Overbilling and Informed Financial Consent — A Contractual Solution

U.S. hospitals and physicians regularly charge uninsured patients and patients receiving care outside their health-plan networks far more what most health insurers pay and far more than their actual costs. Such practices have triggered over 100 lawsuits and prompted calls for pricing transparency in Congress and price regulation in several states. This Perspective argues that the theory of implied contracts, a foundation in most first-year courses in contract law, offers a useful legal and ethical mechanism for handling these troubling problems in health care billing

Towards an Updated Approach to Neighborhood Planning

Since the publication of the earliest conceptions of the neighborhood by Clarence Perry in the 1920's and the subsequent formalization of neighborhood planning standards and criteria in the manual Planning The Neighborhood (Hygiene of Housing Committee 1960), there have been far-reaching changes of both a social and technical nature which suggest the need for a new look at this approach to neighborhood planning. The purpose of this article is to reexamine the neighborhood unit concept in light of this advancing knowledge and evaluate how applicable those original assumptions underlying the neighborhood are for the contemporary planner developing a process to plan our residential environments. This review begins with a brief synopsis of the earliest physical planning model for neighborhoods. Following this, recent research concerning the relationships between social, mental, and physical outlooks upon, and uses of the neighborhood will be introduced to uncover a broadened array of concerns which should be considered when planning residential environments. These ideas are then applied in an illustrative planning process which concludes the paper

Comparison of the Energy Efficiency Prescribed by ASHRAE/ANSI/IESNA Standard 90.1-1999 and ASHRAE/ANSI/IESNA Standard 90.1-2004

This document presents the qualitative comparison of DOE’s formal determination of energy savings of ANSI/ASHRAE/IESNA Standard 90.1-2004. The term “qualitative” is used in the sense of identifying whether or not changes have a positive, negative, or neutral impact on energy efficiency of the standard, with no attempt made to quantify that impact. A companion document will present the quantitative comparison of DOE’s determination. The quantitative comparison will be based on whole building simulation of selected building prototypes in selected climates. This document presents a comparison of the energy efficiency requirements in ANSI/ASHRAE/IESNA 90.1-1999 (herein referred to as Standard 90.1-1999) and ANSI/ASHRAE/IESNA 90.1-2004 (herein referred to as Standard 90.1-2004). The comparison was done through a thorough review of all addenda to Standard 90.1-1999 that were included in the published ANSI/ASHRAE/IESNA Standard 90.1-2001 (herein referred to as Standard 90.1-2001) and also all addenda to Standard 90.1-2001 that were included in the published Standard 90.1-2004. A summary table showing the impact of each addendum is provided. Each addendum to both Standards 90.1-1999 and 90.1-2001 was evaluated as to its impact on the energy efficiency requirements of the standard (greater efficiency, lesser efficiency) and as to significance. The final section of this document summarizes the impacts of the various addenda and proposes which addenda should be included in the companion quantitative portion of DOE’s determination. Addenda are referred to with the nomenclature addendum 90.1-xxz, where “xx” is either “99” for 1999 or “01” for 2001, and z is the ASHRAE letter designation for the addendum. Addenda names are shown in bold face in text. DOE has chosen not to prepare a separate evaluation of Standard 90.1-2001 as that standard does not appear to improve energy efficiency in commercial buildings. What this means for the determination of energy savings for Standard 90.1-2004 is that the baseline standard for comparison is Standard 90.1-1999 and all addenda to both Standards 90.1-1999 and 90.1-2001 must be considered to determine the overall change in efficiency between Standard 90.1-1999 and Standard 90.1-2004

l Issues Relating to Newborn Screening

The analysis in this part of the report is grounded in the rights-based Code of Rights, and takes into account the public health paradigm and the striking aspects of dealing with genetic risks in families. In this context, it is important to distinguish public health screening from personal clinical services. Traditionally, public health law has been prescriptive in form and has compelled participation. This is in contrast with the increasingly adopted consumer-based approach that promotes informed choice and consent and which is in keeping with the complexities and sensitivities surrounding genetic medicine. Information about newborn screening should be given to parents by or during the third trimester, and again before the samples are taken. The applicability of the Code in the context of screening needs to be borne in mind. The significance of the ‘screening pathway’ needs to be appreciated: ‘It is a critical part of informed consent …to know about the entire screening pathway and the possible things that might occur before [taking] the first step’. Clear, unambiguous information needs to be provided, emphasising that the purpose of ‘participation’ is in the interests of the newborn. If newborn screening increasingly operates in a paradigm that actively promotes informed choice and consent, parents or guardians will need to be informed throughout the screening process; this includes being notified about results. The policy of ‘no news is good news’ may have to be reconsidered in the light of complex issues raised by technologies that reveal carrier status, or if screening is extended to include late-onset disorders. Surveys and empirical studies should be undertaken in New Zealand to inform policy in this and other areas. Public discussion, e.g. led by parliamentarians, needs to take place. Activities to monitor and evaluate the programme need to be more explicitly stated in information given to parents. Related to this, is the importance of distinguishing between initiatives taken for the purposes of fulfilling the aims of the programme and those that go beyond aims of the programme. Policies regarding retention and use of samples that clearly make and communicate that distinction need to be provided, especially to parents. The utility of the retained blood samples is heavily dependent on the state of the technology. With DNA technologies and profiling, the degree and scope of information that can be derived from dried blood spots will potentially be very significant and have far-reaching implications. There is tremendous long-term value in retention, for example, for the purposes of quality management, programme expansion, research on testing and treatment and epidemiologic studies. Current and relevant scientific literature on the stability of metabolites, DNA extraction and testing technology and optimal storage conditions needs to be taken into account with regard to any policy development in this area. Two options are provided in order to reconcile the inter-relationships between the various provisions of the Code of Rights on consent, storage and quality assurance and the NHC screening guidance: to maintain the status quo by more actively communicating information about right 7(9) and right 7(10); or to prescribe, with legal authority, a minimum retention period to guarantee all samples are available for QA-related activities. The public availability of policies and procedures setting out, for example, the taking and documenting of informed consent would be helpful, in order to increase parental and public awareness, understanding and confidence

ANSI/ASHRAE/IESNA Standard 90.1-2010 Preliminary Qualitative Determination

A preliminary qualitative analysis of all addenda to American National Standards Institute (ANSI)/American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE)/Illuminating Engineering Society of North America (IESNA) Standard 90.1-2007 (Standard 90.1-2007 or 2007 edition) that were included in ANSI/ASHRAE/IESNA Standard 90.1-2010 (Standard 90.1-2010 or 2010 edition) was conducted. All 109 addenda processed by ASHRAE in the creation of Standard 90.1-2010 from Standard 90.1-2007 were evaluated by DOE for their impact on energy efficiency. DOE preliminarily determined whether that addenda would have a positive, neutral, or negative impact on overall building efficiency

Independent evaluation of a simple clinical prediction rule to identify right ventricular dysfunction in patients with shortness of breath

BACKGROUND: Many patients have unexplained persistent dyspnea after negative computed tomographic pulmonary angiography (CTPA). We hypothesized that many of these patients have isolated right ventricular (RV) dysfunction from treatable causes. We previously derived a clinical decision rule (CDR) for predicting RV dysfunction consisting of persistent dyspnea and normal CTPA, finding that 53% of CDR-positive patients had isolated RV dysfunction. Our goal is to validate this previously derived CDR by measuring the prevalence of RV dysfunction and outcomes in dyspneic emergency department patients. METHODS: A secondary analysis of a prospective observational multicenter study that enrolled patients presenting with suspected PE was performed. We included patients with persistent dyspnea, a nonsignificant CTPA, and formal echo performed. Right ventricular dysfunction was defined as RV hypokinesis and/or dilation with or without moderate to severe tricuspid regurgitation. RESULTS: A total of 7940 patients were enrolled. Two thousand six hundred sixteen patients were analyzed after excluding patients without persistent dyspnea and those with a significant finding on CTPA. One hundred ninety eight patients had echocardiography performed as standard care. Of those, 19% (95% confidence interval [CI], 14%-25%) and 33% (95% CI, 25%-42%) exhibited RV dysfunction and isolated RV dysfunction, respectively. Patients with isolated RV dysfunction or overload were more likely than those without RV dysfunction to have a return visit to the emergency department within 45 days for the same complaint (39% vs 18%; 95% CI of the difference, 4%-38%). CONCLUSION: This simple clinical prediction rule predicted a 33% prevalence of isolated RV dysfunction or overload. Patients with isolated RV dysfunction had higher recidivism rates and a trend toward worse outcomes

Analysis of Energy Saving Impacts of New Commercial Energy Codes for the Gulf Coast

Report on an analysis of the energy savings and cost impacts associated with the use of newer and more efficiently commercial building energy codes in the states of Louisiana and Mississippi

The Influence of Epidermal Growth Factor on Surface Morphology of Fetal Rat Hepatocytes in Primary Culture

In an attempt to understand the hormonal regulation of somatomedin secretion in the fetus, we have confirmed that epidermal growth factor (EGF) stimulates fetal rat hepatocytes in primary culture to secrete somatomedin in a time and a dose-dependent fashion. Transmission electron microscopy (TEM) revealed that the cultured cells had ultrastructural features consistent with those of fetal hepatocytes. Scanning electron microscopy (SEM) showed that cells grown in either Medium 199 or EGF supplemented Medium 199 formed cellular aggregates within 6 h. The surface features of cells in control and experimental cultures were indistinguishable up until 24 h after exposure to EGF. At this point in time, morphological differences between treatment groups were first apparent with SEM. In the presence of EGF, cellular aggregates were thicker, cells were more rounded in contour, and the number of microvilli and cytoplasmic excrescences (blebs) was greater than in control cultures. These differences were further accentuated at 48 h after exposure to the growth factor. Since the appearance of microvilli and blebs coincides with increasing production of somatomedin, they may represent morphological evidence of secretory activity