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.     

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.     

The Virtuous Polity, The Accountable Polity: Liberty and Responsibility in The Federalist

The Federalist claims to present a republican response to thetypical political problems faced by republics. That solutionrequired a departure from all models of republics known at thattime, and in particular a break with Anti-Federalist modelsthat posited heavy reliance on responsibility, understood aseither political accountability or as moral and political virtue.The Federalist challenges the Anti-Federalist notion that a"no-gap polity" is the means to safe and effective republicanism.It also challenges those who believe that virtue of people orrulers is the precondition of a republican polity. Publius doesrequire quasi-virlues of certain sorts—and thus does notrely entirely on calculating selfinterest—but these aresignificantly different from the virtues posited by earlierrepublican theorists or certain contemporary interpreters ofThe Federalist.     

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.     

Project USA: American competitiveness and what must be done to restore it

The United States today faces a loss of influence as a world power, a reduction in American independence as a policymaker, and a decline in the standard of living on which Americans have come to depend. History teaches that nations weaker and less productive than the United States can rise to become economic powerhouses and rapidly increase their standards of living. History also teaches that nations failing to recognize their fundamental problems will inevitably decline. American politicians must face what is abundantly clear: the United States is losing ground and must act quickly to reverse its course. This White Paper outlines what must be done. Information about the nation's current status must be analyzed and communicated. Incentives to improve the level of competence in government must be provided and maintained. The emphasis of government policy must be changed to reflect broad economic and technological interests as opposed to special interests. Savings must be encouraged and increased. Infrastructure must be improved Tax laws must be modified to help bring these changes about. Economic and technological issues must be elevated to the importance they require. American thinking must reflect the new realities: that the age of leadership through military power is over, that the requirements for success in the world of the 1990s and beyond require a sound and growing economy that is internationally competitive. The US can accomplish these goals only through foundation-shaking, comprehensive, fundamental changealong the lines we propose herein.This paper is the executive summary (with minor editing modifications) of a white paper that is available from Cornell University's Johnson Graduate School of Management.