The use of expensive health technologies in the era of managed care: the remarkable case of neonatal intensive care

The use of neonatal intensive care (NIC) continued to rise rapidly in the 1990s despite the concerns of observers about its cost effectiveness and its successes being mostly in facilities with high volume and capabilities. The objective of this study is to test the effects of insurance type, competition among hospitals, and market pressure from managed care plans on the supply and cost of NIC. The analysis uses logistic and linear models with techniques to avoid bias from (a) market area definitions based on actual patient flows and (b) self-selection of hospitals by patients with unmeasured risk of needing NIC. The data source contains all births in short-term hospitals in New Jersey during 1990 and 1994. Both the number of days and charges for NIC are reported. Key findings are that the decision of a hospital to offer NIC was associated with teaching status, the proportion of infants in the market area with documented high risk, and the market concentration of major competitors. The market share of managed care plans and the concentration of enrollment were not associated with either NIC being offered or with the standardized charges. Whether a particular patient was given to a NIC depended on patient risk factors and whether a NIC unit was present, but not on payer group. The results are consistent with the hypothesis that young insured parents (with the advice of their obstetricians) prefer hospitals with NIC and also are relatively profitable enrollees for health plans. In conclusion: using the results here and in other research, public and private policy makers may consider several ways to strengthen the incentives for health plans to contract for cost-effective birth-related services. The results also raise questions for a number of regulatory and payment policies and call for better public data on costs and outcomes for NIC.     

A useful tool for evaluating potential mediators

Conclusion Overall, the guidelines published by NIDR are a useful set of standards that should become a valuable reference tool for those responsible for evaluating and selecting mediators. Each institution that is involved in this process will find the guidelines useful as they develop their own criteria. George H. Friedman is vice president for case administration of the American Arbitration Association, 140 West 51st St., New York, N.Y. 10020.Allan D. Silberman is vice president for education and training with the AAA.The authors are grateful for the input on this brief commentary received from their AAA colleagues Thomas R. Colosi, vice president for national affairs, and Robert E. Meade, vice president for program development.     

Public policy economics: A survey of current pedagogical practice

This article reports on a survey of economics courses in our graduate program, identifies some of their weaknesses, and presents a number of suggestions for their improvement. The major theme that underlies my suggestions is to increase the active problem-solving roles for students in these courses, not leave the task exclusively to other courses. This can be facilitated by readings that emphasize the different processes of resource allocation, by limited use of case materials, and by development of interactive computer simulation models.     

Can Civil Society Organizations Solve the Crisis of Partisan Representation in Latin America?

This article takes up the question of whether civil society organizations (CSOs) can and do act as mechanisms of representation in times of party crisis. It looks at recent representation practices in Argentina, Bolivia, and Brazil, three countries where political parties have experienced sharp crises after several decades of mixed reviews for their party systems. At such moments, any replacement of parties by CSOs should be especially apparent. This study concludes that the degree of crisis determines the extent that CSOs' representative functions replace partisan representation, at least in the short term. Where systems show signs of re‐equilibration, CSOs offer alternative mechanisms through which citizens can influence political outcomes without seeking to replace parties. Where crisis is profound, CSOs claim some of the basic party functions but do not necessarily solve the problems of partisan representation.     

The happy land homicides: 87 deaths due to smoke inhalation

We reviewed all 87 deaths from the Happy Land Social Club fire. All deaths were due to smoke inhalation. The carboxyhemoglobin (COHb) concentrations ranged from 37 to 93% with a mean of 76.5%. The vast majority (97%) of the decedents had a COHb concentration over 50%. Cyanide blood concentrations ranged from 0 to 5.5 mg/L with a mean of 2.2 mg/L. Nine decedents had no cyanide detected, and seven had cyanide concentrations of less than 1 mg/L. Fewer than one third of the decedents had thermal injuries, and most were partial thickness burns involving less than 20% body surface area. Ethanol was detected in 72% of decedents with a range of 0.01 to 0.29 g% and a mean blood concentration of 0.11 g%. Cocaine or cannabinoid use was identified in 9% of the decedents. All decedents were visually identified, and all had soot in the airway extending to the major bronchi. Carboxyhemoglobin concentrations corresponded well with deaths from smoke inhalation. Cyanide concentrations did not correspond with the extent of smoke inhalation, and the role of cyanide in contributing to these deaths is doubtful. Hydrogen chloride inhalation, as evidenced by comparison of the pH of tracheal mucosa to controls, was not a factor.