the best care would be provided in this economic atmosphere. Don Flynn and colleagues suggest that, "Like the traveling public, patients seeking psychiatric care can observe whether facilities are attractive and service is delivered on time, but they may be in a poor position to judge the quality of service." [17] Even third-party professional review of quality is difficult. Counterfactual conditional judgments are hard to make with confidence. Where one might readily judge that a timely medical treatment would have saved a patient from a worsened medical condition ("If only penicillin had been ordered...."), the analogous psychiatric judgement may be less compelling ("If only ECT had been ordered...."). If quality cannot regularly be tested and assured, it is easily subject to compromise for financial reasons. When profit margins falter, there will be increased demands to cut quality corners, for example, to prefer group counseling when individual counseling might have been used previously, to raise the patient-to-staff ratio, or to use less professionally prepared staff.

The Double-Agent Conflict

The doctor-patient relationship would also be subject to new pressures in a competitive mental health care environment. An important ethical consideration in appraising economic arrangements in health care delivery is the structure of incentives put in place. One need not assume that all practitioners will yield to the new incentives nor that as a group they are especially venal. One need only observe that the structure of incentives will tend to incline professional relationships in a certain direction. If that decision is fraught with conflict between the interests of the provider and the patient, then, other things being equal, it is one to be avoided. Placing mental health professionals in a competitive economic environment does just that. It exacerbates the "double agent" problem by forcing professionals to serve both the interests of their patients and the interests of for-profit corporations.

The "double agent" conflict is not new to medicine, of course. A similar economically based conflict has long been part of fee-for-service medicine since providers benefited personally by always doing more for their patients. And the modern for-profit hospital was preceded by the small freestanding proprietary doctors' hospitals of the recent past. Although medicine has thus tolerated a limited profit motive, it did so when the practice setting was under the control of individual professionals or their doctors' hospitals. When medicine previously accepted nonprofessional control over practice settings, it was generally in the context of noncommercial, not-for-profit medicine, in religious hospitals or in the military, for example. Thus the practice setting was controlled by the explicit social commitments of these nonprofessional organizations.

What is new about today's "double agentc problem is the convergence of both for-profit medical care and a commercialized, lay-controlled practice setting. [18] It is not yet clear what the final implications of this new combination of forces will be, but we can at least say that professional-patient relationships in psychiatric medicine are facing new ethical conflicts. Further, there is one dimension of this problem unique to psychiatry. In other areas, conflicts of interests can be resolved or their effects contained by disclosing the professional's conflict to patients and clients. In psychiatry, however, "instances arise in which even though the patient is aware of the mental health professional's conflict of interest, coercion is inherent due to transference phenomena that nullifies this knowledge." [19] Mental health care in this new environment may thus lead to results that serve the interests of neither professional nor patient in the long run. In the worst case, the former may lose professional autonomy and the latter the protection of a fiduciary relationship.

Finally, the marketing strategies of contemporary psychiatry raise important concerns. The emphasis on developing new psychiatric markets in a commercial environment offers a financial inducement to overreach the appropriate role of psychiatry. There is money to be made in the creation of new psychological diseases, in defining behavioral problems as mental disorders, and in cultivating a false public desire for the elusive ideal of perfect mental health. In the long run, this potential in the present commercialized atmosphere may be the most dangerous prospect for psychiatry. It may portend the corruption of the discipline and a public perception of mental health care as a field of Madison Avenue manipulations.

Psychiatry and HMOs

A third alternative to contain costs is to reverse the incentives of fee-for-service medicine. Providers have an incentive to do less, not more, if they are paid a fixed fee per person in advance and are then responsible for providing these individuals with a range of specified services at little or no additional charge. Providers in this arrangement get their money "up front" and receive the same amount whether they provide services or not. But since the provision of services is an expenditure, providers have an incentive always to do less, to do what is done in the most efficient manner possible, and to take preventive measures when they restrain higher future costs. If this arrangement is implemented in a group practice, the result is, as the most common contemporary version is called, a health maintenance organization.

Obviously, one attractive feature of HMOs is their potential for cutting costs. They have, for example, rates of hospitalization up to 40 percent less than the average of FFS practice settings. [20] Until recently, one of the main problems of American health care was a tendency toward overutilization; HMOs reverse this trend. Instead, they emphasize preventing disease and maintaining health. From the patient's perspective, HMOs offer a simplified care and financing situation, an insurance scheme with payment in kind, and little or none of the paperwork required by traditional health insurance arrangements. Further, the presence of competing HMOs plans might be expected to produce new arrays of services at affordable prices. Finally, group practice is increasingly attractive to professionals. Because group resources are shared, expenses can be limited productivity increased, specialization made possible, and responsibilities to patients rotated. [21]

But there are problems with HMOs in the psychiatric context. While most plans have some form of mental health coverage--the majority offering up to thirty days hospitalization and twenty ambulatory visits--in some cases mental health care is a supplementary benefit requiring additional copayments. [22] Though each of the four competing HMOs in Rochester, NY, for example, provide unlimited hospitalization for approved and medically necessary general medical care, they strictly limit the number of inpatient days for mental health care. Anthony Lehman notes that, "all plans limit the number of outpatient visits for mental health care, and most levy additional copayment charges that simply do not exist for non-mental-health visits." [23] Some HMOs employ a subcapitation payment that compartmentalizes and caps mental health care costs. This strategy tends to isolate psychiatric care in the HMOs' services and, given the history of more traditional plans, the money set aside is unlikely to be adequate financially. [24]

The HMO also has an incentive to underutilize, which may adversely affect the quality of care offered. Under this system, access problems abound. Because of adverse selection (those likeliest to use a great many HMO services are those likeliest to join), HMOs tend to market likeliest to join), HMOs tend to market themselves carefully to underutilizing groups. They steer away from the chronically ill, the elderly, and the poor, and toward the healthy, young, and able to pay. Thus they tend to create systematic access barriers to those with the greatest needs by keeping them out of HMOs in the first place and disenrolling them should they use too many resources. Overall, this means further pressure on the public system.

Restricted access to psychiatric care and low utilization rates suggest that HMOs have chosen to concentrate on delivering mental health care to acute, nondisabled patients. But the biggest financial problem facing psychiatry is that of providing care for patients with chronic and disabling mental disorders, patients who rely heavily on Medicare and Medicaid. HMOs have been reluctant to serve this population because their health care needs exceed typical benefit plans and capitation rates. [25]

Often HMO members seeking mental health care find obstacles in their path. A common feature in HMOs is the "gatekeeper," typically a primary care physician whose authorization is needed for referral to a specialist. Given a limited knowledge of the mental health field and lack of sophistication in identifying psychiatric problems, there is concern that gatekeepers will keep HMO members away from needed psychiatric care and perhaps even try to address psychiatric problems medically.

Nationally, only one HMO mental health care provider in five is a psychiatrist, and the goal of most HMOs is a ratio of physicians to members of one to one thousand. HMOs often restrict the use of psychiatrists to diagnosing and prescribing drugs, with nonpsychiatrist mental health professionals typically used for counseling and psychotherapy. Psychiatrist fees in HMOs are about 20 percent less than those in private practice. If psychiatrists joining an HMO wish to maintain their previous incomes, they will have to see more patients. [26] Also, the HMO's group practice structure itself may tend to compromise the quality of psychiatric care to the extent that quality turns on sustaining a therapeutic relationship with one provider.

HMOs, especially for-profit HMOs in competitive relationships, may also create new dilemmas for truthtelling and informed consent. They will have to be held to high standards of honesty and disclosure when they market their services to new customers. The extent of their psychiatric benefits--especially what is not covered--will have to be detailed to potential enrollees. Perhaps information about the ratio of psychiatrists to other mental health care providers, the percent of the HMO's outlays for psychiatric care, and the financial pressures on gatekeepers should be mandated by law.

Informed consent becomes an inherently more complex notion when choice is not for a specific, needed therapy, but for a package of potentially needed therapies. Should an HMO, for example, be bound to alert enrollees to the existence of psychiatric care not covered by their own plan? How reasonable is it to assume intelligent consumer choice about potential mental health care needs? Capitation plans limit patients' options and "it seems doubtful that persons buying health insurance will be able to make truly informed choices among competing capitation plans, assuming that more than one even exists in a given community." [27]

Finally, there is also a "double agent" problem in prepaid group practice arrangements. The HMO psychiatrist has a conflict between concern for the best interest of his or her patient and the financial interest of the HMO iself. In the for-profit context, the HMO conflict may present the same novel complexion of modern proprietary medicine: commercialization of practice combined with lay control. In two respects the conflict here may be worse. Traditionally, self-interest in fee-for-service medicine has been softened by the personal character of the doctor-patient relationship. The group practice of the HMO tends to remove this possibility. Moreover, the HMO member may tend to be a more demanding patient, having paid the bill already as it were. This may further weaken the affective bonds of the doctor-patient relationship and worsen the problem of conflict of interest.

It is clear that capitated group practice arrangements such as HMOs will play a leading role in the future of American health care delivery. [28] Perhaps they have the potential to help reform mental health care delivery as well. But it is too soon to say just now.

A National Health Alternative?

All three of the alternative economic directions examined here may help to contain costs, but they will likely cause serious ethical problems regarding quality, access, and the character of psychiatry. Nonetheless, the status quo cannot long be maintained.

Any promising alternative for reform will have to assure overall fairness in the system, deemphasize the economic dimensions of mental health care in the clinical setting, and protect the integrity of the psychiatrist-patient relationship as it contains costs. Perhaps no single alternative can accomplish all of these goals completely. But there is one other seldom discussed direction for reform: creating a national health insurance program that includes psychiatric coverage.

Health insurance is an inherently rational arrangement since it serves to expand or at least protect the range of future choices and it tends to maximize the utility of resources by transferring dollars from times of relative plenty to times of relative need. But up to 35 million Americans have no health insurance. [29]

Mandating universal participation in a national insurance scheme including psychiatric care would create a social solution to a social problem by ending the inequitable distribution of charity care and bad debt and by stopping the unsavory practice of "dumping" uninsured and chronically ill patients on other providers. It would also create a national constituency with a direct interest in achieving and sustaining the highest quality of care for all. Such a program could assure overall fairness by gauranteeing equitable and universal access to a publicly defined decent minimum of health care, could deemphasize the clinical impact of economics by global budgeting at the national and regional levels, and could free contemporary health professionals from multiple private insurance companies, HMOs, and for-profit corporations. The fact that every other developed nation addresses its health care needs with a national program of insurance or direct provision and that they all spend less for it than Americans do suggests that overall costs might be contained by a national health care plan. [30]

The Canadian experience is instructive. In 1960, before the institution of national health insurance, Canada spent approximately 5.5 percent of its GNP on health care compared to about 5.3 percent in the United States. By 1966, after national health insurance was fully established, the Canadian percentage slipped below that of the United States. By the mid-1980s, the comparable figures were 8.4 percent in Canada and 10.7 percent in the United States. And Canadian doctors did not suffer financially from national health insurance. [31]

Moreover, the introduction of universal health insurance (National Medical Care Insurance) in Canada fostered the integration of psychiatry with the rest of medicine. Psychiatric care was included as a fully insured benefit and flexibility regarding method of reimbursement, site of care, and provincial control was preserved. [32]

There would be many challenges involved in sructuring and financing an American national health insurance system and in designing its particular applications to psychiatry, challenges that cannot be addressed here. But given the problems that we have addressed besetting psychiatric care in the context of DRGs, for-profit medicine, and HMOs, it may well be time to look seriously in another direction.

References

[1] Haroutun Babigan and Sylvia K. Reed, "Capitation Payment Systems for the Chronically Mentally Ill," Psychiatric Annals 17:9 (September 1987), 599-602.

[2] Daniel Dolenc and Charles J. Dougherty, "DRGs: The Counterrevolution in Financing Health Care," Hastings Center Report 15:3 (June) 1985), 19-29.

[3] Marc P. Freiman et al., "An Analysis of DRG-Based Reimbursement for Psychiatric Admission to General Hospitals," American Journal of Psychiatry 144:5 (May 1987), 603.

[4] Thomas G. McGuire et al., "Differences in Resource Use and Cost Among Facilities Treating Alcohol, Drug Abuse, and Mental Disorders: Implications for Design of a Prospective Payment System," American Journal of Psychiatry 144:5 (May 1987), 616-20; Freiman et al., "An Analysis of DRG-Based Reimbursement," 608.

[5] Freiman et al., "An Analysis of DRG-Based Reimbursement."

[6] Joseph English and Richard McCarrick, "DRGs: An Overview of the Issues," General Hospital Psychiatry 8 (1986), 359-64; Joseph English et al., "Diagnosis-Related-Groups and General Hospital Psychiatry: The APA Study," American Journal of Psychiatry 143:2 (February 1986), 131-39.

[7] Stuart Keill, "The Changing Patient Population in General Hospital Psychiatric Services," General Hospital Psychiatry 8 (1986), 352.

[8] John Mezochow et al., "The Impact of Cost Containment on Alcohol and Drug Treatmnet," Hospital and Community Psychiatry 38:5 (May 1987), 506-10.

[9] English and McCarrick, "DRGs," 362.

[10] Richard S. Schwartz, "The Double Life of a Psychiatrist: Role Changes Between Hospital and Office," Psychiatry 50 (February 1987), 83-87.

[11] Steven S. Sharfstein, "Editorial: Economics and Pscyhiatry," General Hospital Psychiatry 7 (1985), 279; Eric Goplerud, "Effects of Proprietary Management in General Hospital Psychiatric Units," Hospital and Community Psychiatry 37:8 (August 1986), 832-36; David Barkholz, "Systems Show Strong Growth in Number of Psychiatric Beds," Modern Health Care (June 6, 1986), 108-12.

[12] Teri Shahoda, "Specialty Services Boost Psych Providers," Hospitals (September 20, 1986), 56-63; Eric Goplerud, "Effects of Proprietary Management," 833.

[13] Shahoda, "Specialty Services Boost Psych Providers."

[14] Armand Checker, "Research Needs in Investor-Owned Psychiatric Facilities," Hospital and Community Psychiatry 37:10 (October 1986), 1049-51.

[15] Institute of Medicine, For-Profit Enterprise in Health Care (Washington, DC: National Academy Press, 1986), 182.

[16] Checker, "Research Needs in Investor-Owned Psychiatric Facilities," 1050.

[17] Don Flinn, Terry McMahon, and Michael Collins, "Health Maintenance Organizations and Their Implications for Psychiatry," Hospital and Community Psychiatry 38:3 (March 1987), 255-63.

[18] Robert M. Veatch, "Ethical Dilemmas of For-Profit Enterprise in Health Care," in The New Health Care for Profit, Bradford Gray, ed. (Washington, DC: National Academy Press, 1983), 125-52.

[19] Robert I. Simon, "The Psychiatrist as a Fiduciary: Avoiding the Double Agent Role," Psychiatric Annals 17:9 (September 1987), 622-26.

[20] Karen Davis et al., "Is Cost Containment Working?" Health Affairs 4:3 (Fall 1985), 81-94.

[21] Boris Astrachan and Steven Sharfstein, "The Income of Psychiatrists: Adaptation During Difficult Economic Times," American Journal of Psychiatry 143:7 (July 1986), 885-87.

[22] Babigan and Reed, "Capitation Payment Systems," 600.

[23] Anthony F. Lehman, "Capitation Payment and Mental Health Care: A Review of the Opportunities and Risks," Hospital and Community Psychiatry 38:1 (January 1987), 31-38.

[24] Lehman, "Capitation Payment and Mental Health Care," 36.

[25] Babigan and Reed, "Capitation Payment Systems," 601.

[26] Varda Backus, "HMOs: Not Always the Best Medicine," Hospital and Community Psychiatry 38:3 (March 1987), 229.

[27] Lehman, "Capitation Payment and Mental Health Care," 32.

[28] Charles J. Dougherty, American Health Care: Realities, Rights, and Reforms (New York: Oxford University Press, 1988), 153-63.

[29] Donald Cohodes, "America: The home of the Free, the Land of the Uninsured," Inquiry 23 (Fall 1986), 227-35.

[30] Dougherty, American Health Care, 164; David Himmelstein and Steffie Woolhandler, "Socialized Medicine: A Solution to the Cost Crisis in Health Care in the United States," International Journal of Health Services 16 (November 1986), 339-52.

[31] Theodore Marmor et al., "National Health Insurance: Some Lessons from the Canadian Experience," in Political Analysis and American Medical Care, Theodore Marmor, ed. (Cambridge: Cambridge University Press, 1983), 165-86, esp. 174-79; and Himmelstein and Woolhandler, "Socialized Medicine," 340.

[32] C.A. Roberts, "More for the Mind Twenty Years Later, the Canadian Experience," The Psychiatric Journal of the University of Ottawa 9:1 (March 1984), 12.

Charles J. Dougherty is professor of philosophy and director of the Center for Health Policy and Ethics at Creighton University, Omaha, NE.
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Publication:The Hastings Center Report
Date:Jun 1, 1988
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