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[Historical recollection Medical School of the University of Puerto Rico 1950-2000].

The School of Medicine of the University of Puerto Rico was founded in 1950 with the mission of educating the much needed physician workforce in order to improve the health of a large portion of the population in Puerto Rico. The main events in its first fifty years of existence are summarized. Emphasis is given to the unique, mutually dependent association between the School of Medicine and the Department of Health of Puerto Rico. Soon after its organization, the school became a principal protagonist in the delivery of specialized medical care to the medically indigent population within the existing Regionalization Program of Health Care services in the island. With the creation and development of various other academic and health services institutions in the island, and the advent of a new system of health care in 1993, based on managed care; the School's interdependence with the Department of Health and its role in the direct care of the medically indigent have waned drastically. The School now faces its greatest challenges as it begins to insert itself into the economically competitive arena of the new health care system; and in redefining its commitments, while searching for new resources, alliances, teaching faculty, hospitals and clinics, enabling it to maintain its leadership in medical education, specialty training and scientific research in Puerto Rico.

History, 20th Century↗

Physician-partnering models offer legal alternatives to traditional gain-sharing.

The HHS Office of Inspector General has condemned gain-sharing arrangements between hospitals and physician groups as being in violation of the civil monetary penalty section of the Social Security Act. Several physician-hospital partnering models, however, are not restricted by the OIG, though arrangements based on these models must be structured carefully so as not to run afoul of other Federal regulations. These models include consultation, program reinvestment, payer contracting, equity/joint ventures, and quality incentive programs.

Decision Making, Organizational↗

Dr. Discontent.

Physicians are angry, that that's bad news for hospitals. Increasingly, doctors are unable to pay soaring liability insurance premiuyms, are refusing to accept new Medicaid and Medicare patients, and are balking at taking ED calls. What's more, many physicians are setting up niche facilities that compete directly with hospitals in the most lucrative service lines.

Attitude of Health Personnel↗

[Patent research as a way to ensure competitiveness of an object of economic activities].

Importance is shown of patent-associated studies at every stage of the life cycle of an object of economic activities. It is argued that a low level of patent-associated studies, failure to meet the deadline set for the completion thereof are responsible for an inadequate level of research activities, waste of time and resource, creation of worthless objects of intellectual property. Special stress is laid on the importance of implicit fulfillment of requirements of the state standards now in force in the sphere of intellectual property.

Economic Competition↗

Medicare payment changes and physicians' incomes.

An effort to control the physician portion of Medicare expenditures and to narrow the income gap between primary care and procedure-based physicians was effected through t he enactment of the Medicare Fee Schedule (MFS). To determine whether academic and private sector physicians' incomes had demonstrated changes consistent with payment changes, we collected income information from surveys of private sector physicians and academic physicians in six specialties: (1) family practice; (2) general internal medicine; (3) psychiatry; (4) general surgery; (5) radiology; and (6) anesthesiology. With the exception of general internal medicine, the anticipated changes in Medicare revenue were not closely associated with income changes in either the academic or private sector group. Academic physicians were underpaid, relative to their private sector counterparts, but modestly less so at the end of the period examined. Our findings suggest that using changes in payment schedules to change incomes in order to influence the attractiveness of different specialties, even with a very large payer, may be ineffective. Should academic incomes remain uncompetitive with private sector incomes, it may be increasingly difficult to persuade physicians to enter academic careers.

Academic Medical Centers↗

The electrospray and its application to targeted drug inhalation.

This review explains the fundamentals of electrostatic spray (electrospray) atomization, with emphasis on operation in the so called cone-jet mode, which produces droplets with a very narrow size distribution. Since the control of droplet size is key to maximizing distal lung deposition, the electrospray should be well-suited to targeted drug inhalation. Electrospray droplets are a few micrometers in diameter, but they originate from a much larger nozzle, which allows nebulization of suspensions without clogging. Also discussed are: the physical principles of the break-up of the liquid ligament; droplet dispersion by Coulombic forces; and the most important scaling law linking the droplet size to liquid flow rate and liquid physical properties. The effects of the most critical of those properties may result in some restrictions on drug formulation. Droplets produced by electrospray are electrically charged, so to prevent electrostatic image forces from causing upper respiratory tract deposition. The charge is neutralized by generating a corona discharge of opposite polarity. Briefly discussed are the main differences between the laboratory systems (with which the electrospray has been quantitatively characterized during research in the past 10 years) and commercial electrospray inhalers under development at BattellePharma. Some remarkable miniaturization has incorporated liquid pump, power supply, breath activation, and dose counter into a palm-size portable device. The maximum flow rates dispersed from these devices are in the range of 8-16 microL/s, which makes them suitable for practical drug inhalation therapy. Fabrication is economically competitive with inexpensive nebulizers. Dramatic improvements in respirable dose efficiency (up to 78% by comparison with commercial metered-dose inhalers and dry powder inhalers) should ensure the commercialization of this promising technology for targeted drug inhalation.

Administration, Inhalation↗

Hospital market structure and the behavior of not-for-profit hospitals.

I exploit a change in hospital financial incentives to examine whether the behavior of private not-for-profit hospitals is systematically related to the share of nearby hospitals organized as for-profit firms. My findings demonstrate that not-for-profit hospitals in for-profit intensive areas are significantly more responsive to the change than their counterparts in areas served by few for-profit providers. Differences in financial constraints and other observable factors correlated with for-profit hospital penetration do not explain the heterogeneous response. The findings suggest that not-for-profit hospitals mimic the behavior of private for-profit providers when they actively compete with them.

California↗

Do pharmaceutical prices respond to potential patient out-of-pocket expenses?

Despite the importance of patient insurance in the market for prescription pharmaceuticals, little is known about the impact of patient reimbursement on the pricing behavior of pharmaceutical firms. I examine the link between potential patient out-of-pocket expenses and pharmaceutical pricing using a unique policy experiment from Germany. Starting in 1989, a maximum reimbursement for a given medicine replaced a flat prescription fee. This change in reimbursement exposes the patient to the price of a prescribed product. Using a product-level panel data set covering several therapeutic categories before and after the policy change, I find that producers significantly decrease prices after the change in potential patient out-of-pocket expenses. Price declines are most pronounced for brand-name products. Moreover, branded products that face more generic competitors reduce prices more.

Drug Costs↗