Applying the common rule to public health agencies: questions and tentative answers about a separate regulatory regime

U. S. Health Researchers Review their Ethics Review Boards: A Qualitative Study

VIRTUALLY ALL RESEARCH INVOLVING HUMAN subjects in the United States must be reviewed by an institutional review board, a form of research ethics review board. This article reports the results of qualitative research on how investigators regard this regulatory regime. Interviews were conducted with forty investigators conducting health-related research. Most respondents shared the regulations' goals, but doubted that the regulations, as implemented, promoted these goals efficiently, effectively and fairly. The interviews suggest that efforts to raise researchers' ethical consciousness have been, over time, quite successful, but that implementation of the regulations remains problematic. Research aimed at better defining the problem to be solved b y the r egulatory sy stem, and at a ssessing the effectiveness of the regulatory tools for solving properly defined problems, could guide a more productive debate about human subject protection.

Legal impediments to implementing value-based purchasing in healthcare

The U.S. healthcare system continually confronts the challenge of controlling costs, improving quality and patient safety, and increasing or maintaining patient access to care. Payors and purchasers of healthcare (both public and private) strive to develop mechanisms to guarantee that they are purchasing the highest-value care – seeking to ensure that amounts paid take into account and provide incentives encouraging the delivery of high-quality, cost-efficient care. Through “value-based purchasing” (“VBP”) strategies, healthcare payors and purchasers are transforming from passive payors of claims (as in a traditional fee for service system) to active purchasers of quality care. To date, employers, health plans, and the Centers for Medicare and Medicaid Services (“CMS”) have implemented well over 100 VBP programs. However, progress is slower than anticipated. As the Institute of Medicine (“IOM”) and others have noted, adoption of VBP reforms may be hampered by legal barriers arising from a number of state and federal laws. The goal of this paper is to identify potential state and federal legal impediments to implementing VBP in healthcare.

Ethics, practice, and research in public health

Ethical issues that can arise in distinguishing public health research from practice are highlighted in 2 case studies--an investigation of a tuberculosis outbreak in a prison and an evaluation of a program for improving HIV prevention services. Regardless of whether such public health investigations represent research or practice, we see a need for ethics oversight procedures that reflect actual risks and enable timely responses to crises. Such oversight should accommodate the perspectives of persons and communities affected by public health threats and by governmental responses to those threats; it should further recognize that public health ethics is a distinct field combining bioethics, political philosophy, human rights, and law.

The role of state law in protecting human subjects of public health research and practice

“Public health practice” consists of activities and Programs managed by public health agencies to promote health and prevent disease, injury, and disability. Some of these activities might be deemed to fit within the broad definition of “research” under federal regulations, known as the Common Rule, designed to protect human research subjects. The Common Rule defines research as “a systeniatic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.” Public health activities that might under some circumstances be considered research include disease reporting, review of medical records, surveys, interviews, focus groups, specimen collection (blood, urine, etc.), and laboratory testing (both identifiable and anonymous).

There are questions about the extent to which the Common Rule applies or was intended to apply to public health practice: and it has been suggested in any case that Common Rule regulation of public health practice may not be socially optimal for both practical and principled reasons.