Consideraciones éticas y médico-legales sobre la limitación de recursos y decisiones clínicas en la pandemia del COVID-19 / Medico-legal and ethical considerations on resource limitation and clinical decisions during the COVID-19 pandemic

La pandemia por COVID-19 ha suscitado problemas éticos y médico-legales, entre los que destaca la asignación equitativa de recursos sanitarios, sobre todo en relación a la priorización de pacientes y el racionamiento de recursos. El establecimiento de prioridades está siempre presente en los sistemas sanitarios y depende de la teoría de justicia aplicable en cada sociedad. El racionamiento de recursos ha sido necesario en la pandemia por COVID-19, por lo que se han publicado documentos de consenso para la toma de decisiones sustentadas en cuatro valores éticos fundamentales: maximización de los beneficios, tratar a las personas igualmente, contribuir en la creación de valor social y dar prioridad a la situación más grave. De ellos derivan recomendaciones específicas: maximizar beneficios; priorizar a los trabajadores de la salud; no priorizar la asistencia por orden de llegada; ser sensible a la evidencia científica; reconocer la participación en la investigación y aplicar los mismos principios a los pacientes COVID-19 que a los no-COVID-19

The COVID-19 pandemic has raised ethical and medico-legal problems, which include the equitable allocation of health resources, especially in relation to the prioritization of patients and the rationing of resources. Priority setting is always present in healthcare systems and depends on the theory of justice applicable in each society. Resource rationing has been necessary in the COVID-19 pandemic, and therefore consensus documents have been published for decision-making based on four fundamental ethical values: maximization of benefits, treating people equally, contributing to creating social value and giving priority to the worst off, from which specific recommendations derive: maximize benefits; prioritize health workers; do not prioritize attendance on a first-come, first-served basis; be sensitive to scientific evidence; recognize participation in research and apply the same principles to COVID-19 patients as to non-COVID-19 patients

[The UN-Convention on the Rights of People with Disabilities and the transition from school to vocational training and career in Germany: public data sources under close scrutiny]. / Die UN-Behindertenrechtskonvention und der Übergang Schule-Ausbildung-Beruf in Deutschland: Öffentliche Datenquellen auf dem Prüfstand.

This paper analyzes public data sources and their requirements for the transition from school to vocational training and career of people with disabilities in the context of Article 31 of the UN-Convention on Rights of People with Disabilities. Different focuses of the public data sources within the involved systems and challenges in data analysis will be presented. These manifest themselves as cross-system interface problems when it comes to the identification and whereabouts of young people with disabilities at the transition from school to vocational training and employment. With these challenges public data sources on the transition from school to vocational training and employment are especially under scrutiny when it comes to developing and implementing policies in respect to the Convention on Rights for People with disabilities and the provision of adequate planning data.

[Autopsies in Switzerland, Germany and Austria: considerations about legal facts and the current situation]. / Obduktionen in der Schweiz, Deutschland und Österreich: Rechtliche und rechtstatsächliche Untersuchungen.

Significant reasons militate for the implementation of clinical autopsies: On the part of physicians and nurses, there is quality assurance, establishment of legal certainty regarding possible accusations of medical errors and development of treatment methods. On the part of patients and their relatives, there is consolation and relief in cases of unexpected death, insight into genetic dispositions and insurance law concerns, to name only a few. However, a continuing decrease of clinical autopsies can be observed in Switzerland, Germany and Austria. The thesis asserting that the often required informed consent of the deceased during his/her lifetime or of close relatives is a crucial reason for this decrease needs to be called into question due to recent studies. Mainsprings are rather structural reasons, such as the often deficient communication with the patient or close relatives, economic reasons, namely the frequently insufficient remuneration for the clinical autopsy, organizational causes, in particular the repeatedly encountered suboptimal collaboration between the individual departments and the pathology department, the high administrative effort and probably the decreasing appreciation of the clinical autopsy.

Wielding the wand without facing the music: allowing utilization review physicians to trump doctors' orders, but protecting them from legal risk ordinarily attached to the medical degree.

This Note identifies a discrepancy in the law governing the decisionmaking that directs patient care. Seeking treatment that a third party will pay for, a patient needs not only a physician-prescribed course of treatment but also an insurer's verification that the cost is medically necessary or otherwise covered by the patient's plan. Both of these decisions directly impact the ultimate care delivered to the patient, but are governed by two very different liability regimes. A patient who suffers an adverse outcome may sue his physician in tort, while a patient who suffers from a lack of coverage may generally sue his insurer only under contract. In other words, when a patient suffers from inadequate care, his potential remedies vary considerably depending on whether the physician or the insurer is the defendant. This discrepancy in liability is the consequence of the federal law governing the administration of employer-sponsored health plans, and its extensive preemption of related state law. Many commentators have called for legal reform to address the distortion of managed care liability that results, arguing that managed care liability must be consistent or that wronged beneficiaries must have access to meaningful remedies. This Note argues that the federal law governing managed care organizations is problematic for a different reason and that the first step toward reform may be more elementary than previously suggested. Specifically, it suggests that the law governing insurers' coverage decisions is inconsistent with the law governing treatment recommendations. Patients suffer the same harm from error in both contexts-but because they can recover substantially more from treating physicians, doctors are named as defendants even when the insurers make errors. Further, this Note argues that simply aligning these two standards might offer a gateway to reform.

[Drug utilization and pharmaceutical cost-containment in germany-perspectives 1 year after enactment of the GMG]. / Arzneimittelversorgung und Kostendämpfungspolitik Perspektiven 1 Jahr nach dem GMG.

After 3 decades of health care cost containment in Germany, enactment of the most recent reform (Health Insurance Modernization Act, GMG) marks a watershed insofar as, apparently, the potential has been largely exhausted for further savings in pharmaceutical spending. Yet the new drugs segment maintains its role as a growth driver, owing to the continuing shift from older to new, and frequently more expensive, products. This observation holds true even after introducing phase 2 reference pricing, covering so-called me too products. Health economic analyses would be required to better differentiate pharmaceutical products based on their incremental cost-effectiveness ratio. However, the opportunity was missed with the GMG to introduce formal health-economic evaluations and thus overcome the counterproductive silo mentality associated with traditional German component management. International experience from Australia, Canada, and the United Kingdom suggests that economic evaluations, while informing rational reimbursement decisions, may in fact contribute to increasing pharmaceutical expenditures. Further tightening of pharmaceutical component management in Germany may result in increasing inefficiencies due to underuse of effective products; furthermore, it appears conceivable that ("second order") dynamic inefficiencies and, hence, social costs might be the consequence of reduced pharmaceutical research and development expenditures.

[Effects of minimum volume regulations on the provision of health care services in cardiology]. / Auswirkung von Mindestmengen auf die stationären Versorgungsstrukturen der Kardiologie.

In order to improve the quality of medical care, minimum volumes for services were set. Hospitals are only permitted to continue to provide these services and settle accounts with the health insurance companies if they are able to achieve these minimum annual volumes. This study is based on service data of the year 2002 from 88 neighboring hospitals of the hospital association Cologne, Bonn and region. In the study, the influence of these regulations on the provision of health care services in cardiology were examined. The cases were grouped according to the different examined services, followed by an analysis of the number of cases for each hospital in comparison to four fictitious minimum quantity models. When the hospital's volume remained below the minimum quantity, these cases were assigned to the nearest hospital still able to provide the service. For the services coronary angiography, PTCA, AICD implantation, EPS and ablation, only marginal case redistributions were determined. Depending on the minimum quantity, service concentrations are only expected for pacemaker implantations. Due to the increasing service concentration as a consequence of the DRG-payment system, a bureaucratic regulation of minimum volumes has become superfluous for most cardiological services. Instead of minimum volume regulations, recommendation of minimum volumes should be made in cardiological guidelines.

Utilization review and managed health care liability.

This article explores the development of jurisprudence interpreting application of the Employee Retirement Income Security Act of 1974 to patient care denials by managed care. It identifies quality-of-care protections for patient care under present federal law. If an insurance company utilization review denies care based on patient-specific reasoning, then the patient may have recourse against the utilization review on the basis of a state law claim of malpractice grounded in medical decision-making by the insurance company.

[Health situation of and health service provided for adult migrants--a survey conducted during school admittance examinations]. / Gesundheitliche Lage und Gesundheitsversorgung von erwachsenen Migranten--ein Survey bei der Schuleingangsuntersuchung.

BACKGROUND: In spite of the increasing numbers of migrants in Germany, only few epidemiological studies have been carried out to investigate the health status of ethnic minorities in Germany. Results from national and international studies on the health of immigrants are inconsistent showing either increased or decreased morbidity in relation to native inhabitants. A survey was undertaken to study the self-reported health status, help-seeking behaviour, and health care utilization among immigrants and Germans. METHODS: 565 adults (276 immigrants and 289 Germans, 97% parents) in Bielefeld, Germany, were interviewed while they accompanied children who attended the pre-school medical examinations. In the analysis descriptive statistics and logistic regression models were used. RESULTS: The self-reported general health status of the study population was good for Germans and immigrants. Germans utilized health care facilities and preventive programmes (e. g. screening programmes) more frequently than immigrants. Furthermore, Germans reported higher levels of satisfaction with health care and a higher level of knowledge about several diseases as compared to immigrants. Logistic regression models indicate that neither migration itself (OR = 0.7, 95% CI = 0.4 - 1.1) nor socio-economic factors (OR for low vs. high social level = 1.2, 95% CI = 0.6 - 2.4) were significantly associated with physical diseases among the study population. CONCLUSIONS: We found no indications that immigrants are less healthy compared to Germans. Further investigations are needed to clarify the differences in patterns of health care utilisation and participation in preventive programmes among Germans and ethnic minorities.

Finance issue brief: medical necessity: year end report-2003.

The information in this issue brief is based on a 50--state survey and a recent literature review. The Health Policy Tracking Service recognizes the complexity of this issue and discourages the use of this document as a sole resource on the issue.

[Quality of Statutory Inpatient Database Before Introducing DRGs]. / Formale Qualität von Leistungsdaten auf rahmengesetzlicher Grundlage im Vorfeld der DRG - Einführung.

According to the legislation of the Federal Republic of Germany (Gesundheitsstrukturgesetz 1993) defined performance figures must be listed for each case of inpatient care. As hospital morbidity data are essential for further development of the health care system and for introducing the DRGs, the corresponding statistical data of a German federal territory of the year 2000 were studied in respect of several aspects of their quality: conformity with the requirements of law, plausibility and ability to transport essential medical information. Notable variations were found between the departments and different medical disciplines without interdependence to variant hospital status. Only about 40 % of departments of surgical disciplines transferred data according to legal requirements. Some disciplines showed higher percentages of unspecific coding (e.g. traumatology). The described deficits impair data reliability. The study offers a feedback to hospital departments with regard to their formal data quality. Periodic investigation may thus help to improve data quality in future.