Harald T Schmidt | University of Pennsylvania (original) (raw)

Papers by Harald T Schmidt

Legitimation ethischer Entscheidungen im Recht

todeclare-unesco-on-ethics-human-rights.html; see also C. Macpherson, "Global bioethics: did the ... more todeclare-unesco-on-ethics-human-rights.html; see also C. Macpherson, "Global bioethics: did the universal declaration on bioethics and human rights miss the boat?", J Med Ethics 33 (2007), 588 et seq. 4 W. Landman/U. Schüklenk, "UNESCO 'declares' universals on bioethics and human rights-many unexpected universal truths unearthed by UN body", Developing World Bioethics 5 (2005), iii et seq. 5 See also Macpherson, see note 3, 588 et seq and note 49. Williams' criticism is interesting in light of the WMA's practice of engaging with stakeholders. At the time of writing the WMA was consulting on a new version of the Declaration of Helsinki. The declaration is widely regarded as the pre-eminent guidance on medical research. However, the consultation process has been set up in a way that restricts input to the extent that comments are invited exclusively via the WMA's national organisations (or the experts they choose to consult). A previous consultation inviting general comments over the summer of 2007 was poorly advertised, and the results were not made publicly available. See also H. Schmidt/A. Schulz-Baldes, "The 2007 Draft Declaration of Helsinki-Plus ça Change...?", Hastings Center Bioethics Forum, available at http://www.bioethicsforum.org/Declaration-of-Helsinki-new-draft.asp.

Frontiers in public health services & systems research, 2013

Employers are increasingly using wellness incentives, including penalties for unhealthy behavior.... more Employers are increasingly using wellness incentives, including penalties for unhealthy behavior. Survey data suggests that people are willing to accept the principle of penalizing those perceived to take health risks, but the equally relevant question of the magnitude of acceptable penalties is unclear. While the principle of penalizing overweight and obese people has some support, findings from a population-level experiment (n=1,000) suggest that the acceptable size of penalties is comparatively small, around $50: more than 10-fold below levels favored by advocates. Reward-based incentives are favored over penalty-based ones by a factor of 4. Of two different ways of framing penalty programs, poorer and higher weight groups appear to find the one that is more overtly penalizing less acceptable. Levels of incentives matter on effectiveness as well as on ethical grounds, as it cannot be assumed that it is equally easy for all to meet health targets to secure a benefit or avoid a pen...

JAMA Health Forum, 2021

IMPORTANCE Medicaid work requirements seek to promote health and personal responsibility but can ... more IMPORTANCE Medicaid work requirements seek to promote health and personal responsibility but can also jeopardize health care access. Physicians have a central function in assisting patients with exemption requests, but it is unclear how their role affects patient welfare, professionalism, and the ethical and legal justification of programs. OBJECTIVE To understand the degree of variability in physician response to assist patients with depression in receiving a Medicaid work requirement exemption. DESIGN, SETTING, AND PARTICIPANTS We conducted a mailed survey experiment among practicing primary care physicians in the first 4 approved states (Arkansas, Kentucky, Indiana, New Hampshire) in July and October of 2019. We report response, cooperation, refusal, and contact rates in line with American Association for Public Opinion Research (AAPOR) standards. EXPOSURES In each state, we used an experimental factorial design to randomize recipients to 1 of 4 patient clinical scenarios. MAIN OUTCOMES AND MEASURES The primary outcome was the indicator of willingness to assist a patient reporting depression with an exemption. RESULTS We received 715 responses (overall AAPOR response rate: 21%; cooperation rate: 84%; refusal rate: 4%; contact rate: 25%). Respondents' mean (SD) age was 54 (12) years; mean (SD) time since graduation, 26 (12) years; 435 (61%) identified as male; 177 as Democrat (25%); 156 as Republican (22%); 197 as Independent/other (28%); and 185 as declined/unknown (26%); the mean (SD) share of Medicaid patients was 29% (21%). We found that 97 of 387 physicians (25%) would offer assistance even when state policy would not support an exemption, and 170 of 315 (54%) would not offer assistance when regulations would require this. Moreover, 49 of 245 respondents (20%) who deemed an exemption appropriate indicated that they would not assist. State, administrative effort, political affiliation, and perceived appropriateness were statistically associated with the odds of assisting with an exemption. CONCLUSIONS AND RELEVANCE In this survey study of primary care physicians, we found substantial variation regarding willingness to assist patients qualifying for a work requirement exemption where none should exist. Insofar as work requirements are implemented again, it is critical to proactively identify measures to ensure that patients qualifying for exemptions are not put at risk due to either the burdensomeness of exemption procedures, or physicians' political or personal views.

Public Health Ethics Analysis, 2016

Chronic diseases include conditions such as heart disease, stroke, cancer, diabetes , respiratory... more Chronic diseases include conditions such as heart disease, stroke, cancer, diabetes , respiratory conditions, and arthritis. In high-income countries, chronic diseases have long been the leading causes of death and disability. Globally, more than 70 % of deaths are due to chronic diseases, in the United States , more than 87 % (World Health Organization [WHO] 2011). Almost one in two Americans has at least one chronic condition (Wu and Green 2000). Aside from the cost in terms of human welfare, treatment of chronic disease accounts for an estimated three quarters of U.S. health care spending (Centers for Disease Control and Prevention [CDC] 2012). Chronic diseases directly affect overall health care budgets, employee productivity, and economies. Globally, noncommunicable diseases account for twothirds of the overall disease burden in middle-income countries and are expected to rise to three-quarters by 2030, typically in parallel to economic development (World Bank 2011). Of particular concern to many low-and middle-income countries is that threats to population health occur on two fronts simultaneously: "In the slums of today's megacities, we are seeing noncommunicable diseases caused by unhealthy diets and habits, side by side with undernutrition" (WHO 2002). Four modifi able risk factors are principal contributors to chronic disease , associated disability, and premature death: lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption (CDC 2012). One in three adult Americans is overweight , another third is obese, and almost one-fi fth of young people between The opinions , fi ndings , and conclusions of the author do not necessarily refl ect the offi cial position , views , or policies of the editors , the editors ' host institutions , or the author ' s host institution .

Nature Medicine, 2021

Many vaccine rationing guidelines urge planners to recognize, and ideally reduce, inequities. In ... more Many vaccine rationing guidelines urge planners to recognize, and ideally reduce, inequities. In the United States, allocation frameworks are determined by each of the Centers for Disease Control and Prevention's 64 jurisdictions (50 states, the District of Columbia, five cities and eight territories). In this study, we analyzed vaccine allocation plans published by 8 November 2020, tracking updates through to 30 March 2021. We evaluated whether jurisdictions adopted proposals to reduce inequity using disadvantage indices and related place-based measures. By 30 March 2021, 14 jurisdictions had prioritized specific zip codes in combination with metrics such as COVID-19 incidence, and 37 jurisdictions (including 34 states) had adopted disadvantage indices, compared to 19 jurisdictions in November 2020. Uptake of indices doubled from 7 to 14 among the jurisdictions with the largest shares of disadvantaged communities. Five applications were distinguished: (1) prioritizing disadvantaged groups through increased shares of vaccines or vaccination appointments; (2) defining priority groups or areas; (3) tailoring outreach and communication; (4) planning the location of dispensing sites; and (5) monitoring receipt. To ensure that equity features centrally in allocation plans, policymakers at the federal, state and local levels should universalize the uptake of disadvantage indices and related place-based measures.

International journal of health policy and management, Oct 29, 2017

Financial conflicts of interest exist between industry and physicians, and these relationships ha... more Financial conflicts of interest exist between industry and physicians, and these relationships have the power to influence physicians' medical practice. Transparency about conflicts matters for ensuring adequate informed consent, controlling healthcare expenditure, and encouraging physicians' reflection on professionalism. The US Centers for Medicare & Medicaid Services (CMS) launched the Open Payments Program (OPP) to publicly disclose and bring transparency to the relationships between industry and physicians in the United States. We set out to explore user awareness of the database and the ease of accessibility to disclosed information, however, as we show, both awareness and actual use are very low. Two practical policies can greatly enhance its intended function and help alleviate ethical tension. The first is to provide data for individual physicians not merely in absolute terms, but in meaningful context, that is, in relation to the zip code, city, and state averages....

International journal of health policy and management, Jan 15, 2017

Increasingly, healthcare and non-healthcare employers prohibit or penalize the use of tobacco pro... more Increasingly, healthcare and non-healthcare employers prohibit or penalize the use of tobacco products among current and new employees in the United States. Despite this trend, and for a range of different reasons, around half of states currently legally protect employees from being denied positions, or having employment contracts terminated, due to tobacco use. We undertook a conceptual analysis of legal provisions in all 50 states. We found ethically relevant variations in terms of how tobacco is defined, which employee populations are protected, and to what extent they are protected. Furthermore, the underlying ethical rationales for smoker protection differ, and can be grouped into two main categories: prevention of discrimination and protection of privacy. We critically discuss these rationales and the role of their advocates and argue that enabling equality of opportunity is a more adequate overarching concept for preventing employers from disadvantaging smokers.

American journal of public health, 2017

Equity and Noncummincable Disease Reduction Under the Sustainable Development Goals

SSRN Electronic Journal, 2015

Currently proposed Sustainable Development Goals (SDGs) include a timely call to significantly re... more Currently proposed Sustainable Development Goals (SDGs) include a timely call to significantly reduce the burden of noncommunicable diseases (NCDs). Existing policy guidance highlights cost-effective interventions for NCDs, but focusing just on cost-effectiveness risks exacerbating socioeconomic and health inequalities rather than reducing them. In implementing the SDGs, targets and interventions that benefit the worst off should be prioritized. The United Nations should develop practical guidance to assist policy makers at the country level with incorporating equity considerations.

PLoS medicine, 2015

Harald Schmidt and Anne Barnhill highlight the need to ensure equity in the proposed Sustainable ... more Harald Schmidt and Anne Barnhill highlight the need to ensure equity in the proposed Sustainable Development Goals.

BMJ (Clinical research ed.), Jan 25, 2015

D i s c u s s i o N P a P e R about this series... This series is produced by the Health, Nutriti... more D i s c u s s i o N P a P e R about this series... This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank's Human Development Network. The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate. are entirely those of the author(s) and should not be attributed in any Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual authors whose name appears on the paper. Enquiries about the series and submissions should be made directly to the Editor Martin Lutalo (mlutalo@worldbank.org) or HNP Advisory Ser-For more information, see also www.worldbank.org/hnppublications.

The Lancet, 2015

In her 2012 reconfi rmation speech as WHO Director-General, Dr Margaret Chan asserted: "universal... more In her 2012 reconfi rmation speech as WHO Director-General, Dr Margaret Chan asserted: "universal coverage is the single most powerful concept that public health has to off er. It is our ticket to greater effi ciency and better quality. It is our saviour from the crushing weight of chronic noncommunicable diseases that now engulf the globe". 1 The UN General Assembly is currently considering proposals for Sustainable Development Goals (SDGs), succeeding the Millennium Development Goals. 2 SDG 3, focusing on health, specifi cally includes universal health coverage (UHC) among its targets. Unquestionably, UHC is timely and fundamentally important. 3-5 However, its promotion also entails substantial risks. A narrow focus on UHC could emphasise expansion of access to health-care services over equitable improvement of health outcomes through action across all relevant sectors-especially public health interventions, needed to eff ectively address non-communicable diseases (NCDs). WHO fi rst endorsed UHC in its 2005 resolution on sustainable health fi nancing, calling on states to provide "access to [necessary] promotive, preventive, curative and rehabilitative health interventions for all at an aff ordable cost". 6 The resolution and its UHC concept fi rmly and narrowly centre on health insurance packages fi nanced through pre-payment. This narrow understanding is echoed in major recent reviews of 65 empirical studies on UHC progress. 7-9 The proposed SDGs also separate population-level public health measures from UHC, addressing the former as distinct targets, not under UHC. 2 Yet, a broader understanding encompassing nonclinical measures can also be found in relevant WHO documents. 4,5 Independent of UHC's conceptual indeterminacy, clinical health services are an essential part of UHC, 4,5,10 and are likely to dominate post-2015 state health system improvements. In implementing UHC, how can we ensure continued emphasis on the full spectrum of public health interventions? Unmediated, a narrow UHC focus risks that fi ve distinct pressures prioritise expanded curative clinical services at the expense of individual and population-level health promotion, prevention, 11 and action on social determinants of health. 12 The risk is that this focus leads to more health-care services, but worse overall health outcomes, with less equitably distributed benefi ts. First, unbalanced, the introduction of UHC usually increases inequity by disproportionately benefi ting the wealthiest groups. 13 Although there are some exceptions, UHC progress analyses from 11 countries at diff erent levels of development suggest poorer people often lose out initially. UHC expansion generally begins with civil

Frontiers in Public Health, 2015

Mayo Clinic proceedings, 2011

Fairness and wellness incentives: what is the relevance of the process-outcome distinction?

Preventive medicine, 2012

To determine whether the commonly drawn distinction between the fairness of incentives targeting ... more To determine whether the commonly drawn distinction between the fairness of incentives targeting behavioral processes (or effort) and those targeting outcomes (or achievement) provide suitable grounds for favoring either approach in healthcare research, policy and practice. Conceptual analysis, literature review. A categorical distinction between process- and outcome-based incentives is less crisp than it seems. Both processes and outcomes involve targets, and both are subject to differences - across and within socio-economic groups - in circumstance and perspective. Thus, a spectrum view is more appropriate, in which the fairness of incentive programs increases with the extent of control that people have. The effectiveness of incentives is a further relevant consideration, and some available evidence suggests that incentives closer to the outcome-end of the spectrum can be more effective. Simple distinctions between processes and outcomes by themselves provide little assurance that...

Moving forward with wellness incentives under the Affordable Care Act: lessons from Germany

Issue brief (Commonwealth Fund), 2012

Health care payers in the United States and abroad have used wellness incentives as a tool to imp... more Health care payers in the United States and abroad have used wellness incentives as a tool to improve health and reduce costs. In Germany, public insurers operate many such programs. Participation nearly doubled between 2004 and 2008, reaching one-quarter of the publicly insured population. An evaluation of one large wellness program there found that it reduced costs. However, population-level survey data also suggest that individuals with low incomes or poor health are less likely to enroll. In the United States, the Affordable Care Act raised the maximum allowed size of wellness incentives, which could lead to wide differences in insurance premiums between users and nonusers of programs, and may risk reintroducing a form of medical underwriting. The German experience confirms the cost-saving potential of programs, but also suggests that they should be evaluated rigorously to ensure they do not disadvantage those with health problems or low incomes.

Journal of health politics, policy and law, 2014

Employer interest in offering financial incentives for healthy behaviors has been increasing. Som... more Employer interest in offering financial incentives for healthy behaviors has been increasing. Some employers have begun to tie health plan-based rewards or penalties to standards involving tobacco use or biometric measures such as body mass index. The Patient Protection and Affordable Care Act attempts to strike a balance between the potential benefits and risks of wellness incentive programs by permitting these incentives but simultaneously limiting their use. Evidence about the implications of the newest generation of incentive programs for health, health costs, and burdens on individual employees will be critical for informing both private and public decision makers. After describing the many pieces of information that would be valuable for assessing these programs, this article proposes more narrowly targeted reporting requirements that could facilitate incentive program development, evaluation, and oversight.