MACRA and Stark: Strange Bedfellows at the Heart of Health Care Reform

The enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was well-received by all as it repealed Medicare’s Sustainable Growth Rate and, in its place, mandates the implementation of a new system for health care delivery and payment. Under MACRA, health care providers are expected to work together and coordinate their efforts with the goal of improving patient outcomes and controlling costs. For the first time ever, federal reimbursements will be tied to quality of care and improved cost efficiencies. However, as a new law, MACRA’s potential for success needs to be measured in terms of its “fit” within the existing legal framework. Specifically, MACRA’s fee-for-value approach needs to be assessed against the Ethics in Patient Referrals Act (Stark). As a strict liability law that encourages health care providers to continue working in silos, Stark has had a chilling effect on the health care industry as multi-million dollar penalties have been assessed for a single prohibited referral made by a physician for certain federally reimbursable health care services. Ironically, the type of conduct Stark prohibits is the very conduct that MACRA needs health care providers to engage in to achieve its goals. This misalignment between the two laws poses a significant impediment to MACRA’s successful implementation. This Article discusses the inherent misalignment between MACRA and Stark, provides an overview of the original intent behind both laws, and shows which provision of Stark is in direct contravention of MACRA. Specifically, it advocates that the provision of Stark that regulates physician compensation is an impediment to health care reform and unnecessary in light of the modern-day, more robust Anti-Kickback Statute. This Article addresses a cutting-edge issue in health care law and contributes to the ongoing debate on how to best reconcile MACRA and Stark to achieve the goals of health care reform

¿Debe tipificarse la corrupción privada en Ecuador? Análisis comparado del delito de corrupción en los negocios en España y de las normas del derecho de la competencia (Tema Central)

This article purpose is to analyze a widespread behavior within the world of business: private acts of corruption, also known as bribery in the corporate world. In general, we tend to focus our discussions with regard to public corruption,2 and we tend to be as rigid as we can with it, but contrary to this very little is usually done when it comes to only private corruption. Therefore, in this essay I will try to explain the Laws of Spain and Ecuador with regard to this matter, and I will try to illustrate the intimate and close relationship between corruption as a criminal offence and Antitrust Law. In that sense, I will explore precedents and leading cases from all over the world, the different types of offences and, finally, from the perspective of spanish unlawful act. I will set out my point of view with regard to which I consider the best way to deal with this matter, and lastly, I shall try to respond whether this kind of behaviors should be subjected to punishment by criminal law.El presente artículo pretende revisar una conducta muy desarrollada y habitual en el mundo empresarial: la corrupción privada, también conocida como el soborno entre particulares. En general, se debate y se intenta ser lo más rígido posible en todas las cuestiones vinculadas a la llamada corrupción pública,1 pero poco se combate a la corrupción que únicamente se produce entre privados. Se intentará exhibir cómo son las legislaciones de España y Ecuador en relación a esta temática, y se mostrará la íntima y estrecha relación que existe entre la figura penal y el Derecho de defensa de la competencia. Se repasarán los antecedentes internacionales sobre la materia, los distintos modelos de injusto existentes, y, finalmente, a partir del tipo penal español, se señalará la mejor manera de tratar esta cuestión, y respecto a si el Derecho penal se encuentra legitimado para penar estas conductas

Heat Pump and Steam Accumulator Electrical Energy Storage System (Esheatpac System)

Esheatpac is an electricity storage system that combines heat pump, steam accumulator, and steam-water cycles technologies. It includes a heat pump, powered by an electric compressor, which produces saturated steam that is stored in steam accumulators as pressurized liquid water. Later, this steam produces electricity in a turbo-generator. Combination of efficiency of heat pump and Rankine cycle heat rate allows reaching efficiencies of up to 100% or higher, without requiring any auxiliary fuel. Efficiencies of up to 124.5% can be achieved by providing natural gas, with the combination of heat pumps with COP equals 2.65 and Rankine cycles with heat rate of 47%. The above means that it is possible to extract from the system the same or higher amount of electricity that enters it, after remaining stored for the time required, up to almost 25% more. Esheatpac is an optimal solution for when it is required to store large amounts of electricity and medium discharge times. Today, the only storage systems that meet these conditions are pumped hydro storage (PHS) and compressed air energy storage (CAES). Compared to PHS, Estheapc presents the advantages of its better performance, a maximum of 85%, and less environmental and public opposition problems, in addition to the limitations to find suitable locations. Compared to CAES, it presents the advantages of its better performance, 50% in current plants, and much lower storage capacities, on the order of seven times less, which also means a lower material investment

Emergency surgery and Limitation of therapeutic effort in relation to neurologic deterioration in elderly patients – a survey of European surgeons

Background. In emergency surgery, a very heterogeneous approach is required in the decision making process, especially when considering the patient’s postoperative quality of life as well as medical, ethical, and legal factors. In some cases, the presence of an Advance Directive (AD) form may potentially help resolve the surgeon’s dilemma. Objectives. The primary objective of this survey was to investigate the opinions of surgeons across a representative cross-section of European countries regarding the decision making process using a specific case scenario so as to identify similarities and differences in practice. A secondary objective was to identify the possibility of establishing a more uniform approach and best practice. Method. A survey was conducted of surgeons from a range of European countries. Questionnaires were designed to obtain an overview of decision making in relation to the Limitation of Therapeutic Effort (LTE) using a specific case study and the level of awareness and practical use of ADs. Surveys were distributed via email to the members of the ESTES (European Society for Trauma and Emergency Surgery) and AEC (Association of Spanish surgeons), with voluntary, anonymous participation. Conclusions. Clear and additional support in the form of legal and ethical guidance with clinical protocols for surgical practice in such case scenarios is necessary. Wider use of ADs, together with education about their role and support for patients and relatives, would benefit the type of patient described in our scenario. A multidisciplinary team should play a more active role in decision making in order to avoid surgical procedures that are potentially futile. The concepts of LTE and Quality of life need a broader understanding among surgeons as well as more consistent application

Paleomicrobiological Study in Dental Calculus: Streptococcus mutans

Morphological types of bacterial remains preserved in ancient tartar of teeth from extinct human groups, which included some communities of coastal gatherers, fishermen, hunters, and farmers, and those practicing a mixed economy, were analyzed. Previous studies have shown the presence of bacteria in ancient tartar. The aim of this work was to determine whether Streptococcus mutans was present in ancient populations (500-12,000 years old). Teeth samples were from ancient skulls obtained from different anthropological collections: the north and south of Chile (before the Spanish conquest), Palencia, Spain, and an eastern Mediterranean region (Levant). Optical microscopy showed Gram positive and Gram negative bacteria. Scanning electron microscopy identified morphological types of bacteria. Transmission electron microscopy enabled categorization of bacterial structures. Fluorescence microscopy helped label and identify S. mutans, using polyclonal antibodies. Bacterial morphotypes were related to different subsistence patterns. Hunters, fishermen, and gatherers had a less diverse flora with bacillary and coccal morphotypes. Agricultural groups showed greater diversity with additional filamentous and spiral morphotypes. The best preserved ultrastructural feature was the cell wall. The existence and colonization capacity of the mutans-like streptococci preserved in tartar was established for the ancient populations studied, with the exception of Cerro Sotta (south of Chile). Hence, their occurrence could not be related to diet or subsistence pattern

City for creatives: what attracts and repeats the Greater Concepcion Area, Chile. Distances between global and local discourses

Objetivo: En el contexto de una discusión, aún abierta, en torno al concepto de ciudad creativa, el presente artículo contrasta discursivas globales con apreciaciones locales de personas consideradas creativas, identificando características urbanas que atraen y generan arraigo, y otras que producen desafección e incomodidad. Metodología: El caso de estudio fue el Área Metropolitana de Concepción (AMC), Chile, realizando entrevistas a personas consideradas creativas; los entrevistados fueron seleccionados mediante técnica de bola de nieve, y el universo muestral se acotó bajo la lógica de saturación. Finalmente, la información obtenida se sistematizó con el software de Análisis de Contenido, T-Lab.8.1. Conclusiones: Los resultados se contrastaron con un estado del arte y discursivas académicas globales, evidenciando consensos, disensos y jerarquías, develando el necesario y local ajuste de una planificación y diseño urbano, en pos de una política de competitividad urbana basada en la fijación y atracción de talento creativo, máxime, de sistemas urbanos intermedios se trata. Originalidad: Estudiar la capacidad de atracción-retención que ejercen las urbes intermedias para con los grupos creativos, con una óptica centrada en las personas y sus experiencias, es poco habitual, pese a que resulta fundamental en un escenario de competencia global por atraer el talento y capital humano avanzado.Objectiu: En el context d'una discussió, encara oberta, entorn del concepte de ciutat creativa, el present article contrasta discursives globals amb apreciacions locals de persones considerades creatives, identificant característiques urbanes que atreuen i generen arrelament, i altres que produeixen desafecció i incomoditat. Metodologia: El cas d'estudi va ser l'Àrea Metropolitana de Concepció (AMC), Xile, realitzant entrevistes a persones considerades creatives; els entrevistats van ser seleccionats mitjançant tècnica de bola de neu, i l'univers mostral es va delimitar sota la lògica de saturació. Finalment, la informació obtinguda es va sistematitzar amb el programari d'Anàlisi de Contingut, T-Lab.8.1. Conclusions: Els resultats es van contrastar amb un estat de l'art i discursives acadèmiques globals, evidenciant consensos, dissensos i jerarquies, desvetllant el necessari i local ajust d'una planificació i disseny urbà, darrere d'una política de competitivitat urbana basada en la fixació i atracció de talent creatiu, més, de sistemes urbans intermedis es tracta. Originalitat: Estudiar la capacitat d'atracció-retenció que exerceixen les urbs intermèdies envers els grups creatius, amb una òptica centrada en les persones i les seves experiències, és poc habitual, malgrat que resulta fonamental en un escenari de competència global per atreure el talent i capital humà avançat.Objectives: In the context of a discussion, still ongoing, about the concept of creative city, this article contrasts global discourses with local appreciations of people considered the creative class, identifying urban characteristics that attract and establishes roots, and others that produce disaffection and discomfort. Methodology: The case study was conducted in the Metropolitan Area of Concepción (AMC), Chile, conducting interviews with people considered the creative class; the interviewees were selected using snowball sampling, and the sample universe was bounded under the logic of saturation. Finally, the information obtained was systematized with the Content Analysis software, T-Lab.8.1. Conclusions: The results were contrasted with a state of the art developments and global academic discursive, evidencing consensus, dissents and hierarchies and revealing the necessary and local adjustment of urban planning and design; in pursuit of a policy of urban competitiveness based on the attraction and retention of creative talents, especially within intermediate urban systems. Originality: Studying the attraction-retention capacity of intermediate cities for creative groups -with a focus on people and their experiences- is unusual, although it is essential in a scenario of global competition to attract talent and advance human capital.Peer Reviewe

Productividad total de los factores en la agricultura chilena: 1961-1996

Resumen: El objetivo de este trabajo es medir el cambio de la productividad en la agricultura chilena durante el período 1961-96. La Productividad Total de los Factores (PTF) fue calculada mediante índices Törnqvist. Los datos utilizados para estimar estos índices incluyen precios y cantidades de 51 cultivos, de la mano de obra, de la tierra, del capital y de factores intermedios. El análisis revela que mientras los productos crecieron un 2,69% anual, el uso de factores de producción bajó un 0,09%; por lo tanto, la PTF creció a una tasa promedio anual del 2,78% entre 1961 y 1996. Se realizó además un análisis para siete períodos correspondientes a diferentes regímenes políticos. La PTF creció a un promedio anual de 1,83% con Alessandri (1961-64), 3,12% bajo el período de Frei Montalva (1965-70), 1,52% durante Allende (1971-73), 6,11% en la primera parte del régimen de Pinochet y -0,28% en el segundo período de Pinochet (1981-89), 3,12% bajo Aylwin (1990-93) y 5,28% bajo Frei Ruiz-Tagle (1994-96). Los resultados sugieren que el programa de reforma agraria implementado en los sesenta no tuvo un efecto negativo en el crecimiento de la PTF. Palabras Claves: Productividad Total de los Factores; Indice Törnqvist; Agricultura; Chile Abstract: The main objective of this paper is to determine the productivity growth in the Chilean Agricultural sector during the 1961-1996 period. Total Factor Productivity (TFP) was calculated using the Törnqvist index, which is a discrete approximation to the Divisia index. The data used to estimate these indexes are prices and quantities for 51 crops, and for four inputs - labor, land, capital and intermediate factors. The rate of annual growth for the period 1961-96 was 2,69% and 0,09%, for products and inputs, respectively. Therefore, the TFP grew at an average annual rate of 2,78%. Given a significant annual variability in TFP growth, an analysis was carried out for seven sub-periods corresponding to different political regimes. TFP grew at an annual average of 1,83% with Alessandri (1961-64), 3,12% under the period of Frei Montalva (1965-70), 1,52% during the Allende years (1971-73), 6,11% during the first part of the Pinochet regime and 0,28% in the second period of Pinochet (1981-89), 3,12% during Aylwin (1990-93) and 5,28% under Frei Ruiz-Tagle (1994-96). The results suggest that the land reform program implemented in the 1960s did not have a negative effect on TFP growth, as has been previously argued by some authors.Total Factor Productivity, Törnqvist Index, Agriculture, Chile, Productivity Analysis, D24, O33,