Survival of the fittest. The 'competition' model for health care.

The following are excerpts from an article first published in the Health/PAC Bulletin in 1981. This lengthy analysis was written in response to various proposals made during the late 1970s and early 1980s to unfetter the invisible hand of free-market competition in order to solve the nation's health care "crisis." Twelve years later...the health care "crisis" is considerably more grave, and it has become even more popular to wave the "invisible" hand in the hope it will go away. Twelve years later, the objections Sigelman raises have not gone away either, and his conclusions--that in the face of the competition model, the need is greater than ever for consumers to organize to compel providers to deliver services that respond to the needs of the community--is, unfortunately, prophetic.

Interactions between parents and pediatric primary care physicians about children's mental health.

Interaction patterns between parents and pediatricians were examined during 1,378 well-child visits to four public and private pediatric clinics. During 327 visits, parents listed at least one psychosocial concern related to their child's mental health. At 37 percent of these visits, parents said they did not wish to discuss the concern with the physician. Physicians failed to address concerns during approximately 35 percent of visits at which parents were willing to discuss them. Successful parent-physician interactions were three times more frequent in private practices than in a public clinic; they were more likely when fewer concerns were stated and less likely when behavior problems were the concern. Parents concerned about the parent-infant relationship were four times more likely to be referred to outside mental health services, although these cases were relatively rare. Older children and families receiving Medicaid were also more likely to be referred to such services.

Infant home apnea monitoring. A five-year assessment.

Home apnea/bradycardia monitoring is commonly utilized in the management of infants who have had apnea episodes. Little is established, however, regarding appropriate decision-making guidelines and efficacy. The 5-year experience of the Western Massachusetts Apnea Evaluation Program was reviewed to examine patient outcome and to identify prognostic clinical features. Significant recurrent sleep apnea occurred in 7 of 110 infants in the combined awake and asleep group, and in 2 of 45 siblings of babies dying of SIDS. Unclear histories, normal laboratory tests, and uncertain diagnoses made it impossible to identify features that would indicate infants at risk for recurrence of apnea. Our data indicate that home apnea monitoring lacks specificity but is probably effective in reducing morbidity and mortality. It currently appears to be the most optimal means of managing infantile apnea.

Palm-reading the invisible hand: a critical examination of pro-competitive reform proposals.

KIE: The current emphasis of government policymakers on stemming health care cost inflation by means of marketplace competition rather than regulation is assessed in terms of its potential impact on those covered by employer-paid health insurance, the poor, and the elderly. The competitive strategy is seen as creating serious problems of equity and access to care for the poor and for those at high medical risk.^ieng