Physician agreements to control medical prepayment plans: Federal Trade Commission. Adoption and publication of enforcement policy with respect to physician agreements to control medical prepayment plans

The Federal Trade Commission has adopted, and is publishing with this notice, a statement of enforcement policy with respect to physician agreements to control medical prepayment plans. The statement sets forth the general approach the Commission intends to use in its case-by-case enforcement program for evaluating physician agreements to form, operate, or control such plans and for evaluating the practices of plans that are controlled by a group of physicians.     

Medicare and Medicaid programs; requirements for physician incentive plans in prepaid health care organizations--HCFA. Final rule

This final rule amends the regulations established by a March 27, 1996, final rule with comment period. The regulations govern physician incentive plans operated by Federally-qualified health maintenance organizations and competitive medical plans contracting with the Medicare program, and certain health maintenance organizations and health insuring organizations contracting with the Medicaid program. As explained in the March 27 rule, the provisions of this final rule will also have an effect on certain entities subject to the physician referral rules in section 1877 of the Social Security Act.     

Beyond competition: the normative implications of consumer-driven health plans

The Federal Trade Commission/Department of Justice 2004 report Improving Health Care: A Dose of Competition appeals to efficiency arguments in promoting a wide range of health care market reforms. But the market-based reforms discussed in Improving Health Care are not simply neutral with regard to equity in access to services; they are likely to have substantial and inequitable distributional effects. We use the case of consumer-driven health plans (CDHPs), the pillar of the Bush administration's private-sector health reform efforts, to illustrate the limitations of viewing health policy reform through the lens of Improving Health Care. We conclude that the speculative efficiency gains from CDHPs need to be balanced against well-documented equity concerns within a normative framework. Moreover, other important ethical issues arise with regard to the risks imposed on the population by the introduction of policies that are based on a faith in markets rather than empirical evidence.     

Consumer-defined health plans: emerging challenges from tort and contract

The emergence of Consumer-Defined Health Plans with large deductibles means that many people will be financially responsible for all or most of their healthcare during any given year. This increasing exposure to costs will bring important changes in the physician-patient relationship, as patients seek more information about the care their physicians propose. Litigation can be anticipated in two areas. First, in tort law, informed consent claims may allege that providers failed to disclose the likely costs and medical importance of their care. Second, in contract law, patients may challenge the reasonableness of the prices they are charged. This Article explores potential causes of action in both areas. Ultimately, increasing transparency of pricing may lend greater rationality not only to pricing structures but also, it is to be hoped, to healthcare itself, as cost-worthiness of care assumes higher priority in medical decisionmaking.     

Nurse practitioner challenges to the orthodox structure of health care delivery: regulation and restraints on trade

Until recently, physicians have been the primary health care providers in the United States. In response to the rising health care costs and public demand of the past decade, allied health care providers have challenged this orthodox structure of health care delivery. Among these allied health care providers are nurse practitioners, who have attempted to expand traditional roles of the registered nurse. This article focuses on the legal issues raised by several major obstacles to the expansion of nurse practitioner services: licensing restrictions, third party reimbursement policies, and denial of access to medical facilities and physician back-up services. The successful judicial challenges to discriminatory practices against other allied health care providers will be explored as a solution to the nurse practitioners' dilemma.     

Medicare and Medicaid programs; requirements for physician incentive plans in prepaid health care organizations--HCFA. Final rule correction; notice of changes in compliance dates, with comment period

In the March 27, 1996, issue of the Federal Register, we published, at 61 FR 13430, a final rule with comment period that implements requirements in sections 4204(a) and 4731 of the Omnibus Budget Reconciliation Act of 1990 that concern physician incentive plans. In the preamble of that rule, we set forth dates by which prepaid health plans had to comply with certain of the rule's provisions. This document clarifies and changes some of those deadlines, and provides an opportunity for public comments on them. It does not otherwise change the requirements set forth in the rule. In addition this document corrects the March 27 rule's inadvertent reversal of the nomenclature change made by a previous final rule.     

Administration of grants and agreements with institutions of higher education, hospitals, and other non-profit organizations; direct grant programs--DoE. Final regulations

The Secretary amends 34 CFR parts 74 and 75 to add the Office of Management and Budget (OMB) control numbers to certain sections of the regulations. Those sections contain information collection requirements approved by OMB. The Secretary takes this action to inform the public that these requirements have been approved.     

Medicare and Medicaid programs, health care financing research and demonstration cooperative agreements and grants and availability of funds for cooperative agreements and grants--HCFA. General notice

This notice announces the availability of HCFA funds for certain priority research and demonstration cooperative agreements and grants for the Federal fiscal year 1985. HCFA makes funds available for activities that will help to resolve major health care financing issues or to develop innovative methods for the administration of Medicare and Medicaid. This notice contains information about the subject areas for cooperative agreements and grants that will be given priority; project requirements; application procedures and other pertinent information. It also cancels the February 4, 1985 closing date for HCFA waiver-only applications that was announced on November 9, 1983.     

Tax administration as health policy: hospitals, the Internal Revenue Service, and the courts

Since 1969 federal tax policy has permitted nonprofit hospitals to turn away indigent patients or to transfer them to public hospitals. The Internal Revenue Service made health policy, but its officials remain convinced that they were not making policy at all. Convinced that it was reasoning from legal principles, the Revenue Service accepted the hospital industry's view of the history and purpose of hospitals. The federal courts further obscured the problem. Moreover, the Revenue Service took no interest in the effects of its ruling on the services provided by tax-exempt hospitals until 1989. We describe these events and seek to explain them by linking the recent history of health policy to the assumptions that govern the making of tax policy. We conclude that the making of health policy by tax officials who are not accountable for it and who believe that they are not making policy at all is not in the public interest.     

The Department of Health and Human Services issues proposed regulations on physician incentive payments by hospitals

Hospitals tempted to operate their own physician incentive plans are reminded that, under OBRA 1986, they are precluded from paying physician incentives of any kind to reduce or limit Medicare or Medicaid covered services. In light of the proposed regulations and the guidance of the preamble, hospitals should review their incentive plans to determine whether physicians providing direct patient care are receiving prohibited payments. Further, supervising physicians who are receiving incentives for certain hospital departments may not influence direct care over patients served by those departments, even through other physicians. Some risk may also exist if incentives are based on a formula that considers patients of the supervising physician's medical group. Finally, it may be useful to develop a utilization and quality of care review program specifically designed to assure that patient undertreatment does not occur as a result of any supervising physician incentive program.     

Vertical restraints among hospitals, physicians and health insurers that raise rivals' costs. A case study of Reazin v. Blue Cross and Blue Shield of Kansas, Inc. and Ocean State Physicians Health Plan, Inc. v. Blue Cross and Blue Shield of Rhode Island

Two recent district court opinions consider whether affiliations among hospitals, doctors and health insurers--through contract or ownership--violate the antitrust laws. This Article applies a raising rivals' costs framework to the facts of those cases in order to assess whether the practices at issue were unreasonable.