Study results: employer-based coverage of genetic counseling services

Because advances in genetic medicine are likely to affect the cost and delivery of employer-sponsored health care, plan managers require a basic understanding of related services. By describing and analyzing a survey of health plan managers, the author shows where they may need more information about genetic services in order to negotiate coverage and make informed purchasing decisions. Given these current information gaps, genetic counselors may be helpful to health plan managers by providing information and quality assurance about genetic medicine as it continues to integrate itself into medical practice and as plan managers seek cost-containment approaches in the face of rising health care costs.     

Whistle While You Work: Whistleblowing in the Presence of Competing Incentives and Pressures

This instructional case connects whistleblowing incentives and ethical issues in different reporting environments. It provides three different whistleblowing scenarios that allow students to identify and grapple with multiple whistleblowing incentives, issues and resultant ethical dilemmas present in both the academic and financial reporting environments. The purpose of the case is threefold. First, the case makes students aware of the whistleblowing incentives and ethical issues present in different environments. Second, by linking academic and financial whistleblowing issues across scenarios, students see the relevance of whistleblowing ethics in their current lives and are motivated to develop ethical habits now. Third, the case forces students to practice making decisions in situations with conflicting incentives, uncertainty and ambiguous guidance. Strong conflicting incentives can cloud and challenge whistleblowing intentions.     

Ethical considerations in health care benefits administration

Defining the scope of coverage and limitations in various health plans has become an increasingly difficult and confusing issue. The historical shift to managed care has fundamentally altered the limitations on health care benefits. Because of the existence of "benefits exclusions," confusing issues have emerged in managed care situations. Fundamental fear of health care rationing has raised the awareness of the general public to the ethics of this issue. This article discusses the definitions and examples of certain types of health benefit exclusions and the ethical considerations related to such exclusions.     

Healthcare professionals’ perceptions of risk in the context of genetic testing for the prediction of chronic disease: a qualitative metasynthesis

Advances in genomic technologies and a growing trend towards stratified and preventive approaches to medicine mean that increasing numbers of individuals may have access to information about their genetic makeup, and their risk of developing diseases. This is likely to impact on healthcare professionals involved in the delivery of genetic tests, or in supporting patients who are affected by a disease with a genetic risk factor. It is therefore important to understand healthcare professionals’ perceptions about providing these services, and how they feel about communicating information about genetic risk to patients. This paper provides a systematic review and metasynthesis of qualitative research exploring healthcare professionals’ perceptions of genetic risk in the context of predictive genetic testing for chronic disease. Healthcare professionals expressed a range of reservations about the utility of predictive testing in this context. Professionals judged patients’ understanding of risk information to be limited and subject to bias and a range of sociocultural influences. Concerns about the psychosocial impact of genetic risk information were frequently cited, both in relation to individual patients and the wider impact on their families and communities. The need for provision of multidisciplinary support was described. The concept of responsibility was also an important theme. Healthcare professionals recognized the responsibility that accompanies risk knowledge, and that ultimately this responsibility lies with the patient, not the provider. Our analysis suggests that professionals’ evaluation of the utility of predictive genetic testing is influenced not only by resource deficits, but may also be interpreted as a response to challenging ethical and social issues associated with genetic risk, that are not well aligned with current medical practice.     

“Bounds for Ruin Probabilities in the Presence of Large Claims and their Comparison”, Vladimir Kalashnikov,April, 1999

Abstract

Performance measurement systems and report cards which attempt to measure and report the quality of care provided by managed health-care organizations, have become mainstream in health insurance markets as managed care penetration continues to increase. However, little is known about the impact formal plan evaluations have on the contracting and enrollment decisions made by health insurance purchasers and consumers. Information regarding the link between performance evaluations and enrollment is crucial for those charged with projecting future enrollments in and risk profiles of managed care organizations. This paper describes the performance measurement systems currently being used to evaluate managed care plans and reviews the empirical literature for evidence regarding the impact of measures on plan enrollments.     

Defining management accounting constructs: A methodological note on the risks of conceptual misspecification

This paper stresses the need for a sound conceptual specification of research constructs prior to fitting them to explanatory models. It emphasizes that in addressing the conceptual level of the predictive validity framework [Libby, R., Bloomfield, R., & Nelson, M. (2002). Experimental research in financial accounting. Accounting, Organizations and Society, 27, 775–810], special attention must be paid to two issues: (1) the production of a specific agreed-upon meaning and domain for each construct of interest; and (2) the specification and conceptual justification of the nature and direction of the epistemic relationships between constructs, dimensions and indicators (i.e., reflective vs. formative models; latent vs. emergent models). The paper highlights the importance of both issues especially in the case of practice-defined variables, and it provides guidelines on how to address both aspects of conceptual specification. While the issues raised are pertinent to many research areas, the paper concentrates on the implications for management accounting and control systems (MACS) research, using interactive use of control systems [Simons, R. (1995a). Levers of control. Boston: Harvard Business School Press] to illustrate how researchers should go about specifying meaning and epistemic relationships in MACS research.     

Can patients drive the future of health care?

As the traditional system of health care in the United States gives way to a regime run increasingly by the private sector, a powerful force is emerging: the patient. According to Harvard Business School professor Regina Herzlinger, health care is much like other service industries. Providers that hope to survive must cater to increasingly demanding and well-educated consumers. In a review of Herzlinger's book Market-Driven Health Care: Who Wins, Who Loses in the Transformation of America's Largest Service Industry, Alexandra Wyke, managing editor at the Economist Intelligence Unit, argues that the path to consumerism in medicine will be longer and bumpier than Herzlinger suggests. Consumers of medicine don't simply want health care to be more convenient; they want cures for all ills. How can providers gratify this appetite for ever better medicine? Furthermore, patients are not always capable of making sound decisions about their medical care. And health care professionals, who emphasize the complex nature of decision making in medicine, are doing their best to keep patients from holding the health care steering wheel. Herzlinger has written a bullish book on the virtues of market-driven health care, but, Wyke contends, she has overlooked the far-reaching effects that emerging technology could have in shaping medicine--especially in reducing the need for specialists. She also has given short shrift to the young managed-care industry, which has succeeded in controlling costs and is now under competitive pressure to meet patients' needs better.     

Interventionist research in accounting: reflections on the good,the bad and the ugly

Our paper advances understanding of interventionist research (IVR) as a qualitative accounting research approach. It reflects on the potential value, challenges and key issues, as manifested by the good, the bad and the ugly. The reflection contributes towards clarifying the IVR landscape, thereby forging a future path for IVR as a legitimate qualitative methodology, to enthuse qualitative researchers to produce accounting research relevant to theory, practice and society. The primary contribution is synthesising the interventionist theory and practice literature encompassing a view of the good, the bad and the ugly in interventionist accounting research.     

Risk perception of mobile communication: a mental models approach

Some lay people confronted with a new base station project fear serious health consequences from the high‐frequency radiation, while experts consider exposure under the current international standards as unproblematic. These conflictive estimations may be attributed to the different mental models of lay people and experts. Less is known about lay people’s knowledge in regard to mobile communication and their intuitive understanding of the associated health risks. An adaptation of the ‘Mental Models Approach’ was used to reveal lay people’s beliefs about mobile communication and to learn more about lay people’s information requirements, potential knowledge gaps, and misconceptions. Through the means of open interviews with Swiss experts (N = 16), lay people (N = 16), and base station opponents (N = 15), different mental models were constructed and evaluated. Comparisons between the expert and the lay groups showed several qualitative differences in all identified knowledge domains. Knowledge gaps in regard to changing exposure magnitudes due to the interaction patterns of cell phones and base stations as well as misconceptions about regulation issues and scientific processes were found in both lay groups. In addition, lack of trust in responsible actors and disaffection with base station location processes were mentioned. The reported qualitative insights may be useful for the improvement of further risk communication tools.     

Image theory: An alternative description of audit decisions

Building upon an analysis of audit decisions by Waller & Felix (1984) [in Moriarty, S. and Joyce, E. (eds) Decision Making and Accounting: Current Research (Norman, OK: University of Oklahoma Press, 1984)], an alternative to the expected utility and “heuristics and biases” characterization of decision-making is presented. In this alternative, Image Theory, decisions are about adoption of goals and adoption of plans for attaining the goals, as well as about whether the plans are succeeding. The audit process is interpreted in terms of Image Theory and the salient research issues that this interpretation suggests are examined.     

An examination of ethical standards for tax issues

This study examines the extent to which educational background and demographic factors are associated with students' personal standards for ethical issues involving tax professionals. Two hundred and twenty-three students about to complete an introductory tax course were given ten brief scenarios focusing on the ethical and professional responsibilities of CPAs with tax practices. For each scenario, the students were asked whether they believed the opinion or the situation described was considered appropriate under existing professional standards, and whether they personally believed the opinion or situation described was appropriate. They were also asked whether they believed evading taxes was immoral. The results indicated that female students had higher personal ethical standards for issues involving tax professionals than did male students. Exposure to a course in auditing (the accounting course generally having the most extensive coverage of ethical issues) was associated with higher ethical standards, but exposure to a general course on ethics was not. Students aspiring to be tax professionals had higher ethical standards for issues involving tax professionals than those that did not, but their beliefs about the morality of tax evasion were not significantly different. The implications of these and other results are discussed.     

Ethical values: the real crisis in health care

This author argues that the growth of apathy and greed and loss of ethical values in the current health care delivery system is due to the change in the foundation of the expectations between the consumer and the provider of health care. The agendas of the "third parties" involved with the provision of health care has caused confusion in the mind of the consumer and loss of autonomy for the health care provider. A historical perspective is provided that includes discussion of the issues of culpability for the current outcomes. Finally, the author discusses possible remedies to the current system.     

The US 2000–2002 market descent: clarification

Didier Sornette and Wei-Xing Zhou respond to the issues raised by Anders Johansen in his comment ‘An alternative view’ published in Quantitative Finance 3 C6.     

On the role of sunk costs and asset specificity in outsourcing decisions: a research note

The accounting literature has argued that firms overengage in outsourcing because they tend to ignore the transaction costs involved in buying services from external suppliers. A field experiment with managers of health care organizations shows that decision makers are actually quite sensitive to the asset specificity associated with the “buy” option in an outsourcing decision. However, they also appear inappropriately sensitive to the sunk costs inherent in most real-life outsourcing decisions, and may actually underengage in outsourcing. Prior commitment to internal procurement systematically reduced the willingness to outsource, relative to a pure “make or buy” scenario.     

The influence of self-interest and ethical considerations on managers’ evaluation judgments

Recent empirical studies support self-interest as the sole basis for economic decisions (as predicted by agency theory). However, cognitive moral development (CMD) theory suggests that decision makers will allow ethical/moral considerations to constrain their economic behaviour. The purpose of this study is to resolve the essential conflict between the tenets of agency theory and CMD theory. The results of a laboratory experiment suggest that both moral reasoning level and adverse-selection conditions (self-interest) can have a significant effect on managers’ project evaluation decisions. Specifically, managers are likely to continue a project that is expected to be unprofitable only when adverse selection conditions are present and moral reasoning level is low. Thus, agency theory may not be generalizable to accounting-based economic performance.     

Accounting for decisions and decisions for accounting

Behavioral decision theory (BDT) is concerned with “accounting for decisions”. The development of this interdisciplinary field is traced from the appearance of several key publications in the 1950s to the present. Whereas the 1960s saw increasing theoretical and empirical work, the field really started to flourish in the 1970s with the appearance of the review by Slovic & Lichtenstein (Organizational Behavior and Human Performance, pp. 549–744, 1971), and key papers on probabilistic judgment (Tversky & Kahneman, Science, pp. 1124–1131, 1974), and choice (Kahneman & Tversky, Econometrica, pp. 263–291, 1979). From the early 1980s to the present, BDT has seen considerable consolidation and expansion and its influence now permeates many fields of enquiry. After this brief history, eight major ideas or findings are discussed. These are: (1) that judgment can be modeled; (2) bounded rationality; (3) to understand decision making, understanding the task is more important than understanding the people; (4) levels of aspiration/reference points; (5) use of heuristic rules; (6) the importance of adding; (7) search for confirmation; and (8) thought as construction. Next, comments are addressed to differences between BDT and problem solving/cognitive science. It is argued that whereas many substantive differences are artificial, two distinct communities of researchers do exist. This is followed by a discussion of some major shortcomings currently facing BDT that include questions about the robustness of findings as well as overconcern with a few specific, “paradoxial” results. On the other hand, there are many interesting issues that BDT could address and several specific suggestions are made. Moreover, these issues represent opportunities for accounting research and several are enumerated. Finally, BDT presents “decisions for accounting” in the sense that scarce resources need to be allocated to different types of research that could illuminate accounting issues. The argument is made that BDT is one research metaphor or paradigm that has proved useful in accounting and that should be supported. Such support, however, may mean that some researchers may work on issues that, at first blush, might seem distant from accounting per se.     

Sickness absence and health care in an economic federation

This paper addresses vertical fiscal externalities in a model where the state governments provide health care and the federal government provides a sickness benefit. Both levels of government tax labor income and policy decisions affect labor income as well as participation in the labor market. The results show that the vertical externality affecting the state governments’ policy decisions can be either positive or negative depending on, among other things, the wage elasticity of labor supply and the marginal product of expenditure on health care. Moreover, it is proved that the vertical fiscal externality will not vanish by assigning all powers of taxation to the states.      

Announcement and Publication Decisions and the Use of Prediction Errors in Cross-Sectional Analysis: Evidence on Seasoned Equity Issues

An important concern for empirical analysis of market responses to public releases of information is whether the voluntary nature of announcement and publication decisions imparts a selectivity bias and, if so, how this bias affects empirical results. Using a database of SEC filings of equity issues, all related Wall Street Journal published announcements are identified. The published announcements are used to classify proposed issues into subsamples with homogeneous information structures. Announcement and WSJ publication decisions are found to be non-random but, for industrial firms, not significantly related to firm size or exchange listing. Coefficients estimated without controlling for selectivity are found not to be significantly biased for either industrial or utility issues. However, for industrial issues, significance levels are considerably lower when selectivity bias is controlled. The hypothesis common to other studies of new issue announcement effects that observations from different information structures can be pooled, with coefficient estimates restricted to be equal across information structures, is rejected. The results have implications for the methods used to study cross-sectional market responses     

Poxvirus‐vectored Vaccines Call for Application of the Precautionary Principle

Genetically engineered viruses (GEVs) used as live vaccines are, and will increasingly become, important for prevention of disease in human as well as animal populations. Poxviruses have a number of attractive theoretical and practical advantages as gene expressing vaccine vectors: their large genomes render construction of multivalent vaccines feasible, the vaccines are easy to produce, the virus particles are very thermostable, and inoculation is followed by long‐lasting, protective immune responses. On the other hand, administration and environmental release of GEVs may represent potential unintended harms to human, animal and ecosystem health. We will argue that a strict application of risk‐cost/benefit analyses do not cope appropriately with the current lack of scientific understanding and the complexity of ecosystems that will become GEV recipients, and fail to take into account the deeper ethical groundings that shape the scientific and public opinions. To avoid serious, unintended ecological effects of GEVs, it may be necessary to elaborate the ethical basis for protecting health and the environment. The Precautionary Principle (PP) may provide a basis for adequate consideration of ecological and ethical issues of vital importance to protection of health and environment from unforeseen adverse effects of poxvirus‐vectored vaccines. To operationalise the PP, we suggest that there is a need to identify and systematise lack of scientific understanding, and to acknowledge uncertainty by initiating research with a broad focus involving interdisciplinary research. In this paper we present three main issues related to the employment of the PP: i) identification of scientific uncertainty and its ethical significance in risk assessment and risk management processes, ii) the need for broad risk assessment as a response to scientific uncertainty, and iii) the need for transparency and public involvement to enhance the debate about normative standards concerning acceptability of benefits, risks and uncertainty with regard to GEV use and release.