El derecho de acceso sanitario en el contexto del Real Decreto-ley 16/2012: la perspectiva de organizaciones de la sociedad civil y asociaciones profesionales / Right of access to healthcare in the context of the Royal Decree-Law 16/2012: the perspective of civil society organizations and professional associations

Objetivo. La publicación del Real Decreto-ley 16/2012 (RDL 16/2012), que introduce cambios estructurales en el Sistema Sanitario Público Español, puede situarse en el contexto más amplio de políticas de ajuste en el momento actual de crisis económica. En el análisis de la interrelación de crisis económica, políticas sanitarias y salud, la participación ciudadana se nombra entre las potenciales estrategias para mitigar un impacto de la situación en la población. Desde esta valoración, se plantea el interés de un conocimiento de la perspectiva de la ciudadanía sobre las modificaciones introducidas por el RDL 16/2012. Métodos. Revisión narrativa de publicaciones de organizaciones de la sociedad civil y asociaciones profesionales relacionadas con el RDL 16/2012 en el contexto español. Resultados. Se observa una amplia respuesta ciudadana a la introducción del RDL 16/2012. Los documentos revisados incluyen un análisis del cambio del modelo sanitario inherente al RDL 16/2012, así como la previsión de su impacto en el acceso sanitario, la calidad asistencial y la salud. Las organizaciones de la sociedad civil y las asociaciones profesionales aportan recomendaciones y propuestas, además de ofrecer su colaboración en la elaboración de estrategias alternativas de ahorro. Conclusiones. La respuesta al RDL 16/2012 por parte de organizaciones de la sociedad civil y asociaciones profesionales indica el interés de fomentar canales de participación ciudadana para el desarrollo de políticas sanitarias basadas en el objetivo de mantener el carácter universal y la sostenibilidad del Sistema Sanitario Público Español en el momento actual de crisis económica y sistémica (AU)

Objective. The recent publication of the Royal Decree-Law 16/2012 (RDL 16/2012), which introduces structural changes in the Spanish Public Healthcare System, can be placed in the broader context of budgetary adjustments in response to the current economic crisis. An analysis of the interrelationships among economic crisis, healthcare policies, and health reveals that citizen participation is one of several potential strategies for reducing the impact of this situation on the population. This observation raises the interest to know the citizens’ perspectives on the modifications introduced by the RDL 16/2012. Methods. Narrative review of documents related to the RDL 16/2012 published by civil society organizations and professional associations in the Spanish context. Results. A broad citizen response can be observed to the introduction of RDL 16/2012. The documents reviewed include an analysis of changes in the healthcare model inherent to the RDL 16/2012, as well as predictions on its impact on access to healthcare, healthcare quality, and health. The civil society organizations and professional associations offer recommendations and proposals, as well as collaboration in elaborating alternative strategies to reduce costs. Conclusions. The response of civil society organizations and professional associations underscores the importance of strengthening citizen participation in the development of healthcare policies aimed at maintaining the universal character and sustainability of the Spanish Public Healthcare System in the current moment of economic and systemic crisis (AU)

Law, bioethics and practice in France: forging a new legislative pact.

In France, bioethics norms have emerged in close interaction with medical practices. The first bioethics laws were adopted in 1994, with provisions for updates in 2004 and most recently, in 2011. As in other countries, bioethics laws indirectly refer to certain fundamental values. The purpose of this paper is threefold. First, I shall briefly describe the construction of the French bioethics laws and the values they are meant to protect. Secondly, I will show that the practice of clinical ethics, as reported in a few studies on ART, living organ donation and PGD, challenge the role attributed to doctors as "gatekeepers" of those fundamental values. Thirdly, I will suggest that the quality of medical practices would improve if the law focused on strengthening the tacit pact between doctors and patients, rather than putting doctors in charge of enforcing societal values. Doctors, for their part, would limit their role to what they can do best: provide sufficient patient support and safe care. Against those who argue that we should dispense with bioethics laws altogether, I hold that the laws are useful in order to limit the development of abusive practices. However, a new legislative approach should be adopted which would a positive presumption in favor of patients' requests.

Primary care in Europe: entering the age of austerity.

Many European countries have well-developed health systems that offer universal access to health services and which have a strong primary care sector. However, as the financial crisis in Europe progresses, it is leading to significant cutbacks in publicly funded health services. A key objective for primary care physicians will therefore be to work in an environment where resources will be much more limited than in the past. In the longer term, the role of primary care physicians in European health systems will continue to expand to meet the aim of shifting health services to the generally more cost-effective setting of primary care.

Application of "less is more" to low back pain.

An initiative of the National Physicians Alliance, the project titled "Promoting Good Stewardship in Clinical Practice," developed a list of the top 5 activities in primary care for which changes in practice could lead to higher-quality care and better use of finite clinical resources. One of the top 5 recommendations was "Don't do imaging for low back pain within the first 6 weeks unless red flags are present." This article presents data that support this recommendation. We selectively reviewed the literature, including recent reviews, guidelines, and commentaries, on the benefits and risks of routine imaging in low back pain. In particular, we searched PubMed for systematic reviews or meta-analyses published in the past 5 years. We also assessed the cost of spine imaging using data from the National Ambulatory Medical Care Survey. One high-quality systematic review and meta-analysis focused on clinical outcomes in patients with low back pain and found no clinically significant difference in pain or function between those who received immediate lumbar spine imaging vs usual care. Published data also document harms associated with early imaging for low back pain, including patient "labeling," unneeded follow-up tests for incidental findings, irradiation exposure, unnecessary surgery, and significant cost. Routine imaging should not be pursued in acute low back pain. Not imaging patients with acute low back pain will reduce harms and costs, without affecting clinical outcomes.

General practice meeting the needs for psychiatric care in Croatia.

BACKGROUND: In recent decades, general practitioners (GPs) have become critical components of mental health services. However, in Croatia the role of GPs in mental health services is still mostly perceived as "gate keeping", whereas seeking help for serious mental illnesses is mostly restricted to psychiatrists. The aim of this study is to investigate the practices and attitudes of family doctors in providing care for psychiatric patients. SUBJECTS AND METHODS: The study included 111 GPs, working in 38 different locations in four major towns in Croatia. Data were collected using a questionnaire, specifically designed for the purpose of this study. RESULTS: By their own estimation, GPs prescribed antidepressants without a psychiatrist's recommendation in about 37% of patients who use them. Also, GPs prescribed sedatives without a psychiatrist's recommendation in about 60% of patients who use them. Although certain categories of psychiatric patients (elderly, patients with PTSD) were almost always referred to a psychiatrist, it was GPs' attitudes toward psychiatric casualties and their proneness to prescribe antidepressants and sedatives without a psychiatrist's recommendation that predicted whether a patient will be treated by himself of referred to a psychiatrist. "Interest/Competency" and "Knowledge" of the GPs positively correlated with the number of courses attended as a part of continuous medical education (CME). CONCLUSION: Overall, the role of GPs in mental health services in Croatia is changing into a more active one, as a significant portion of patients with depression and anxiety are being treated by GPs. Personal interest and self confidence in proper knowledge and skills, in part acquired also from current CME programs, are determinants of higher autonomy of GPs in treating psychiatric patients. Psychiatrists, as active promoters of community mental health should more actively encourage their alliance with GPs, especially through offering higher quality CME courses.

Has the influence of managed care waned? Evidence from the market for physician services.

Managed care has been the dominant organization of health care coverage in the United States, and seeks to achieve cost control by constraining services. The restrictive practices of managed care organizations have been widely criticized and the role of managed care in constraining health care services may be declining. Physician behavior is also believed to be influenced by the practices of managed care organization. This study examines the evolving nature of managed care and its restrictive effects on the provision of physician services. Physicians can choose whether and to what extent they are involved in managed care, so it is an endogenous decision. We employ instrumental variables method to correct for this endogeneity. Using data from the Community Tracking Study physician surveys from 2000-2001 and 2004-2005, we find that managed care organizations have became relatively less restrictive over time in terms of limiting the provision of physician services, compared to non-managed care organizations. These results suggest that managed care and non-managed care are converging in their effects on the provision of physician services.

Telehealth as gatekeeper: policy implications for geography and scope of services.

Why, despite enthusiasm, is telehealth still a relatively minor part of healthcare delivery in many health systems? We examined two less-considered policy issues: (1) the scope of services being offered by telehealth and how this matches existing arrangements for insured services; and (2) how the ability of telehealth services to minimize barriers associated with geography is dealt with in a system organized and financed on geographical boundaries. Fifty-three semistructured interviews with key stakeholders involved in the management of 43 Canadian telehealth programs were conducted. In addition, quantitative activity data were analyzed from 33 telehealth programs. Two telehealth approaches emerged: telephone-based (N = 3), and video-conferencing-based (N = 40). Most programs reflected, rather than superceded, existing geographical boundaries; with the technology being used, the videoconferencing models imposed significant barriers to unfettered access by outlying communities because they required sites to acquire expensive technology, be affiliated with an existing telehealth network, and schedule visits in advance. In consequence, much activity was administrative and educational, rather than clinical, and often extended beyond the set of mandatory insured services. Despite high hopes that telehealth would improve access to care for rural/remote areas, gatekeeping inherent in certain telehealth systems imposes barriers to unfettered use by rural/remote areas, although it does facilitate other valued activities. Policy approaches are needed to promote a closer match between the expectations for telehealth and the realities reflected by many existing models.

Has the use of physician gatekeepers declined among HMOs? Evidence from the United States.

Since the mid-1980s, health maintenance organizations (HMOs) have grown rapidly in the United States. But despite initial successes in constraining health care costs, they have come under increasing criticism for their restrictive practices. This suggests that, to remain viable, HMOs must change their behavior. Yet few studies offer empirical evidence on the matter. The present study investigates one cost-containment mechanism often associated with HMOs: the assignment of primary care physicians as gatekeepers (who, among other things, monitor patients' use of specialist physicians). In particular, we estimate the effect of physician-HMO involvement on the percentage of HMO patients for whom physicians serve as gatekeepers. We examine this relationship over two time periods: 2000-2001 and 2004-2005. Because physicians can choose whether and to what extent they participate in HMOs, we employ instrumental variables (IV) estimation to correct for the endogeneity of the HMO measure. Although the single-equation estimates suggest that HMO assignment of physician gatekeepers diminished modestly over time, the endogeneity-corrected estimates show no change between the two time periods. Thus, one major tool used by HMOs to constrain health care costs--the physician gatekeeper--has not declined even in a period of backlash against managed care.

[Family doctor-based health care]. / Hausarztbasierte Versorgung.

The idea of family doctor-based health care corresponds to a social necessity for economical health care and a basic requirement for family doctors. However, this request is turned into the opposite by the legal description of a "particularly qualified family doctor". Economic interests dominate, dissect the family doctor level and influence long-standing family doctor-patient relationships and put the performance of social goals into question. Against that, the Family Doctor Association is setting the concept for family doctor-based integrated care, which also places quality demands, but does not exclude physicians basically or by selection of the compulsory health insurance fund.

Managed care redux: health plans shift responsibilities to consumers.

Confronted with conflicting pressures to stem double-digit premium increases and provide unfettered access to care, health plans are developing products that shift more financial and care management responsibilities to consumers, according to findings from the Center for Studying Health System Change's (HSC) 2002-03 site visits to 12 nationally representative communities. Plans are pursuing these strategies in collaboration with employers that want to gain control over rapidly rising premiums while continuing to respond to employee demands for less restrictive managed care practices. Mindful of the managed care backlash, health plans also are stepping up utilization management activities for high-cost services and focusing care management on high-cost patients. While the move toward greater consumer engagement is clear, the impact on costs and consumer willingness to assume these new responsibilities remain to be seen.

Bone and joint diseases around the world. The UK perspective.

Rheumatology is a discipline that has evolved through the influence of physical medicine, with the aid of advances in immunology and epidemiology. An ageing population has seen osteoarthritis and osteoporosis, among other rheumatic diseases, flourish. Health provision relies on the National Health Service (NHS), funded largely, but no longer exclusively, through direct taxation. Access to specialist rheumatology services (secondary care) is achieved by referral through a general practitioner (primary care). Increasingly, primary care is charged with planning clinical services supported by budgets devolved from central government. Rheumatology is a popular discipline for trainee specialists, but consultant numbers are inadequate. One rheumatologist per 85,000 population is deemed desirable, whereas in practice the number is less than one per 120,000. These figures belie the uneven distribution of services. The National Institute for Clinical Effectiveness assesses all new therapies according to their clinical- and cost-effectiveness. Those approved should, in theory, be funded, but this system remains imperfect. A unique initiative in the UK is the central register for those taking biologic agents. Regrettably, the NHS has been underfunded and steps are under way to reverse this in order to match the proportion of gross domestic product spent on health care by other major European economies. The delivery of medical services will have to change to accommodate increasing numbers of women graduates, now exceeding 50%, by increasing job sharing and part-time posts. UK rheumatology has close links with Europe and the US, while increasingly its horizons are broadening, to great advantage.