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grading rubric, week 3, final class.docx
Senior Project Progress Report
Complete a two to three page (excluding title and reference pages)
report on the progress you have made to date on your Senior Project.
You must use a minimum of three scholarly sources. Your report, and any
citations used, must be in APA style as outlined in the Ashford Writing
Center. Your progress report should cover the following:
- Topic: Identify the topic that you have selected for your Senior Project and provide a brief explanation for why you have chosen to address this topic *This may be copied from the Week Two assignment if evaluated as Distinguished Performance. Otherwise, make adjustments per Week Two feedback.
- Organization Specific Rationale: Provide a brief overview of the health care organization that you have selected for your Senior Project including a summary of the challenges and/or opportunities impacting the balance between health care costs, quality, and access to services that the organization is currently facing. The challenges and/or opportunities should directly relate to your rationale for why you have chosen your topic (i.e., training program) to help the organizational leaders manage this challenge/opportunity. Challenges and/or opportunities should be grounded in the research (e.g., web-based resources, electronic articles, or personal interviews). The more informed you are, the better prepared you will be to complete your Senior Project.
- Training: Identify the audience for your training program and provide a brief outline of the topics it will address. Include a minimum of three to five learning outcomes that are targeted for your identified audience. Specifically, what do you want your audience to know and/or be able to do after they have completed training? How does this training program align with the overall challenges and/or opportunities that the organization is facing? Overall, how will the training program benefit the organization?
Carefully review the Grading Rubric for the criteria that will be used to evaluate your assignment.

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Health Final Paper
Health Final Paper
For this project, you are to complete the following case study. This project needs to be completed in a Microsoft Word document answering each question individually. The document should be set up in a numbered format. For example:Type your answer hereType your answer hereInclude references in APA format for each pertinent question and include a Reference page as well.This assignment should follow the conventions of Standard American English (correct grammar, punctuation, etc.). Your writing should be well ordered, logical and unified, as well as original and insightful. Your work should display superior content, organization, style, and mechanics.Case StudyDB is a 50 YO African American woman. She has been diagnosed with type 2 Diabetes Mellitus and hypertension. DB takes the following medications: Novolin 70/30 insulin breakfast and supper, Lasix and Cymbalta. DB lives with her husband and 3 children, ages 13, 15 and 17. Her height is 5’6”.Weight: 185 pounds.Activity level: sedentaryDB reports the following 24-hour food intake:Wakes up at 6am: Skips breakfast because needs to be at work at 6:45am. Will have coffee with 2 sugars and cream at work.11am lunch: usually eats out. Yesterday - ate at a popular fast food restaurant. Ate: 2 pieces of fried chicken, 1 biscuit, 1 cup cole slaw, 1 large sweet tea, 1 cup mashed potatoes with gravy, 1 slice of fruit pie.3pm snack: regular size candy bar from vending machine at work6pm dinner: 1 large plate of spaghetti with meat sauce. 1 slice of garlic toast with parmesan cheese. 1 large glass of diet soda.9 pm bedtime snack: 1 bowl of chocolate ice creamGoes to bed at 10pm.DB reports that she will walk 1 mile on Saturday and Sunday at a local mall. DB will eat some vegetables, such as corn and potatoes. DB reports that she rarely eats green vegetables. DB’s favorite ways to prepare foods are to grill them or fry them. DB’s family eats at least three meals a week together as a family.Questions:Assess DB’s food intake for calories, fat, saturated fat, carbohydrate, dietary fiber, protein, and sodium. Please indicate how you assessed the diet and include your work.Analyze the 24-hour recall using example fitday.com orwww.choosemyplate.gov. Provide an in text citation for the source of your nutrient analysis.Show the results of your food intake analysis in a table or cut and past your data table from the web site. Sample data table to present the results of you intake analysis[img height="85" width="431" border="0" src="http://content-hsc.kaplan.edu/NS270_1005B/images/product/table1.jpg" align="center">24 hour recall nutrient analysis on _____________.comEquation to calculate percentage CHO, PRO, FATCalculate DB’s BMI and identify weight classification.Calculate DB’s energy needs using Mifflin St. Jeor equationMifflin St Jeor Energy EquationIdentify your calorie goal to achieve a healthy weight. Support your answer.Identify the dietary guidelines you are choosing (Joslin, American Diabetes Association, DASH) to address DB’s diabetes, and hypertension. Provide an in text citation. Updated Dietary RecommendationsBased on DB’s calorie goal calculate the grams CHO, PRO, FAT, Saturated Fat goals based on a nutrient standard you select.Equation to calculate grams CHO, PRO, FAT, Saturated fat, dietary fiberIdentify the nutrient goals for dietary fiber, sodium, potassium, calcium, magnesiumCompare DB’s intake to the recommended intake. Present this data in a table and discussion format. Your discussion should include your assessment DB’s intake of Calories, CHO, PRO, FAT, saturated fat, sodium, dietary fiber highlighting any shortage or excess of these nutrients. [img height="239" width="325" border="0" src="http://content-hsc.kaplan.edu/NS270_1005B/images/product/table2.jpg" align="center">Identify current nutrient deficiency as you find it on the nutrient analysis. You can cut and paste your data table from your nutrient analysis software or create your own data table to show which nutrients are below 100% RDA/AI. Your answer should also include a short written description of DB’s actual nutrient deficiency. [img height="460" width="796" border="0" src="http://content-hsc.kaplan.edu/NS270_1005B/images/product/table3.jpg" align="center">Sample shown is from fitday.comSample comparison of intake by food groupDietary exchange calculator:http://diabeteslibrary.org/View.aspx?url=DiabeticExchangeListUsing the DRI tables for vitamins and elements identify additional nutrients DB would potentially be deficient in based on identified missing foods/food groups. http://iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/Nutrition/DRIs/DRI_Vitamins.ashxDRI: Vitamins http://iom.edu/Activities/Nutrition/SummaryDRIs/~/media/Files/Activity%20Files/Nutrition/DRIs/DRI_Elements.ashxDRI ElementsWrite a summary of the potential nutrient deficiency you identify in b and c.Identify potential pharmacotherapy issues related to DB’s drug prescriptions. For each medication identify:Why the medication is prescribed?Important facts about this medication.How do you take this medication?Identify considerations for timing, and missed doses.Special warnings about this medication.How do these drugs affect nutrients?Suggested websites:http://www.pdrhealth.com/drugs/rx/rx-a-z.aspx http://www.drugs.com/drug_information.html (food & drug information under “What should I avoid)Create a 1-day meal plan for DB and explain how the menu meets the some of the guidelines you set in question 1c. You may use the 1 day sample meal plan link below to help the process.Address these aspects:Identify calorie and % CHO, PRO, FAT goalsIdentify timing for meals and snacksIdentify CHO goals for meals and snacksCreate a sample menu to match your goalsComplete a nutrient analysis on your menuDay 1 SampleDescribe how you would educate DB on the meal plan you created and your health maintenance recommendations.During your counseling session, DB confesses to not taking as much of her prescribed medicines so that she can sell it to people at her church that she thinks need it more than she does. She assures you that she charges less than her friends would have to pay for it at the pharmacy. How would you counsel her regarding this new information?ID: NS270-09-09-P

DISCUSSION QUESTION and Commonwealth Fund
DISCUSSION QUESTION and Commonwealth Fund
DISCUSSION QUESTION 1How should the federal government participate in supporting health care
for all when the constitution does not include health care as a federal
responsibility?ASSIGNMENTView the article, Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008.
Click on 'Download Fund Report (PDF)' and read Exhibits 1, 2, 3, 4, 5,
6, 13, 14, 15, and 21. Of these Exhibits, select the three you believe
are the most important in terms of current health policy in the U.S.
Analyze why you selected your three choices, and provide some data to
back up your choices. Prepare a four- to five-page paper expounding on
your choices, and provide justification for the importance over the
other topics covered in the Exhibits.
Your paper must be four to five double-spaced pages (excluding title and
reference pages) and formatted according to APA style as outlined in
the Ashford Writing Center. Utilize a minimum of five to seven
scholarly and/or peer-reviewed sources that were published within the
last five years. All sources must be documented in APA style, as
outlined in the Ashford Writing Center.

Two Discussion Question
Two Discussion Question
Discussion Question 1In the course text, read case 4 -1 on pages 98 (bottom) to 101. On page
102, what is your response to question #4? Justify your response.Case 4–1 NATIONAL STANDARDS ON CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES (CLAS)In 1997, the Office of Minority Health (OMH) in the U.S. Department of Health and Human Services began work on national standards for culturally and linguistically competent health care. The stated goal was to help reduce health disparities. OMH published draft standards in December 1999 and solicited public comment through a variety of channels over a 4-month period. On December 22, 2000, it published the final standards. Although the standards are primarily directed at health care organizations, OMH encourages their use by individual providers as well as by policy makers, accreditation and credentialing agencies, purchasers, patients, advocates, educators, and the health care community in general (OMH, 2001).CULTURALLY COMPETENT CARE (GUIDELINES FOR ACTIVITIES RECOMMENDED BY OFFICE OF MINORITY HEALTH FOR ADOPTION AS MANDATES BY FEDERAL, STATE, AND NATIONAL ACCREDITING AGENCIES)Standard 1Health care organizations (HCOs) should ensure that patients/consumers receive effective, understandable, and respectful care from all staff members that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.Standard 2HCOs should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area.Standard 3HCOs should ensure that staff members at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.LANGUAGE ACCESS SERVICES (MANDATED REQUIREMENTS FOR ALL RECIPIENTS OF FEDERAL FUNDS)Standard 4HCOs must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact in a timely manner during all hours of operation.Standard 5HCOs must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to received language assistance services.Standard 6HCOs must assure the competence of language assistance provided to limited English-proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).Standard 7HCOs must make available easily understood patientrelated materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area.ORGANIZATIONAL SUPPORTS FOR CULTURAL COMPETENCEStandards 8–13 are guidelines for activities recommended by the Office of Minority Health for adoption as mandated by federal, state, and national accrediting agencies. Standard 14 is suggested for voluntary adoption by HCOs.Standard 8HCOs should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.Standard 9HCOs should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations.Standard 10HCOs should ensure that data on individual patient’s/consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated.Standard 11HCOs should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area.Standard 12HCOs should develop participatory, collaborative partnerships with communities and use a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities.Standard 13HCOs should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers.Standard 14HCOs are encouraged to regularly make available to the public information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information (OMH, 2001). From page 102What would you change about these regulations if you were in charge at the U.S. Department of Health and Human Services? Discussion Question 2In the course text, read case 6-1, pages 171 through 175. What is your response to question #5 on page 176? Case 6–1 GLOBAL MEDICAL COVERAGEBACKGROUNDBlue Ridge Paper Products, Inc. (BRPP) in Canton, NC is a paper company making predominantly food and beverage packaging. It was the largest employer left in Western North Carolina in 2006, with 1,300 covered employees in the state and 800 elsewhere. Started as a Champion Paper plant in 1908, it was purchased by the employees and their union (a United Steelworkers local) in May 1999 with the assistance of a venture capital firm and operates with an Employee Stock Ownership Plan (ESOP). To purchase it, the employees agreed to a 15% wage cut and frozen wages and benefits for seven years. From the buyout through the end of 2005, the company lost $92 million and paid out $107 million in health care claims. It became profitable in 2006. Maintaining health benefits for members and retirees is a very high priority item with the employees and the union, although retiree medical benefits have been eliminated for salaried employees hired after March 1, 2005.BRPP employees are “predominantly male, over 48, with decades of services and several health risk factors. They work 12-hour, rotating shifts, making it extremely difficult to manage health conditions or improve lifestyle” (Blackley, 2006). The ESOP has worked hard to reduce its self-insured health care costs. Health insurance claims for 2006 had been estimated at $36 million, but appeared likely to hold near $24 million, which is still 75% above the 2000 experience. A volunteer Benefits Task Force of union and nonunion employees worked to redesign a complex benefit system. After two years of 18% health care cost increases, the rate of growth dropped to 2% in 2003. It was 5% in 2004 and a negative 3% in 2005.Programs initiated in 2001 included a plan offering free diabetic medications and supplies in return for compliance and a tobacco cessation plan with cash rewards. In 2004, the company opened a full-service pharmacy and medical center with a pharmacist, internist, and nurses. In 2005, it began a Population Health Management program. Covered employees and spouses who completed a health risk assessment were rewarded with $100 and assigned a “personal nurse coach.” The nurse coach assists those who are ready to change to set individual health goals and choose from among one or more of 14 available health programs, which may include “cash rewards, waived or reduced co-pays on over 100 medications, free self-help medical aids/equipment, educational materials, etc.”Where BRPP could not seem to make headway was with the prices paid to local providers. Community physicians refused deeper discounts. Even banding together in a buying cooperative with other companies could not move the local tertiary hospital to match discounts offered to regionally dominant insurers. This hospital was not distressed and had above-average operating margins.Articles on “medical tourism” in the press and on television attracted the attention of benefits management. Reports were of high quality care at 80% or less of U.S. prices with good outcomes. BRPP contacted a company offering services at hospitals in India, IndUShealth in Raleigh, NC, and began working on a plan to make its services available to BRPP employees.IndUShealthIndUShealth provides a complete package to its U.S. and Canadian clients, including access to Indian superspecialty hospitals that are Joint Commission International accredited and to specialists and supporting physicians with U.S. or U.K. board certification. It arranges for postoperative care in India and for travel, lodging, and meals for the patient and an accompanying family member—all for a single package price. For example, it represents the Wockhardt hospitals in India, which are Joint Commission International accredited and affiliated with Harvard Medical International. Other Indian hospitals boast affiliations with the Johns Hopkins Medical Center and the Cleveland Clinics.Mitral Valve ReplacementOne of the first cases considered was a mitral valve replacement. IndUShealth and BRPP sought package quotes from a number of domestic medical centers and could get only one estimate. That quote, from the University of Iowa academic medical center, was in the $68,000 to $98,000 range. The quote from India was for $18,000 including travel, food, and lodging for the patient and one companion. Testifying before the U.S. Senate Special Committee on Aging, Mr. Rajesh Rao, IndUShealth CEO, (2006) cited the following costs.ProcedureTypical U.S. CostIndia CostHeart bypass Surgery$55,000 to $86,000$6,000Angioplasty$33,000 to $49,000$6,000Hip replacement$31,000 to $44,000$5,000Spinal fusion$42,000 to $76,000$8,000EMPLOYEE PARTICIPATIONTo encourage employee participation, BRPP prepared a DVD on its medical tourism initiative, which it called Global Health Coverage. It outlined the opportunities and described the Indian facilities and credentials. The next step was to be a trip by an employee “due diligence” committee to India to inspect facilities and talk with doctors. Then they would discuss how to handle the option in the next set of union negotiations.SENATE HEARINGSOn June 27, 2006, the U.S. Senate Special Committee on Aging held hearings entitled “The Globalization of Health Care: Can Medical Tourism Reduce Health Care Costs?” Both BRPP and IndUShealth presented together with others.When testifying to the Senate subcommittee, Bonnie Grissom Blackley, benefits director for BRPP, concluded:Should I need a surgical procedure, provide me and my spouse with an all expense-paid trip to a Joint Commission International-approved hospital, that compares to a 5-star hotel, a surgeon educated and credentialed in the U.S., no hospital staph infections, a registered nurse around the clock, no one pushing me out of the hospital after 2 or 3 days, a several-day recovery period at a beach resort, email access, cell phone, great food, touring, etc., etc. for 25% of the savings up to $10,000 and I won’t be able to get out my passport fast enough.BLUE RIDGE PAPER PRODUCT’S TEST CASEThe test case under the new arrangement was a volunteer, Carl Garrett, a 60-year-old BRPP paper-making technician who needed a gall bladder removal and a shoulder repair. He reportedly was looking forward to the trip in September 2006, accompanied by his fiancée. A 40-year employee approaching retirement, he would be the first company-sponsored U.S. worker to receive health care in India. The two operations would have cost $100,000 in the United States but only $20,000 in India. The arrangement was that the company would pay for the entire thing, waive the 20% co-payment, give Garrett about a $10,000 incentive, and still save $50,000.The United Steel Workers Union national office objected strongly to the whole idea, however, and threatened to file for an injunction. The local district representative commented, “We made it clear that if healthcare was going to be resolved, it would be resolved by modifying the system in the U.S., not by offshoring or exporting our own people.” USW President Leo Gerard said, “No U.S. citizen should be exposed to the risk involved in travel internationally for health care services” and sent a letter to members of Congress that included the following (Parks 2006):Our members, along with thousands of unrepresented workers, are now being confronted with proposals to literally export themselves to have certain “expensive” medical procedures provided in India.With companies now proposing to send their own American employees abroad for less expensive health care services, there can be no doubt that the U.S. health care system is in immediate need of massive reformThe right to safe, secure, and dependable health care in one’s own country should not be surrendered for any reason, certainly not to fatten the profit margins of corporate investors.The union also cited the lack of comparable malpractice coverage in other countries. The company agreed to find a domestic source of care for Mr. Garrett, but may continue the experiment with its salaried, nonunion employees. Carl Garrett responded unhappily, “The company dropped the ball …. people have given me so much encouragement,” he said, “so much positive response, and they’re devastated. A lot of people were waiting for me to report back on how it went and perhaps go themselves. This leaves them in limbo too” (Jonsson, 2006, p. 2). This is the Question from 176How might state and national governments respond to this expanding phenomenon?

SPECIALTY HOSPITALS AND COMMUNITY HOSPITALS
SPECIALTY HOSPITALS AND COMMUNITY HOSPITALS
Read Case 5-1 in the course text pages 136 (bottom) to page 141. Answer the discussion questions on the top of page 142. Your paper must be four to five double-spaced pages (excluding title and
reference pages) and formatted according to APA style as outlined in
the Ashford Writing Center. Utilize a minimum of five scholarly and/or
peer-reviewed sources that were published within the last five years.
All sources must be documented in APA style, as outlined in the Ashford
Writing Center.Case 5–1 SPECIALTY HOSPITALS AND COMMUNITY HOSPITALSBACKGROUNDThe Medicare Prescription Drug, Improvement, and Modernization Act of 2003 included an 18-month moratorium on payments to specialty hospitals (cardiac, orthopedic, and surgical) that were not operating or under development by November 2003 and in which physicians had an ownership or investment interest. This moratorium expired in June 2005. The CMS effectively extended the moratorium by continuing to review its criteria for approving or starting to pay new specialty hospitals.Specialty hospitals have been around for a long time—children’s hospitals, rehabilitation hospitals, psychiatric hospitals, eye and ear hospitals, and cancer hospitals. The Omnibus Budget Reconciliation Act of 1989 included a provision against payment for physician referrals to facilities in which they had an economic interest, but specifically exempted ambulatory surgery centers and “whole” hospitals. Thus far, specialty hospitals have qualified as whole hospitals.A specialty hospital is defined as an inpatient hospital in which at least two thirds of the claims are in one or two major diagnostic categories or diagnosis-related groups (DRGs). In February 2003, 110 hospitals met these criteria. Of those, 92 were cardiac, orthopedic, surgical, or women’s hospitals. They had tripled in number between 1990 and 2003 and were concentrated in states without certificate of need (CON) legislation. Seventy-four percent were for-profit hospitals and on average were 50 percent physician-owned. Seventy percent had some physician ownership. Their growth and that of the ambulatory surgery centers were in part attributed to the substitution of DRG-based reimbursement for fee-for-service payment in the late 1980s. DRGs are not finely calibrated to reflect the actual costs of different kinds of cases that would fall within the same grouping.Has there been a difference between the older group of specialty hospitals and the new ones? The older ones tended to operate as nonprofits that supplemented the existing facilities in the community. The newer ones tend to be for-profit, physician owned and to duplicate the facilities and services already supplied by community hospitals. It can be argued that when community hospitals perform the kinds of profitable procedures that are attractive to for-profit specialty hospitals, they use the profits to cross-subsidize other community services (Altman et al., 2006). Vladeck (2006) suggested that they subsidize the following:• Health professions education• Losses in special departments (burn centers, trauma centers, neonatal intensive care units, and AIDS clinics)• Standby (emergency and surge capacity) costs• Uncompensated care• Other community services.These services accounted for 16% to 18% of a community hospital’s budget. Some states compensate hospitals for some of these services. For example, New York compensates 8.95% for health professions education.Specialty hospitals can be very attractive to physicians. They are drawn to these focused factories by the following:• Their control over scheduling, staffing, admission, discharge, and so forth• Added profits from ancillary services and technical component revenues• Profits from case mix within DRGs• Selection of the patients and their payer mix• Reduced “on-call” responsibilities• Avoiding participation in hospital governance and other mandated activities.They do have to pay for additional capital facilities and equipment that would normally be supplied by the community hospital; however, the variety and scale of these investments are considerably reduced by the narrow range of services provided.Community hospital advocates point to the fact that physicians may select only those patients with adequate insurance, can “cherry pick” the healthier patients, avoid emergency department duties, and avoid surveillance under some quality improvement and utilization review programs.Community hospitals have responded by (Greenwald et al., 2006):• Prohibiting physicians with a competing ownership interest from participating in governance• Buying up the potentially referring primary care practices• Signing exclusive service contracts with insurers• Providing other resources, such as office space, to their competitors• Offering inpatient specialist “management” subcontracts to offset ownership• Advertising their own “centers of excellence”• Making economic credentialing decisions that penalize competing physicians.The legal status of these measures under federal and state anticompetitive statutes is likely to be in litigation for quite some time.Results of StudiesThe Medicare Prescription Drug, Improvement, and Modernization Act of 2003 required the Medicare Payment Advisory Commission (MedPAC) and the U.S. Department of Health and Human Services to study a number of related issues during the moratorium period. The MedPAC’s report (Guterman, 2006; Stensland & Winter, 2006) concluded that physicians were responding to incentives built into the DRG payment rates. These incentives resulted from the wide variation in the relative costliness of cases. Cardiac hospitals seemed to treat more of the profitable cases than community hospitals. Orthopedic hospitals seemed to treat more complex cases, but in healthier patients than community hospitals. No conclusions were reached about the surgical hospitals. Patient satisfaction also seemed higher in the specialty settings.The study also concluded that the specialty hospitals delivered less uncompensated care, but that this was offset by the payment of property and corporate income taxes and by not receiving disproportion share hospital payments. The U.S. Department of Health and Human Services study (Greenwald et al., 2006) reached similar conclusions and observed that physicians did refer to hospitals they owned, but often continued to take emergency department calls to maintain their referral base. The studies did not identify much differential impact on either quality or utilization. Their recommendation was to modify the DRG prices to reflect costs more closely and to remove the incentives they provided.CMS DecisionsCMS ended the moratorium in August 2006 and proposed to follow the MedPAC’s recommendations to revise the DRG payments so that they would be closer to hospital costs than hospital charges. It also proposed a rule that specialty hospitals would have to accept patient transfers under the Emergency Medical Treatment and Labor Act. At oversight hearings before the Senate Finance Committee, this decision was questioned sharply by ranking Senators Chuck Grassley (R-Iowa) and Max Baucus (D-Montana), who noted the negative impact on community hospitals and the apparent conflict with the intent of existing self-referral prohibitions.The Various Points of ViewThe prologue to a series of articles on these issues in the January-February 2006 issue of Health Affairs (25:94) noted that:In the larger context, though, the issues are not so simple. A decade ago, “market-driven reform” meant competition between integrated delivery organizations whose incentives for quality and efficiency derived from the capitated payments they received. Specialty competition and price transparency are fee-for-service strategies that exacerbate the distress of multi-specialty groups that thrived under capitation and were the darlings of the policy community a decade ago.The proponents of three economic system views have sought support in press releases, testimony, lobbying, and the published literature. All three sides used parts of the U.S. Department of Health and Human Services and MedPAC studies to support their positions.Oligopolistic CompetitionOn May 30, 2006, the American Hospital Association supported the senators for continuing “to stand up for the needs of patients and the community hospitals that take care of them.” Berenson et al. (2006) suggested that the specialty hospital movement and parallel physician efforts to control service lines within community hospitals may signal the restoration of the types of hospital–physician relationships that preceded managed care.Administered SystemChoudhry et al. (2005) wrote about the role of law in this situation and recommended that the issue be controlled by CON determinations to avoid duplication of resources and increased utilization. Altman et al. (2006) seemed to support the administered approach by asking, “Could U.S. Hospitals Go the Way of U.S. Airlines?” They argue that specialized competition, coupled with price transparency and consumer price sensitivity, would result in community hospital downsizing, reduced community services, reduced staffing levels, and reduced salaries.Free-Market CompetitionThe American Association of Orthopedic Surgeons’ December 2005 “Position Statement on Specialty Hospitals” urged the repeal of all CON laws to foster “healthy competition.” Their statement also attributed that position to the Federal Trade Commission and the Department of Justice. Havighurst’s (2005) commentary on Choudhry et al. (2005) took a strong position that CON inappropriately supported the oligopoly position of the community hospitals. In January 2006, the American Medical Association president-elect issued a statement continuing its strong support of specialty hospitals (Champlin, 2006). Porter and Teisberg (2006) also argued against the CON approach because it supported local monopolies, but acknowledged the risks associated with physician ownership and self-referral.DISCUSSION QUESTIONS1. What has happened with this debate since mid 2006?2. How might one try to come to an objective conclusion?3. Senator Grassley noted during the Senate Finance Committee hearings that “it appears that 40 new specialty hospitals have opened” during the moratorium and the investigation. Do some research to find out whether this is true and how it might have happened.4. If you were a legislative decision maker, what solutions would you propose after the MedPAC proposals to reduce selected DRG payments substantially and redefine a number of groupings for orthopedic and cardiac procedures that were headed off by a campaign by lobbyists for medical device makers, hospitals, and specialist physicians?
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