Collection from third party payers of reasonable costs of healthcare services--DoD. Final rule

This final rule would amend the DoD regulation that implements 10 U.S.C. 1095. This statute generally provides for collection by the United States from third party payers of reasonable costs of healthcare services provided in facilities of the Uniformed Services to DoD beneficiaries who are also beneficiaries under the third party payer's plan. This final rule also implements recent legislative amendments that expanded their third party collection authority to cover outpatient services, automobile liability and no-fault insurance policies, and Medicare supplemental insurance plans. Active duty members are included in collections from automobile liability and no-fault insurance carriers. In addition the final rule revises methods for determining reasonable costs for inpatient care services.     

Improving direct-care compensation in nursing homes: Medicaid wage pass-through adoption, 1999-2004

Because states play such a prominent role in the U.S. health care system, they have long grappled with how to best control health care costs while maintaining high quality of care. There are many policy tools available to address efficiency and quality concerns--from pure state regulation to market-oriented competition designs. Given public discourse and official party platforms, one would assume that states controlled by Democrats would be more likely to adopt regulatory reforms. This study examines whether party control, as well as other economic and political factors, is associated with adopting wage pass-through (WPT) policies, which direct a portion of Medicaid reimbursement or its increase toward nursing home staff in an effort to reduce staff turnover, thereby increasing efficiency and the quality of care provided. Contrary to expectations, results indicate that states with Republican governors were against WPT adoption only when for-profit industry pressure increased; otherwise, they were more likely to favor adoption than their Democratic counterparts. This suggests a more complex relationship between partisanship and state-level policy adoption than is typically assumed. Results also indicate that state officials reacted predictably to prevailing political and economic conditions affecting state fiscal-year decisions but required sufficient governing capacity to successfully integrate WPTs into existing reimbursement system arrangements. This suggests that WPTs represent a hybrid between comprehensive and incremental policy change.     

Just compensation: a no-fault proposal for research-related injuries

Biomedical research, no matter how well designed and ethically conducted, carries uncertainties and exposes participants to risk of injury. Research injuries can range from the relatively minor to those that result in hospitalization, permanent disability, or even death. Participants might also suffer a range of economic harms related to their injuries. Unlike the vast majority of developed countries, which have implemented no-fault compensation systems, the United States continues to rely on the tort system to compensate injured research participants—an approach that is no longer morally defensible. Despite decades of US advisory panels advocating for no-fault compensation, little progress has been made. Accordingly, this article proposes a novel and necessary no-fault compensation system, grounded in the ethical notion of compensatory justice. This first-of-its-kind concrete proposal aims to treat like cases alike, offer fair compensation, and disburse compensation with maximum efficiency and minimum administrative cost. It also harmonizes national and international approaches—an increasingly important goal as research becomes more globalized, multi-site trials grow in number, and institutions and sponsors in the United States move to single-IRB review.     

The interplay between economic and political logics: path dependency in health care in England

The purpose of this article is to use the ideas of path dependency to understand why policies implemented by governments for health care in England were and are suboptimal in terms of the control of total costs, the equitable distribution of hospital services, and efficiency in delivery. We do this by relating the economic logic of achieving these objectives to the political logic of a state-hierarchical system in which ministers are accountable for the effects of policies and doctors largely decide the supply and demand of health care. The initial policy path of the National Health Service (NHS) controlled costs but lacked systems to achieve equity and efficiency in the funding of hospitals. Policies were introduced to achieve equity, but not efficiency, in the 1970s. The Thatcher government sought efficiency through a budgetary squeeze in the 1980s, which culminated in the NHS funding crisis of 1987 - 1988. The result was the policies of the NHS internal market, which promised efficiency by introducing a purchaser-provider split and a system of provider competition in which money would follow the patient. These promises justified an injection of extra funds for three years, but only a pallid model of the internal market was implemented. The Blair government abandoned the rhetoric of competition but maintained the purchaser-provider split and continued to constrain total NHS costs, which resulted in the funding crisis of 1998 - 1999. Current policies are to substantially increase spending on health care and reintroduce a system of provider competition in which money will follow the patient.     

National health policy: Efficiency-equity synchretism

A new emphasis in national health policy to encourage efficiency has been born in an environment of slower economic growth and an aging population. The increased reliance on market incentives to reduce health care costs does not signal the abandonment of equity as a social objective. To the contrary, the new emphasis on efficiency is intended to provide more and better health care through the generation of savings from the use of management systems to improve productivity. Market incentives and new management systems to increase efficiency are not the antithesis of equity but tools to provide better health care to the poor and to the elderly in an environment of fiscal constraints.     

Recovering from research: a no-fault proposal to compensate injured research participants

National advisory committees have considered the obligations owed to research participants in the event of research-related injuries. These committees have repeatedly concluded that injured research participants are entitled to compensation for their injuries, that the tort system provides inadequate remedies, and that the United States should adopt no-fault compensation. But because the advisory committees have made no concrete proposals and have taken no steps toward implementing no-fault compensation, the United States continues to rely on the tort system to compensate injured research participants. This Article argues that recent legal developments and a transformation in the global research landscape make maintaining the status quo morally indefensible and practically unsustainable. Recent legal developments exacerbate the longstanding difficulties associated with the tort system as a method of compensation; nearly every injured research participant will have difficulty recovering damages, and certain classes of injured research participants--those in federal research and those abroad--are prevented from recovering altogether, resulting in substantial unfairness. In the past ten years, many of the countries substantially involved in research have mandated systematic compensation. By not mandating compensation, the United States has become a moral outlier and risks having its noncompliant research embargoed by foreign ethics committees, thereby delaying important biomedical advances. This Article examines alternative compensation mechanisms and offers a concrete no-fault compensation proposal built on systems already in place. The proposed system can be implemented in the United States and countries around the world to help harmonize various national compensation systems and to more equitably and effectively make those injured by research whole.     

Factors affecting perceptions of medical errors

The purpose of the study was to assess how three factors affect subjects' perceptions of a medical error made in a hypothetical scenario. The factors were (i) type of compensation system, (ii) degree of procedural “voice” present in the physician-patient relationship, and (iii) magnitude of damage sustained by the patient. Perceptions were defined to include subjects' (i) emotional reactions to the incident, (ii) causal attributions about the incident, (iii) evaluations of the faimess of the compensation systems, and (iv) compensation demands. Results indicated that damage magnitude was the only factor that affected subjects' emotional reactions to the described incident and their compensation requests. When damage was severe, subjects reacted more negatively to the event and demanded greater compensation. Subjects rated the no-fault system and greater voice conditions as more fair. In general, subjects causally analyzed the error incident in a manner that was less blameworthy of the physician when procedural justice was high, especially if this was combined with a no-fault compensation system. Results were discussed in terms of Wexler and Winick's (1991) model of therapeutic jurisprudence.     

Subsistence Emissions and Luxury Emissions

In order to decide whether a comprehensive treaty covering all greenhouse gases is the best next step after UNCED, one needs to distinguish among the four questions about the international justice of such international arrangements: (1) What is a fair allocation of the costs of preventing the global warming that is still avoidable?; (2) What is a fair allocation of the costs of coping with the social consequences of the global warming that will not in fact be avoided?; (3) What background allocation of wealth would allow international bargaining (about issues like 1 and 2) to be a fair process?; and (4) What is a fair allocation of emissions of greenhouse gases (over the long-term and during the transition to the long-term allocation)? In answering each question we must specify from whom any transfers should come and to whom any transfers should go. As the grounds for the answers we usually face a choice between fault-based principles and no-fault principles.     

Modelling Criminal Justice System Costs by Offence

This paper illustrates how to estimate criminal justice system costs by offence type. Criminal justice system costs are all the costs the authorities incur to prevent and investigate crime, prosecute criminals, impose sentences, and take care of victims and offenders. There are two approaches: the break-down and the bottom-up approaches. The break-down approach decomposes the aggregate budget into smaller pieces. The bottom-up approach multiplies known costs per activity by volumes for each activity and offence type. Both approaches can be combined with two types of estimates: incidence-based and prevalence-based estimates. An incidence-based estimate identifies all costs attributable to crimes committed or processed in a specified period regardless of whether these costs exceed this time period. A prevalence-based estimate identifies all costs incurred in a specified period regardless of when the crime was committed or processed. This paper looks at the differences between the two approaches and the two estimates and indicates which combination works best depending on the type of analysis and the availability of data. The methodologies are illustrated using examples from The Netherlands. These examples show that the availability of reliable data is crucial. The more assumptions have to be made, the less reliable the end results. Investing in better data in this area should be a first priority for governments interested in criminal policy evaluation.     

The Economics of the Grounds for Divorce in Great Britain

Despite similarities in their socio-economic environments and the provision of identical legal grounds for divorce, England & Wales is dominated by fault divorce decrees whereas no-fault divorce dominates in Scotland. Indeed, during the past fifteen years, the shares of fault and no-fault divorce have increasingly diverged across these two regions. The paper proposes an explanation for this remarkable contrast based on cost incentives generated by procedural and legal interventions within the respective legal systems. In particular, the introduction of the Simplified Procedure in Scotland and the reduction in the time bar to divorce in England & Wales are key causal factors.     

Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2003 rates. Final rule

We are revising the Medicare acute care hospital inpatient prospective payment systems 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 describe the 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, 2002. We also are setting forth rate-of-increase limits as well as policy changes for hospitals and hospital units excluded from the acute care hospital inpatient prospective payment systems. In addition, we are setting forth changes to other hospital payment policies, which include policies governing: Payments to hospitals for the direct and indirect costs of graduate medical education; pass-through payments for the services of nonphysician anesthetists in some rural hospitals; clinical requirements for swing-bed services in critical access hospitals (CAHs); and requirements and responsibilities related to provider-based entities.     

Consumer-sponsored prepaid group practice: restructuring the health care system

The traditional separation of health care delivery and financing systems is breaking down as various new types of health care facilities are established and as payment continues to be a major concern. Group Health Cooperative of Puget Sound (GHC) was organized as a prepaid group practice system responsive to consumers. Costs, methods of payment and delivery of care are interrelated and are all influenced by consumer ownership. GHC has been refining its benefit programs since 1945. Strategies for controlling use and costs focus on improved provider management and on flexibility. This article explains how the structure of GHC benefits the consumer.     

Compensation for medical injury in New Zealand: does "'no-fault" increase the level of claims making and reduce social and clinical selectivity?

The issues of patient safety and quality of care have gained policy attention with a growing appreciation of the scale and impact of medical injury in health systems. While the focus is clearly on the prevention of iatrogenic injury, the question of patient compensation is now also considered important, if only because in fault-based tort systems the fear of litigation may itself be a barrier to the disclosure and open discussion of medical error. No-fault systems, by contrast, do not require proof of culpability, and thus may both reduce barriers to compensation and increase disclosure of error. Little evidence, however, is available on the performance of such systems. This article reports on the analysis of two data sources-a sample of hospital admissions and a complete set of compensation claims for medical injury. Both are for the same year and region of New Zealand, a country that has maintained a no-fault system of accident compensation for a quarter of a century. Just over 2 percent of hospital admissions were associated with an adverse event that was potentially compensable under scheme criteria. While the claims process was well targeted, the level of claims making and receipt was low, with the ratio of successful claims to potentially compensable events being approximately 1:30. Comparison of social and clinical characteristics of the two data sets revealed a degree of selectivity. Compared with the hospital events, the typical successful claimant was younger and female and was much more likely to have experienced a surgical adverse event that, while unexpected, was not due to substandard care. It is concluded that, in interpreting these results, account needs to be taken of a number of features unique to the New Zealand system. These include: the limited payoff for a compensation claim (no pain and suffering or lump sum, free hospital care); the relative complexity of the grounds for claim (either rarity and severity or practitioner error); and a history of limited litigation for medical error. This suggests that, while the New Zealand system is well targeted, cheap, and free of financial and legal barriers, a change in legal doctrine alone has not in itself been sufficient to remove completely the selective and low level of claims making traditionally associated with patient compensation under tort.     

Medical Error and Patient Safety: Understanding Cultures in Conflict

Evidence documenting the high rate of medical errors to patients has taken a prominent place on the health care radar screen. The injuries and deaths associated with medical errors represent a major public health problem with significant economic costs and erosion of trust in the health care system. Between 44,000 and 98,000 deaths due to preventable medical errors are estimated to occur each year, making medical errors the eighth leading cause of death in the United States. However, the recent prominence of the issue of safety or error does not reflect a new phenomenon or sudden rift in the quality of health care (although it is a system fraying at the edges). Rather, the prominence of the issue reflects a radical change in the culture of health care, and in how relationships within the health care system are structured and perceived. In this paper, I discuss the multiple factors responsible for the change in the culture of health care. First, the culture has shifted from a clinician cantered system, in which decision making is one–sided, to a shared system of negotiated care between clinician and patient, and, often, between administrator or payer. Second, the nature of quality in health care has changed due to the geometric increase in the availability of technological and pharmaceutical enhancements to patient care. Third, the health care culture continues to rely on outdated models of conflict resolution. Finally, the regulatory structure of health system oversight was set in place when fee–for–service care governed physician–patient relationships and where few external technologies were available. In the current health care culture, that structure seems inadequate and diffuse, with multiple and overlapping federal and state regulatory structures that make implementation of patient safety systems difficult.     

Bending the health cost curve: the promise and peril of the Independent Payment Advisory Board

Underlying today's and the future's health-care reform debate is a consensus that America's health-care financing system is in a slow-moving but deep crisis: care appears substandard in comparison with other advanced industrial countries, and relative costs are exploding beyond all reasonable measures. The Obama Administration's Patient Protection and Affordable Care Act (ACA) attempts to grapple with both of these problems. One of ACA's key instrumentalities is the Independent Payment Advisory Board-the IPAB, designed to discover and authorize ways to reduce the rate of growth of Medicare and other categories of health spending. The IPAB is a peril. Expert boards to perform regulatory tasks in the interest of efficiency and social goals always run a high risk of being captured by the industry they are supposed to regulate. Even should it succeed at its task of reducing the rate of growth of Medicare spending, who is to say that the reductions will not come at a heavy cost in reduced quantity and effectiveness of medical care? But the IPAB also has promise. The need for a better process than our current specialist-driven one to assign value to the medical services provided by Medicare is great. The bellwether status of Medicare payment systems means that commercial insurance consumers and payors would also benefit mightily from bringing more coherent, technocratic, and cost-effectiveness oriented logic to this process. And the current system of relative Medicare reimbursement rates is, in the judgment of many, currently well out of whack. We quail when we consider the magnitude of the tasks the IPAB faces--even its initial task. Nevertheless, we remain optimistic that this administrative agency will manage to bend the long-run healthcare cost curve and moderate future price increases.     

Real reform begins within: an organizational approach to health care reform

Health care systems are under pressure to control their increasing costs, to better adapt to evolving demands, to improve the quality and safety of care, and ultimately to ameliorate the health of their populations. This article looks at a battery of organizational options aimed at transforming health care systems and argues that more attention must be paid to reforming the delivery mechanisms that are so crucial for health care systems' overall performance. To support improvement, policies can rely on organizational assets in two ways. First, reforms can promote the creation of new organizational forms; second, they can employ organizational levers (e.g., capacity development, team-based organizations, evidence-informed practices) to achieve specific policy goals. In both cases organizational assets are mobilized with a view to creating complete health care organizations -- that is to say, organizations that have the capacity to function as high-performing systems. The challenges confronting the development of more complete health care organizations are significant. Real health care system reforms may likewise require implementing ecologies of complex innovation at the clinical, organizational, and policy levels. Policies play a determining role in shaping these new spaces for action so that day-to-day practices may change.     

Navigating the Legal System After a Motor Vehicle Collision

More often than not, individuals involved in motor vehicle collisions (MVCs) do not sustain physical injuries. When individuals are involved in serious, injury-causing MVCs, the consequences may be devastating. Injured persons sometimes elect to pursue legal action to address the medical costs incurred and earning losses experienced in association with their injuries and the resulting impairments in function. This article presents a comprehensive review of the requirements of MVC-related litigation and the laws that govern this process, with emphasis placed on Ontario law in effect at the time of writing. Information considered germane to the decision to pursue legal action is reviewed, including the likely settlement amount, length of the legal process, costs associated with legal services and fee agreements that govern remuneration paid to the lawyer. Also described are no-fault regime and civil lawsuit, the two avenues of compensation that injured persons can pursue in an effort to recover losses and obtain the assistance they need to recover from their MVC-related injuries.     

Economic origins of the no-fault divorce revolution

Richard Posner argues that late twentieth-century divorce-law reform rendered marital relationships in the United States increasingly contractual in nature. Chief among such reforms was the no-fault divorce revolution: the widespread switch in states’ legal regimes from fault-based, mutual-consent divorce to no-fault based, unilateral divorce, which swept across America in the 1970s. While a growing literature considers the no-fault divorce revolution’s effects on divorce rates, almost no work considers its causes. Taking Posner’s observation as its starting point, this paper develops testable hypotheses relating to the potential origins of no-fault divorce reforms in the US.     

试论适用无过错责任原则的侵权案件中的证明责任分配

长期以来,适用无过错责任原则的侵权案件中的证明责任如何分配众说纷纭。但是,学界一直尚未有从证明责任基本理论角度专门探讨该问题的文章。笔者试从基本理论出发探讨了适用无过错责任原则的侵权案件中的证明责任的分配原则,据此对我国相关立法规定提出了质疑和合理化建议,深入探求了因果关系推定时的证明责任归属,主张高度危险作业致人损害的侵权诉讼以及饲养动物致人损害的侵权诉讼中对因果关系不存在的证明责任应当由加害人承担。     

Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2006 rates. Final rule

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs to implement changes arising from our continuing experience with these systems. In addition, in the Addendum to this final rule, we describe the changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs. 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 in full or in part on a reasonable cost basis subject to these limits. These changes are applicable to discharges occurring on or after October 1, 2005, with one exception: The changes relating to submittal of hospital wage data by a campus or campuses of a multicampus hospital system (that is, the changes to Sec. 412.230(d)(2) of the regulations) are effective on August 12, 2005. Among the policy changes that we are making are changes relating to: The classification of cases to the diagnosis-related groups (DRGs); the long-term care (LTC)-DRGs and relative weights; the wage data, including the occupational mix data, used to compute the wage index; rebasing and revision of the hospital market basket; applications for new technologies and medical services add-on payments; policies governing postacute care transfers, payments to hospitals for the direct and indirect costs of graduate medical education, submission of hospital quality data, payment adjustment for low-volume hospitals, changes in the requirements for provider-based facilities; and changes in the requirements for critical access hospitals (CAHs).