Managed care liability and the capitated provider

While there have been no reported cases as yet on the subject of ERISA preemption of claims arising from utilization review decisions by providers, it will unquestionably be a significant issue facing providers that participate in capitated arrangements. If preemption is determined not to be available, providers will be exposed to risks from which health plans are currently shielded. Providers conducting utilization review should be following this issue as it develops, but should also be obtaining insurance for this risk to the extent it is available (e.g., it will not be available for punitive damages). Providers should also consider negotiating provisions in their contracts with health plans to the effect that any utilization review conducted by the provider is on behalf of the health plan and that the provider's utilization review activities will be covered under the health plan's liability insurance.     

Clinical Challenges in Addressing Intimate Partner Violence (IPV) with Pregnant and Parenting Adolescents

Intimate partner violence (IPV) has been identified as a significant issue for pregnant and parenting adolescents. This study thematically analyzed data from focus groups with service providers (n?=?43) who work with pregnant and parenting adolescents to learn about barriers and strategies for addressing IPV. Service providers described four primary barriers to addressing IPV with their adolescent clients: adolescent clients?? definitions of love, intergenerational relationship patterns, cultural norms about gender and violence, and developmental-contextual considerations. Service providers also indicated that they respond to adolescents?? IPV related concerns by taking steps to identify IPV, building working relationships, and taking appropriate follow-up action. Results suggest that providers can benefit from increased training and skill development in working with IPV, as well as working in interdisciplinary, collaborative teams to increase effectiveness with challenging cases. Programs should consider integrating IPV prevention initiatives that target broader social norms. Future research should pilot and test the effectiveness of targeted IPV training and programmatic interventions with service providers who work with this population.     

The Delta Dental case: "Fair procedure" comes to managed care. Delta Dental Plan of California v. Banasky

All providers contemplating managed care contracts, both individual and institutional, should carefully review the health plans' internal administrative review and dispute resolution procedures before making their decisions, especially if the contracts will represent significant income for the provider. While there may be judicial recourse in California and in other states that adopt the holding in Delta Dental, in other states providers may well be held to the health plans' internal administrative decisions as a matter of contractual agreement. Health plans should also review their own policies and procedures for adequacy under applicable state law. The health care community will not know the full extent of Delta Dental's implications until later cases area decided, but for now it seems certain that another wave of change in this area is just beginning.     

Equity in assessment: discrimination and disability issues from an Australian legal perspective

Assessment equity concerns all educational authorities and practitioners. When educators consider issues of equity, their predominant concern is accommodation of students with special needs, cultural issues, and creating alternative assessment activities that have equivalence to standard activities, so as not to advantage or disadvantage any student in their demonstration of knowledge. This paper examines equity issues in assessment from a legal perspective, drawing on case history from Australia, and based in discrimination and disability law. The paper is intended to assist authorities and practitioners to understand legal implications of educational assessment in order to promote practices that reduce the likelihood of legal claims and the resultant use of financial and human resources away from educational activities. However, the discussion of cases and judgements is also intended to raise issues of whether educational providers and authorities should be more conscionable in their consideration of educational equity and assessment.     

As outcomes measurement and management become widespread, providers should beware of legal pitfalls

Until new statutes and court decisions clarify the law applicable to outcomes research, providers will continue to face new questions. In the meantime, paying careful attention to satisfying the requirements of existing laws protecting peer review information will put providers in the best position to minimize their exposure. Providers should review their current outcomes measurement and management systems to ensure that (1) they are structured to take full advantage of the confidentiality protections available under state law, and (2) appropriate access to outcomes data for those who need it is clearly provided for in the relevant documentation.     

论商事仲裁的性质与仲裁员的权力义务

商事仲裁兼具契约性和司法性,商事仲裁员既是民间法官又是服务提供者。作为民间法官,为完成其裁判争议的职能,仲裁员应当享有一系列与法官相同或类似的权力。同时,无论是作为民间法官还是服务提供者,仲裁员又负有一系列约定或法定的义务。     

社会性别主流化视角下的家政工社会与法律保护分析

随着时代的进步,社会的发展,社会性别主流化日益受到人们的普遍关注。而与此同时,非劳动法上的劳动者——家政工的社会与法律保护问题日益严峻。我国家政服务行业的从业人员大约有1500万,其中96%以上是女性。虽然家政服务业这种灵活多样的就业方式得到政府的支持,有着广阔的发展前景,为许多人提供了就业机会和岗位,但是,这些从业人员却并不是我们通常所说的劳动法上的劳动者,而受到劳动法律规范和相关法律的应有保护。针对现行相关立法的缺漏与不足,社会各界应高度关注并积极应对,更新观念,尽快完善相关立法,制定各种有效、配套的政策与措施。     

Department of Justice challenging big insurers' "Most Favored Nation" clauses

The DOJ's latest actions suggest that MFNs in managed care contracts should be evaluated on a case-by-case basis, focusing on the actual or potential impact that the MFNs have on price competition among providers and payors in the relevant marketplace. For health care providers desiring to avoid MFNs, however, the DOJ's heightened activity in this area might furnish an appropriate reason to resist such clauses. To date, the DOJ's focus has been on the market power of payors with MFN status. However, the DOJ's reasoning applies equally to providers that wield buying power in contracting with others. Although the DOJ has yet to take up this latter issue, MFNs imposed by increasingly powerful provider organizations can expect to receive similar scrutiny from the DOJ, especially as their market influence grows.     

How do we provide the digital footprint with eternal rest? Some criteria for legislation regulating digital wills

This article analyses the implications of the death of digital service users on their digital footprint and assesses some of the solutions—contractual and legislative—that have been posited to date by digital service providers and by Parliaments of a few countries. In view of the different initiatives analysed, and the experience gained in their implementation, the paper presents legal certainty, effectiveness and transparency as criteria that should guide the regulation of the digital footprint in the case of death. These criteria must allow for the adoption or regulation of mechanisms for managing the digital footprint of digital service users to be clear and trustworthy for them and efficient and easily recognized and adopted by digital service providers.     

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.     

Canada: community stakeholders withdraw from consultation processes with CSC

In November, a group of twelve community-based HIV/AIDS organizations and service providers announced their decision to withdraw from participation in consultation processes and committees of the Correctional Service of Canada (CSC).     

Special report on reimbursement. The safe harbor for small investment interests: where do joint ventures go from here?

There is no specific federal self-referral legislation presently proposed or in effect that statutorily prohibits providers from referring Medicare or other patients to entities in which the referrers have an investment interest, except for existing "Stark" legislation, which applies only to clinical laboratory services, effective January 1, 1992. (See Newsletter, Vol. 6, No. 1, January 1991, at 3.) Thus, health care joint ventures are not per se illegal. The publication of the Safe Harbor Regulations does nothing to change this fundamental fact, and it should not cause providers to abandon existing joint ventures, or planned ones, in a "knee-jerk" fashion, without careful analysis. Of course, there is no guarantee that expanded "Stark" legislation, or some other new self-referral legislation, will not be enacted in the future to prohibit providers from referring patients to entities in which they have an investment interest. Because of this uncertainty, all health care joint ventures should contain "unwinding" provisions to govern the rights and obligations of investors in the event that the venture is required to, or the participants voluntarily elect to, dissolve. Any new venture being contemplated should plan for dissolution, and existing ventures should undertake an internal review of their charter documents to assess whether the rights and duties of all participants upon dissolution are properly spelled out. If not, amendments should be made now, while all participants are on good terms. A failure to agree in advance upon such important issues is an invitation to discord, and possibly even litigation.     

Enhancement technologies and the person: an Islamic view

The availability of newer choices in contemporary bioethics, especially enhancement technologies, poses a challenge for Muslim patients and their care providers in making appropriate decisions. How should they reconcile personal autonomy with ethical guidelines of Islamic Shariah (jurisprudence)? This article discusses such concerns.     

California expands the duty to warn patients exposed to and infected with HIV. Reisner v. Regents of the University of California

There is still no general definitive guide for hospitals and other health care providers concerning the extent of their duty to warn third parties of a patient's HIV status. However, even in states like California that have statutorily eliminated any duty to directly inform third parties, the Reisner case clearly indicates that liability to third parties may arise indirectly based on a failure to warn HIV-exposed or -infected patients of their status and the risks of communicating the virus to others. Accordingly, health care providers should take several actions: 1. Ascertain, with the assistance of legal counsel, the precise dictates of applicable state statutes and case law regarding (a) a provider's obligation to warn HIV-exposed or -infected individuals of the potential of communicating the virus to others; (b) additional statutory requirements such as notification of public health authorities; and (c) whether notice to third parties at risk of exposure from the patient is required or even permitted. 2. Develop and implement written policies regarding notification and counseling of exposed or infected patients, including counseling patients on the risks of communicating the virus to third parties; and 3. Develop and implement written policies regarding permissive or mandatory notification and counseling of exposed or infected third parties. In this context, providers should be aware that patient confidentiality and privacy laws may prohibit disclosure of the identity of exposed or infected patients to third parties.     

“通知删除”规则的再检讨

“通知删除”规则通过激励网络服务提供者接收来自权利人的侵权通知,采取相应必要措施,配合权利人维权,制止网络侵权行为的蔓延。我国《侵权责任法》第36条已然将《信息网络传播权保护条例》所规定的“通知删除”规则修正为“通知与必要措施”规则。实践中,包括接入、传输服务提供者等在内的网络服务提供者应当适用“通知删除”规则,并根据案件的具体情况,参考比例原则采取必要措施,且其采取的措施并不限于“定位清除”,还包括建立顺畅的“通知受理转通知”渠道以及提供侵权行为人相关信息、终止网络服务等与其所提供服务的特点相匹配的措施。     

Joint Commission completes transition to functional standards

The Joint Commission's new emphasis on performance-based standards led it to identify functions it believed were likely to have the most significant impact on patient outcomes. Carrying out these functions requires an interdisciplinary team approach to patient care. Thus, the old strategy of handing out one manual chapter to each department head and asking him or her to implement the standards in that chapter will not work in 1995. Rather, providers will have to allocate already stretched human and financial resources to redesign their methods of assessing and improving patient outcomes in order to comply with yet another major revision of the Accreditation Manual for Hospitals. To ensure an adequate understanding of and compliance with Joint Commission standards, organizations should make the entire CAMH "required reading" for its leadership and make it available in strategic areas of the hospital for review by all employees. While the Joint Commission recognizes that its new functional approach will take some time to implement, all providers that want to ensure that they remain accredited should begin now to orient their leadership, staff, and employees to the new functional standards in the CAMH and the ways in which those standards affect patient outcomes.     

The failure of community benefit

Though proponents of tax exemption for health care providers continue to extol the virtues of the community-benefit test, Part II of this article illustrates that the train pretty much has already left the station on this front. Both the federal government and the states increasingly look to uncompensated care as the touchstone of exemption for health care providers. To a great extent, this transition back to a "relief of the poor" standard for exemption is the result of the inherent lack of precision in community benefit standards, along with the general trend of empirical evidence that nonprofit health care providers behave similarly to their for-profit counterparts. Faced with this situation, federal and state policymakers naturally have focused on charity care as the one quantifiable behavioral difference to justify exemption. Nevertheless, some empirical evidence suggests that nonprofits may engage in socially desirable behavior other than simply free care for the poor, and the arguments that a mixed ownership system provides the best overall health care model cannot be dismissed out of hand. Thus, despite my past criticisms of the community benefit formulation, I have come to the view that we should seriously consider the options available beyond complete repeal of the community benefit test or a return to a strict charity-care exemption standard. I continue to believe that we should demand a fairly high level of "accountability" from exemption, however, and that exemption should have some direct causal connection to whatever socially-desirable behavior we are seeking. While one option along these lines is to adopt Nina Crimm's approach of rewarding specific behaviors through a deduction or credit system, using "enhancing access" as a test of exemption may provide the best combination of flexibility and verifiable behavioral differences to support continued exemption for health care providers.     

论竞价排名服务提供者注意义务的边界

在搜索引擎竞价排名关键词引发的商标权侵权和反不正当竞争案件中,服务提供者的注意义务边界是判断其是否应当承担帮助侵权责任的关键。我国各地司法判决对此问题的回应呈现出一定差异。搜索引擎的竞价排名服务虽然属于广告业务,但与传统广告不同,其本质是一种网络信息检索服务。在个案中,应考查竞价排名服务提供者对于侵权行为的预见水平和控制能力,为市场竞争和技术的精进留下自由的发展空间,在消费者、权利人、市场经营者、网络服务提供者的利益之间寻求平衡。竞价排名服务提供者注意义务的边界的设定应当以追求社会福利的最大化为目标。     

Special report on antitrust. Criminal antitrust enforcement--when, who, and why?

Government civil antitrust enforcement and private antitrust litigation are not always easy to avoid, because even innocent actions can be alleged to have been improperly motivated or to adversely affect competition. On the other hand, criminal antitrust violations can be readily avoided by following a set of basic, simple, and easy to remember rules: 1. Providers should not agree with competing or potentially competing providers on any terms of price, quantity, or quality of service; 2. Providers should not agree with competing or potentially competing providers as to which patients (or payors) will be served, what kinds of services will be offered, or where to locate offices or facilities; and 3. Providers should not agree with competing or potentially competing providers to refuse to offer services to payors or other alternative delivery systems. There are circumstances in which exceptions to these general rules are appropriate, such as when an agreement among providers is necessary in order to participate in a legitimate alternative delivery system, preferred provider organization, or individual practice association. However, these exceptions are narrow and technical. The best advice is the following warning to providers by Charles F. Rule, former U.S. Assistant Attorney General for antitrust: "You should never act as if an exception applies until after you have consulted an experienced antitrust lawyer or until you have obtained adequate assurance that competent counsel has structured the system to eliminate antitrust problems."     

电子信息时代侵犯著作权罪的入罪标准研究

以电子信息技术侵犯著作权的犯罪往往由多个无意思联络的行为人共同实施,单一化的传统入罪标准难以有效规制。基于该类犯罪高度分工化的特征,犯罪主体可以被划分为网络服务提供者和侵权资源提供者两大类型。网络服务提供者怠于履行其内容审查义务、情节严重的行为应当被认定为犯罪,内容审查义务的边界是确定其入罪标准的核心,但同时需要注意入罪标准、内容审查义务与信息传播权间的界限。大部分侵权资源提供者的行为仍然适用传统的入罪标准,但其中非法经营额所涵盖的范围需要适当扩张。