Finding elderly patients lying on the floor beside their beds despite the presence of elevated bedrails seems paradoxical: how can a patient fall out of bed when the bedrails are up? Surprisingly, this paradox constitutes one of the leading incidents plaguing hospitals in the United States today. It exemplifies a much larger problem created, we believe, by the uncritical adoption of measures designed to enhance patient welfare, but which may in fact undermine it. This article documents our experience with bedrails, reviews the literature, and comments on the rationale for routine adoption of bedrails for the hospitalized elderly. It concludes by advocating that a randomized, controlled study be conducted to determine whether bedrails constitute protection or a hazard to the average elderly patient.

Although only historians in the future will know, it appears that non-marital and unconventional sexual relations between individuals today are on the increase. One of the more notable landmarks of this trend is the case, Marvin v. Marvin, in which the court recognized the rights of unmarried cohabitants. Individuals now seek wider legal recognition of a variety of interpersonal relationships and, by so doing, are rejecting the limitations of society's traditional agreement, marriage.

This article examines a small subset of the legal interactions and consequences when individuals establish non-marital relationships. Two types of situations and cases will be examined—“reluctant paternity” and the transmission of herpes simplex disease. These may turn out to be unimportant legal curiosities, but they are useful for examining the conflict of rights of privacy and duties of disclosure (right to information) in intimate (here, sexual) interactions between two people. The cases to be examined in detail are in areas of great flux, where a court in one state cites to recently overturned decisions in another state's courts.

Direct reimbursement by insurers for the services of nurses and nurse practitioners is a primary goal of many state and national associations of nurses. Direct reimbursement means either that a nurse is paid directly by the insurer for nursing or nurse practitioner services rendered, or that the patient is reimbursed for costs incurred for those services. The issue is important to nurses for several reasons.

First, reimbursement allows rhe consumer of health care a wider choice of types of providers from whom to purchase care. As a practical matter, if an insurer does not reimburse for the care rendered by one type of professional, patients are likely to seek care from another whose services are paid by health insurance. The General Accounting office, for example, has lited restrictive third party reimbursement practices as one of the obstacles impeding the wider use of nurse-midwives. Second, some types of health care are less expensive when rendered by a nurse or a nurse practitioner; reimbursement thus can provide quality care at a lower cost. Third, reimbursement is a form of recognition that practice styles are changing. In 1983, West Virginia became the first state that explicitly reimburses for care provided by “nonsalaried duly licensed registered professional nurses engaged in private nursing practice or partnership.”

Expenditures for health care have reached a point where they represent almost 10 percent of the gross national product; health care has become one of the country's largest industries. Moreover, the cost of health care continues to increase more rapidly than inflation. Many policy makers and critics of the health care system believe that the promotion of competition among health care providers can be instrumental in keeping the price of health services down.

The health care boom and ever accelerating health care expenditures have stimulated the availability of new providers, and many hope that these alternative providers will enhance competition in the health care system. Non-physician practitioners, such as podiatrists, optometrists, chiropractors, and nurse-midwives, and such non-traditional delivery mechanisms as health maintenance organizations (HMOs), preferred provider organizations (PPOs), ambulatory surgical centers, and birthing centers, have been gaining increasing support at both the federal and state levels of government. Proponents believe that these alternative providers and mechanisms not only produce more options for consumers but also help contain the cost of health care in the United States.

For a number of years, some non-physician health service providers have moved to secure status as independent, autonomous providers of health services. In addition, non-physician providers have sought, often through the state legislatures, eligibility to receive payment directly, on a fee-for-service basis, from private and governmental third party payers; alternatively, they have sought for their charges to be reimbursed to their patients by insurers on such a basis. The struggle for autonomy is related to, and is preliminary to, the struggle for access to, or eligibility for, payment through third party payment mechanisms.

The purpose of this article is to explore the implications of access to such payment in the current economic climate concerning the delivery of health services. The primary focus is on the nursing profession, in light of its continuing struggle to secure greater autonomy and to improve the economic rewards for nurses. The nursing profession is waging this struggle because it recognizes that gaining direct access to third party payment would increase the potential for economic success in developing private, independent nursing practices.

American hospitals are in turmoil, experiencing declines in community esteem, reductions in Medicare payments, pressure for cost control by employers and insurers, and internal conflict between managements and medical staffs. Each of these conflicts is simply another facet of an overall problem: American society's recently conceived notion that unlimited access to the best available health services constitutes a right. Americans have adopted this idea, however, without considering the economic consequences in an environment of rapidly advancing technology and an aging population. Costs have escalated rapidly, reaching ten and one-half percent of the gross national product; the health services system is in strong competition with other important societal segments for scarce resources. The money may not be running out, but a rather naive institution, the community hospital, has suddenly found itself in an environment for which it is ill-prepared.

Governmental licensure of health professionals has a long history, but significant federal intervention in hospital financing did not begin until after World War II with the advent of the Hill-Burton program, which provided funds for hospital expansion. Medicare introduced federal payment for hospital care provided to the elderly and used formulas for cost reimbursement in 1966.