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David vs. Goliath in perspective.
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Declining reimbursement will demand innovative delivery methods.
In summary, hospitals will have to find innovative ways to secure market share as federal reimbursement continues to decline and the commercial insurance industry rebels against the cost shifting burden that is being placed on it. Hospitals can also expect increasing pressure to control costs if inflation rates continue to moderate but hospital expenses exceed the current inflation rates. All in all, the reimbursement system will undergo severe "belt tightening," which will force hospitals to change their product mix; accept new payment systems, such as capitation; and reduce expenses in order to achieve profitable operating margins.
Insurer wages own cost-shifting campaign.
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Antitrust implications of chiropractic Peer Review Committees.
Peer Review Committees (PRCs) that aid insurance companies in evaluating chiropractic treatments and fees have been the focus of recent court challenges. Some practitioners have argued that PRC activities constitute price fixing in violation of the Sherman Antitrust Act. PRCs have been successful thus far in claiming an exemption from antitrust scrutiny as a "business of insurance" within the meaning of the McCarran-Ferguson Act. This Note contends that PRCs are not exempt from antitrust regulation; since PRCs do not spread risks and are involved in inter- rather than intra-industry agreements, their activities do not fall within the narrowly defined "business of insurance" exemption. The Note then analyzes the merits of the price fixing allegations under both the "per se" standard and the " rule of reason." First, the Note concludes that the unique nature of the health care market and the legitimate functions served by peer review make the application of a per se standard inappropriate. Second, under the rule of reason, the Note indicates that peer review encourages efficient and innovative health care practices while it deters the escalation of health care costs. The Note concludes that the net effect of peer review is not anticompetitive, especially since PRCs lack the coercive power to compel compliance with the recommendations.
Mortality in an insured population with atrial fibrillation.
In a cooperative study of 3,099 life insurance applicants with atrial fibrillation (AF), 71 deaths over an average duration of 3.3 years were observed and compared with deaths expected and derived from standard insurance mortality tables. A normal mortality was observed in cases of paroxysmal AF with no other identified cardiovascular impairment. Paroxysmal AF with associated mitral stenosis or coronary disease was found to have a significantly increased mortality. Chronic AF with or without other impairments entails a much higher risk than paroxysmal AF, those cases associated with mitral stenosis showing very high excess mortality.
[The problem of private insurance for patients with epilepsy (author's transl)].
324 epileptics were questioned about their approach to private insurance. Only 9,26% of them were covered by a life or accident insurance policy: 3,70% had life insurance, 3,70% accident insurance and 1,86% both. None of the patients had declared his disability to the insurance company. In 6,17% of the 324 epileptic cases an insurance policy had been taken out by their parents. In comparison about 35% of the Italian population in general are insured. A questionnaire was sent to 20 insurance companies; only 5 of them replied, saying that as far as accidents were concerned, they considered epileptics uninsurable. As for life insurance, policies can be contracted at increased premiums, according to the individual case (including the severity of the illness). Physicians must give epileptics fuller information about their insurance plans because, if their illness is detected after an accident, they will find themselves not covered by insurance. Government intervention is called for with the setting-up of special funds for this purpose.
Molten metal burns.
Molten metal burns are a frequent industrial injury among workers in foundries. The injury is typically small but very deep. Usually the depth and seriousness of these injuries is not recognized immediately by emergency department or industrial clinic physicians. In caring for 16 patients with molten metal burns we found that the burns were full thickness and averaged 2.7 percent of the total body surface (0.5 percent to 23 percent). The average hospital stay was 17 days, and ranged from 7 to 68 days. These small but serious burn injuries can result in tremendous loss of work days for both patients and employers, as well as tremendous expense to industrial insurance carriers. Almost all of the expenses for medical care before admission to hospital as well as a third of employee compensation benefits could be eliminated if definitive treatment was immediately available to these patients.
Medical liability insurance debate: occurrence versus claims made.
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Physician-owned companies make a difference because they are different.
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From the president: liability claims up, premiums may follow.
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Group life & Health Insurance Co. v. Royal Drug Co.: the McCarran-Ferguson Act and Health Service Plans.
Until recently, contractual relationships between health care providers and health insurers appeared to be immune from antitrust scrutiny. The Supreme Court ended this apparent immunity in Group Life & Health Insurance Co. v. Royal Drug CO., 440 U.S. 205 (1979), holding that insurance plans offering goods and services to policyholders are not exempted by the McCarran-Ferguson Act from the federal antitrust laws. By denying a McCarran-Ferguson exemption, the Court did not decide the ultimate issue--whether the insurers in fact had violated federal antitrust law. This Note reviews Royal Drug in light of precedent and of the purpose of the McCarran-Ferguson Act. This Note contends that the result in Royal Drug follows logically and consistently from the Court's earlier readings of the Act, but that the Court's reasoning is unclear and, even under its strongest reading, unconvincing; hence, an alternative approach to interpreting and applying the McCarran-Ferguson Act is suggested. Finally, this Note analyzes the application of Royal Drug by lower federal courts and discusses its implications for the interface of health law and antitrust law.
Physician-owned malpractice insurance companies.
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Antitrust risks in health insurance, staff boycotts, and shared services.
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Does market competition belong in health care?
In the first part of a two-part article, the role of market competition in health care is examined in terms of its possible efficacy in reducing costs and restructuring the system.
CSMS--AEtna Malpractice Program. 1979-1980 semi-annual report.
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Private health insurance looks at HMOs.
The Kaiser/Prudential Health Plan, Inc., is a unique venture in HMO development, which may signal future capital involvement in HMOs by private health insurance companies.
CSMS Professional Liability Insurance Program. Ninth Annual Report: August, 1980 Aetna Life & Casualty.
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