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From out of the pastTB in the modern era
POLICYWATCH
politan areas in New York State American public should learn in managed-care enrollment. more about this vital experiment Quality and consumer satisfac- as a stark contrast to the simplistion have consistently shown tic solutions that appear to lead high ratings. T h e R o c h e s t e r in n a t i o n a l p u b l i c o p i n i o n HMOs also have substantial ex- polls.--RB perience serving the Medicaid population of the region under both mandatory and voluntary From Out of the Past...TB in enrollment programs. Regional planning: Among the the Modern Era most unique and potent tools in the Rochester system is the use of [Gostin LO. Controlling the regional planning for major capi- resurgent tuberculosis epidemic: a tal projects. In this case, commu- 50-state survey of TB status and proposals for reform. JAMA 1993; nity leaders have actively used 269: 255-61.] regional health planning principles to control costs and shape the health care delivery system, ublic health laws have not kept pace with either public enhancing the effect of the reguh e a l t h t e c h n o l o g y or latory criteria of the state. Expenditure limits: Hospitals changes that have occurred in in the Rochester region have long similar problem areas since the operated under a global spending 1960s. The control of communicap. This limit was enforced not cable diseases is the oldest functhrough government sanctions, tion of public health and, as Gosbut rather through the sustained tin points out in this and earlier efforts of community leadership. articles, it hasn't changed much. The hospitals participated in the The right of the "state" to reprocess, adding to the legitimacy strict the liberty of an individual and effectiveness of this volun- in order to protect the rest of the population is of long standing. In tary system. The Rochester approach can- most of the United States, the not be automatically transferred roots are to be found in the conto other communities. There is a cept of the "police power" of the unique history in this communi- state. Public health agencies in ty, and it is essential to view the all 50 states are charged with the model in a longitudinal time responsibility and usually proframe. Nevertheless, the princi- vide the authority to examine, ples underlying the Rochester treat, commit, and generally cona p p r o a c h s h o u l d be r e a d i l y trol the behavior of people who adapted to other circumstances. have dangerous diseases such as These principles include: com- tuberculosis (TB). Although the munity-based governance (with mental health community went active and sustained involvement through three decades of reforfrom the business community); mation to bring its similar aunondiscrimination in benefits thorities to alignment with conand premiums; strong emphasis stitutional and ethical principles, on regional health planning; and the public health establishment budgeting for health expendi- has not. The situations, as Gostin tures. Perhaps most important is points out, are similar. the demonstrated success of any Gostin discusses several asapproach to health care reform, pects of TB control: the duty to which stands in stark contrast to pay for and provide services, the speculative benefits of other medical examinations, treatpopular models. Finally, the ment, emergency detention, corn-
p
THE AMERICAN JOURNAL OF SURGERY
mitment, isolation or quarantine, criminal penalties, confidentiality, and antidiscrimination. The findings are similar under each heading: the laws are usually vague, emphasize authority and control more than the duties of public health, and do not provide adequate constitutional safeguards to either those who are infected or those whom we are trying to protect. Although many communities are revising their TB control programs in 1993 and focusing on the need to tighten their control on the behavior of the direct victims, Gostin suggests that the emphasis on control and implied (and, at times, real) punishment makes control more difficult to maintain. Eventually, of course, if such efforts persist, they will be ruled unconstitutional. Gostin makes three, simple recommendations: (1) " T h e exercise of compulsory powers should be based on an individualized [emphasis added] determination that the person poses a significant risk to the public." (2) The person has a right to a fair hearing, including full respect for procedural rights. (3) Health officials should have available to them a graded array of services and measures to deal with each individual problem, balancing the rights of the individual with the need to protect society. Perhaps the most controversial recommendation is that every patient with active TB be placed on a regimen of directly observed therapy (DOT). Some believe this would be unnecessarily intrusive, claiming that compliant patients can be easily distinguished from noncompliant ones. Although Gostin does not dwell on the point, he makes clear the risk of relying on stereotypes. It is very difficult for patients to maintain a complex treatment regimen for 6 months to 2 years when they are feeling otherwise VOLUME 166
SEPTEMBER 1993
III
POLICY WATCH
well and when the medications themselves may cause some discomfort. The notion that this is more common among people in lower socioeconomic s t r a t a is widespread and erroneous. Others have claimed that universal DOT is too expensive. However, studies in several communities have shown how to keep the cost down, and the cost of a relapse, especially with multiple-drug-resistant organisms, is a severe penalty to pay for such attention. Gostin goes an important step further, however. Similar to concepts now accepted in mental health and in the development disabilities field, he urges that each patient participate in developing an individualized treatment plan. Better to call it an individualized program of services--a contract of sorts between the official agency and the infected individual that attempts to meet the needs of both. Some programs have adopted a simple system of vouchers for a cheeseburger or a periodic payment in cash for compliance. Still, such practices fail to take into consideration the variegated needs of individuals if they are to maintain compliance with complex treatment and follow-up requirements. For some it may be a matter of geographic or temporal convenience. For others it may be a bus token, cab fare, day care, privacy protection, food, a shower, a place to sleep, or just a friendly caseworker who cares. Each TB victim who runs the risk of serious illness and/or convey-
IV
ing the disease to others needs a caseworker, a jointly developed plan, and a supportive agency that sees to its duties with as much vigor as its authority. In many instances, neither the duties of the public health agency, its resources, nor its flexibility is sufficient for the task. Public health authorities and elected policymakers need to evaluate their status and rules governing the control of communicable disease, using current-day mental health procedures as a model to bring TB back under control.-GP
Does Health Beget Satisfaction? [Hall J, Milburn M, Epstein A. A causal mode of health status and satisfaction with medical care, Med Care 1993; 31: 84-94.]
all et al attempt to provide a causal model of relations between health status and satisfaction with medical care. The authors correctly note that many studies have demonstrated a positive relationship between ratings of health status and concomitant ratings of satisfaction with medical care. However, the causal nature of this relationship has not been determined. This longitudinal assessment of geriatric patients in a health maintenance organization examines these two constructs. The authors provide a useful delinea-
H
THE AMERICAN JOURNAL OF SURGERY
VOLUME 166
tion of three causal possibilities: that one's health influences one's satisfaction with medical care at a later time; the level of one's satisfaction with medical care affects one's health status at a later time; and finally, that neither causal pattern is supported, i.e., that any relations are spurious. The results provide strong evidence of a causal relationship between initial health status and later ratings of satisfaction. Not surprisingly, self-perceived health emerged as the best predictor. In their discussion, the authors outline a number of interesting interpretations of the "meaning" of their results and the psychosocial factors that may influence patient-caregiver relationships and judgments of satisfaction with medical care. The authors also present a balanced interpretation of the limits of their findings and the need to test similar causal models with other populations and additional variables such as u t i l i z a t i o n of h e a l t h services. Finally, the authors raise the intriguing (and likely) possibility that health status and satisfaction "cause each other," or that there exists a spiraling, interactive relationship between these two variables. It would be a natural extension of this study to attempt to examine such a hypothesis in a model that accommodates the appropriate instrumental variables in a nonlinear model of reciprocal causation.--LWG
SEPTEMBER 1993
politan areas in New York State American public should learn in managed-care enrollment. more about this vital experiment Quality and consumer satisfac- as a stark contrast to the simplistion have consistently shown tic solutions that appear to lead high ratings. T h e R o c h e s t e r in n a t i o n a l p u b l i c o p i n i o n HMOs also have substantial ex- polls.--RB perience serving the Medicaid population of the region under both mandatory and voluntary From Out of the Past...TB in enrollment programs. Regional planning: Among the the Modern Era most unique and potent tools in the Rochester system is the use of [Gostin LO. Controlling the regional planning for major capi- resurgent tuberculosis epidemic: a tal projects. In this case, commu- 50-state survey of TB status and proposals for reform. JAMA 1993; nity leaders have actively used 269: 255-61.] regional health planning principles to control costs and shape the health care delivery system, ublic health laws have not kept pace with either public enhancing the effect of the reguh e a l t h t e c h n o l o g y or latory criteria of the state. Expenditure limits: Hospitals changes that have occurred in in the Rochester region have long similar problem areas since the operated under a global spending 1960s. The control of communicap. This limit was enforced not cable diseases is the oldest functhrough government sanctions, tion of public health and, as Gosbut rather through the sustained tin points out in this and earlier efforts of community leadership. articles, it hasn't changed much. The hospitals participated in the The right of the "state" to reprocess, adding to the legitimacy strict the liberty of an individual and effectiveness of this volun- in order to protect the rest of the population is of long standing. In tary system. The Rochester approach can- most of the United States, the not be automatically transferred roots are to be found in the conto other communities. There is a cept of the "police power" of the unique history in this communi- state. Public health agencies in ty, and it is essential to view the all 50 states are charged with the model in a longitudinal time responsibility and usually proframe. Nevertheless, the princi- vide the authority to examine, ples underlying the Rochester treat, commit, and generally cona p p r o a c h s h o u l d be r e a d i l y trol the behavior of people who adapted to other circumstances. have dangerous diseases such as These principles include: com- tuberculosis (TB). Although the munity-based governance (with mental health community went active and sustained involvement through three decades of reforfrom the business community); mation to bring its similar aunondiscrimination in benefits thorities to alignment with conand premiums; strong emphasis stitutional and ethical principles, on regional health planning; and the public health establishment budgeting for health expendi- has not. The situations, as Gostin tures. Perhaps most important is points out, are similar. the demonstrated success of any Gostin discusses several asapproach to health care reform, pects of TB control: the duty to which stands in stark contrast to pay for and provide services, the speculative benefits of other medical examinations, treatpopular models. Finally, the ment, emergency detention, corn-
p
THE AMERICAN JOURNAL OF SURGERY
mitment, isolation or quarantine, criminal penalties, confidentiality, and antidiscrimination. The findings are similar under each heading: the laws are usually vague, emphasize authority and control more than the duties of public health, and do not provide adequate constitutional safeguards to either those who are infected or those whom we are trying to protect. Although many communities are revising their TB control programs in 1993 and focusing on the need to tighten their control on the behavior of the direct victims, Gostin suggests that the emphasis on control and implied (and, at times, real) punishment makes control more difficult to maintain. Eventually, of course, if such efforts persist, they will be ruled unconstitutional. Gostin makes three, simple recommendations: (1) " T h e exercise of compulsory powers should be based on an individualized [emphasis added] determination that the person poses a significant risk to the public." (2) The person has a right to a fair hearing, including full respect for procedural rights. (3) Health officials should have available to them a graded array of services and measures to deal with each individual problem, balancing the rights of the individual with the need to protect society. Perhaps the most controversial recommendation is that every patient with active TB be placed on a regimen of directly observed therapy (DOT). Some believe this would be unnecessarily intrusive, claiming that compliant patients can be easily distinguished from noncompliant ones. Although Gostin does not dwell on the point, he makes clear the risk of relying on stereotypes. It is very difficult for patients to maintain a complex treatment regimen for 6 months to 2 years when they are feeling otherwise VOLUME 166
SEPTEMBER 1993
III
POLICY WATCH
well and when the medications themselves may cause some discomfort. The notion that this is more common among people in lower socioeconomic s t r a t a is widespread and erroneous. Others have claimed that universal DOT is too expensive. However, studies in several communities have shown how to keep the cost down, and the cost of a relapse, especially with multiple-drug-resistant organisms, is a severe penalty to pay for such attention. Gostin goes an important step further, however. Similar to concepts now accepted in mental health and in the development disabilities field, he urges that each patient participate in developing an individualized treatment plan. Better to call it an individualized program of services--a contract of sorts between the official agency and the infected individual that attempts to meet the needs of both. Some programs have adopted a simple system of vouchers for a cheeseburger or a periodic payment in cash for compliance. Still, such practices fail to take into consideration the variegated needs of individuals if they are to maintain compliance with complex treatment and follow-up requirements. For some it may be a matter of geographic or temporal convenience. For others it may be a bus token, cab fare, day care, privacy protection, food, a shower, a place to sleep, or just a friendly caseworker who cares. Each TB victim who runs the risk of serious illness and/or convey-
IV
ing the disease to others needs a caseworker, a jointly developed plan, and a supportive agency that sees to its duties with as much vigor as its authority. In many instances, neither the duties of the public health agency, its resources, nor its flexibility is sufficient for the task. Public health authorities and elected policymakers need to evaluate their status and rules governing the control of communicable disease, using current-day mental health procedures as a model to bring TB back under control.-GP
Does Health Beget Satisfaction? [Hall J, Milburn M, Epstein A. A causal mode of health status and satisfaction with medical care, Med Care 1993; 31: 84-94.]
all et al attempt to provide a causal model of relations between health status and satisfaction with medical care. The authors correctly note that many studies have demonstrated a positive relationship between ratings of health status and concomitant ratings of satisfaction with medical care. However, the causal nature of this relationship has not been determined. This longitudinal assessment of geriatric patients in a health maintenance organization examines these two constructs. The authors provide a useful delinea-
H
THE AMERICAN JOURNAL OF SURGERY
VOLUME 166
tion of three causal possibilities: that one's health influences one's satisfaction with medical care at a later time; the level of one's satisfaction with medical care affects one's health status at a later time; and finally, that neither causal pattern is supported, i.e., that any relations are spurious. The results provide strong evidence of a causal relationship between initial health status and later ratings of satisfaction. Not surprisingly, self-perceived health emerged as the best predictor. In their discussion, the authors outline a number of interesting interpretations of the "meaning" of their results and the psychosocial factors that may influence patient-caregiver relationships and judgments of satisfaction with medical care. The authors also present a balanced interpretation of the limits of their findings and the need to test similar causal models with other populations and additional variables such as u t i l i z a t i o n of h e a l t h services. Finally, the authors raise the intriguing (and likely) possibility that health status and satisfaction "cause each other," or that there exists a spiraling, interactive relationship between these two variables. It would be a natural extension of this study to attempt to examine such a hypothesis in a model that accommodates the appropriate instrumental variables in a nonlinear model of reciprocal causation.--LWG
SEPTEMBER 1993