A case of wrongful use of quality management. Summit Health, Ltd., v. Pinhas

Summit Health, Ltd., v. Pinhas liberalized the jurisdiction of the Sherman Antitrust Act to include cases of intrastate hospital credentialing. The U.S. Supreme Court decision eased the requirements for plaintiffs to sue when they perceived that health care organizations were acting as monopolies. The court removed the defense that a plaintiff had to prove that the decision of a health care organization affected interstate commerce for the case to be heard in court. Important as the case is in antitrust law, however, greater lessons can be gained by health care organizations from analyzing the events that led to the lawsuit.     

Supreme Court expands view of interstate commerce in peer review proceeding

At the end of May, the U.S. Supreme Court allowed an antitrust claim by a physician against a hospital for an allegedly improper peer review proceeding. Previously, hospitals were allowed to defend against antitrust claims regarding a peer review decision involving one physician on the grounds that the activities did not affect interstate commerce. The Supreme Court has apparently removed this defense by letting stand a Court of Appeals decision allowing a physician's antitrust claim against a hospital that has suspended his privileges.     

Quality improvement act gets first antitrust test

In an opinion issued on February 20, 1990, the Federal District Court for the Central District of California summarily dismissed the claim of Dr. George M. Austin that Santa Barbara Cottage Hospital and five individual physicians conspired to suspend his hospital privileges in violation of Section 1 of the Sherman Act. The decision was based on the court's determination that the actions of the hospital and defendant physicians were immune from federal antitrust liability under the Health Care Quality Improvement Act of 1986. The case is the first test of the Act in connection with a staff privileges claim under the antitrust laws and is the first affirmance of the immunity protections of the Act.     

Hospital leasing decision models

This paper adapts leasing decision models to the hospital case. The appropriate use of alternative formulations is considered in conjunction with an example from the hospital literature. Finally, certain theoretical problems of leasing in a nonprofit environment are considered.     

Contractual Integration of Physician and Hospital Services in the U.S.

Using a binary-choice, probabilistic model, this study analyzes data covering the institutional and market characteristics of 759 hospitals in 81 metropolitan statistical are as in the United States to understand why many of them have chosen to contractually integrate with physician and physician group practices. The results support the theory that the contractual integration of physician and hospital services in the U.S. during the 1990s occurred in response to market pressures to circumvent the transaction costs of monitoring physician utilization of hospital resources. They also support the views of Robinson (1997) and Shortell (1997) that the nature of the coordination, the governance structure, and the part to which market mechanisms play are largely determined by the demands for coordination from the market served by the hospital, the capabilities of the hospital to pull physicians into integration arrangements, and the historical context and constraints binding the hospital's decision making. This revised version was published online in July 2006 with corrections to the Cover Date.     

突发事件下的医院应急群决策模型研究*

针对突发事件下的医院应急管理问题,进行了医院应急群决策模型研究。考虑到医院应急决策者心理行为特征的偏向性,将病人应急方案的选择设计成一个以医院决策者信息与病人集结信息之间距离最小为目标的非线性规划模型。根据病人的伤重程度和应急资源使用度的损益值,获得医院应急情景下的综合价值,根据累积前景理论,通过计算区间概率,获得医院应急情景下不同应急方式的累积前景值。使用模拟植物生长算法求解,莸得病人的最优集结信息。案例分析表明,该决策过程可以使得突发事件下医院应急管理方案达到最优。     

灾后不确定需求下应急医疗移动医院鲁棒选址问题研究

我国灾害医学救援主要采用"现场救治"模式，应急医疗移动医院的选址是否合理直接影响救援效率，但各受灾点伤员数量的不确定性增加了决策的困难。本文引入多面体不确定集合刻画伤员数量的不确定性，同时考虑伤员分类及移动医院分型，构建一个以伤员总生存概率最大化为目标的鲁棒选址模型。利用鲁棒优化理论，将模型转化为等价的混合整数规划问题，通过GAMS软件编程并调用CPLEX求解器求解。最后，以四川芦山地震应急医疗救援为例，验证模型和求解方法的可行性和鲁棒性。结果表明，扰动比例和不确定水平对移动医院的选址和伤员的分配方案有显著影响，决策者可根据自己对不确定性风险的偏好程度选择最佳的扰动比例和不确定水平组合，以获得最优的选址分配方案。     

Design and Analysis of Hospital Admission Control for Operational Effectiveness

Variability in hospital occupancy negatively impacts the cost and quality of patient care delivery through increased emergency department (ED) congestion, emergency blockages and diversions, elective cancelations, backlogs in ancillary services, overstaffing, and understaffing. Controlling inpatient admissions can effectively reduce variability in hospital occupancy to mitigate these problems. Currently there are two major gateways for admission to a hospital: the ED and scheduled elective admission. Unfortunately, in highly utilized hospitals, excessive wait times make the scheduled gateway undesirable or infeasible for a subset of patients and doctors. As a result, this group often uses the ED gateway as a means to gain admission to the hospital. To better serve these patients and improve overall hospital functioning, we propose creating a third gateway: an expedited patient care queue. We first characterize an optimal admission threshold policy using controls on the scheduled and expedited gateways for a new Markov decision process model. We then present a practical policy based on insight from the analytical model that yields reduced emergency blockages, cancelations, and off‐unit census via simulation based on historical hospital data.     

A Brief Review and Assessment of the Leegin Decision: Who Wins and Who Loses When Manufacturers Are Free to Set Retail Prices?

For decades, it has been a per se violation of U.S. antitrust law for manufacturers or distributors to specify retail selling prices. In the spirit of atomistic, unrestrained competition, retailers were free to set prices without undue interference from upstream channel participants. Attempts by manufacturers or other channel participants to restrict retail price setting initiatives were viewed by regulators as an unwarranted and illegal interference with the market mechanism. Restrictions on price setting initiatives would, it was argued, lessen competition and ultimately raise prices above competitive levels to the detriment of consumers. Recently, under the leadership of newly appointed Chief Justice Roberts, a more “business friendly” Supreme Court has reversed this policy; vertical price fixing is no longer a per se violation of U.S. antitrust law. By a five‐to‐four margin, the Court held in Leegin Creative Leather Products that manufacturers could, under certain circumstances, establish binding retail selling prices. Henceforth, retail price setting restrictions will be subject to a rule of reason evaluation whereby price restrictions will be assessed on a case‐by‐case basis. Proponents of the now‐legal restrictions argue that this will ensure that merchandise sold through retail outlets will receive needed support, free riding will be reduced or eliminated, and new brand introduction will be facilitated. Critics argue that the Court's decision marks a return to the days of fair trading; marginal firms will be protected, so‐called “inframarginal consumers” will be forced to pay for services they do not want or need, and prices for many branded products will rise, all to the detriment of consumer welfare.     

Risk, Statistical Inference, and the Law of Evidence: The Use of Epidemiological Data in Toxic Tort Cases

Toxic torts are product liability cases dealing with alleged injuries due to chemical or biological hazards such as radiation, thalidomide, or Agent Orange. Toxic tort cases typically rely more heavily than other product liability cases on indirect or statistical proof of injury. There have been numerous theoretical analyses of statistical proof of injury in toxic tort cases. However, there have been only a handful of actual legal decisions regarding the use of such statistical evidence, and most of those decisions have been inconclusive. Recently, a major case from the Fifth Circuit, involving allegations that Benedectin (a morning sickness drug) caused birth defects, was decided entirely on the basis of statistical inference. This paper examines both the conceptual basis of that decision, and also the relationships among statistical inference, scientific evidence, and the rules of product liability in general.     

Antitrust concerns in managed care provider negotiations. United States v. A. Lanoy Alston, DMD, P.C., et al

Contract negotiations between managed care organizations and providers are potential legal traps, loaded with antitrust implications. A recent court action involving dentists is instructive on the issues for all providers.     

Hospital productivity measurement: An engineering approach

A model for measuring hospital productivity is proposed, based on the determination of standard inputs per case. From these standards and the number of cases passing through a hospital, total standard inputs can be determined. Division of the standard inputs by the actual inputs provides productivity figures for each kind of input. Standard inputs per class of cases are calculated, through a chain of matrices, from standard inputs per elementary operation. Classification of cases into diagnostic categories, and the validity of assuming a typical average set of treatments for each class, are discussed. A numerical example is presented which demonstrates the proposed approach for calculating manpower productivity in a maternity ward.     

Hospital medical director. Documenting roles and responsibilities

Establishing the position of medical director for a hospital entails making a clear exposition of the role of the medical director in relation to the board, the basic administrative structure, and the medical staff. The responsibilities assigned to the medical director in one hospital may differ in more than a minimal manner from those in another institution, and the nature of these relationships may also vary because hospitals differ in their traditions, internal power relationships, and functions. Because of these differences, the need to be precise about roles and responsibilities becomes even more obvious.     

MBO and goal directedness in a hospital context.

In this article, we examine the attempt of two hospitals to implement management by objectives (MBO) as a means of improving organizational planning and control. Our conclusion is that, as a goal-directed form of management technology, MBO may lead to dysfunctional decision making at the institutional level within organizations, especially those facing complex, dynamic environments. However, if viewed as a philosophy of management administered at the sub-unit level, MBO may serve as a catalytic agent for encouraging decentralized decision making and performance evaluation.     

Hospital role on decline.

The era of hospital dominance of the health care field has ended. The new day will belong to insurers and payers. Health maintenance organizations will become the primary actor on the health care scene. If PPOs are added to HMOs, and by 1990 most PPOs will look like HMOs, 70 percent of the U.S. population will be enrolled in such plans. By that time, at least 10 percent of the nation's hospitals will have disappeared.     

The acceptance and accuracy of decision analysis methods

This paper reports a field experiment which compared two approaches to decision analysis, called cases and criteria scaling, in terms of their acceptance to users and their predictive features. The case method simulates decisions likely to occur in practice. Each decision is described by particular values of the decision criteria. Experts consider the values of criteria present in each decision and make a judgment. Regression is used to correlate the criteria values with the judgments. The regression equation provides the prediction model. The criteria scaling method decomposes the decision task. Experts weight each criterion and specify how decisions change across levels of each criterion. The predictive model is made up of the sum of each criterion weight multiplied by the criterion-predictor functional relationship. Both methods were applied to build models which predicted the demands for nursing time, using patient severity indicators, for two hospital units. The case method had considerable predictive accuracy and had favorable participant reactions. Predictions made by criteria scaling overestimated needs and this method was viewed as inaccurate and hard to understand by participants. The implications of these findings are discussed.     

Physician fee-setting requires scrutiny.

To avoid antitrust liability from physician fee-setting in HMOs and PPOs, participating physicians should share the risk of profit and loss. "Health Law" is a regular feature of Physician Executive contributed by the law firm of Epstein Becker and Green, P.C. Douglas A. Hastings, Esq., a partner in the firm's Washington, D.C., offices serves as column editor.     

Hospital medical directors, quality of care, and financial returns

You are a physician executive working very hard within a hospital on all sorts of medical staff issues and quality of care. You answer to the board. The latter, through its administrators, may still have difficulty documenting the precise value of a full-time physician executive. Your hospital is losing money or not making enough profit for capital expenditures and salary raises. It is considering or will have to consider staff cuts. What can you do that will influence the bottom line, produce a quality image, and quantify your value?     

组织内冲突的重复对策模型

结合管理组织的特点将组织内的冲突归为3 种对策模型, 建立了基于渴望紧张评价的对 策仿真模型, 研究在满足个体理性的决策准则的情况下, 合作与非合作行为在重复对策中是如 何产生的, 个体理性与群体理性是如何相互作用的. 结果表明, 重复对策下, 合作行为可能发 生, 但依赖于对策结构的类型, 某些情况下还占主要地位. 进一步给出了模型的3 种改进方法. 与经典的对策分析略有不同, 在该模型中, 局中人决策的主要依据来自于历史信息和自身的愿 望, 使模型更加接近实际.     

竞争、外部效应与专利权人技术许可行为的扭曲

在一般性假设下通过构建专利技术的使用许可证的拍卖模型,运用机制设计方法分析了专利权人面临竞争性产业时的最优技术许可策略,进而从创新知识传播或反垄断的角度考察了其许可行为的扭曲.技术许可的结果会对产业中的部分生产者施加负外部效应,这导致其购买专利的动机发生改变,并由此影响了专利权人的许可行为.研究结果表明,在最优的许可机制中,外部效应的存在使得专利权人能够以入门费的形式从未被许可的生产者攫取租金;另一方面也导致其许可证的保留价格过高而导致了知识的低效传播.