The effects of regulatory tools on organizational populations

One of the main activities of regulation is the control of market development by influencing the number of firms in an industry, their entry into an industry, and their exit from an industry. Population ecology is used as a framework for explaining both the direct and indirect effects of regulatory activity on entry, exit, and market structure. This framework is then used to derive specific propositions about regulatory effects on entry, exit, and market structure in the health maintenance organization industry.     

Of orphans and balloons

Technologies with significant implications for expenditures continue to reach the health care system. These technologies range from orphan drugs/biologicals used to treat rare diseases to balloons used to treat the common occurrence of benign prostatic hyperplasia (BPH) in aging men. Because payment for these technologies can represent a serious financial drain on third-party payers, utilization has to be carefully evaluated, monitored, and controlled.     

Investigational: what's in a name

The term "investigational" has become the fulcrum upon which coverage decisions turn. All third-party payers, including the federal government, use varying definitions of the term for the purpose of excluding treatments from coverage for payment. Unfortunately, no consistent definition of the term is available to payers to guide them in their coverage decisions.     

From QA to TQM

In the decade from 1950 to 1960, two quality-related processes--medical audit and total quality management--were being developed, one directly in the health care field and the other in the manufacturing sector. These processes remained isolated from each other until the mid-1980s. Each would have a separate but major effect on the health care industry.     

From quality assurance to continuous quality improvement

To change from punitive and legalistic QA to positive and productive CQI, both attitudes and methods must change. This is a difficult challenge, but potential rewards for both the organization and its individual members suggest that the effort is worthwhile and deserves high priority. Members of the executive/management team will likely turn to physician executives for guidance on how to proceed.     

Common sense leadership

Common sense has to do with problem solving. In the complexities of everyday human life, we are faced time and again with the need to solve problems. In fact, every situation we face, at least at the first exposure, requires some form of problem solving. When we want food, we have to solve a series of problems from acquisition to preparation to serving and eating. When we deal with organizational needs, problem solving is the daily fare.     

Coverage, technology assessment, and the courts

Coverage decisions by third-party payers are relying more and more heavily on the conclusions of technology assessment programs about the safety and effectiveness of technologies applied in specific clinical situations. Assessment programs vary markedly in the sophistication and rigor of their methodology. Payers differ as to how such assessment information is integrated into their decision-making processes. Finally, coverage decisions about a specific technology can vary widely across the country.