Special report on health care delivery systems. Trends in the integrated delivery of health care and the corporate practice of medicine

The prospects for federal legislation preempting state corporate practice restrictions are unclear. The health care reform bill originally introduced by President Clinton contained a provision that would have preempted "any state law related to the corporate practice of medicine" insofar as it applied to the arrangements between non-fee-for-service health plans and their participating providers. H.R. 3600/S. 1757, 103d Cong., 1st Sess. 1407(b) (1993). Whether and in what form a preemption provision may survive the legislative process and see a Presidential signature remains to be seen. The particular fate of the federal legislation notwithstanding, however, health care executives can nevertheless remain confident that the legal treatment of the "corporate practice" of medicine will continue to be of vital concern as the various forms of health care organizations evolve in the ongoing struggle to deliver quality medicine at affordable prices.     

Developing Codes of Conduct: Regulatory Conversations as Means for Detecting Institutional Change

The introduction of a new corporate governance code in Sweden, modeled after prevailing Anglo-Saxon norms of corporate governance, offers the opportunity to investigate global regulatory convergence. Using the metaphor of regulatory space, this article analyzes the positions of the parties who submitted formal responses to the introduction of "The Swedish Code of Corporate Governance—A Proposal from the Code Group." While the globalization of financial markets might forecast unconditional acceptance of the proposed code by business and financial interests, the analysis of who made comments, and what was said, reveals three categorically distinct groups: Swedish business "insiders" connected to the existing institutional framework who opposed changes that would erode traditional division of functions, including collective responsibility for the actions of company boards; "outsiders" (i.e., foreign investors and more marginal Swedish investors) aligned with Anglo-Saxon internationalization of the markets who would change the system of corporate accountability; and the professions (i.e., auditors), who advocated for their professional interests. Of the three groups, Swedish business insiders were most successful in gaining support for their positions. Although international financial and political interests were key to the introduction of the Code in the first place, the article demonstrates how the dynamics of national (local) culture and power structures influence the transfer of regulatory law across jurisdictions.     

Special report on reimbursement. Final Medicare fraud and abuse safe harbors are published

There has been great concern in the health care industry that business arrangements that do not comply with the Safe Harbors will automatically be deemed illegal. HHS has confirmed that this is not so; the commentary to the Regulations expressly states that "The failure of a particular business arrangement to comply with these provisions does not determine whether or not the arrangement violates the statute because...this regulation does not make conduct illegal. Any conduct that could be construed to be illegal after the promulgation of this rule would have been illegal at any time since the current law was enacted in 1977....This regulation is intended to provide a formula for avoiding risk in the future." 56 Fed. Reg. at 35955. In the final analysis, the majority of transactions will fall outside the Safe Harbors and thus will continue to be judged by the standards established by the Medicare antifraud statute enacted 14 years ago. Under these standards, as HHS states, "the degree of the risk [in any particular transaction] depends on an evaluation of the many factors which are part of the decision-making process regarding case selection for investigation and prosecution." Id. at 35954. Providers that are mindful of these criteria should therefore still be able to accomplish, with relative safety, transactions that do not qualify for Safe Harbor protection.     

An integrated delivery systems review: common problems to be addressed

The most critical element in developing a successful IDS is identifying the needs and goals of the parties within the context of the realities of their local health care market. It is therefore unwise to select the structure of a proposed IDS until this process has been completed. An honest goals assessment might result in the immediate formation of a PHO, MSO, medical foundation or other formal IDS, or might alternatively point in the direction of something much less structured, such as a joint marketing contractual arrangement (sometimes called a "PHA"), which can be relatively inexpensive to implement and can provide a fairly immediate response to quickly changing market conditions. Some organizations might even decide to utilize a number of different IDS vehicles in order to offer physicians a menu of affiliation options. The legal issues that arise when forming an IDS can almost always be dealt with in a reasonable manner. The real key to success is entering into integration discussions with an open mind, rather than a preconceived commitment to a particular integration.     

Regulation, deregulation and public bureaucracy

Abstract. In 1982, a new Liberal-Conservative government launched a grand deregulatory campaign as part of its programme for restoring the Danish economy. After some initial success, the campaign lost momentum. The government gradually realised that it was difficult to mobilise both economic interests and public opinion for the cause of deregulation. Bureaucratic resistance and disinterest among economic interest organisations together with the erosion of political commitment to deregulation after a couple of years stopped the campaign. Still, some results were reached where least expected.