New York's Blue Cross and Blue Shield, 1934-1990: the complicated politics of nonprofit regulation.

The story of New York Blue Cross is one of complex interaction with state and federal regulators and also with hospitals, the medical profession, commercial insurers, and the public, who make up the regulatory environment. Negotiation, cooperation, and adaptation among parties whose goals and assumptions were partly parallel characterize the relationships. As we can see from New York Blue Cross's origins and its role in the development and administration of certificate-of-need legislation, Medicare, insurance practice and regulation, and hospital rate setting, this story does not represent the capture of government by a special interest, nor the gradual souring of a public interest organization, nor disinterested and distant government regulation.     

Comment on Kartell v. Blue Shield of Massachusetts, Inc.: an antitrust analysis of Blue Shield's reimbursement schemes

In Kartell v. Blue Shield of Massachusetts, Inc., the First Circuit held that Blue Shield's reimbursement practice known as the "ban on balance billing" did not constitute an unlawful restraint of trade in violation of the antitrust laws. Underlying the First Circuit's decision was deference to what it viewed as efforts by Blue Shield and by the Commonwealth to promote cost containment. This Comment argues that, to the contrary, under an appropriate analysis of antitrust law, the practices employed by Blue Shield did constitute unreasonable restraints of trade on the physicians' service industry in Massachusetts, given Blue Shield's market dominance in the Commonwealth. The Comment also argues that such inhibition of the competitive functioning of this industry is unwise, and that costs should instead be contained by effectuating the antitrust laws and encouraging the development of competitive forces within this industry.     

Examining exclusionary conduct of HMOs and PPOs: a case comment on Northwest Medical Laboratories v. Blue Cross and Blue Shield of Oregon.

As the climate of the health care industry has changed to one of cost-containment and competition through the growth of HMOs and PPOs, health care providers have become the subjects of antitrust litigation. One such case, Northwest Medical Laboratories v. Blue Cross and Blue Shield of Oregon, involved a medical laboratory and a radiology center who claimed that they were victims of an illegal group boycott after defendant's pre-paid health plan denied them preferred provider status. The Oregon Court of Appeals, using the traditional antitrust analysis applied to other industries for decades, failed to consider the intricacies that exist within the health care industry. This result led to an inaccurate market share computation and an inadequate rule of reason analysis. This Comment examines the shortcomings of the Northwest Medical opinion and argues that, in applying the antitrust laws to the health care industry, courts in future cases must recognize and respect the unique features of the business of providing health care.     

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.     

Seeking common ground: a history of labor and Blue Cross.

In recent years, voluntary health insurance costs have become a major source of friction in labor-management negotiations. What was once a "fringe" has led to job actions, strikes, and intensive bargaining. We examine the history of labor's participation in New York Blue Cross from the 1930s to the recent past and show that labor's participation in the plan was crucial to Blue Cross's success in the plan's early decades. By the late 1950s, serious tensions developed over rate increases and the participation of labor in Blue Cross governance. Ultimately, the issue was one of the control over what was provided by the plans and who would pay for the costs of care. We posit that labor was never able to achieve an important role in the control of the third-party payer, and in the antilabor environment of the 1980s this proved detrimental to labor's interests.     

Capture and culture: organizational identity in New York Blue Cross.

This article explores the changing corporate culture of New York's Blue Cross and Blue Shield plan in its first fifty years. As the plan grew, corporate culture evolved over four sequential phases: the plan first had the character of an experiment, then that of a movement, a business, and, most recently, a corporate agglomerate. Accompanying this evolution has been an identity crisis, as the need to adapt to a turbulent environment has challenged the plan's settled understanding of its core values, namely, voluntarism, community, and cooperation.     

Sharing governmental authority: Blue Cross and hospital planning in New York City.

Hospital planning in New York has been since the 1930s an intensely political process with high stakes. The leaders of Blue Cross and their allies used the hospital planning process in the city and the state as a means to extend and protect corporate authority in what they took to be the public interest. When Blue Cross was established in the 1930s, its leaders used the mechanisms of formal planning as part of their solution to pressing problems in the organization and distribution of hospital services. In the decade after World War II, Blue Cross had an immense impact on hospital planning in New York as a result of its growth and its underwriting policies. Conflicts between Blue Cross and state regulators beginning in the 1950s led to a new formulation of the politics of planning. Blue Cross became a partner with the state in regulating hospitals. The state and Blue Cross behaved as co-regulators until the 1980s. The interpretation in this paper revises the earlier accounts of health politics in New York by Law (1976) and Alford (1975).     

The public presentation of Blue Cross, 1935-1965.

I explore the public presentation of Blue Cross, examining in detail the political, cultural, and institutional messages that shaped its advertising. Blue Cross advertisements had the twin purpose of attempting to increase the number of its own subscribers while criticizing the idea of a national health insurance policy. These twin aims did structure the Blue Cross campaigns but may well have worked at cross-purposes.     

Iatrogenic conditions as an object of forensic medical studies

The author proposes an original definition of iatrogenic states and their forensic medical model based on the analysis of the causes underlying the development of these conditions. A rationale for the application of this model in the forensic medical practice is formulated.     

Digital photography as an object of forensic medical examination

The possibility of diagnosing skin lesions by means of digital pictures was investigated. A "Zenit ET" film camera, HP flatbed scanner, amateur "'Panasonic" and "Sony" videocameras, miniature USB camera and digital photocameras were used to obtain images. Above 1000 images were studied. Criteria were fixed for the required quality of images. A method was developed to formalize images by means of a color etalon and mathematical assessment of formalized skin lesions. Stages were suggested for the computer-based analysis of images. Computer software was developed for the automated formalization of images and for the statistical processing of values of image elements. It was demonstrated that digital photography can be an independent informative object of forensic medical examination.     

Vitreous potassium as a measure of the postmortem interval: an historical review and critical evaluation

This is an historical review of the articles published in English on the use of vitreous potassium to determine the PMI. External factors which influence the validity of the test are sampling techniques, analytical instrumentation and environmental temperature during the PMI. Internal factors that are recognized at the present time which influence vitreous potassium are the age of the individual, the duration of the terminal episode and the presence or absence of nitrogen retention.