Resurrection of the Prohibition on the Corporate Practice of Medicine: Teaching Old Dogma New Tricks

Unfortunately, the federal government has become a willing participant in the risk-sharing strategy. The federal government has undermined the corporate practice doctrine and has adopted risk-sharing strategies of its own. The federal government needs to embrace the prohibition on the corporate practice of medicine in order to prevent insurance companies from shifting the financing function to physicians. Only then can we reveal the true costs of maintaining the system of private health insurance. Part II of this Article will examine the premises underlying the corporate practice of medicine doctrine. This Part will reveal that the doctrine resulted from a mixture of protectionist motives on the part of organized medicine and an idealized conception of the physician-patient relationship by the courts. Part III will examine how federal policy helped lead to the demise of the doctrine. This Part will reveal that the federal government was more concerned about cost containment than with preserving an idealized physician-patient relationship. Part IV will describe the financial risk-shifting mechanisms that have arisen in response to the need to control health care costs. Part V will explain how risk sharing is either dangerous because of its potential to alter the physician-patient relationship, or dishonest because it merely allows private sector payers to benefit from a hidden public subsidy. Part VI will examine how a healthy respect for the rationales underlying the corporate practice doctrine would lead to a prohibition on risk-sharing arrangements. Part V1I then describes the inadequate federal response to risksharing arrangements. Finally, Part VIII describes why the danger and dishonesty of risk sharing cannot be ameliorated by any means other than a blanket prohibition on the practice

Markets, Myths, and A Man On The Moon: Aiding and Abetting America’s Flight From Health Insurance

The United States health care system is a tragic product of blind distrust of government and unquestioning faith in markets—the belief that the market will always do a more efficient job of allocating resources better than the government. However, health care is a peculiar commodity that differs from other goods and services that are distributed in the market. There is a real question about whether it is appropriate to provide health coverage pursuant to an insurance model, let alone provide it through an insurance model in the market. While the pooling of risks guarantees a greater number of people will suffer the full impact of loss, the insurance model yields corrupted results because it is subjected to the dictates of the market, and profit maximization prevents high-risk individuals from entering the pool of insured individuals. Fragmented coverage for some individuals, and no coverage for many others, produces negative externalities in the form of higher costs, which is why the insurance model is defective: it depends upon the exploitation of externalities for its success. Attempting to provide coverage through this model results in inadequate health coverage and ineffective cost containment. The appropriate governmental response would be to provide subsidies that induce the production of positive externalities, while prohibiting or penalizing activity that produces negative externalities. Without federal intervention, citizens will not consume health care at socially optimal levels. Unfortunately, efforts to intervene have resulted in insurers and employers engaging in or threatening a flight from health insurance, which may leave even fewer people protected. In effect, American health care policy is being held hostage by infatuation with markets, reducing coverage for increased payments along the way

Legal Obstacles to Bringing the Twenty-first Century in the Classroom: Stop Being Creative, You May Already Be in Trouble

There are unimaginable benefits available if legal educators can bring the law classroom into the twenty-first century through the use of popular media and celebrities in their teaching. With the introduction of “pop culture,” the professor can permanently alter the student\u27s view of the course material. Bringing pop culture into the classroom will make the course material more relevant to our students’ lives outside the classroom. This will enhance both their willingness and their ability to master legal concepts. There are two major obstacles to bringing pop culture into the classroom. The initial major obstacle is the Copyright Act of 1976 (“Copyright Act”), which restricts the use of copyrighted material. Although the act allows a limited safe harbor for “multiple copies for classroom use.” Educators may find the safe harbor to be unduly restrictive. The other potential obstacle is that the use of celebrities in hypotheticals also gives rise to problems associated with the celebrities’ “right of publicity.” In order to utilize celebrities in the teaching process, the educator must ensure that the use does not constitute commercial speech. The sad fact is, that in order to effectively teach law, we need to overcome the restraints that law sometimes places on educational creativity

The Princess and the Pea: The Assurance of Voluntary Compliance Between the Texas Attorney General and Aetna\u27s Texas HMOs and Its Impact on Financial Risk Shifting by Managed Care

The Texas Attorney General attempts to regulate managed care organizations and their shifting of financial risk by utilizing Assurance Voluntary Compliance to make the costs associated with the provisions of health insurance more transparent. A primary technique used to shift financial risk to providers of healthcare services is through the use of downstream entities which are commonly provider-sponsored organizations. It is the relationship between the downstream entity and the individual physicians that ultimately affects patient care, the doctor-patient relationship, and the quality of care. The regulatory community throughout the United States has made the regulation of downstream entities its number one priority. It was in this context that then-Texas Attorney General Dan Morales filed suit against six health maintenance organizations (“HMO”) in December 1998, which ultimately led to the creation of Assurance Voluntary Compliance. The Assurance Voluntary Compliance led to HMO’s introducing “consumer driven” health plans. These new health plans call for the consumer to bear a greater responsibility of risk. In effect, the consumer is being called upon to assume the role of insurer in the consumer’s own health care expenditures. In the long term, it is unlikely that consumers will be able to manage risk, control costs, and ensure quality better than the managed care industry, employers, and health care providers that the consumers will be forced to replace

Prospectus, February 28, 2001

https://spark.parkland.edu/prospectus_2001/1007/thumbnail.jp

Toward Establishing Integrated, Comprehensive, and Sustainable Meningitis Surveillance in Africa to Better Inform Vaccination Strategies.

Large populations across sub-Saharan Africa remain at risk of devastating acute bacterial meningitis epidemics and endemic disease. Meningitis surveillance is a cornerstone of disease control, essential for describing temporal changes in disease epidemiology, the rapid detection of outbreaks, guiding vaccine introduction and monitoring vaccine impact. However, meningitis surveillance in most African countries is weak, undermined by parallel surveillance systems with little to no synergy and limited laboratory capacity. African countries need to implement comprehensive meningitis surveillance systems to adapt to the rapidly changing disease trends and vaccine landscapes. The World Health Organization and partners have developed a new investment case to restructure vaccine-preventable disease surveillance. With this new structure, countries will establish comprehensive and sustainable meningitis surveillance systems integrated with greater harmonization between population-based and sentinel surveillance systems. There will also be stronger linkage with existing surveillance systems for vaccine-preventable diseases, such as polio, measles, yellow fever, and rotavirus, as well as with other epidemic-prone diseases to leverage their infrastructure, transport systems, equipment, human resources and funding. The implementation of these concepts is currently being piloted in a few countries in sub-Saharan Africa with support from the World Health Organization and other partners. African countries need to take urgent action to improve synergies and coordination between different surveillance systems to set joint priorities that will inform action to control devastating acute bacterial meningitis effectively

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Genome-wide association meta-analysis identifies 48 risk variants and highlights the role of the stria vascularis in hearing loss

Hearing loss is one of the top contributors to years lived with disability and is a risk factor for dementia. Molecular evidence on the cellular origins of hearing loss in humans is growing. Here, we performed a genome-wide association meta-analysis of clinically diagnosed and self-reported hearing impairment on 723,266 individuals and identified 48 significant loci, 10 of which are novel. A large proportion of associations comprised missense variants, half of which lie within known familial hearing loss loci. We used single-cell RNA-sequencing data from mouse cochlea and brain and mapped common-variant genomic results to spindle, root, and basal cells from the stria vascularis, a structure in the cochlea necessary for normal hearing. Our findings indicate the importance of the stria vascularis in the mechanism of hearing impairment, providing future paths for developing targets for therapeutic intervention in hearing loss

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication