An analysis of competitive bidding by providers for indigent medical care contracts.

This article develops a model of behavior in bidding for indigent medical care contracts in which bidders set bid prices to maximize their expected utility, conditional on estimates of variables which affect the payoff associated with winning or losing a contract. The hypotheses generated by this model are tested empirically using data from the first round of bidding in the Arizona indigent health care experiment. The behavior of bidding organizations in Arizona is found to be consistent in most respects with the predictions of the model. Bid prices appear to have been influenced by estimated costs and by expectations concerning the potential loss from not securing a contract, the initial wealth of the bidding organization, and the expected number of competitors in the bidding process.

Health care expenditure containment in the United States: strategies at the state and local level.

The current status of state and local strategies to contain health care expenditures in the United States is described. These strategies are classified as predominantly regulatory, competitive or voluntary. The actions of two major groups of purchasers of care--state government programs for the indigent and private employers--in support of expenditure containment strategies are discussed as well. The large number of approaches to expenditure containment currently being attempted, and their diverse character, are hypothesized to be a result not only of increased health care inflation and the concern it causes purchasers of care, but also of fundamental changes in the health care industry in the United States which have realigned traditional provider interest groups.

A comparison of existing and alternative competitive bidding systems for indigent medical care.

Competitive bidding is gaining in popularity as a means of containing costs in indigent medical care programs. The economic implications of the bidding systems employed by Arizona and California are discussed in light of the existing literature. Two alternative bidding approaches are proposed for consideration by policymakers--the sealed bid 'Vickrey' auction and the 'ascending Dutch' auction. While the incentives it contains for providers are not optimal, the ascending Dutch auction has the greatest potential for effective implementation since it accommodates the realities of public sector budget constraints and political pressures for direct control over program expenditures.

Competitive bidding as a cost-containment strategy for indigent medical care: the implementation experience in Arizona.

The State of Arizona recently instituted a competitive bidding process, in order to establish a health services delivery system for indigents and to determine capitated reimbursement levels for providers in that system. This article describes the implementation of that bidding process, and identifies factors which had a significant impact on the implementation experience. Implementation of competitive bidding in Arizona encountered problems which appear to be common to the implementation of innovative public programs. It also uncovered political liabilities that suggest that effective implementation of competitive bidding for indigent medical care contracts in other environments will be difficult, even if technical implementation problems can be overcome.

Variability in the amount of beta-globin mRNA in beta0 thalassemia.

Globin mRNA isolated from a number of beta0 thalassemia patients of different ethnic origins was analyzed by RNA-cDNA hybridization and, in two cases, by fingerprint analysis of 125I-labeled mRNA. Quantitation of the relative amounts of alpha- and beta-mRNA by hybridization to purified alpha-and beta-cDNA revealed that in approximately half the cases, there was less than 1% as much beta-mRNA as alpha-mRNA. In the rest of the cases, low levels of beta-like mRNA were detected in amounts 4-12% as abundant as alpha-mRNA. There was variability in the yield of beta-like mRNA in patients of the same racial group, in the same patient at different times and in similarly affected siblings: beta-mRNA was virtually absent in some samples, whereas low but significant levels were found in other samples. In one patient, beta-like mRNA was not detected in peripheral blood RNA, but was present in the RNA of bone marrow cells. In one case, the thermal stability of the beta0 thalassemia mRNA-beta-cDNA hybrid was measured and found to be slightly lower than that of the authentic beta-mRNA-beta-cDNA hybrid. In none of the cases tested was there synthesis of beta-globin chains directed by beta0 thalassemia mRNA in a cell-free protein-synthesizing system, even when beta-like mRNA was detected in the sample by hybridization assays. mRNA from two patients was labeled in vitro with 125I, digested with T1 RNAase and fractionated in two dimensions. Analysis of the resulting fingerprints revealed the presence of prominent alpha chain-specific oligonucleotides without detectable beta chain-specific oligonucleotides, and thereby confirmed the results of hybridization assays showing absent or very low levels of beta-mRNA in the same RNA samples. Our results support the concept that beta0 thalassemia is heterogeneous in its molecular basis even within the same racial group: in some patients, it is associated with absent beta globin mRNA, whereas in other patients, it is associated with low but significant levels of nonfunctional beta or beta-like globin mRNA. The variable amounts of beta-like mRNA detected in different samples from the same patient, and in patients with the same genotype, indicate that as yet undefined factors can influence the yield of beta-like mRNA observed in beta0 thalassemia.

Normal erythropoietic helper T cells in congenital hypoplastic (Diamond-Blackfan) anemia.

To examine the erythropoietic function of T and null cells in congenital hypoplastic (Diamond-Blackfan) anemia, we fractionated the peripheral blood of three normal subjects and three affected patients into subclasses of null, T and B cells. Mixtures of these cells were co-cultured in plasma clots in the presence of erythropoietin. Erythroid colonies grew in cultures of normal null cells if either normal or patient T cells were co-cultured with them. Null cells of patients with hypoplastic anemia did not produce erythroid colonies under any culture conditions. We conclude that in this disorder, T cells function normally as helper cells in erythropoiesis and do not suppress colony formation, whereas the erythroid progenitor cells in the peripheral blood null-cell fractions are deficient in either number of function.

Erythroid precursors in congenital hypoplastic (Diamond-Blackfan) anemia.

To explore the etiology of congenital hypoplastic anemia (CHA) or the Diamond-Blackfan anemia, erythropoietin responsive committed erythroid precursors were enumerated by the plasma clot method. These included blood and marrow erythroid burst-forming units (BFU-E) and marrow erythroid colony-forming units (CFU-E). The peripheral blood nucleated cells of 11 patients and the marrow cells of seven of these patients were examined. Studies were repeated in several patients during relapse and after induction of remission. BFU-E were undetectable in the marrow and blood of all but one relapsed patient, and the numbers of marrow CFU-E were depressed in all relapsed patients. Blood BFU-E remained low in all of the patients in remission. No evidence was obtained for suppression of normal CFU-E or BFU-E by CHA lymphocytes. Erythropoietin dose-response curves performed in two patients revealed a 10-fold increase in erythropoietin requirement for marrow CFU-E colony growth. This marked unresponsiveness to erythropoietin was strikingly improved by steroid therapy in one patient. We suggest that CHA is the result of a qualitative and/or quantitative deficiency of BFU-E. If BFU-E are produced, they must be relatively unresponsive to erythropoietin. The abnormal BFU-E give rise to erythropoietin unresponsive CFU-E and, thence, to proerythroblasts that are, in turn, trapped in that early stage of development because of their poor erythropoietic response. Hence, red cell production is deficient. Steroids appear to improve the erythropoietin response of CHA erythroid precursors.

Human erythroid burst-forming unit: T-cell requirement for proliferation in vitro.

Human mononuclear leukocytes were fractionated into populations of null, T and B cells by immunoabsorbent column chromatography followed by E-rosette formation and purification of T cells by differential centrifugation and osmotic lysis. The unfractionated and fractionated cell populations were first separately cultured for 14 days in plasma clots in the presence of two international units erythropoietin. Typical erythroid burst-forming unit (BFU-E)-derived colonies grew in the unfractionated cell cultures but not from T- or B-cell cultures. BFU-E colonies grew in null cell cultures but most of the colonies were small and variably hemoglobinized with less than three subcolonies. When intact T cells were added to null cells and cocultured, many typical large BFU-E colonies with more than 10 well homogenized subcolonies appeared. Increasing numbers of large BFU-E colonies in null cell cultures were induced by stepwise addition of T cells but not by the addition of B cells. A conditioned medium in which T cells had been induced to divide by tetanus toxoid substituted for intact T cells in this T-cell-dependent BFU-E colony formation observed in null cells. These findings demonstrate that the BFU-E, a committeded erythroid stem cell, resides in the null cell fraction of peripheral blood, but its proliferative capacity and differentiation in vitro requires a soluble product of T cells. Such experiments now permit a new approach to the assessment of various disorders of erythropoiesis. Erythroid hypoplasia in a particular case may be due to dysfunction of the committed precursor cell or to a failure of a helper effect induced by T cells.

Studies of globin chain synthesis and globin mRNA content in a patient homozygous for hemoglobin Lepore.

Globin chain synthesis and globin mRNA content were studied in blood cells of a patient homozygous for Hb Lepore. Peripheral blood cells incubated with tritiated leucine synthesized approximately 1.5 to 3% as many Lepore globin chains as alpha chains. Globin mRNA in peripheral blood cell RNA was assayed by molecular hybridization assays using human alpha and beta cDNA, and the results indicated the presence of approximately 1% to 2% as much beta-like mRNA (presumably deltabeta Lepore mRNA) as alpha mRNA. The amount of Lepore deltabeta chain mRNA in peripheral blood cells is therefore proportional to the amount of Lepore globin chain synthesis in the same cells. An incidental observation was the finding that peripheral blood cell RNA of this patient, at a time when she was being heavily transfused, contained substantially higher levels of beta-like mRNA (relative to alpha mRNA) than in subsequent studies. Cell-free translation of this mRNA however revealed that it contained authentic beta chain mRNA which must have been derived in some way from the transfused blood cells.

Production of mouse globin in heterokaryons of mouse erythroleukaemia cells and human fibroblasts.

In an effort to activate the globin genes of non-erythroid cells, tetraploid murine erythroleukaemia cells (Friend cells) were fused with diploid human amniotic fibroblasts. When the Friend cells were pretreated with dimethylsulphoxide, an average of 27% heterokaryons was observed. These cells stained with benzidine, an indication that they contained haemoglobin. The cells incorporated radioactive amino acids into proteins. Electrophoresis of [3H]leucine-labelled lysates on SDS urea polyacrylamide gels indicated that up to 7% of the newly synthesized protein co-electrophoresed with globin. CM cellulose chromatography demonstrated the presence of mouse but not human globin chains. Hybridization analyses of cytoplasmic RNA also revealed only mouse globin mRNA in the heterokaryons. Although heterokaryons form readily between mouse erythroleukaemia cells and human fibroblasts, and globin synthesis does occur, only the erythroid partner in the fusion system employed here directs globin production.

Absence of messenger RNA and gene DNA for beta-globin chains in hereditary persistence of fetal hemoglobin.

The relative amounts of alpha-amd beta-globin mRNA and globin gene DNA were measured in reticulocyte RNA and lymphocyte DNA of an individual with homozygous hereditary persistence of fetal hemoglobin whose red blood cells contain 100% fetal hemoglobin (hb F: alpha2gamma2.) Molecular hybridization assays used as probes full-length DNA copies of human alpha- and beta-globin messenger RNA. The results of these hybridization assays demonstrated the expected amounts of alpha-globin mRNA and gene DNA, but absence of beta-globin mRNA and absence of beta-globin gene DNA. In the individual studied, hereditary persistence of fetal hemoglobin is associated with total deletion of the beta-globin structural gene.