System Constraints on Optimal Care

Health care systems operate at many levels and take many forms: hospital risk management policies, insurance company coverage determinations, Medicaid and Medicare reimbursement rules, the medical malpractice system, federal regulation of physician business practices, and national health association policies. This month's issue looks at how these systems—essential to the delivery of health care in the 21st century—affect the day-to-day practice of medicine and how physicians manage the unintended consequences of systems that sometimes constrain good patient care.

Volume 10, Number 5: 263-354 Full Issue PDF
  • Case and Commentary
    May 2008

    Physician's Accountability for System Failure

    David Lovinger, MD
    Dr. Jones has a duty to determine how the test results were lost and why, disclose this information to his patient, Mrs. Taylor, and see that she is not held responsible for the costs of rerunning the test.
    Virtual Mentor. 2008; 10(5):267-270. doi: 10.1001/virtualmentor.2008.10.5.ccas1-0805.
  • Case and Commentary
    May 2008

    Securing Diagnostic Services within System Constraints

    Bruce Patsner, MD, JD
    A physician has an obligation to order necessary diagnostic tests for a patient on Medicaid with whom he or she has an established patient-physician relationship regardless of whether the cost of the necessary test will be reimbursed.
    Virtual Mentor. 2008; 10(5):278-281. doi: 10.1001/virtualmentor.2008.10.5.ccas3-0805.
  • Case and Commentary
    May 2008

    Medical Culture and Error Disclosure

    Amy G. Lehman, MD, MBA
    When medical errors have occurred, physicians at different levels of training face various pressures imposed by the culture and hierarchy of medicine, risk management, and malpractice liability systems. Despite these pressures, the preferred course of action, professionally and ethically, is to disclose mistakes to patients.
    Virtual Mentor. 2008; 10(5):282-287. doi: 10.1001/virtualmentor.2008.10.5.ccas4-0805.
  • Case and Commentary
    May 2008

    Do Secret Shoppers Have a Place in Medicine? Commentary 1

    James C. Loden, MD
    A pro and con argument for and against employing secret shoppers to evaluate a clinical practice environment.
    Virtual Mentor. 2008; 10(5):288-291. doi: 10.1001/virtualmentor.2008.10.5.ccas5-0805.
  • Case and Commentary
    May 2008

    Do Secret Shoppers Have a Place in Medicine? Commentary 2

    Richard C. Frederick, MD
    A pro and con argument for and against employing secret shoppers to evaluate a clinical practice environment.
    Virtual Mentor. 2008; 10(5):291-294. doi: 10.1001/virtualmentor.2008.10.5.ccas5-0805.
  • Medical Education
    May 2008

    The Ambulatory Long Block: A Systems-Based Practice Innovation

    Eric J. Warm, MD
    There are many elements and much coordination involved in the design and implementation of an effective resident training program in systems-based practice.
    Virtual Mentor. 2008; 10(5):295-299. doi: 10.1001/virtualmentor.2008.10.5.medu1-0805.
  • In the Literature
    May 2008

    Keeping Patients Safe: The Ethics of Quality Improvement

    Sara Platte, MD
    Quality improvement initiatives in clinical medicine are part research and part patient care and pose challenges to traditional forms of ethical oversight.
    Virtual Mentor. 2008; 10(5):300-303. doi: 10.1001/virtualmentor.2008.10.5.jdsc1-0805.
  • Health Law
    May 2008

    ERISA: A Close Look at Misguided Legislation

    Lee Black, JD, LLM
    ERISA, a piece of federal legislation passed in 1974 to protect pension funds and other retirement benefits, has been the source of much controversy and litigation concerning the liability of insurers in employer health benefit plans who deny coverage or reimbursements for specific medical treatments.
    Virtual Mentor. 2008; 10(5):307-311. doi: 10.1001/virtualmentor.2008.10.5.hlaw1-0805.
  • State of the Art and Science
    May 2008

    Amniocentesis: Indications and Risks

    Maura Parker Quinlan, MD, MPH
    Learn the risks and benefits associated with amniocentesis and the about the American College of Obstetrics and Gynecology's current recommendation that the genetic test be offered to all pregnant women.
    Virtual Mentor. 2008; 10(5):304-306. doi: 10.1001/virtualmentor.2008.10.5.cprl1-0805.
  • Policy Forum
    May 2008

    Medicare's “Never-Event” Initiative

    Jared Hossack, MD, MBA
    Medicare will not pay for treatment of 8 preventable, hospital-acquired conditions (e.g., object left in place during surgery, catheter-associated urinary tract infection) that were not present when the patient was admitted.
    Virtual Mentor. 2008; 10(5):312-316. doi: 10.1001/virtualmentor.2008.10.5.pfor1-0805.
  • Medicine and Society
    May 2008

    Can Health Care Engineering Fix Health Care?

    Peter J. Fabri, MD, PhD
    Health care engineering, if applied to medicine, can transform the health care system for the better.
    Virtual Mentor. 2008; 10(5):317-319. doi: 10.1001/virtualmentor.2008.10.5.msoc1-0805.
  • History of Medicine
    May 2008

    The U.S. Health Care Non-System, 1908-2008

    George B. Moseley III, JD, MBA
    Learn about the development of the systems for delivery and reimbursement of health care in the U.S. from the unregulated free-market state in 1908 to the complex, highly managed state in which it exists in 2008.
    Virtual Mentor. 2008; 10(5):324-331. doi: 10.1001/virtualmentor.2008.10.5.mhst1-0805.
  • Viewpoint
    May 2008

    The Teaching of Law in Medical Education

    Nirav D. Shah, JD
    Medical schools should have formal curriculum on the laws and regulations that pertain to medical practice.
    Virtual Mentor. 2008; 10(5):332-337. doi: 10.1001/virtualmentor.2008.10.5.oped1-0805.