Applying antitrust law to nonprofit healthcare entities: arguments for a greater attention to detail

This Article begins with an antitrust primer, then analyzes the appropriate application of antitrust principles to nonprofit healthcare providers. In light of the inherent charitable character of nonprofit healthcare providers, the author contends that the government and the courts should accord some deference to nonprofit hospitals when they are seeking approval of mergers. To date, this has not generally been the case, although a few recent court decisions have rested their approval of mergers, in part, upon the nonprofit character of the merging entities. The author, in particular, believes the paradigmatic local nonprofit hospital with a community board is less likely than a for-profit hospital to abuse any market power that it may obtain through a merger; consequently, any such merger should not be analyzed solely under the traditional presumptions of antitrust jurisprudence. Rather, the premerger analysis should involve meaningful consideration of the hospital's charitable character.     

Understanding the physician-owned specialty hospital phenomenon: the confluence of DRG payment methodology and physician self-referral laws

Physician-owned specialty hospitals have flourished in today's healthcare arena, but also have been the subject of a great deal of controversy. The author argues that the rise of specialty hospitals has been the result of a confluence of two healthcare policies: (1) skewed DRG payment methodologies and (2) the misapplication of exemptions to the Stark Law's ban on physician self-referral. This Article examines the aspects of these healthcare policies that have allowed for the explosion of specialty hospitals, as well as the arguments for and against the creation and need for specialty hospitals. The Article also analyzes the reform proposals to correct the Stark and DRG methodologies and how those proposals will affect both specialty and general hospitals.     

The conundrum of charitability: reassessing tax exemption for hospitals

Tax exemption is an ancient, honorable and expensive tradition. Tax exemption for hospitals is all of these three, but it also places in sharp focus a fundamental problem with tax exemption in general. Organizations can retain their tax exemption while changing circumstances or expectations undermine the rationale that led to the exemption in the first place. Hospitals are perhaps the best example of this problem. The dramatic changes in the health care environment have eliminated most of the characteristics of a hospital that originally persuaded the citizenry to grant it an exemption. Hospitals have entered into competition with tax-paying businesses, and have increasingly behaved like competitive actors. Such conduct may well be beneficial, but it does not follow that tax exemption is appropriate. Rather than an undifferentiated subsidy, a shift to focused goals will provide charitable hospitals with the opportunity and incentive to "do the right thing."     

Managing medical staff disability issues: liability of private hospitals under ADA Titles I and III

This Article examines the extent to which private hospital are liable for discrimination against medical staff members with disabilities, under the Americans with Disabilities Act ("ADA"). Specifically, the discussion focuses on the ways in which Title I, covering employment relationships, and Title III, covering places of public accommodation, apply to hospitals and their medical staff physicians. With respect to Title I, the author focuses on possible liability with respect to independent contractor physicians who have staff privileges at a hospital. The focus with respect to Title III involves claims filed by physicians against hospitals as places of public accommodation. The author concludes that the courts have applied the ADA in a manner broader than intended by Congress, and that private hospitals should assume that both Title I and Title III are applicable to staff privilege decisions. Therefore, any action that adversely affects a disabled physician should be supported by well-documented, objective evidence of a nondiscriminatory reason for that action.     

Failed hospital mergers

The spate of hospital mergers in recent years has yielded both substantial increases in market power and many divestitures. These seemingly contradictory results stem from the pressures imposed by stakeholders of merging hospitals and the inability of those stakeholders to exert control over nonprofit institutions prior to the effectuation of a merger. This Article examines several recent mergers, analyses their failures, and recommends that the judiciary and state attorneys general look carefully at merging nonprofits so as to fill the void left by the lack of market control mechanisms.     

Corporate reorganization: the last gasp or last clear chance for the tax-exempt, nonprofit hospital?

The current revolution in health care organization and financing, increased competition, and a retrenching of industry from its commitments to expansion of health care benefits challenge the nonprofit hospital's existence as a viable entity. Hospital governing boards and administrators have turned to corporate reorganization in order to maintain their financial position and to continue to serve their communities. This Article examines the not-for-profit concept and the problems facing nonprofit hospitals. It reviews the pros and cons of reorganization and the for-profit/nonprofit controversy. It questions whether the hybridization of the hospital results in a stronger or weaker species and discusses the possible effects of the newly structured entity on the quality and delivery of health care. Finally, the Article suggests that the nonprofit hospital may survive only by a continued commitment to societal and communal values, to service rather than to profit; that this commitment is adequate justificaton for the preservation of the nonprofit system, and its preservation will reinforce and strengthen the concept.     

Arising from the dead: challenges of posthumous procreation

The medical capabilities derived from modern reproductive technology, such as in vitro fertilization and cryopreservation, have enabled physicians and scientists to intervene in the procreative process in innumerable ways. However, this intervention in the natural reproductive process raises both moral and legal concerns. In this Article, Professor Schiff explores some of the conflicts that may result when an individual or couple elects to cryopreserve gametes or embryos and subsequently, one or both of the contributors dies, or when gametes are harvested from a dead body. This Article will specifically address the moral and legal responses to circumstances where the decedent has either clearly expressed opposition to posthumous use of the reproductive material or else the decedent's intent regarding posthumous use of the material is ambiguous. By discussing philosophical and moral positions relating to personhood and the body and analyzing legal issues such as reproductive choice and organ donation, Professor Schiff creates the necessary format to examine and recommend the proper legal treatment of this controversial aspect of posthumous procreation.     

The debate over specialty hospitals: how physician-hospital relationships have reached a new fault line over these "focused factories"

Within the last 20 years, the fragile symbiotic relationship between physicians and hospitals has become increasingly strained. Physicians have created new healthcare delivery systems, including a host of for-profit, physician-owned specialty hospitals. Proponents of specialty hospitals argue that they provide high quality facilities and allow for innovative treatments. Opponents, however, contend that such hospitals "cherry pick" patients who otherwise would help to subsidize general hospitals, and point to the various fraud and abuse issues raised by physician-owned specialty hospitals. This Article examines the specialty hospital phenomenon and the arguments for and against such entities. It also analyzes whether an extension of the present federal moratorium on the construction of new physician-owned specialty hospitals is in the best interests of the country's healthcare system. The author concludes that the data are unclear as the overall impact of such hospitals and that they should not be further constrained until when and if the facts are clear.     

Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2004 rates. Final rule

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital costs to implement changes arising from our continuing experience with these systems. In addition, in the Addendum to this final rule, we are describing changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs. These changes are applicable to discharges occurring on or after October 1, 2003. We also are setting forth rate-of-increase limits as well as policy changes for hospitals and hospital units excluded from the IPPS that are paid on a cost basis subject to these limits. Among other changes that we are making are: changes to the classification of cases to the diagnosis-related groups (DRGS); changes to the long-term care (LTC)-DRGs and relative weights; the introduction of updated wage data used to compute the wage index; the approval of new technologies for add-on payments; changes to the policies governing postacute care transfers; payments to hospitals for the direct and indirect costs of graduate medical education; pass-through payments for nursing and allied health education programs; determination of hospital beds and patient days for payment adjustment purposes; and payments to critical access hospitals (CAHs).     

法律经济学视野中的赠与承诺——重解《合同法》第186条

《合同法》第186条关于赠与承诺的规定无法诉诸"权利义务相一致"的简单说辞获得解释,笼统地认为强制执行有利于受诺人而不利于承诺人的观念是错误的。未经公证的赠与承诺之所以不会被法院强制执行,在程序上,是因为证据匮乏而导致法律实施成本过高;在实体上,是因为受诺人承诺的信任超出了合理的限度。合同法只鼓励人们对他人的承诺付出合理的信任,而不是过度的信任。同样的逻辑可以解释,为什么经过公证的赠与承诺应当被法院强制执行。强制执行捐赠承诺,除了上述因素之外,还包括阻止捐赠活动中的搭便车。     

EMTALA: reaching beyond the emergency room to expand hospital liability

The Office of the Inspector General and private plaintiffs are vigorously pursuing EMTALA violations. These efforts are particularly troubling to hospitals, who face difficult statutory interpretation and application questions, especially in light of managed care reimbursement requirements. Two recent cases, one of them from the United States Supreme Court, expand hospital liability under EMTALA. This Article reviews current EMTALA standards and regulations, and analyzes how the recent decisions, in the absence of congressional action, are likely to impose substantial burdens upon hospitals.     

A cure for the Blues: resolving nonprofit Blue Cross conversions

This Article analyzes the issues involved in converting nonprofit Blue Cross organizations to for-profit status. These issues have arisen in the context of litigation regarding the "reorganization" of Blue Cross and Blue Shield of Missouri ("BCBSMo"). BCBSMo had reorganized by creating and transferring a majority of its business to a new for-profit subsidiary. Missouri consumer groups and state regulators characterized the "reorganization" as a conversion requiring BCBSMo to transfer its assets to a foundation dedicated to charitable health purposes. BCBSMo, however, denied that it had any obligation to leave behind its assets in the nonprofit sector. The BCBSMo litigation raises issues common to most conversions of nonprofit healthcare organizations, particularly conversions of nonprofit Blue Cross plans. This Article provides a road map for state regulators and the public to follow in ensuring that the public interest is fully protected in such conversions.     

Gainsharing: a call for guidance

Gainsharing is a device by which hospitals and physicians share in the development, implementation, and proceeds resulting from the mechanisms to make the provision of healthcare more efficient and cost effective. The goal of gainsharing programs is to save hospitals money while maintaining the same or better quality of care--a goal that will ultimately result in both better care and lower expenses for payors and for society as a whole. Nevertheless, the OIG has ruled that gainsharing programs are per se illegal. This Article analyzes the reasons behind the OIG's determination and argues that, contrary to the OIG's conclusion, the advisory opinion process is legally and practically the best way to deal with the issues raised by gainsharing programs.     

Community control and pricing patterns of nonprofit hospitals: An antitrust analysis

Traditional control of nonprofit hospitals by the communities they serve has been offered as justification for restraining antitrust enforcement of mergers that involve nonprofit hospitals. The community is arguably a constraint on a nonprofit's inclination to exercise market power in the form of higher prices; however, community control is likely to be attenuated for hospitals that through merger or acquisition become members of hospital systems--particularly those that operate on a regional or multiregional basis. We report findings from a study in which we examined empirically the relationship between market concentration and pricing patterns for three types of nonprofit hospitals that are distinguishable based on degree of community control: an independent hospital, a member of a local hospital system, and a member of a nonlocal hospital system. Study results indicated that when conditions existed to create a more concentrated market, (1) all three types of nonprofit hospitals exercised market power in the form of higher prices, and (2) hospitals that were members of nonlocal systems were more aggressive in exercising market power than were either independent or local system hospitals. The results have important implications for antitrust enforcement policy.     

Clashing Rights, the Welfare of the Child and the Human Rights Act

Under the Human Rights Act so far there has been until very recently little judicial or even academic recognition of the difference between resolving clashes of Convention rights and addressing conflicts between utilitarian concerns and such rights. This article has chosen to illustrate that failure of recognition and to consider methods of resolving the conflict between rights, by concentrating on one particular clash of rights – that between media free speech under Article 10 and the privacy of children under Article 8. It argues for presumptive equality for the two rights and for conducting a 'parallel analysis' of their application to the circumstances of a particular case. It contends that therefore the principle that the child's welfare is paramount must be abandoned in its present form, as must the presumptive priority accorded to Article 10 where that principle is not found to apply.     

气候贸易措施：GATT 第20 条的限制性和适用的不确定性

《京都议定书》的第一个承诺期即将到期,发达国家出于各种原因可能不断出台或完善应对气候变化的国内措施,气候贸易措施有单边化的趋势。尽管单边的气候措施与贸易自由的冲突会日益明显,但是发达国家很有可能寄望于GATT第20条例外条款寻找缺口。从规则上来讲,GATT第20条为援引例外设定诸多限制条件,发挥社会利益与贸易自由的平衡作用,但是由于措词模糊,第20条的适用更依赖于个案的司法平衡,为适用结果带来诸多不确定性因素。因此,本文结合WTO经典案例,深入分析GATT第20条的限制条件,剖析司法适用中的不确定性因素,提出多边机制应对气候变化问题是现阶段化解各种矛盾的积极选择。     

Expanding the Borders of Common Article 3 in Non-International Armed Conflicts: Amending Its Geographical Application Through Subsequent Practice?

The geographic footprint of contemporary warfare often challenges the existing understanding of the term ‘non-international armed conflict’, a term not defined in international humanitarian treaty law. This article examines whether the opening lines of Common Article 3 of the Geneva Conventions include a geographical requirement. Controversy surrounds this question which until recently has received little attention. The customary interpretation of Common Article 3 is that it has a geographical scope of application limited to non-international armed conflicts which take place exclusively within the borders of a single member state (internal armed conflict). The 2016 ICRC Commentaries to the First Geneva Conventions challenges this traditional view and argues in favour of a broader interpretation of the scope of application of Common Article 3. This re-interpretation recently has gained traction in scholarship. The ICRC’s position serves as a possible solution to prevent a lacuna in humanitarian protection in situations where conflicts fit neither the understanding of ‘international armed conflict’ nor ‘internal armed conflict’. By evaluating the merits of the arguments posed by the ICRC, the article assesses whether the phrase ‘conflict not of an international character’, as included in Common Article 3, conclusively limits its geographical application to an armed conflict occurring within the boundaries of a single state.

     

Citizen Led Policing in the Digital Realm: Paedophile Hunters and Article 8 in the case of Sutherland v Her Majesty's Advocate

In Sutherland v Her Majesty's Advocate, the Supreme Court unanimously dismissed an appeal which argued that the use of communications obtained by a paedophile hunter group as evidence in criminal prosecution was a violation of Article 8 of the European Convention on Human Rights. The case raises fundamental questions of the scope of the right to private life as regards to the content of communications and the role played by private actors in the criminal justice process. This note argues that by limiting the protection of Article 8 to private communications which satisfy a contents-based test, the Court has bypassed the Article 8(2) balancing test to the detriment of the due process rights of the accused. The note concludes that the decision opens up the prospect of the state circumventing the accused's Article 8 privacy rights by lending tacit approval to the proactive investigations of these private ‘paedophile hunter’ groups.