The impact of health maintenance organizations and competition on hospitals in Minneapolis/St. Paul

The Healthcare Educational and Research Foundation (HERF) in Minneapolis undertook a two-year research project to study the effects of health maintenance organizations (HMOs) and competition on the hospital industry in Minneapolis/St. Paul. This article summarizes HERF's major findings surrounding three key questions: (1) do the HMOs in Minneapolis/St. Paul use fewer hospital resources relative to conventional payers?; (2) do recent overall community trends in inpatient use suggest evidence of hospital utilization-reducing effects attributable to HMOs?; and (3) given the highly visible competitive process among Minneapolis/St. Paul providers, do hospital cost and revenue data suggest any evidence of cost-containment? The findings (based on data through 1982) indicate that for comparable patients, Twin Cities HMOs appear to use fewer medical care resources per hospitalized patient. There was, however, no clear evidence of community-wide, utilization-reducing effects directly attributable to the "competitive effect" of HMO introduction and development in the market. In addition, there was no empirical evidence that HMOs (which had enrolled 25 percent of the consumer market by 1982), or other large buyers of inpatient services, have selected hospitals on the basis of price as hypothesized by competition advocates.     

The competitive impact of health maintenance organizations on hospital finances: an exploratory study

In this study we explore whether HMO-induced competition has contained expenditures in Minneapolis/St. Paul hospitals. Specifically, we assessed the impact of HMOs on revenue, cost, and net income per admission in Twin Cities hospitals from 1979 to 1981. Some HMOs have obtained negotiated discounts from hospitals. We found that hospitals which gave larger discounts did not have lower costs per admission. This finding suggest that discounts do not force hospitals to operate more efficiently. In addition, hospitals with a large share of patients from HMOs or government Medicare and Medicaid programs did not have lower costs per admission than other hospitals during the years from 1979 to 1981. This finding casts doubt on the claim that discounts are justified by lower costs for HMO or government patients. Finally, neither HMO market share nor discounts had an adverse effect on hospital profits. During the three years studied, hospital profits in the Twin Cities showed an upward trend. This study concludes that if competition is to succeed it must encompass more than HMOs. HMOs may be important, but they are only one agent in the market. Thus, public policy created to induce competition must go beyond the simple stimulus of HMO growth.     

Medicare program; payment to health maintenance organizations and competitive medical plans--HCFA. Final rules with comment period

These regulations implement section 114 of the Tax Equity and Fiscal Responsibility Act of 1982 by authorizing Medicare reimbursement for health care services to eligible health maintenance organizations (HMOs) and competitive medical plans (CMPs) on a prospective basis for those entities that have a risk contract or on a reasonable cost basis for those that have a cost contract. The regulations set forth the requirements that an entity must meet in order to be: Eligible to enter into a Medicare contract (either risk or reasonable cost) as an eligible organization; and Reimbursed by Medicare on a capitation basis (either prospectively or retrospectively) for items and services furnished to Medicare enrollees. In addition, these regulations implement sections 2322 and 2350 (b) and (c) of Pub. L. 98-369 (Deficit Reduction Act of 1984), which further amended the Social Security Act concerning payments to HMOs and CMPs.     

Incomplete contracts and competition: another look at fisher body/general motors?

In this paper we analyze the problem of the enforcement of incomplete contracts with endogenous outside options. Some of the equilibria we outline may reverse one of the main results presented in the standard literature. We then revisit the literature on the highly debated Fisher Body/General Motors merger and suggest an explanation based on GM??s need to control the Fisher brothers?? outside options.     

Health maintenance organizations; reestablishment of compliance by Kaiser Foundation Health Plan, Inc.: Public Health Service. Notice, continued regulation of health maintenance organizations

On December 4, 1981, the Office of Health Maintenance Organizations (OHMO) notified Kaiser Foundation Health Plan, Inc. that Kaiser-Georgetown Community Health Plan, Inc.), (formerly Georgetown University Community Health Plan, Inc.), 4200 Wisconsin Avenue, NW., Suite 300, Washington, D.C., a federally qualified health maintenance organization (HMO), had successfully reestablished compliance with its assurance to the Secretary that it would maintain a fiscally sound operation. This determination took effect on December 1, 1981.     

Medicare program, health maintenance organizations: technical amendments--HCFA. Final rule with comment period

This rule amends the HCFA regulations that pertain to prepaid health care to provide for uniform use of certain terms throughout part 417, simplify, clarify, and update content that pertains to the furnishing of health care services by, and the organization and operation of, Federally qualified health maintenance organizations (HMOs); and redesignate certain sections, correct internal crossreferences, and make minor conforming changes to ensure internal consistency. These are technical and editorial changes intended not to change the substance of the rules but rather to make it easier to find particular content and to better ensure uniform understanding of the regulations. The purpose of redesignations is to free section numbers in areas where it is necessary to insert new provisions (in logical order) to reflect changes in the Public Health Service Act.     

Medicare and state health care programs: fraud and abuse, civil money penalties and intermediate sanctions for certain violations by health maintenance organizations and competitive medical plans--HHS. Final rule

This final rule implements sections 9312(c)(2), 9312(f), and 9434(b) of Public Law 99-509, section 7 of Public Law 100-93, section 4014 of Public Law 100-203, sections 224 and 411(k)(12) of Public Law 100-360, and section 6411(d)(3) of Public Law 101-239. These provisions broaden the Secretary's authority to impose intermediate sanctions and civil money penalties on health maintenance organizations (HMOs), competitive medical plans, and other prepaid health plans contracting under Medicare or Medicaid that (1) substantially fail to provide an enrolled individual with required medically necessary items and services; (2) engage in certain marketing, enrollment, reporting, or claims payment abuses; or (3) in the case of Medicare risk-contracting plans, employ or contract with, either directly or indirectly, an individual or entity excluded from participation in Medicare. The provisions also condition Federal financial participation in certain State payments on the State's exclusion of certain prohibited entities from participation in HMO contracts and waiver programs. This final rule is intended to significantly enhance the protections for Medicare beneficiaries and Medicaid recipients enrolled in a HMO, competitive medical plan, or other contracting organization under titles XVIII and XIX of the Social Security Act.     

Medicare program; explanation of enrollee rights and other provisions applicable to health maintenance organizations and competitive medical plans--HCFA. Final rule

This rule revises current Medicare requirements relating to health maintenance organizations and competitive medical plans. It eliminates the requirement that an organization enroll two new Medicare beneficiaries for each present Medicare enrollee converted from a cost to a risk contract (the "two-for-one" rule), expands the amount and type of information which an organization must provide to enrollees, and requires annual notice of enrollees' rights under the plan. This rule also authorizes HCFA to terminate a contract with an organization for noncompliance with the composition of enrollment standard requiring that no more than 50 percent of an organization's membership be comprised of Medicare or Medicaid enrollees (hereinafter referred to as the "50/50 rule") and authorizes sanctions when an organization fails to comply with the 50/50 rule or the terms of any waiver or exception to that rule. These provisions conform our regulations with changes made by the Omnibus Budget Reconciliation Acts of 1986, 1987 and 1989.     

Medicare and state health care programs: fraud and abuse, civil money penalties and intermediate sanctions for certain violations by health maintenance organizations and competitive medical plans--HHS. Correction to final regulations

This document corrects technical errors that appeared in 42 CFR part 1003 of the final rule published in the Federal Register on July 15, 1994 (59 FR 36072). Specifically, the final rule set forth the Secretary's authority to impose sanctions and civil money penalties on health maintenance organizations, competitive medical plans and other prepaid health plans contracting under Medicare and Medicaid. This correction notice sets forth the corrected text for sections 1003.100, 1003.103 and 1003.106, some of which was inadvertently omitted or amended.     

Medicare program; establishment of an expedited review process for Medicare beneficiaries enrolled in health maintenance organizations, competitive medical plans, and health care prepayment plans--HCFA. Final rule with comment period

This final rule with comment period establishes a new administrative review requirement for Medicare beneficiaries enrolled in health maintenance organizations (HMOs), competitive medical plans (CMPs), and health care prepayment plans (HCPPs). This rule implements section 1876(c)(5) of the Social Security Act, which specifies the appeal and grievance rights for Medicare enrollees in HMOs and CMPs. This rule requires that an HMO, CMP, or HCPP establish and maintain, as part of the health plan's appeals procedures, an expedited process for making organization determinations and reconsidered determinations when an adverse determination could seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function. This rule also revises the definition of appealable determinations to clarify that it includes a decision to discontinue services.     

Full reporting by health maintenance organizations (HMOs) and competitive medical plans (CMPs) paid on a cost basis--HCFA. Final rule

This rule affects HMOs and CMPs that contract with HCFA to furnish services to Medicare beneficiaries and be paid on a cost basis. It requires a cost HMO or CMP to include in its cost report the costs of hospital and skilled nursing facility (SNF) services even if it has elected (under section 417.532(c) of the HCFA regulations) to have HCFA's intermediary process those claims and pay the hospital or SNF directly. This change is necessary so that HCFA can determine and compare the cost of all services furnished by HMOs and CMPs with the cost of equivalent services paid for under the fee-for-service system. This rule also adds a definition and makes technical changes to clarify and update certain related provisions of subparts O and U of part 417 of the HCFA rules.     

Full reporting by health maintenance organizations (HMOs) and competitive medical plans (CMPs) paid on a cost basis--HCFA. Correction notice

Federal Register document No. 95-16411, beginning on page 34885 of the issue of July 5, 1995 amended part 417 of the HCFA regulations to require full reporting by HMOs and CMPs of the costs of all services furnished to their Medicare enrollees. In that final rule we amended section 417.546 to remove paragraph (b). However, we failed to remove, from the introductory text of the section, a reference to the paragraph (b) that we removed. This notice corrects our oversight.     

Medicare program; contracts with health maintenance organizations (HMOs) and competitive medical plans (CMPs)--HCFA. Final rule with comment period

This rule clarifies and updates portions of the HCFA regulations that pertain to the following: The conditions that an HMO or CMP must meet to qualify for a Medicare contract (Subpart J). The contract requirements (Subpart L). The rules for enrollment, entitlement, and disenrollment of Medicare beneficiaries in a contracting HMO or CMP (Subpart K). How a Medicare contract is affected when there is change of ownership or leasing of facilities of a contracting HMO or CMP (Subpart M). These are technical and editorial changes that do not affect the substance of the regulations. They are intended to make it easier to find particular provisions, to provide overviews of the different program aspects, and to better ensure uniform understanding of the rules.     

Team boundary-spanning activities and performance of technology transfer organizations: evidence from China

The Journal of Technology Transfer - This study performs an in-depth analysis of the causes and consequences of team boundary-spanning activities in the context of Chinese technology transfer, by...     

Health maintenance organizations; exclusion of gamete intrafallopian transfer and zygote intrafallopian transfer as basic health services--HCFA. Notice

This notice informs the public of the determination by the Administrator of the Health Care Financing Administration that gamete intrafallopian transfer and zygote intrafallopian transfer are unusual, infrequently provided, and not necessary for the protection of individual health. This determination permits Federally qualified health maintenance organizations to exclude these services from the basic health services they must provide to their members.     

Metaphor and Metonymy: An Analysis of R.A.V. v. city of St. Paul Minnesota

International Journal for the Semiotics of Law - Revue internationale de Sémiotique juridique -