---------------------------The Value of Drug Addiction Research---------------------------

Michael Nader from the Wake Forest Primate Center presents his talk titled The Value of Drug Addiction Research. He suggests that we are approaching the problem of drug addiction in the wrong manner, and we need to reassess our current policies.

Sunday, November 02, 2014

Why is studying international health and different healthcare systems important?

With the amazing globalization that we face every day, many diseases of an infectious nature can easily migrate to different parts of the world to spread disease. Chapter 2 of Comparative health systems. Global perspectives offers several of these notable examples, such as severe acute respiratory syndrome (SARS) and Avian flu. Yet, all types of infectious diseases are able to migrate to different parts of the world through the regular interactions of people as travel on holiday, carry-on the normal business practices required in a global market, or even transmission through shipping various products from one country to another. Understanding the interrelatedness of people around the world is vital to addressing infectious disease transmission which affect us here at home.

Interestingly enough, noninfectious diseases can also be transmitted globally, but by a much slower mechanism called development. Developing nations initially have much higher rates of various infectious diseases, but with the development of industry as well as a change in dietary habits, the major causes of death shift to cardiovascular disease, diabetes, and respiratory diseases (Johnson & Stoskopf, 2010, p. 20). Understanding the clear link between these environmental factors as nations develop and disease allows for appropriate public policy to ensure meaningful preventative interventions.

In the United States of America, we have experienced a severe economic recession and realized that we as Americans had to make serious choices about the use of each healthcare dollar. So it is only natural with such limited resources that we would have to leverage knowledge. The easiest way to leverage knowledge is to work with and learn from other countries with respect to medical and public health research. More than ever organizations like the Centers for Disease Control (CDC) are called to do this very work. They directly influence how we stop the immediate transmission of diseases from entering and spreading throughout our country, as well as how we can learn from other countries to improve our own health and well-being as Americans in numerous other ways, such as improved medical therapies for diseases we share with other countries (CDC, 2014).



Johnson, J., & Stoskopf, C. (2010). Comparative health systems. Global perspectives.

Boston, MA: Jones and Bartlett Publishers.

            Center for Disease Control. (2014) Global Health. Atlanta, GA: Author. Retrieved from







Transtheoretical Model of Behavior Change (TTM): Research, Models, and Education.

            The transtheoretical model of behavior change (TTM) is an example of how research can support the creation of a model and how appropriate healthcare education can lead to the advancement of population health initiatives (Nash, Reifsnyder, Fabius, & Pracilio, 2010). This model accurately represents the transition from unhealthy behavior or condition, such as tobacco smoking or obesity, to healthy behavior and wellness. The available research demonstrates this is an effective means of motivating patients towards either a healthy lifestyle or appropriately self-managing a chronic condition.

Because the greatest challenge facing the American healthcare system today comes in the form of chronic care management of diseases, such as cardiovascular disease or diabetes, an understanding of this model is extremely important in delivering appropriate and effective healthcare (Nash et al., 2010). Physicians, the leaders of our health care teams, report that they themselves do not have training in behavior change (Moser & Stagnaro-Green, 2009).  And yet, in a variety of settings, TTM has had “unprecedented impacts” (Nash et al., 2010, p. 34) on treatment outcomes when integrated in healthcare delivery.

Any practicing clinician or healthcare provider has experienced the frustration of pushing a tobacco smoking patient towards a goal of cessation. The practitioner and the patient clearly know that tobacco smoking has many negative effects, and yet the patient is unable to quit smoking. TTM is an effective, viable alternative to this authoritarian and ineffective form of patient education and support. TTM and similar models can be used in a variety of prevention and treatment scenarios, ranging from addiction to unhealthy diets to proper administration of medication. Clearly, this is a call for continuing research, training, and integration of TTM into our current health care system, particularly due to the fact that the cost of TTM is modest compared to the significant problems we face today and in the future managing chronic diseases.



Moser E.M. & Stagnaro-Green, A. (2009). Teaching behavior change concepts and skills during the third-year medicine clerkship. Academic Medicine, 84(7), 851-8. http://dx.doi: 10.1097/ACM.0b013e3181a856f8.

Nash, D. B., Reifsnyder, J., Fabius, R. J. & Pracilio, V. P. (2010). Population health: Creating a

culture of wellness. Sudbury, MA: Jones & Bartlett Learning.


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            It is clear that the U.S. healthcare system was in disarray with its growing expenditures and worsening healthcare outcomes for certain groups within the U.S. population (Nash, Reifsnyder, Fabius, & Pracilio, 2010). Although American healthcare has demonstrated many positive attributes (Stossel, 2007), problems with healthcare financing, access to care, certain technologies, and disparity in healthcare outcomes grew (Nash et al., 2010). Historically our government has found a role in healthcare administration and governance. Incidents of this not only include licensing boards and regulatory bodies, but often in systemwide reform such as the creation of Medicare and Medicaid (Center for Medicare and Medicaid Services [CMS], 2014a).

            Incidents of these policy reforms have not always been positive. While the Patient Protection and Affordable Care Act (PPACA) has introduced many positive outcomes within the U.S. health care system (United States Department of Health and Human Services [HHS], 2014), there have been negative consequences to the healthcare reform law. Bloomberg Businessweek (2013) reports large-scale termination of policies that did not meet the high standard of the new law. Also, existing policies and new policies that do meet the high standards have increased in costs dramatically for many. Even leaving some uninsured.

            Two key goals of the PPACA are to increase access to healthcare for the entire population and lower costs (HHS, 2014). As an immediate byproduct of healthcare reform, this has been somewhat damaging to the momentum of progress (Bloomberg Businessweek, 2013), but healthcare reform moves slowly and many of the goals the United States desires to achieve can only be realized over many years (Nash et al., 2010).

            Similarly, an important healthcare initiative has been the improvement of health information technology and transmission of personal health information. The government’s role has been significant in requiring and financing of Electronic Health Records (EHRs) (CMS, 2014b). With the high costs of health care already at the brink (Nash et al., 2010), the idea of exposing the industry to more costs seemed unthinkable. Instituting EHRs and similar technologies, though a much-needed component within health care delivery (Nash et al., 2010) would not have been possible for the entire U.S. healthcare system without appropriate government financing at a time historically when America was suffering from a recession.

Many healthcare providers and administrators, such as those within our own practice, resisted implementation of these expensive technologies. An independent medical practice, such as ours, could not have financed these expensive technologies. Also, appropriate implementation is a slow process. Our office like many experienced very long lag times during training in early implementation. For a brief period of time, many providers felt that healthcare was being diminished due to the use of EHRs. Yet today, the improved health benefits for patients are starting to be realized as we progress through every stage of the Meaningful Use requirements mandated by the government to earn the incentive monies. While earlier published research echo what my practice experienced with respect to resistance and concerns about cost (Hoffman & Podgurski, 2008), a more recent publication has verified the benefits of this initiative and concerns about cost have lessened (iHealthBeat, 2013). Again, the benefits to our healthcare system are not immediately realized and often take years to be achieved.

            Healthcare administration, regulations, and reform are not perfect. Increased standards do often increase some costs and increased costs must be shouldered by the consumer and taxpayer, but hopefully they will benefit Americans individually as patients and as a society in general. Over time when certain initiatives have failed to meet their goals or conditions have worsened due to an unrealized negative consequence, then appropriate changes must be made once again. As Americans, we tend to consider this progress. Hopefully by examining what works well in healthcare reform in other countries we can adapt their best practices to the unique situation here at home (Palfreman & Reid, 2008). While there are certainly risks we must realize when attempting change and progress to improve the current situation in U.S. healthcare today, the idea to do is nothing at all is much more risky. When all involved work together from government to business to individual patients, progress can be realized over time.







Center for Medicare and Medicaid Services. (2014a). History. Retrieved from


Center for Medicare and Medicaid Services. (2014b). EHR incentive programs.

Retrieved from http://www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/index.html

Hoffman, S. &Podgurski, A. (2008, October 30). Case Western Reserve University professors call for regulation of Electronic Health Records. news center. Retrieved from


Nash, D. B., Reifsnyder, J., Fabius, R. J. & Pracilio, V. P. (2010). Population health: Creating a

culture of wellness. Sudbury, MA: Jones & Bartlett Learning.

Palfreman, J. (Writer/Director) & Reid, T.R. (Writer) (2008). Sick around the world.

[Television series episode]. In D. Fanning (Executive producer), Frontline.

Arlington, VA: Public Broadcasting Service.

Patient Protection and Affordable Care Act, 42 U.S.C. section 18001 (2010).

Cost of EHR Systems Outweigh Financial Benefits, Survey Finds. (2013, August 15). iHealthBeat: Reporting Technology Impact on Health Care. Retrieved from http://www.ihealthbeat.org/articles/2013/8/15/cost-of-ehr-systems-outweigh-financial-benefits-survey-finds

Stossel, J. (2007). Sick in America, whose body is it anyway? [Television series episode].  20/20.

New York, NY: American Broadcasting Service News.

Tozzi, J. (2013, October 29). Yes, People Are Losing Their Insurance Under Obamacare.

Bloomberg Businessweek. Retrieved from http://www.businessweek.com/articles/2013-


United States Department of Health and Human Services. (2014). About the law.

Retrieved from http://www.hhs.gov/healthcare/rights/index.html



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The United States has moved away from the concept of merely addressing disease of our citizens, and has moved toward a goal of health maintenance, disease prevention, and overall well-being. The United States has recently begun numerous initiatives to address the health of the U.S. population. The United States now sees the importance of such determinants as emotions, financial circumstances, social environment, and even spirituality as the United States attempts to achieve overall wellness and health (Substance Abuse and Mental Health Services Administration [SAMSHA], 2014). To achieve optimal health and wellness of all U.S. citizens, the current health care delivery system must address prevention, screening, behavior change, patient self-care, chronic care management, disease management, and health care disparities (Nash, Reifsnyder, Fabius, & Pracilio, 2010).

The United States currently has a confluence of stakeholders in our health care delivery system. The government has a role in overseeing the care and wellness of our citizens through regulations and often public health care delivery, citizens, who are the patients, private businesses that wish to have healthy employees, the scientific community, the health care industry, the health care educational system, social and ethnic groups, nonprofit ethical organizations, and so on (Nash et al., 2010). A result of these varied and often conflicting stakeholders is poor outcomes, high costs, inadequate delivery, and limited access (Nash et al., 2010).

In an attempt to address these issues, the U.S. government has begun to work with various stakeholders. The cornerstone of the current administration is the Patient Protection and Affordable Care Act (PPACA, 2010). President Obama, working with various stakeholders, addressed specific issues as they related to access to care, namely, mandating insurance coverage for all U.S. citizens, removing denials for pre-existing conditions, allowing young adults to stay on their parents’ insurance coverage, ending arbitrary denials of claims, and instituting an appeal process for denials of claims (United States Department of Health and Human Services [HHS], 2014a).  The PPACA also addressed issues related to prevention of disease, health maintenance, technology, and information sharing.

Clearly at this point, the various goals of the PPACA have yet to be achieved, but sharing the burden with other stakeholders has begun. Other initiatives also seek to achieve the goals of the PPACA began prior to this legislation and continues today. The government has worked closely with individual health care providers to form Accountable Care Organizations (ACOs) that have been structured to improve delivery of care and lower costs (Centers for Medicare and Medicaid Services [CMS], 2014a). Another important initiative is the government’s assistance to improve medical technology and data sharing in a meaningful way through health care providers’ Electronic Medical Records (EHRs) (CMS, 2014b). Nash et al. (2010) suggest the Patient Centered Medical Home (PCMH) is a key issue for integrated and collaborative care needed to improve health care and outline how various governmental and private health care institutions and companies have begun to institute these delivery models. The National Committee for Quality Assurance (NCQA) (2014) is one of several credentialing bodies to ensure that the PCMH meets established goals.  In addition, the government has begun working with health care providers to monitor specific health care metrics such as preventative measures and evidence-based clinical decision-making criteria. This has been achieved largely with Physician Quality Measure Reporting, today known as PQRS (American Medical Association (AMA), 2014).

This country has set important health care goals to be reached (HHS, 2014b). It is clear that integrated and collaborative health care systems must include various stakeholders working together. Private business depends upon low costs to continue to exist as an entity, and the government must use health care dollars wisely and ensure the health care of its citizens. Individuals have a desire to be healthy and well and need to take a greater role in achieving these ends (Nash et al., 2014). Health care providers of all kinds must work together in a team-based system to improve health care delivery includes treatment of disease as well as prevention (NCQA, 2014).  There will be no other way in which we can meet the current health care needs of our U.S. population unless all stakeholders work together. The government has a vital role in achieving these goals, but it is not solely responsible for the health and well-being of the entire population. To shunt all responsibility onto the government would be to dismantle the good that we have achieved with regard to health care in this country (Stossel, 2007) and to limit the greater good that is achievable by working together in concert with shared responsibility. This country has grown to greatness on a foundation of rights and freedoms. However, this country is always aware that with rights and freedoms, ultimately come shared responsibility. Although the current system has many flaws and shortcomings, the recent regulations and initiatives have allowed the United States to be set in the right direction.










American Medical Association. (2014). Physician Quality Measure Reporting. Retrieved from


Centers for Medicare and Medicaid Services. (2014a). Accountable care organizations (ACO).

Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html

Centers for Medicare and Medicaid Services. (2014b). EHR incentive programs.

Retrieved from http://www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/index.html

Nash, D. B., Reifsnyder, J., Fabius, R. J., & Pracilio, V. P. (2010). Population health: Creating a

culture of wellness. Sudbury, MA: Jones & Bartlett Learning.

National Committee for Quality Assurance. (2014). Patient centered medical home recognition.

Retrieved from http://www.ncqa.org/Programs/Recognition/ Practices/ PatientCenteredMedicalHomePCMH.aspx

Patient Protection and Affordable Care Act, 42 U.S.C. section 18001 (2010).

Stossel, J. (2007). Sick in America, whose body is it anyway [Television series episode]?  In  20/20.

New York, NY: American Broadcasting Service News.

Substance Abuse and Mental Health Services Administration. (2014). Eight dimensions of  wellness: A holistic guide to whole-person wellness. Rockville, MD: Author. Retrieved from http://www.promoteacceptance.samhsa.gov/10by10/dimensions.aspx

United States Department of Health and Human Services. (2014a). About the law.

Retrieved from http://www.hhs.gov/healthcare/rights/index.html

United States Department of Health and Human Services. (2014b). Health People 2020: Health-

related quality of life and well-being.  Retrieved from http://www.healthypeople.gov /2020/about/ QoLWBabout.aspx



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The United States currently spends 17% of its GDP on health care costs (Johnson, 2010). If changes do not occur, this figure could grow to 25%. Such astronomical costs can only lead to further financial stress upon an already burdened system. Currently the United States does not truly have a health care system. It has a “sick care” system that addresses acute and chronic illness (Nash, Reifsnyder, Fabius, & Pracilio, 2010). Not focusing on prevention represents a lost opportunity to lower costs and improve the general health and well-being of our citizens.

Much work has been done in this area. Repeatedly it has been demonstrated that the return on the investment for prevention is significant (Nash et al., 2010). One such study at the University of Michigan Health Research Center focused on such health determinants as alcohol consumption, physical activity, smoking, and even seatbelt usage in an employee wellness program. The results demonstrated a real value of managing health risks in a preventative way rather than addressing at a later time the negative health outcomes of chronic and acute disease. Johnson & Johnson found similar results with a return on investment of four dollars for every dollar spent on prevention (Centers for Disease Control and Prevention [CDC], 2014). These results have not only been demonstrated in employee wellness projects but also in community-based projects by the CDC. Thus benefits can be recognized through prevention with individuals, with businesses, and with communities as a whole.

With these very promising results, it is hard to believe that the United States spends only 5% of its total healthcare dollars on prevention (Nash et al., 2010). The conundrum lies in how to achieve appropriate preventative care. Routinely, the United States looks to its medical doctors to deliver appropriate healthcare, but a family physician would have to work an average of 22 hours per day to meet all of the necessary guidelines for acute, preventative, and chronic care of a typical practice (Yarnell et al., 2009). Clearly, this is impossible. There is simply not enough money or healthcare providers to deliver all the care we currently require. Something must change.

Several new initiatives have attempted to address this problem. Two of these are accountable care organizations (ACOs) and patient centered medical homes (PCMH).  ACOs attempt to join together individual physician practices of various specialties along with other health care professionals to coordinate care efficiently and create a significant cost savings while improving the delivery of care (Center for Medicare and Medicaid Services, 2014).  PCMH focuses on individual practices to create a team approach to offer holistic care that addresses prevention as well as appropriate acute and chronic disease care (National Committee for Quality Assurance, 2014). As the United States moves forward in addressing its healthcare crisis, new pay structures are being considered to remunerate health care providers for delivering preventative care.

No single stakeholder is responsible for all of the health care of the nation. Individuals, health care providers, employers, and communities must work together to address the growing healthcare crisis.








Center for Disease Control and Prevention. (2014). Investing in prevention improves productivity and reduces employer costs. Retrieved from http://www.cdc.gov/policy/resources/ Investingin_ReducesEmployerCosts.pdf

Center for Medicare and Medicaid Services. (2014). Accountable Care Organizations (ACO).

Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html

Johnson, Toni. (2014, March 23). Healthcare Costs and U.S. Competitiveness. CFR.org. Retrieved from http://www.cfr.org/competitiveness/healthcare-costs-us-competitiveness/p13325

Nash, D. B., Reifsnyder, J., Fabius, R. J., & Pracilio, V. P. (2010). Population health: Creating a

culture of wellness. Sudbury, MA: Jones & Bartlett Learning.

National Committee for Quality Assurance. (2014). Patient centered medical home recognition.

Retrieved from http://www.ncqa.org/Programs/Recognition/ Practices/ PatientCenteredMedicalHomePCMH.aspx

Yarnall, K. S. H, Østbye, T., Krause, K. M., Pollak, K. I., Gradison, M., & Michener, J. L. (2009) Family physicians as team leaders: “Time” to share the care. Preventing Chronic Disease 6(2), A59.  Retrieved from http://www.cdc.gov/pcd/issues/2009/ apr/08_0023.htm.


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Medical Errors and Quality Health Care

From the Hippocratic Oath, the promise make by the physician to willingly refrain from doing any injury, there is today a clear directive upon the healthcare provider of today to Do No Harm. Yet one of the biggest challenges facing the U.S. health care system is medical errors (Nash, Reifsnyder, Fabius, & Pracilio, 2010). When addressing health care quality and safety, a key measure is technical performance. A health care team must assure that the appropriate testing occurred, the appropriate evaluation took place, the accurate diagnosis was achieved, and an effective treatment was planned and executed.

            Certainly this is no easy task. Often the image of high-quality medical care in America consists of expensive, modern technology, mandatory certification and credentialing, and costly, new pharmaceuticals. Much of this has been true for the United States. But often, improving healthcare can be achieved at a very low cost. Recent research has shown health care organizations  significantly improving the quality of healthcare by reducing medical errors with simple initiatives such as preventive screenings, checklists, and enhanced discharge planning from hospitals (Nash, Reifsnyder, Fabius, & Pracilio, 2010).

            It is unusual to consider that highly-trained experts could benefit from something as simple as a checklist. Gawande (year)the surgeon, public health educator, and author has written on this very issue (2007). He recounts how in the early days of airplanes, a group of Army pilots used a checklist to improve safety. Today, similar checklists have been instituted with remarkable effects. With the numerous clinical challenges facing a team, certain mundane, yet crucial issues, may be overlooked. Anyone who has operated has remembered a sponge count an instrument count to ensure nothing was left inside of a patient during closure. Similarly, hand washing or the number of days a line or drain should be left in a patient must never be overlooked. These two simple issues if overlooked may lead to infection and ultimately lead to increased morbidity and mortality rates.

            In this manner, a coordinated healthcare team of various experts and providers at different levels can identify problems and create meaningful solutions (Nash et al., 2010). What good is the most expensive drug that can cure a disease if it is not administered correctly to the patient? As the healthcare industry faces the current challenges in America, various stakeholders must work together to improve the quality of the care that we currently have. Small, yet transformational, changes may be possible, if we apply known successful solutions, such as a checklist strategy. Similar solutions to challenges in quality should also be based upon accurate identification of problems followed by meaningful, cost-effective solutions at every level of healthcare delivery.



Gawande, A. (2007, December 10). The checklist. The New Yorker. Retrieved from http://www.newyorker.com/magazine/2007/12/10

Nash, D. B., Reifsnyder, J., Fabius, R. J. & Pracilio, V. P. (2010). Population health: Creating a

culture of wellness. Sudbury, MA: Jones & Bartlett Learning.




            Recently the United States has begun to modernize healthcare delivery through the use of electronic medical records (EMRs) (Center for Medicare and Medicaid Services [CMS], 2014). The importance of this cannot be overstated. Population health depends upon the appropriate acquisition and use of accurate health care data (Nash, Reifsnyder, Fabius, & Pracilio, 2010). From hemoglobin A1Cs to body mass index calculations, accurate data allows health care teams to fully appreciate the health status of patients and decide upon appropriate interventions.

            Although various EMRs have been around for quite a while, the government recognized that all EMRs did not have similar functions. Therefore the CMS began a coordinated effort to overhaul health information technology for the U. S. health care system through Meaningful Use incentives (2014). In this way, qualified health care providers would be funded to acquire high- functioning systems meeting certain criteria . While financing permitted the initial purchase of certified systems, further financial incentives required systems to be used to gather and transmit specific data and provide patients with specific healthcare information, including preventative education.

            While this initiative has moved health care delivery forward, it has not been without significant costs. While Medicaid and Medicare incentives are significant, they will eventually end, and health care providers will still be required to make very large monthly payments for continued service and routinely be required to carry the cost of further upgrades. While independent practices struggle today to make payroll, these new costs may eventually cause all practices to sell out to corporate entities (Speights, 2013). As the shift from independent practice to hospital-owned or health care system-owned practices continues, an amazing increase in costs occurs for the same services (When doctors sell out, hospitals cash in, 2013). So while improvement to the health information system has had a positive impact on healthcare delivery, it has also had some negative impacts as well.

            The health of patients is determined by more than just medical care, and consideration must be given to other health fields that require documentation and transmission of patient data. While the Patient Protection and Affordable Care Act (2010) has increased much-needed access to behavioral health services for Americans, there has been no similar initiative for electronic behavioral health records (Getz, 2013). Just as the need for accurate and transmittable data in behavioral health exists, the electronic record dilemma is further complicated by increased need for confidentiality of all mental health records and few real financing options for those who deliver behavioral health services ( Getz, 2013; Health Insurance Portability and Accountability Act, 1996; United States Department of Health & Human Services, 2014).

Integrated healthcare has been promoted in accountable care organizations and patient- centered medical homes to increase quality and lower costs. As the United States continues to address its ongoing issues with information technology, communication between various health care providers and institutions is not enough. Integrated care allows us to take in various health determinants and work in an interdisciplinary manner to improve treatment outcomes, lower costs, and enhance the health and well-being of patients (Nash et al., 2010).  Therefore, various fields and professions - medical and non-medical - involved with the health and well-being of patients must have access to electronic record-keeping systems that can appropriately share protected patient data. Equal oversight and financing from the federal government is needed in instituting high-functioning, protected electronic record systems that collect and transmit data for all patient care in behavioral health as well as other professions.



Center for Medicare and Medicaid Services. (2014). EHR incentive programs.

Retrieved from http://www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/index.html

Getz, L. (2013). EHRs in behavioral health — a digital future? Social Work Today, 13(3), 24.

Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. § 1320d-9 (2010).

Nash, D. B., Reifsnyder, J., Fabius, R. J., & Pracilio, V. P. (2010). Population health: Creating a

culture of wellness. Sudbury, MA: Jones & Bartlett Learning.

Patient Protection and Affordable Care Act, 42 U.S.C. section 18001 (2010).

Speights, K. (2013, June 8). Obamacare Shoving Doctors Out of Private Practice. The Motley Fool. Retrieved from http://www.fool.com/investing/general/2013/06/08/obamacare-shoving-doctors-out-of-private-practice.aspx

United States Department of Health & Human Services. (2014). HIPAA Privacy Rule and Sharing Information Related to Mental Health. Retrieved from http://www.hhs.gov/ocr/privacy/ hipaa/understanding/special/mhguidance.html

 When doctors sell out, hospitals cash in. (2013, July 8). Community Oncology Alliance. Retrieved from http://www.communityoncology.org/site/blog/detail/2013/07/08/july-8-2013-when-doctors-sell-out-hospitals-cash-in.html


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Cultural influences, particularly religion and ethnicity, must be considered when policy attempts to overcome barriers or resistance to delivering healthcare.

            Cultural influences, particularly religion and ethnicity, must be considered when policy attempts to overcome barriers or resistance to delivering healthcare. As with women in Nigeria under Sharia law who struggle to have even basic rights, such as the right to life and free from harm (Deeter, 2003), there are many challenges to deliver healthcare around the world that relate to culture.

            The examples are numerous: Jehovah’s Witnesses refuse blood transfusions. Recently in Seoul,  routine heart surgery to correct a child’s congenital abnormality was refused; the child died (Deccan Herald, 2014). Other notable cases of ultra-conservative religious parents refusing medical treatment for their children are easily found and numerous. Also, religious issues present health concerns. One such issue occurs in New York City. The Orthodox Jewish custom of oral suction circumcision appears to have infected male babies in New York with herpes (Blau & Lestch, 2014).

Americans have heard of cases of African girls enduring genitalia mutilation and female circumcision with horrific life-long complications (Katz, 2014). Many American health clinics have seen parents object to vaccines, such as the Human Papilloma Virus (HPV) vaccine Gardasil, which not only prevents the HPV, but significantly reduces risk of cervical cancer. (Nierenberg, 2013). Other examples of atrocities against women, same-sex oriented persons, and so on, as well as examples of one ethnic group or religion acting against another occur around the world. Those affected experience debilitating injuries, starvation, lack of medical care, or even death.

As healthcare policy makers address issues along these lines, they must allocate funding to address core issues to resolve inter-tribal conflicts and inter-religious conflicts. They must address misunderstanding and misinformation concerning healthcare issues with respect to many religious and cultural beliefs, but do so in a culturally-sensitive manner.

I personally experienced some of these cultural challenges abroad. While in Haiti in 2000, I was one of three healthcare providers leading a large team to deliver much-needed medical care to the local population. Cultural-sensitivity and respect was a must when interacting with Haitian patients. Voodoo is a significant religion and often the only resource for combating disease. Getting buy-in from the local leaders and those seeking care is essential. Very often, the voodoo priests were threatened and drum-beating would occur outside the camp – which was quite unsettling if you have seen Hollywood movies of voodoo rituals. Appropriate interviews with patients to ascertain what they believed and what they had tried prior to seeing us was essential. Then we used interpreters to explain why certain remedies we provided might be more helpful or work alongside voodoo remedies that were not harmful. Ideally, the government moving voodoo into a purely religious profession and out of healthcare practice is needed, but a difficult task. Addressing cultural inputs is essential in Haiti, around the world, and at home in America.









Baby dies after parents refuse treatment for religious reason. (2014, December 13). Deccan

             Herald. Retrieved from http://www.deccanherald.com/content/120327/baby-dies-


Blau, R. & Lestch, C. (2014, August 3). Herpes in newborns raise concerns about oral suction

             circumcisions, city officials hope to regulate practice. New York Daily News. Retrived

             from http://www.nydailynews.com/new-york/herpes-newborns-raises-concerns-oral-


Deeter, J. (2003). Nigeria -The road north. Nigerian women speak out. [Television series

             episode]. FRONTLINE/World. Berkley, CA: WGBH educational foundation. Retrieved

Katz, A. (2014, February 6). Blood, fear and ritual: Witness to female circumcision in Kenya.

              Time Lightbox. New York, NY. Retrieved from http://lightbox.time.com/2014/02/06/


Nierenberg, C. (2013, March 18). Despite physician advice, parents refuse HPV vaccine.

              Yahoo News. Sunnyvale, CA. Retrieved from http://news.yahoo.com/despite-physician-




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Population Health Ethics

 There historically has been a distinct difference between the delivery of health care from the perspective of the medical community’s focus on individuals and the population-focused delivery of interventions from the public health perspective (Shickle, 2009). As such, conflicts arise due to limited resources and competing ideologies of best use and fairness. Therefore, routinely, decisions have to be made that require an ethical perspective. Having a clear understanding of the concepts and theories surrounding these conflicts and being able to put them into practice is essential.

In my studies to earn a PA degree and an MBA, I have taken courses that focus on these issues, not truly considering these as real world issues for actual practice. The Centers for Disease Control and Prevention (CDC, 2014) has a Public Health Ethics Unit that offers direction and guidance in steering the CDC in its decision-making process. Health care institutions and organizations are now mandated via administrative rules, external quality agencies, and third-party payors to incorporate ethics committees and review boards with the expressed intent of guiding the decision-making process in an ethical manner and reviewing past decisions to ensure an ethical direction was taken.

In my own practice, we have a mandate from Center for Medicare and Medicaid Services (CMS) to institute an ethics committee around patient rights. The Hospital Corporation of America (HCA, 2008) offers a tool that we use for guidance in forming and maintaining an ethics committee. HCA refers to leading authorities such as the American Medical Association (AMA) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for guidance in matters concerning ethics committees.

But are these committees and review boards mere formality? The fear is that actual opportunities to improve clinical practice ethically will be missed due to the busyness of the work week and committee members will rush through the quarterly meetings in a distracted-manner, only to return to business as usual.  To avoid this, the committee rotates membership and attempts to include motivated participants. The committee presents actual patient issues as well as real problems with the overall delivery of clinical services. The committee includes a member of the health care community not employed by the practice and one non-health care member who has received care or has had a family member who has received care (though not necessarily from the practice).

                        The committee, in this way, has been able to rule on individual patient complaints and incident reports and generally determine best use of limited resources. Ethical decision-making concepts have helped correct processes that lead to medical errors and guided future business decisions. As always, “buy-in” from administration, providers, and the ancillary staff is necessary for this work to be effective. A demoralizing issue can occur if decisions reached by the committee to steer clinical practice are dismissed as irrelevant or impractical. To address the obstacle of “buy-in,” a culture of ethics has been forged with the language used and emphasis placed on ethical issues such as safety, health, confidentiality, rights, fairness, and equity.








Centers for Disease Control and Prevention. (2014). Advancing excellence & integrity of CDC science. Retrieved from http://www.cdc.gov/od/science/integrity/phethics/

Hospital Corporation of America. (2008). HCA’s Clinical ethics manual. Retrieved from http://webcache.googleusercontent.com/search?q=cache:uwqgy9ygZucJ:hcaethics.com/CPM/HCA%2520Manual_2008-09.doc+&cd=3&hl=en&ct=clnk&gl=us

Shickle, D. (2009). The ethics of public health practice: Balancing private and public interest within tobacco policy. British Medical Bulletin, 19(1), 7-22. http//dx.doi.org/10.1093/bmb/ldp022


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