The Business of Plastic Surgery: Employment Contracts.

SUMMARY: Plastic surgeons are increasingly choosing to practice as employed physicians: either in an academic position, a single-specialty or multispecialty group, or within a franchise-type business. Employment offers advantages with regard to immediate income, minimal investment in practice start-up costs, and easier access to prospective patients. Surgeons considering such employment must perform due diligence to determine whether the position offered is a good fit. Once the decision is made to offer the plastic surgeon a position, an employment contract is negotiated. It is imperative that all parties understand the provisions of the contract, so that there are no misunderstandings between the employer and employee for the duration of the term. This article introduces physician recruitment offers and employment contracting. The key components of a contract are described, and compensation options are explained. Negotiation of the contract is critical so that all aspects are understood and agreed on, and the responsibilities of all parties are delineated.

Effects of United States WIC infant formula contracts on brand sales of infant formula and toddler milks.

The United States (US) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides free infant formula to low-income families with infants. State WIC agencies periodically solicit bids from manufacturers for the exclusive contract to provide infant formula in exchange for considerable rebates. Using Nielsen 2006-2015 retail scanner data, we estimated a difference-in-difference model to examine how winning a WIC infant formula contract affects sales of the new (winning) and former brands, including effects on sales of products not eligible for WIC (spillover). One year following a contract change, volume sales of WIC infant formula increased 322% (p < 0.01) for the new brand and decreased 77% (p < 0.01) for the former brand. Spillover effects included a 43% increase in sales of toddler milks for the new brand 2 years after the contract change. State WIC contracts allow manufacturers to market formula directly to consumers and may reduce breastfeeding policy effectiveness.

An empirical analysis of hospital ED pricing power.

OBJECTIVES: Empirical evaluation of market power that hospitals gain over health plans through hospitals' ability to cancel their contracts with plans while keeping large shares of plans' emergency patients and getting paid for them at above-market rates. STUDY DESIGN: Case-study analysis of 5 California hospitals that initially had contracts with most commercial health plans and then cancelled all those contracts at the same time. METHODS: We conducted a before-and-after case-study analysis comparing volume, price, and net revenues for the 5 study hospitals 3 years before and up to 4 years after the cancellation of their commercial contracts. The volume and price trends in study hospitals were compared with data on control hospitals in the same geographic area over the matching study period. RESULTS: Despite substantially increasing their prices on a noncontracted basis, the 5 study hospitals collectively retained 50% of their commercial health plan volume in first 2 years after the cancellation and 41% of their commercial volume in years 3 and 4, with net commercial revenues increasing as a result. At the same time, the simulated costs of treating the patients from out-of-network hospitals more than doubled for the health plans. CONCLUSIONS: In hospital-payer negotiation, many hospitals have an upper hand: Their threat to retain large portions of their emergency patients and revenues after becoming out of network is credible and it imposes disproportionate costs on the payers, which partially explains the continuing rise in hospital prices.

Financial Performance of Medicare Advantage Contracts in 2014 and Plan Renewal, Consolidation, and Termination Rates in the Subsequent Year.

BACKGROUND: Starting in 2014, the Affordable Care Act mandated that Medicare Advantage (MA) contracts spend at least 85% of total revenue on claims and quality improvement [ie, the medical loss ratio (MLR)] and submit revenue and cost data annually in MLR reports. These reports can improve transparency of the financial performance of MA contracts. However, little is known about revenues and costs of insurers that participate in MA and its impacts on status changes in the following year. OBJECTIVE: To characterize revenues and costs of MA contracts in 2014, with a focus on MLRs and gross margins, and to assess heterogeneity in subsequent-year plan renewal and termination rates by gross margins. RESEARCH DESIGN: Cross-sectional data from MLR reports submitted in 2014 by MA contracts and from 2015 Part C & D Plan Crosswalk Files regarding plan renewal, termination, and other status changes from 2014 to 2015. SUBJECTS: Three hundred eighty-nine MA contracts. MEASURES: Primary outcomes are MLRs and gross margins. RESULTS: MLRs averaged 93% in 2014; 11% of contracts reported MLRs of at least 100%. Fifty-six percent reported negative margins, or costs that exceeded revenues. Seventeen percent of plans in contracts in the lowest quartile of gross margins were terminated in 2015, compared to under 5% of plans in the highest-margin contracts. CONCLUSIONS: In 2014, MA contracts reported MLRs greater than the mandatory minimum of 85%. Gross margins likely contribute to trends in plan and insurer availability. MLR reports from subsequent years can help explain fluctuations in insurers' participation in MA.

Health provider networks with private contracts: Is there under-treatment in narrow networks?

Contracts between health insurers and providers are private. By modelling this explicitly, we find the following. Insurers with bigger provider networks, pay providers higher fee-for-service rates. This makes it more likely that a patient is treated and hence health care costs and utilization increase with provider network size. Although providers are homogeneous, the welfare maximizing provider network can consist of two or more providers. Provider profits are positive whereas they would be zero with public contracts. Increasing transparency of provider prices increases welfare only if consumers can "mentally process" the prices of all treatments involved in an insurance contract. If not, it tends to reduce welfare.

Development of perceived job insecurity among young workers: a latent class growth analysis.

PURPOSE: Individual differences in the development of perceived job insecurity among young workers may be influenced by characteristics of the first job (contract type and sector) and individual background (education and previous unemployment), and can have implications for subsequent health and well-being. The aim of this study was to investigate the development of perceived job insecurity during the early career, as well as associations between different patterns of development (i.e., trajectories), predictors and outcomes. METHODS: We conducted a latent class growth analysis to identify trajectories of perceived job insecurity and investigated their respective associations with predictors and outcomes across 6 years in a sample of 1711 German labor market entrants. RESULTS: Six trajectories were identified: three showed stable job insecurity perceptions (stable moderate, 36%; stable low, 32%; stable high, 5%), two showed decrease (moderate to low, 12%; high to moderate, 3%), and one showed increasing job insecurity perceptions (low to moderate, 13%). Temporary contracts and previous unemployment predicted trajectories characterized by increasing, higher initial or higher overall levels of perceived job insecurity. In contrast, public sector employees and university graduates were less likely to experience persisting or increasing job insecurity. The trajectories differed in their overall levels of self-rated health and job satisfaction, but not with respect to change in these outcomes. Instead, increasing perceived job insecurity was associated with decreasing life satisfaction. CONCLUSIONS: The findings suggest that an insecure career start and individual risk factors may predispose young workers to an unfavorable development of both job insecurity perceptions and levels of well-being.

Informal employees in the European Union: working conditions, employment precariousness and health.

BACKGROUND: The aim of this study is to estimate the prevalence of informal workers and their working conditions and employment precariousness in the EU-27; and to explore the association of different contract arrangements with health outcomes and how they are influenced by working and employment conditions. METHODS: A sample of 27 245 working-age employees from the fifth European Working Condition Survey of 2010 was analysed. Logistic regression models were fitted to estimate the contribution of different contract arrangement (permanent, temporary and informal) and working and employment precariousness variables on health outcomes (psychosocial well-being and self-rated health). RESULTS: Prevalence of informal employees in the EU-27 is 4.1% among men and 5.1% among women. Although informal employees have the poorest working conditions and employment precariousness, they did not seem to reflect poorer health. Precariousness employment variables have a greater impact than working conditions variables in reducing the association between health outcomes and type of contract arrangement, especially in the case of informal employees. CONCLUSIONS: Informal employment in the EU-27 is characterized by worse working conditions and employment precariousness than the conditions for formal employees. There is no evidence at all that being in informal employment implies better health outcomes compared to permanent employees.

[Effectiveness of individual supported employment for people with severe mental disorders]. / Efectividad de una estrategia de apoyo individualizado al empleo para personas con trastornos mentales graves.

OBJECTIVE: To assess the effectiveness of an individual placement and support (IPS) strategy in people with severe mental disorders in Tenerife Island (Spain). METHODS: Patients of Community Mental Health Services with severe mental disorders were randomly assigned to two groups. One of them received IPS (n=124), and the control group (n=75) was advised in the usual job search. Patients were followed up for an average of 3.4 years and an analysis was made of how many patients worked at least one day, working hours, wages, the number of contracts and the number of hospital admissions. Non-parametric methods were used to compare the results (Mann-Whitney U test). RESULTS: The percentage of patients who worked at least one day was 99% in the IPS group compared with 75% in the control group; they worked on average 30.1 weeks per year vs 7.4; the monthly salary was € 777.9 vs € 599.9; the number of contracts per person was 3.89 vs 4.85, and hospital admissions were 0.19 vs 2.1. CONCLUSIONS: The IPS strategy is effective for the labour integration of people with severe mental illness getting them to work longer, have higher wages and fewer hospital admissions.

"Contract to Volunteer": South African Community Health Worker Mobilization for Better Labor Protection.

In this paper, we explore the increasing activity around labor rights for South African community health workers (CHWs). Contextualizing this activity within broader policy and legal developments, we track the emergence of sporadic mobilizations for decent work (supported by local health activist organizations) and subsequently, the formation of a CHW union. The National Union of Care Workers of South Africa (NUCWOSA) was inaugurated in 2016, hoping to secure formal and secure employment through government and the consequent labor and occupational health protections. Various tensions were observed during fieldwork in the run up to NUCWOSA's formation and raise important questions about representation, legitimacy, and hierarchies of power. We close by offering suggestions for future research in this developing space.

Association Between Monetary Deposits and Weight Loss in Online Commitment Contracts.

PURPOSE: To examine the characteristics of voluntary online commitment contracts that may be associated with greater weight loss. DESIGN: Retrospective analysis of weight loss commitment contracts derived from a company that provides web-based support for personal commitment contracts. Using regression, we analyzed whether percentage weight loss differed between participants who incentivized their contract using monetary deposits and those who did not. SETTING: Online. PARTICIPANTS: Users (N = 3857) who voluntarily signed up online in 2013 for a weight loss contract. INTERVENTION: Participants specified their own weight loss goal, time period, and self-reported weekly weight. Deposits were available in the following 3 categories: charity, anticharity (a nonprofit one does not like), or donations made to a friend. MEASURES: Percentage weight loss per week. ANALYSIS: Multivariable linear regressions. RESULTS: Controlling for several participant and contract characteristics, contracts with anticharity, charity, and friend deposits had greater reported weight loss than nonincentivized contracts. Weight change per week relative to those without deposits was -0.33%, -0.28%, and -0.25% for anti-charity, charity, and friend, respectively ( P < 0.001). Contracts without a weight verification method claimed more weight loss than those with verification. CONCLUSION: Voluntary use of commitment contracts may be an effective tool to assist weight loss. Those who choose to use monetary incentives report more weight loss. It is not clear whether this is due to the incentives or higher motivation.

Culturally appropriate organization of water and sewerage projects built through public private partnerships.

This paper contributes to the pursuit of socially sustainable water and sanitation infrastructure for all people by discovering statistically robust relationships between Hofstede's dimensions of cross-cultural comparison and the choice of contract award types, project type, and primary revenue sources. This analysis, which represents 973 projects distributed across 24 low- and middle-income nations, uses a World Bank dataset describing high capital cost water and sewerage projects funded through private investment. The results show that cultural dimensions explain variation in the choice of contract award types, project type, and primary revenue sources. These results provide empirical evidence that strategies for water and sewerage project organization are not culturally neutral. The data show, for example, that highly individualistic contexts are more likely to select competitive contract award types and to depend on user fees to provide the primary project revenue stream post-construction. By selecting more locally appropriate ways to organize projects, project stakeholders will be better able to pursue the construction of socially sustainable water and sewerage infrastructure.

Contract care in dentistry: sense-making of the concept and in practice when multiple institutional logics are at play.

In 2009 contract dental care was introduced into Sweden's Public Dental Service under a programme called Dental Care for Health (DCH). Previous research has revealed a possible dilemma whereby dental care professionals had the role of insurance agent foisted upon them, as they were assigned the task of 'selling contracts'. Using qualitative interviews, this study explores how these professionals make sense of contract dental care today. Drawing on the concepts of occupational and organisational professionalism, in combination with the institutional logics perspective, we discern that dental care professionals are entangled in multiple rationalities when reasoning about and dealing with DCH. A professional logic comes into play over health issues and preventive care, while market and corporate logics are present in relation to selling contracts and taking responsibility for the financial aspects of DCH, all of which creates tensions in these professionals. Overall, dental care professionals in the welfare sector respond both to an organisational and an occupational professionalism.

Current practice and perspectives in CRO oversight based on a survey performed among members of the German Association of Research-Based Pharmaceutical Companies (vfa).

In recent years, the number and scope of outsourced activities in the pharmaceutical industry have increased heavily. In addition, also the type of outsourcing has changed significantly in that time. This raises the question of whether and how sponsors retain the capability to select and to control the contract research organizations (CROs) involved and what expertise still has to be present in the development department as well as other relevant departments to ensure adequate oversight, also in line with the expectations of regulators and health authorities. In order to answer these questions, a survey was conducted among the German vfa member companies. The survey describes the latest developments and experiences in outsourcing by 18 German vfa member companies. It concentrates on measures how to implement Quality Assurance (QA) when performing outsourced clinical studies. This study shows that the majority of companies apply a full-outsourcing, preferred-provider model of clinical trial services, with the clinical research department playing the major role in this process. A large amount of guiding documents, processes and tools are used to ensure an adequate oversight of the services performed by the CRO(s). Finally the guiding principles for all oversight processes should be transparent communication, a clearly established expectation for quality, a precise definition of accountability and responsibility while avoiding silo mentality, and a comprehensive documentation of the oversight's evidence. For globally acting and outsourcing sponsors, oversight processes need to be aligned with regards to local and global perspectives. This survey shows that the current implementation of oversight processes in the participating companies covers all relevant areas to ensure highest quality and integrity of the data produced by the outsourced clinical trial.

Use of risk mitigation practices by family nurse practitioners prescribing opioids for the management of chronic nonmalignant pain.

BACKGROUND: Ongoing opioid analgesic use in patients suffering from chronic nonmalignant pain (CNMP) has been associated with the development of opioid misuse, abuse, addiction, and overdose. To prevent these adverse outcomes, it is important that family nurse practitioners (FNPs) implement recommended risk mitigation practices (RMPs) when treating CNMP patients with opioids. METHODS: A national sample of 856 FNPs was invited to answer an online survey about their utilization of opioids and RMPs in treating CNMP. RESULTS: One hundred sixty-eight FNPs responded (20% response rate), of whom 51.2% affirmed that they prescribe opioids for CNMP. Of the 86 FNPs who prescribe opioids, 66.7% said that less than 25% of their patients were receiving ongoing opioid therapy. The most frequently prescribed opioids were hydrocodone (77.9%) and oxycodone (58.1%). With respect to RMPs, 50 of the 86 opioid-prescribing FNPs (58.8%) reported using treatment contracts with their CNMP patients. Far fewer (20.9%) used formal screening tools to gauge the risk of opioid abuse and misuse. Most respondents (54.94%) reported using prescription monitoring programs, whereas only 33.0% reported using urine toxicology to monitor opioid use. Of the prescribing FNPs, 15.1% reported using abuse-deterrent opioid formulations. Age was found to be a correlate for prescribing opioids for CNMP, with those under 40 years of age less likely to use urine toxicology than those over 41 (45.2% vs. 4.2%; χ2(6) = 11.90, P = .06). Additionally, respondents who did not use treatment contracts reported significantly fewer years in practice (10.5 years, SD = 6.1) than those who did (13.6 years, SD = 1.54, df = 2.82, P = .02). CONCLUSIONS: Although RMPs are recommended for use in all CNMP patients receiving ongoing opioid therapy, FNPs do not consistently implement them. In the midst of the current opioid epidemic, FNPs must be vigilant about using appropriate opioid prescription practices.