The Federal Trade Commission and the Department of Justice are considering an overhaul of the guidelines that both agencies have used for the past 17 years to evaluate the competitive effects of mergers and acquisitions.
The two federal entities announced jointly today that they will conduct public workshops and solicit public comments about the Horizontal Merger Guidelines—which were last significantly revised in 1992—to determine if they accurately reflect current merger practices and to account for legal and economic developments.
"The bulk of the merger guidelines are over 17 years old," FTC Chairman Jon Leibowitz said in a media release today. "The 1992 Guidelines explicitly stated that they would be revised from time to time. We think the time has come to do that."
The guidelines outline enforcement policy at FTC and DOJ, and describe the framework and specific standards normally used by the agencies in analyzing mergers. The guidelines are intended to reduce the uncertainty associated with enforcement of the antitrust laws in the merger area.
Merger guidelines were first adopted in 1968 by DOJ. They were substantially revised in 1982 and again in 1992, when they became the Horizontal Merger Guidelines, jointly issued by the FTC and DOJ. The section on efficiencies was revised in 1997. The agencies also issued a detailed Commentary on the Horizontal Merger Guidelines in 2006.
Any guideline changes could impact a number of healthcare sector businesses. However, American Hospital Association spokesman Rick Wade says hospital and health systems mergers fall under a different set of guidelines because of the unique issues that hospital mergers raise. "We will monitor this because some issues that could arise that would eventually have an impact on hospitals," Wade says.
The agencies will issue a set of questions about the current guidelines and possible revisions. Following a public comment period and the review of original research addressing those questions or other issues related to the guidelines, the agencies will host five workshops that will be open to the public and press. The first workshop will be held in Washington on Dec. 3, followed by workshops in Chicago, New York City, and San Francisco in December and January. A final workshop also will be held in Washington.
The FTC will post a set of questions on its Web site later today in the hopes of receiving written comments from attorneys, economists, academics, consumer groups, and businesses.
Guidelines topics to be discussed include: The method of analysis used by the agencies; the use of more direct forms of evidence of competitive effects; market definition; market shares and market concentration; unilateral effects, especially in markets with differentiated products; price discrimination; geographic market definition; the relevance of large buyers; the distinction between uncommitted and committed entry; the distinction between efficiencies involving fixed and marginal cost savings; the non-price effects of mergers, especially the effects of mergers on innovation; and remedies.
Public comments are also invited on whether to incorporate aspects of the 2006 Commentary on the Horizontal Merger Guidelines into the guidelines themselves.
In opening the first day of what could turn into a lengthy hearing on the Senate Finance Committee's healthcare reform bill, committee Chairman Max Baucus (D-MT) said today, "The time has come to reform America's healthcare. The times demand nothing less."
Baucus appeared confident this morning that work by the panel on the bill—which has had 564 amendments proposed for it—could be completed by the end of the week. "I look forward to constructive floor debate starting at early as next week," he said.
Even with midnight sessions, however, this could be a tough row to hoe. The Senate Health, Education, Labor and Pensions Committee, which approved its healthcare reform bill two months ago, took 13 days (with 54 hours and 23 markup session) to address hundreds of amendments as well.
To get the ball rolling, Baucus will introduce a revised Chairman's Mark later today. At least one of the changes will deal with physician payment. "At one point, I want to acknowledge up front that we did not do as much to correct the payment of doctors—especially as I would have liked under the incredibly misnamed sustainable growth rate (SGR)," he said. "The SGR needs to be fixed permanently. I look forward for further progress on this."
Baucus described his mark as "a balanced, common sense plan” that takes the "best ideas from both sides"--that is designed to get the 60 votes in the Senate that it needs to pass. "All Americans should have access to affordable quality healthcare coverage," he said.
However, the Chairman's Mark appeared to get little solid endorsement from the entire Finance panel, which has 13 majority members and 10 minority members. Votes for amendments are expected to follow along party lines. Senate Finance Committee Minority Leader Charles Grassley (R-IA) said that pressure was placed on having the bill done "right now instead of having it done right."
Sen. Orrin Hatch (R-UT) suggested that Baucus may want to consider the "reset" button—creating a different healthcare reform bill--that would attract bipartisan support.
Sen. John Kerry (D-MA), however, said the efforts to create a new healthcare reform bill "is not a rush," he said. "This is long overdue."
For instance, Baucus said, in a recent Kaiser Family Foundation survey, healthcare coverage for the average family now costs more than $13,000 a year. "If that current trend continues just 10 years from now (in 2019), the average family plan will cost more than $30,000—greater than a two-fold increase. No one should have to live in fear of financial ruin from increasing insurance premiums. This bill would fix that," he said.
"Let's begin our consideration of this bill," he concluded. "Let us make this a time for progress, let us seize our opportunity to make history and let us to our part to make quality affordable healthcare available to all."
I discussed the challenges of determining whether an imaging test is effective in last week's column, Measuring the Effectiveness of Imaging Tests Not Clear Cut. Today, I highlight a solution that is already addressing some of those concerns and is changing how imaging tests are being ordered in Minnesota.
The Imaging e-Ordering Coalition is an alliance of healthcare providers, technology companies, and diagnostic imaging organizations that have joined forces to promote health information technology-enabled decision support as a means to ensure patients are receiving medically appropriate diagnostic imaging tests.
Participants in The Coalition are the American College of Radiology, the Center for Diagnostic Imaging in Minneapolis (which operates 51 diagnostic imaging centers in nine states), GE Healthcare, Medicalis Corporation, Merge Healthcare, and Nuance Communications, Inc.
Recently, I spoke with Scott Cowsill, chair of The Coalition and senior product manager of diagnostic imaging at Nuance Healthcare, and Liz Quam, director of the Center for Diagnostic Imaging Institute and founding member of the Imaging e-ordering Coalition to discuss the goals of group.
The Coalition uses the radiology order entry technology developed at Boston's Massachusetts General Hospital (see How Many Slices Do You Really Need, HealthLeaders magazine, September 2009). "We have almost 15,000 clinical criteria guidelines in our database and that is one of the most, if not the most, robust comprehensive clinical criteria guidelines for high tech, diagnostic imaging, databases out there," says Cowsill, adding that the database is maintained through a proprietary relationship with MGH. The Coalition is striving to condense that information into a consumable, usable, and deployable mechanism for the private sector, he says.
For instance, if a patient comes to a primary-care physician complaining of headache, loss of hearing, and sinusitis, the technology factors in that information along with the patient's age and sex and provides a score based on a scale of one to nine as to whether the test being ordered will be effective. That score is based on the millions of exams that are run through the system, explains Cowsill.
And it provides all of that data in real time, says Quam. It doesn't just predict how effective that imaging modality may be, the decision-support technology also provides alternative suggestions. Based on the indications in the above scenario, a head MR may be offered as the better diagnostic modality, explains Cowsill.
"It is a consult for the physician at the time the physician is treating the patient," says Quam. "At the same time it doesn't erode the trust relationship between the physician and patient."
When physicians have to seek approval from radiology benefits managers, a patient may wonder whether they really need a test or if the test is denied because the physician wasn't persistent enough on their behalf, explains Quam. Under the RBM model, physicians can keep appealing a denial of coverage until they ultimately get approval, she says. But with e-ordering "patients and payers can be assured that the appropriate test was ordered."
So what do the payers think about e-Ordering as a substitute for the RBM model? In Minnesota, the large payers are already on board with the technology, says Quam. "We electronically can document that a decision-support tool was used by the family physician, so it is all in real time and that information goes back to the health plan," she says, adding that the health plan may require that you use the clinical decision support and then on backend they can analyze the data.
"Everybody in MN—health plans and providers—who are not always on same side—are vehement advocates of the clinical decision support, because we have seen it work," says Quam.
"Imaging is the most expensive element of care in this country," says Cowsill. So will e-Ordering help rein in those costs?
In a letter to the U.S. Senate Committee on Finance earlier this year, Barry A. Bershow, MD, medical director of quality & informatics for Minneapolis, MN-based Fairview Health Services claimed that it can.
"A number of provider groups were searching for an effective way to reduce costs and get good information to physicians ordering high tech diagnostic imaging. Calling an RBM vendor had proven to be time consuming, costly, interrupted work flow, and didn't help the patient and physician do shared decision making," Bershow wrote. "Working collaboratively with employers and health plans, as well as having our state's Department of Health and Human Services at the table, we developed a system for providing clinical decision support at the point of ordering by the primary-care physician."
Bershow noted that system had two major effects: "First, we saved 303 hours of labor per month at our system. The second was the right test was ordered the first time, while the patient was still in the exam room."
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A patient's death following an operating room flash fire serves as a good reminder for surgical teams to review preventive measures.
It is also proof that this particular type of fire will generate above-normal interest from the media.
The incident occurred at Heartland Regional Medical Center in Marion, IL. The patient, identified by the Associated Press and other news outlets as Janice McCall, 65, of Energy, IL, died September 8 at another medical center after the fire allegedly burned her at Heartland Regional September 2.
Nearly four dozen-related news articles popped up on a Google search Monday from across the country, a status that few patient deaths reach.
Heartland Regional was tight-lipped about the incident when contacted Friday. "Right now, we are not going to comment on that," said a director of marketing. She hung up before answering other questions, and the hospital didn't return subsequent requests from HealthLeaders for information.
Robert Howerton, an Illinois attorney for McCall's family, told the Associated Press he has requested medical records from Heartland Regional, and otherwise had few details about the incident. Our attempts to reach Howerton were unsuccessful as of Monday afternoon.
Roots of surgical blazes are age-old
The causes of surgical fires have long been known, as these blazes require a confluence of elements known as the "fire triangle":
Ignition sources (e.g., electrocautery pens)
Fuels (e.g., drapes or alcohol prepping solutions)
Oxidizers (e.g., oxygen-enriched atmospheres)
A common scenario is for oxygen to pool in a fold of a surgical drape near an incision point. When a clinician activates an eletrocautery device, the heat of the device ignites the drape, causing a quick-burning flash fire. The fire is promoted by the presence of the pooled oxygen, though oxygen itself does not burn.
Patient injuries from the fires can range from minor singes to burned respiratory tracts to death.
Factors that would need to be examined in Heartland Regional's incident include whether oxygen was flowing near the patient's face, whether alcohol-based skin prep was used, and what type of surgical device was present, said Mark Bruley, BS, CCE, vice president for accident and forensic investigation at the ECRI Institute, an independent healthcare research firm in Plymouth Meeting, PA.
Until those details are released, it's hard to know what preventive measures might have been warranted, Bruley said.
New recommendations are pending
Expect updated guidance about surgery precautions on patients who need oxygen from the ECRI Institute in collaboration with the Anesthesia Patient Safety Foundation.
An upcoming issue of the ECRI Institute's Health Devices will detail the revised recommendations. The key change is that, with certain exceptions, the traditional practice of open delivery of 100% oxygen should be discontinued, Bruley said.
If supplemental oxygen is needed during a surgical procedure, the patient's airway should be sealed by using a tracheal tube or laryngeal mask, the ECRI Institute will recommend.
"These new recommendations represent significant changes to clinical practice for anesthesia professionals," Bruley says.
Last year, the American Society of Anesthesiologists published an industry advisory to help hospitals increase awareness about surgical fires.
Northern Ireland's Department of Health is set to embark on a multi-million pound investment in new IT systems. Hewlett-Packard has been awarded the contract to modernize technology controlling hospital patient administration in the country. Health Minister Michael McGimpsey told BBC News health and social care relied on information technology "to provide an efficient and effective business."
Microsoft Corp. is promoting its free online service for storing files and collaborating on projects as a way for teachers to keep classes on track even if schools close because of a flu outbreak. Microsoft has launched a how-to Web site that walks teachers through the steps of setting up accounts for their classes on Office Live Workspace, a free Web service. Teachers can use it to post handouts and presentations, and students can log on to get assignments, chat and work with classmates on shared files.
The state of Kentucky has hired ACS State Healthcare LLC to develop the Kentucky Health Information Exchange. The Exchange is an electronic health information system that will allow for the exchange of digital medical records between healthcare facilities, doctors' offices, and the Kentucky Department of Medicaid Services.
Maryland's three largest hospital systems and a large retirement community operator are building a statewide information exchange network. The exchange—Chesapeake Regional Information System for Our Patients, or CRISP—was approved for $10 million in start-up state funding. Its purpose is to let hospitals, insurance providers and healthcare professionals freely and securely share information about patients.
The Health IT Policy Committee heard testimony from several experts involved with health IT privacy and security issues. Jodi Daniel, director of the Office of Policy and Research at the Office of the National Coordinator for Health IT, opened the meeting by saying privacy and security protections should be a critical component of "meaningful use" standards for electronic health records.
In this Washington Post editorial, Sammy Zakaria and David Meyerson, cardiologists at Johns Hopkins Medical Institutions, tout the Veteran Administration's VistA electronic health record system as the most cost effective solution to building a national electronic health record.
