PPS waivers: implications for Medicare, Medicaid, and commercial insurers

This paper compares the Medicare prospective payment system (PPS) to four all-payer rate-setting systems that operated under HCFA waiver authority. The study examines the experience of Medicare, Medicaid, and commercial insurers under the two approaches. Data from several American Hospital Association surveys and from Medicaid 2082 report forms are analyzed. The paper concludes that the all-payer waiver programs have been as successful as PPS in controlling the rate of growth in Medicare costs. In addition, Medicaid programs are more successful in controlling their outlays in all-payer rate-setting environments than when they "go alone." Finally, there is no evidence to suggest that hospitals can increase charges in response to greater financial need under either PPS or the state waivers. Nevertheless, it appears that commercial insurers are better able to compete with Blue Cross plans in all-payer rate-setting states than elsewhere.     

Significance of functional and nutritive pulmonary circulation for vital reactions in the form of embolisms

The functional and nutritive circulation in the lungs is connected by anastomoses between the pulmonary and bronchial arteries. The anastomoses have the structure of blocked arteries from which arteriovenous anastomoses proceed to the peribronchial plexus. The pulmonary artery is provided with a flow impulse by the anastomoses, and oxygen-containing blood is admixed with the venous blood, thus forming an "aortalization" in the lungs. By diverting the bloodstream, venous blood can reach the bronchial artery. The peculiarities of the lung circulation are important for vital reactions in the form of macro- and microembolisms. Macroembolisms prove the functionality of the system if branches of the pulmonary artery are closed before the arteries are blocked. A hemorrhagic infarction either arises or does not arise, and the hemorrhagic infarction cannot exceed a certain limit. A microembolism is over and above the anastomoses. If the microembolism is greater, pressure in the arteria pulmonaris can cause blood from the pulmonary artery to overflow into the bronchial artery. Because arteriovenous anastomoses arise from the blocked arteries, microemboli can now reach the systemic circulation. Thus, the system described can explain the passage of microemboli into the systemic circulation, avoiding the capillaries of the lungs; on the other hand, larger microembolisms can prove the functionality of the system.     

Assessment of competency for execution? A guide for mental health professionals

Assessment of competency for execution presents two compelling ethical questions for mental health professionals: whether clinicians can ethically provide such assessment, and if so, how it should be done in order to maximize quality and minimize ethical conflict. In this article we address the issue of whether to participate and, if so, how. The question of whether to participate is discussed by summarizing the arguments for and against participation and offering guidelines for making a decision. The question of how to proceed is discussed in two contexts: preadjudication (before a formal decision about competency) and postadjudication (following a determination of "incompetent" and transfer of the offender to another facility for treatment and further assessment). Finally, recommendations are made regarding research that would improve the quality of execution competency assessments.     

Medicaid in the 1990s: Trends, Innovations, and the Future of the "PAC-Man" of State Budgets

Rapidly escalating health-care inflation and congressionallymandated expansions have led to large increases in spendingfor Medicaid, the federal-state program of health care for thepoor. These increases came at a time when state budgets werealready under recession-induced stresses. In addition, 1991brought new pressures for Medicaid spending from the courtsand closer federal scrutiny and control over revenues used forthe program's state "match." Yet the Medicaid picture is farfrom bleak. Diversity, innovation, and an emerging stale policyrole also characterize the program in ways that epitomize thestrengths and weaknesses of the American intergovernmental system.     

Facing the powers that be

Lobbyists, entrenched forces in congress and self-interested friends will try to stymie Clinton's efforts. A look at four key arenas of combat.     

Historical geography of the population of Michoacan. Eighteenth century

The author incorporates geographic variables into this study of population dynamics in Michoacan, Mexico, during the eighteenth century.