"Managed Care, Physician Incentives, and Norms of Medical Practice: Racing to the Bottom or Pulling to the Top?"

The incentive contracts that managed care organizations write with physicians have generated considerable controversy. Critics fear that if informational asymmetries inhibit patients from directly assessing the quality of care provided by their physician, competition will lead to a "race to the bottom" in which managed care plans induce physicians to offer only minimal levels of care. To analyze this issue we propose a model of competition between managed care organizations. The model serves for both physician incentive contracts and HMO product market strategies in an environment of extreme information asymmetry--physicians perceive quality of care perfectly, and patients don't perceive it at all. We find that even in this stark setting, managed care organizations need not race to the bottom. Rather, the combination of product differentiation and physician practice norms causes managed care organizations to race to differing market niches, with some providing high levels of care as a means of assembling large physician networks. We also find that relative physician practice norms, defined endogenously by the standards of medical care prevailing in a market, exert a "pull to the top" that raises the quality of care provided by all managed care organizations in the market. We conclude by considering the implications of our model for public policies designed to limit the influence of HMO incentive systems.

Technologies for aerobraking

Aerobraking is one of the largest contributors to making both lunar and Mars missions affordable. The use of aerobraking/aeroassist over all propulsive approaches saves as much as 60 percent of the initial mass required in low earth orbit (LEO); thus, the number and size of earth to orbit launch vehicles is reduced. Lunar transfer vehicles (LTV), which will be used to transport personnel and materials from LEO to lunar outpost, will aerobrake into earth's atmosphere at approximately 11 km/sec on return from the lunar surface. Current plans for both manned and robotic missions to Mars use aerocapture during arrival at Mars and at return to Earth. At Mars, the entry velocities will range from about 6 to 9.5 km/sec, and at Earth the return velocity will be about 12.5 to 14 km/sec. These entry velocities depend on trajectories, flight dates, and mission scenarios and bound the range of velocities required for the current studies. In order to successfully design aerobrakes to withstand the aerodynamic forces and heating associated with these entry velocities, as well as to make them efficient, several critical technologies must be developed. These are vehicle concepts and configurations, aerothermodynamics, thermal protection system materials, and guidance, navigation, and control systems. The status of each of these technologies are described, and what must be accomplished in each area to meet the requirements of the Space Exploration Initiative is outlined

"Physician Incentives In Managed Care Organizations: Medical Practice Norms and the Quality of Care"

This brief considers the interaction between physician incentive systems and product market competition in the delivery of medical services via managed care organizations. At the center of the analysis is the process by which health maintenance organizations (HMOs) assemble physician networks and the role these networks play in the competition for customers. The authors find that although physician practice styles respond to financial incentives, there is little evidence that HMO cost-containment incentives cause a discernable reduction in care quality. They propose a model of the managed care marketplace that solves for both physician incentive contracts and HMO product market strategies in an environment of extreme information asymmetry: physicians perceive the quality of care they offer perfectly and their patients do not perceive it at all.

The shadow in the balance sheet: The spectre of Enron and how accountants use the past as a psychological defence against the future

Accounting frameworks play a crucial role in enabling us to make sense of business. These frameworks provide a common language for individuals, organizations and broader economic groupings to understand and make decisions about the commercial realm in which they operate. From a psychodynamic perspective, the language of accounting also plays an important role. On the one hand it offers a way to tame the uncertainty and unknowability of the future by representing it in the same comforting terms as it does the past, thus reducing anxiety. Accounting provides a ‘shorthand’, which achieves a balance between positive and negative, debit and credit, asset and liability. On the other hand, accounting can also provide an arena in which fantasies about the future can be staged. However, the use of accounting language is problematic, particularly when it comes to dealing with the future. First, accounting frameworks are inherently backward looking and second, the reassuring sense of clarity and predictability they give are bought at the price of unrealistic simplification. The shadow is never far away and is a constant source of surprises in the unfolding future of a business. Rationalizing and sanitizing the shadow through accounting language may alleviate anxiety but fails to provide an escape from its effects, and echoes from the shadow side of business are capable of shaking the world in the form of accounting scandals. Governments and businesses have reacted to scandals such as Enron and Worldcom by tightening legislation and refining accounting standards but little, if anything, has been done to bring us any closer to confronting the shadow of business where these scandals have their r

Time-Resolved Spectroscopy of Condensed Matter

Contains reports on three research projects.Joint Services Electronics Program (Contract DAAG29-78-C-0020)National Science Foundation (Grant DMR78-23555)National Science Foundation (Grant DMR76-80895

Gastrointestinal Foreign Bodies

Retained foreign bodies within the gastrointestinal tract (GIT) are common emergency presentations. The majority will pass spontaneously or be removed endoscopically, but a few selected cases may require emergency surgery for removal. This chapter reviews the management of foreign bodies within the GIT including both instances of foreign body ingestions and foreign body insertions. The scope of this chapter is not limited to evidence‐based data on selection of cases for conservative management but also includes data on endoscopic and surgical management

Leader Development and Emotional Competence: Authentic Leadership, Self-Awareness, and Personal Integrity

Can leadership be taught? (Doh, 2003) The dramatic growth of leadership academies, institutes, and programs from political science to business and psychology to reserve officer training corps for U.S. military services makes this a compelling question. We say yes and then: How can it be taught? And how are leaders developed? Ours is a developmental theory for teaching leaders and suggests that emotional competence is at the heart of developing authentic leaders with personal integrity