Coming to grips with risk-sharing: capitation in the long-term care industry.

"Risk" means the transference of the financial payment for specified services from one entity to another. Risk transfers can occur from payers to providers or between providers. Risk can be transferred through a number of different payment structures. The concept of sharing risk originated several decades ago as employers began to tighten their health care budgets. Meticulous attention to details is a necessity if risk contracting is to be a profitable venture for long-term care providers. Long-term care providers are in different stages of development with risk-sharing contracting. With some attention to detail, the formation of the right team, and an understanding of costs, ancillary provider risk sharing can be profitable for all partners involved. This article details issues that should be considered before entering into a risk-sharing arrangement.

Choosing an advantageous risk-sharing arrangement.

Providers entering into risk-sharing arrangements with managed care organizations have several options regarding the amount of risk they can assume. The four most common forms of arrangements are based on service guarantees, case rates, episode rates, and global capitation. Providers must determine carefully which of these arrangements is most beneficial for them.

Managed care and the infectious diseases specialist.

There is growing demand to contain health care costs and to reassess the value of medical services. The traditional hospital, academic, and research roles of the infectious disease (ID) specialist are threatened, yet there is an increasing need for expertise because of growing antimicrobial resistance and emerging pathogens. Opportunities exist to develop and expand services for the care of patients infected with human immunodeficiency virus and in infection control, epidemiology, outcomes research, outpatient intravenous therapy, and resource management. It is important for ID physicians to appreciate the principles involved in managed care and the areas in which ID services can be valuable. To be effective, physicians need to know about tools such as practice guidelines, physician profiling, outcomes monitoring, computerized information management, risk sharing, networking, and marketing, as well as related legal issues. With a positive attitude toward learning, application, and leadership, ID physicians can redefine their role and expand their services through managed care.

Ectopic pregnancy: duplex Doppler evaluation.

Of 398 patients in whom there was a clinical suspicion of ectopic pregnancy, 96 (24%) were found to have the condition. Of the 96, 70 underwent duplex Doppler imaging. A viable ectopic fetus was seen in 10 of 70 (14%), and an extrauterine sac without an identifiable fetus was seen in an additional 27, giving a sensitivity for imaging alone of 53%. Fetal heart activity was detected with Doppler in 13 (19%). High-velocity flow, which suggested the presence of an ectopic pregnancy, was detected in 38 of 70 (54%) patients (total preoperative sensitivity, 73%). In the 91 patients who did not have an ectopic pregnancy, duplex Doppler imaging of the intrauterine contents alone allowed an ectopic pregnancy to be excluded in 29 (32%) on the first examination and in a further 21 on the second scan (specificity, 55%). Nine vascular adnexal masses were falsely considered to be ectopic pregnancies (specificity, 90%). The positive predictive values were 47% for imaging alone and 85% for Doppler. The negative predictive values were 60% for imaging alone and 81% for Doppler.

Morphologic and functional studies of immature rat oocyte-cumulus complexes after cryopreservation.

The effects of freezing and thawing (F/T) on functional activity of immature rat oocyte-cumulus complexes (OCC) were studied. The OCC were divided into three groups according to the number of cumulus-cell layers surrounding them. The OCC were then frozen and thawed (F/T), with dimethyl sulfoxide (DMSO) as cryoprotectant. The survival rates after thawing increased significantly (P less than 0.001) as the number of cumulus-cell layers increased. Germinal vesicle breakdown (GVBD) was evaluated in F/T oocytes. After 2 hours, significantly (P less than 0.05) fewer oocytes demonstrated GVBD than did those in the control group. There was no difference, however, after 4 hours of culture. A significant (P less than 0.05) decrease in follicle-stimulating hormone (FSH)-dependent cyclic adenosine monophosphate (cAMP) accumulation was observed in the F/T group. However, the amount of cAMP produced was sufficient to maintain the oocyte in meiotic arrest. There was a borderline significant decrease of the coupling between cumulus cells and the oocyte in F/T OCC, as evaluated by the transport of 3H-uridine into the oocyte. It is concluded that immature rat oocytes can be successfully cryopreserved when they are surrounded by five or more layers of cumulus cells. FSH responsiveness and intercellular communication were essentially maintained. There was a slight delay in GVBD, which needs further clarification.