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PubMed1985

Antitrust aspects of exclusive contracts in medical imaging.

Exclusive contracts between radiologists and hospitals may be more frequently scrutinized for antitrust violations because of the Hyde v Jefferson Parish Hospital District No. 2 case. In the Hyde case, the lower court decided antitrust law had been violated, and it was the first antitrust case about exclusive medical contracts to be reviewed by the U.S. Supreme Court. The case is a precedent for considering similar circumstances according to traditional business antitrust analyses such as per se violations, tying arrangements, group boycott, and market foreclosure. Areas that may be scrutinized for anticompetitiveness include hospital privileges when radiologists have exclusive contracts with the community's only hospital or provide services unique within an area, and physicians' access to scarce resources (e.g., computed tomography [CT], magnetic resonance [MR] imaging). Radiologists must understand antitrust implications of their hospital contracts; examine the terms of staff appointment, bylaws, and rights; and be able to guide their attorneys through contract negotiations.

Contract Services↗
PubMed1995

Structure, environment and strategic outcome: a study of Pennsylvania nursing homes.

This study applies Porter's model of competitive advantage to the nursing home industry. Discriminant analysis is used to identify organizational and environmental characteristics associated with nursing homes which have demonstrated valued strategic outcomes, and to distinguish the more successful nursing homes from their rivals. The results of the discriminant analysis suggest that nursing homes with superior payer mix outcomes are distinguishable from their less successful rivals in areas associated with a focused generic strategy. The study suggests that nursing homes which are better staffed, of smaller size and lower price are more likely to achieve high levels of self-pay utilization. Independent living units, continuing care retirement communities in particular, are likely to act synergistically with nursing home organizational characteristics to enhance competitive advantage by linking the value chain of the nursing home to that of retirement housing. Nursing homes with higher proportions of Medicare were found to provide a unique product when compared to their rivals. Profit status does not discriminate better self-pay strategic utilization, but for-profit facilities are more likely to pursue a Medicare strategy. Concern was raised that, as nursing homes become more strategically oriented, Medicaid access may become more problematic.

Data Collection↗
PubMedDate not supplied

The Harry R. Horvitz Center for Palliative Medicine (1987-1999): development of a novel comprehensive integrated program.

The Cleveland Clinic is a large multispecialty group practice. The need for a palliative care program was identified and the program started in 1987. A key concept has been that the existing structure of hospice care as defined by Medicare is insufficient to address the needs of patients with incurable disease. The field of palliative medicine implies physician expertise in several key areas: (1) communication; (2) decision-making; (3) management of complications; (4) symptom control; (5) care of the dying; and (6) psychosocial care. The development of the program (the first in the United States) since 1987 has put in place the following major services, listed consecutively: (1) hospital consultation service; (2) outpatient clinics; (3) acute care inpatient service; (4) hospice and home care service; (5) acute-care palliative medicine inpatient unit; and (6) hospice inpatient facility. Program development has meant that a new program has been introduced approximately every 18 months since the start of the program. This has considerable implications for staffing, the management of change, and competition for scarce resources within a contracting health care budget. The staffing of the program has focused on developing specialized attending physicians using a multidisciplinary approach dedicated to enhancing the role of nursing in the field. The major budgeted areas are (1) the acute-care palliative medicine unit, and (2) the hospice and home care service. Specific commitment has been made to research and education because of the desire to develop an intellectual basis for the practice of palliative medicine. This requires structured activities in both areas with a systematic approach to research and education. The complexity of developing a service should not be underestimated. There has been consistent support for the program by senior leadership within the Cleveland Clinic Foundation, including the cancer center. The major lessons learned during program development have been: (1) to focus on quality of patient care; (2) to commit to academic endeavor in research and education; (3) to secure institutional commitment to program development; (4) to establish a positive, proactive, businesslike approach; (5) to defend budget and personnel, albeit within a difficult time in health care; and (6) to commit to success, i.e., never promise anything on which you do not deliver. The future development of post-acute-care services serving predominantly the chronically ill elderly population suggest an expanded administrative and conceptual role for the future development of palliative medicine to help serve the needs of the aging population in the United States.

Clinical Competence↗
PubMed2004

Budget negotiation for industry-sponsored clinical trials.

The specialty of anesthesia is well suited to attract industry-sponsored clinical trials and research revenues because of its fundamental contributions to surgery, critical care, and pain medicine. However, the performance and budgeting of industry-sponsored clinical research over the past decade has been significantly altered by the rapid growth of commercially oriented networks of contract-research organizations and site-management organizations. Further, the competitive nature of today's clinical research climate can make the planning and negotiating of study budgets and contracts stressful, time consuming, frustrating, and full of pitfalls. Because a clinical trial contract is a fixed-price agreement, investigators are obligated to perform the work described in the contract, even if the actual costs exceed the study contract. Successful budgeting for the performance of an industry-sponsored clinical trial thus requires a thorough understanding of the direct and indirect costs associated with performing clinical research. We reviewed budget and contractual considerations for the successful negotiation and performance of industry-sponsored clinical research.

Budgets↗
PubMed1994

Hospitals and antitrust: defining markets, setting standards.

The definition of geographic and product markets is a critical aspect of any antitrust analysis. This paper argues for a different approach to market definition in areas where insurance plans that contract selectively are a significant market presence. Such a proposed approach is described and some policy implications are drawn.

Antitrust Laws↗
PubMed1995

The effect of fixed payment on hospital costs.

New Medicare regulations have replaced the cost-based system of reimbursement of capital expenditures by hospitals with a fixed payment per case based on assigned diagnostic-related groups. For the first time, hospitals must pay the governmental share of their capital costs. At the same time, overall reform points toward more capitation or fixed payments from all payers. This article discusses possible responses to legislative and competitive reforms by hospital management and the resulting effectiveness of the changes. To identify the potential effect of capital payment reform, we highlight some of the key provisions and assumptions of the new regulations, discuss the management implications of a changed capital payment system, and explore alternative models of hospital investment behavior in a world where one price for services for all buyers is a probable scenario.

Budgets↗
PubMed1984

Competitive bidding as a cost-containment strategy for indigent medical care: the implementation experience in Arizona.

The State of Arizona recently instituted a competitive bidding process, in order to establish a health services delivery system for indigents and to determine capitated reimbursement levels for providers in that system. This article describes the implementation of that bidding process, and identifies factors which had a significant impact on the implementation experience. Implementation of competitive bidding in Arizona encountered problems which appear to be common to the implementation of innovative public programs. It also uncovered political liabilities that suggest that effective implementation of competitive bidding for indigent medical care contracts in other environments will be difficult, even if technical implementation problems can be overcome.

Arizona↗
PubMed1996

Shift in power to hospital accountants.

With the introduction of the Prospective Payment System, hospital accountants' role changed from reimbursement maximizers to an important role in decision making. Faced with increased competition, many hospitals are installing financial controls. Many hospitals are engaging in promotion and health awareness campaigns and expanding their services to stabilize income and reduce the effects of a changing environment. Thus, hospitals operate in a more competitive environment with much uncertainty. When faced with uncertainty, organizations often believe that they must convince society that their existence is legitimate. Increasing specialization and organizational complexity in healthcare professions have made the expert important. Experts, such as the role assumed by hospital accountants, maintain power because the organization depends on them for their special skills and information. Scarce resources coupled with uncertainty move hospital accountants as experts into the power equation in the changing control of the U.S. healthcare system. Since accountants often serve as monitors of scarce resources, information about the resource allocation directly affects the distribution of power. This places hospital accountants in a critical role of assisting their institutions in adapting to a new environment.

Accounting↗
PubMed1995

Uncompensated care: hospitals' responses to fiscal pressures.

This Data Watch examines the impact of hospital competition, the Medicare prospective payment system (PPS), and Medi-Cal selective contracting on the provision of uncompensated care by private hospitals in California during 1980-1989. It finds that hospitals subject to more intense competition and greater fiscal pressure from Medicare and Medi-Cal reduced their provision of uncompensated care relative to hospitals facing less pressure from these sources. We estimate that had hospitals not been subjected to increasing price competition from growth of managed care plans and financial tightening in public programs, they would have provided 36 percent more uncompensated care than was actually provided in 1989.

California↗
PubMed1996

Academic health centers in a changing environment.

To evaluate the potential problems facing academic health centers (AHCs) as a result of market-driven health care reforms, we conducted case studies of seven nationally prominent AHCs during 1994. Findings suggest that although AHCs were not yet feeling the predicted impact of competition on their financial health and ability to sustain their academic missions of teaching, research, and care of vulnerable populations, they were adopting a variety of strategies for responding to those perceived threats, especially networking and cost reduction. They were placing considerably less emphasis on restructuring their research and teaching missions to prepare for anticipated fiscal pressure. Our analysis suggests that even the most successful AHCs are likely to be fundamentally altered by the revolutionary changes occurring in health care markets.

Academic Medical Centers↗
PubMedDate not supplied

Population-based disease management under fee-for-service Medicare.

Medicare policymakers are considering testing population-based disease management (PDM) programs under fee-for-service (FFS) Medicare as a way to improve health and cost outcomes for selected subgroups of chronically ill beneficiaries. This paper provides a brief overview of how PDM programs are evolving in the private sector and describes how they differ from other approaches already being tested in Medicare disease management demonstrations. It also discusses some key opportunities and issues to be considered in adapting PDM programs for testing in the FFS Medicare context.

Cost-Benefit Analysis↗
PubMed1984

Development of the Polypay breed of sheep.

Development of the Polypay breed was undertaken to combine into a composite breed the potential for greatly increased reproductive capacity along with desirable growth rate and carcass quality. Four breeds were selected for the foundation of the new breed--the Rambouillet and the Targhee for hardiness, large body size, long breeding season, herding instinct and fleece characteristics; the Dorset for carcass quality, milking ability and long breeding season and the Finnsheep for early puberty, early postpartum fertility and high lambing rate. Dorset X Targhee and Finnsheep X Rambouillet matings were first made in 1968, and reciprocal Dorset-Targhee X Finn-Rambouillet matings were initiated in 1969. Beginning in 1970, the respective two-breed crosses and the four-breed cross (Polypay) were each mated inter se and selected, along with straightbred Rambouillets and Targhees, for lamb production when given two opportunities to lamb/year. Initial comparisons among straightbreds and inter se mated groups showed few important differences in meat-type body conformation, body condition or growth rate, but superior annual reproductive performance by Polypays. Fertility of Polypays at 1 yr of age was high and comparable to that of the Finn-Rambouillets. Response of Polypays to twice-a-year lambing was superior to responses of Rambouillets. Targhees, Dorset-Targhees or Finn-Rambouillets. The 1974 to 1975 annual production of young Polypays was about 13% more lambs weaned than from Finn-Rambouillets and 18% more weight of lamb weaned than from Dorset-Targhees, the best of the other groups for these traits. The current (1979 to 1981) reproductive performance of Polypay ewes selected for high once-a-year lambing rate under typical range management conditions is very competitive with that of 1/2 Finn crossbreds. Annual production of mature Polypays on the twice-a-year lambing schedule was 1.78 lambs weaned and 58.6 kg of lamb weaned/ewe put into fall breeding.

Animals↗
PubMed1995

[Clinical study on Fournier's gangrene--value of "through and through drainage"].

From 1991 to 1994, we experienced 5 patients with Fournier's gangrene. Their age, associated diseases, etiology, area of the disease, microbiologic findings, treatment and prognosis were reviewed. Patient age ranged from 25 to 72 years, with a mean age of 47 years. An associated disease process could be identified in all patients. Two patients had diabetes mellitus, 1 systemic lupus erythematosus, 1 chronic alcoholism and 1 multiple myeloma. The etiology of the infectious process was presumed to be wound infection in 2 patients and indwelling urethral catheter in 2 patients. All patients were treated with broad-spectrum antibiotics. Extensive débridement with later skin graft was done in 2 patients. Multiple Penrose-drains were placed subcutaneously after limited removal of necrotic tissue in 3 patients. In these 3 patients, redness and swelling reduced quickly, the wound was cured without defects of skin except 1 patient who had multiple myeloma and was in a very serious condition. Although inflammation reduced after the placement of drains, the patient with multiple myeloma died of sepsis and DIC. The majority of patients with Fournier's gangrene are immunocompromised. Although extensive débridement is commonly performed as the surgical treatment, defects of the skin seem to have some disadvantages, such as the need for the skin graft and the chance of secondary wound infection. In the narrow excision of necrotic tissue and drainage of involved areas by multiple Penrose-drains, skin defects are minimum, and the effectiveness of the surgical management seems to be competitive with the wide débridement.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗