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Mexiletine, an oral local anesthetic, demonstrates analgesic properties in patients with painful diabetic neuropathy. Corticosteroids have been reported to be useful as general purpose adjuvant analgesics. They ameliorate pain in patients with bone metastases and produce beneficial effects on appetite, nausea, mood, and fatigue. They have most commonly been used in patients with breast or prostate cancer to improve quality of life. A variety of non-pharmacologic therapeutic approaches can be used alone or in combination with analgesic drugs. These include physical therapy, trigger point injections, transcutaneous nerve stimulation, and a variety of behavioral approaches-all of which should be familiar to general physicians. Pain experts should be consulted before using anesthetic and neurosurgical approaches. Chronic pain is commonly associated with reduced physical activity and splinting or immobilization of the injured body part. A graded exercise program with appropriate use of splints and braces and reactivation of the injured part plays a pivotal role in re-establishing the functional status of the patient. Local rubbing and transcutaneous electrical stimulation for "counterirritation" may help to mobilize the patient with localized pain. Trigger point injections with either saline or a local anesthetic provide dramatic relief of painful muscle spasm. Cognitive behavioral interventions including coping skills and modification of thoughts, feelings, and behaviors can help reduce the perception of distress caused by pain. Opioid therapy should be considered only after all other reasonable attempts at analgesia have failed. A history of substance abuse, severe character pathology, and chaotic home environment should be viewed as relative contraindications. Patients should give informed consent before the start of therapy; points to be covered include recognition of the low risk of true addiction as an outcome, potential for cognitive impairment with the drug alone and in combination with sedative/hypnotics, likelihood that physical dependence will occur (abstinence syndrome possible with acute discontinuation), and understanding by female patients that children born when the mother is on opioid maintenance therapy will likely be physically dependent at birth. After drug selection, doses should be given around the clock; several weeks should be agreed on as the period of initial dose titration; and although improvement in function should be continually stressed, all should agree to at least partial analgesia as the appropriate goal of therapy. Failure to achieve at least partial analgesia at relatively low initial doses in the non-tolerant patient raises questions about the potential treatability of the pain syndrome with opioids. Emphasis should be given to attempts to capitalize on improved analgesia by gains in physical and social function; opioid therapy should be considered complementary to other analgesic and rehabilitative approaches. In addition to the daily dose determined initially, patients should be permitted to escalate dose transiently on days of increased pain; two methods are acceptable: (a) prescription of an additional 4 to 6 "rescue doses" to be taken as needed during the month; (b) instruction that one or two extra doses may be taken on any day but must be followed by an equal reduction of dose on subsequent days. Exacerbations of pain not effectively treated by transient, small increases in dose are best managed in the hospital, where dose escalation, if appropriate, can be observed closely and a return to baseline doses can be accomplished in a controlled environment. Evidence of drug hoarding, acquisition of drugs from other physicians, uncontrolled dose escalation, or other aberrant behaviors must be carefully assessed. Documentation is essential and the medical record should specifically address comfort, function, side effects, and the occurrence of aberrant behaviors repeatedly during the course of therapy. Other approaches, including meditation, imagery, music therapy, and biofeedback can reduce participatory anxiety that may lead to avoidance behaviors. Successful use of these therapies requires a cognitively intact patient and a health care professional skilled in their application. Several factors are important in selecting an appropriate procedure for each patient. The role of these approaches is limited because diffuse pain problems rather than focal ones are the most common. Their use is limited by the number of professionals who have expertise in the performance of these procedures. Many of these procedures are most useful in patients with a limited lifespan; yet such patients often consider their pain to be an important marker for their disease and are frightened by the potential, although unlikely complications of these procedures. One approach uses nitrous oxide for patients with far-advanced disease to provide additive analgesia. Nitrous oxide, administered with oxygen through a non-rebreathing facemask in concentrations from 25 to 75% has been demonstrated to be useful when combined with systemic opioid analgesics to control pain and anxiety in patients with advanced disease and pain. Similarly, intravenous barbiturates to manage dying patients who have inadequate analgesia or uncontrollable symptoms and who request that they be maintained in a sedated state represents another type of anesthetic approach.

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Thus, the gene transfer vector in the direct-delivery approach must achieve delivery in the context of significant host barriers, including humoral, reticuloendothelial, and immunologic factors. Earlier protocols were principally of the ex vivo type and relied on recombinant retroviruses as gene transfer vehicles. The technology to derive recombinant retroviruses that can efficiently transfer genes has been sufficiently developed that these vectors have been used for a majority of human protocols (Table 33-1) They can accomplish effective gene transfer to a variety of target cells despite being rendered replication incompetent by genomic deletions. In addition, because these viruses are integrative, they can produce permanent genetic modifications of target cells with the consequence of long-term heterologous gene expression. Whereas the vectors are suited for ex vivo modification of target cells, a variety of limitations have restricted their use in strategies to accomplish direct, in vivo gene transfer. The retrovirus requires proliferative target cells to mediate effective gene transfer. One exception are lentiviruses, the class of retrovirus that includes human immunodeficiency virus, which can integrate also in non-dividing cells. An additional obstacle for retroviruses is the high susceptibility of the virus particle to humoral factors that ablate its gene-transfer capacity. Thus, the basic biology of recombinant retroviruses has been an additional factor restricting initially implemented gene therapy protocols to strategies using ex vivo methodologies. To circumvent the limitations associated with recombinant retroviruses, alternative vector systems have been developed (see Table 33-1). These systems include both non-viral and viral approaches to accomplish gene transfer. In both of these approaches, the goal is to develop a system that can deliver genes in vivo after systemic administration. This development is a step toward deriving a "targetable-injectable" vector-a vector that can deliver therapeutic genes selectively to target cells after direct, in vivo administration. The development of such a vector system would have two very important consequences for potential gene therapy strategies: (1) it Figure 33-1 Methods to modify the adenoviral cellular tropism. Viral tropism is determined by the fiber and its recognition region in the terminus, or "knob" (dotted circle). Binding of the virus to target cells can be modified via either immunologic or genetic methods. Immunologic targeting involves the attachment of molecular conjugates incorporating antibodies against the fiber knob and ligands specific for cognate receptors in target cells. Genetic targeting involves the genetic modification of the fiber gene to generate fiber chimeras with novel ligand specificity. Replication-deficient adenoviruses can be genetically complemented in vivo in cells co-infected with a second vector that encodes the deleted replication-enabling molecules. Tissue- or tumor-specific promoters can regulate the expression of these proteins, thus limiting the occurrence of viral replication to the target tissue. Progeny virus leads to infection of neighboring cells, increased local viral inoculum, and augmentation of therapeutic gene expression. A variety of nonviral systems have been developed and used in strategies to directly deliver genes in vivo. Their design overcomes the potential safety hazards associated with viral gene sequences contained in the viral vectors. Whereas initial formulations were associated with significant target cell toxicity, newer agents appear more promising in this regard. These vectors, delivered to select target organs after direct in vivo delivery, have been used in human clinical trials targeting pulmonary disorders and a wide variety of malignancies. Despite this systemic stability, delivery is at present non-specific, because the liposomes lack any mechanism to achieve targeting. This goal is the principal logic behind the design of molecular conjugate vectors. These synthetic molecules exploit the endogenous cellular receptor-mediated pathway to transfer genes.

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Students are provided with an introduction to safety, skills, and facilitation techniques for low and high elements of outdoor challenge courses. Capstone course for minors, allowing for integration and application of course work, theories, and research to a work setting. Involves discussions, demonstrations, and activities that teach students wilderness skills, safety and judgment, leadership and teamwork, and environmental ethics. Topics covered include basic wilderness first-aid, hazard evaluation, emergency procedures, expedition behavior, self awareness, judgment and decision making, campsite selection, shelter and stove use, fire building, sanitation and hygiene, cooking, nutrition and rationing, equipment care and selection, staying warm and dry, route finding and navigation, Leave No Trace backpacking, weather, natural history, and wilderness ethics. Application of these skills will occur during the 14-day offtrail backpacking trip in a remote wilderness area. Not only will students practice these wilderness skills, but they will also develop leadership abilities by working in a collaborative team environment. Students will be engaged in classroom preparation; training in canoeing and wilderness travel/living skills; group leadership; and environmental education in the Everglades National Park ecosystem. The class will travel and camp for 6 days/nights in the Everglades back country by canoe as a self-contained group. For students planning careers in outdoor recreation, interpretation, and natural George Mason University 2016-2017 Official University Catalog 3531 resources management and planning; and students with a general interest in the course topics. Examines role of philosophers, scientists, naturewriters, and artists in the shaping of environmental thought. Includes extensive reading of Emerson, Thoreau, Muir, Leopold, Carson, Wilson, and others. Emphasizes understanding of contemporary threats to park integrity and preservation of resources. Uses computer technology to study evaluative aspects of program planning and administration. This course examines the history, concepts, theories, and foundations of therapeutic recreation. Conceptual principles for planning interpretive programs and multi-media delivery techniques are discussed. Methods for programming interpretive services, addressing multi-audience accessibility, and administration and evaluation of interpretive services used at recreation and tourism sites are also examined. Examines deterioration and pollution of land and water, noise, crowding, and conflicts among users. Discusses strategies for mitigation of deleterious impacts and depreciative behaviors, and attitudes toward resource conservation, preservation, and use. Includes safety, functionality, durability, and maintenance demand criteria in planning and design; programmatic and operational objectives to be met, including user comfort and convenience, crowd management, and traffic flow, and space relationships. Covers management and leadership theories and techniques, problem-solving and decision making, organizational communications, design of organizational structures and budgeting. George Mason University 2016-2017 Official University Catalog 3535 Prerequisite(s): 60 hours or permission of instructor. Presents concepts associated with leisure, aging, physical challenge, targeting leisure services, research, and public policy. Extends program design by developing competencies in the planning approaches, individual and group assessment techniques, program evaluation, and documentation strategies for people with disabilities and illness. Coordination and administration of special uses and integration with land and resource management plans. Includes agriculture, industry, community, aviation, water, treasure trove, and cultural uses. Right-of-way for oil, gas, and electric transmission, railroads, communication, trams, conveyors, roads, and trails. Primary focus is on the Americans with Disabilities Act and related federal legislation. Covers design and implementation of educational materials and programs to enhance understanding and appreciation of cultural, historical, and natural resources. Examines planning for a spectrum of opportunities, from wilderness to developed sites, with attention to financial consideration and sustainable use of cultural and visual resources.

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A positive test result that strengthened the diagnosis of coronary disease might not change management, unless the abnormal results suggested a greater severity of disease that might warrant another management strategy. If the clinician decided that more information is needed to reduce uncertainty, and if it appears possible that tests might lead to a change in management strategies, the question arises of which test is most appropriate. Several factors influence this decision, including patient preferences, the risk associated with the tests, and the diagnostic performance of the alternative tests. Diagnostic performance of a test is often summarized in terms of sensitivity and specificity, but, as demonstrated in the example in Table 23-2, these parameters depend on which threshold. A low threshold for calling a test abnormal might lead to excellent sensitivity for detecting disease, but at the expense of a false-positive rate. Conversely, a threshold that led to few false-positive results might cause a clinician to miss many cases of true disease. Each point on the curve describes the sensitivity and the false-positive rate for a different Figure 23-2 Interpretation of test results in high- and low-risk patients. The points on the curve reflect the sensitivity and false-positive (1 - specificity) rates of a test at various thresholds. As the threshold is changed to yield greater sensitivity for detecting the outcome of interest, the false-positive rate rises. A test of no value would lead to a curve with the course of the dotted line, whereas a misleading test would be described by a curve that was concave upward (not shown). The choice of threshold depends on the purpose of testing and on the consequences of a false-positive or false-negative diagnosis. For example, if the goal is to screen the population for a disease that is both potentially fatal and potentially curable, a threshold with excellent sensitivity is appropriate even if it leads to frequent false-positive results. In contrast, if a test is used to confirm a diagnosis that is likely to be treated with an invasive procedure, a threshold with high specificity will be preferred. However, if the question was whether to perform coronary angiography in search of severe coronary disease that might benefit from revascularization, a threshold of 2 mm or more would be more appropriate. These choices are usually made after consideration of a variety of factors, including information from the clinical evaluation, patient preferences, and expected outcomes with various management strategies. Insight into the impact of these considerations can be improved through the performance of decision analysis (Table 23-4). The first step in a decision analysis is to define the problem clearly; this step often requires writing out a statement of the issue so it can be scrutinized for any ambiguity. After the problem is defined, the next step is to define the alternative strategies. The four basic alternatives for the initial evaluation are (1) office endometrial biopsy; (2) dilatation and curettage (D & C); (3) hysterectomy; and (4) observation unless bleeding recurred. The expected outcomes for these strategies depend in part on the sensitivity and specificity of the diagnostic procedures (D & C, endometrial biopsy). Assumptions must be made about the next step if the first test was non-diagnostic. Thus, the four basic management strategies actually include at least eight different "game plans" (Table 23-5) (Table Not Available). A wide range of other factors influence the findings of the analysis: the effectiveness and likely compliance with medical therapy for complex hyperplasia, the risk that complex hyperplasia would progress to endometrial cancer, and the expected outcomes with surgery or radiation therapy for endometrial cancer. These outcomes usually differ for patients of different ages and with different underlying risks for the outcomes of interest-in this case, cancer and complex hyperplasia. Optimal strategies are unlikely to be the same for an elderly patient with a short life expectancy and low risk of cancer as for a younger patient with a long life expectancy and a high risk of cancer. The credibility of the decision analysis depends on the credibility of these estimates. Unfortunately, published reports often do not provide information on the outcomes of interest for specific patient subsets. Furthermore, randomized trial data are relevant to the populations included in the trial; hence, the extension of the findings to other genders, races, and age groups requires assumptions by those performing the analysis. For many issues, expert opinion must be used to derive a reasonable estimate of the outcome.

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A full reading of the Honor Code and the associated system can be found at our website, oai. Please note there is a separate process for individuals accused of research misconduct. Allegations of academic misconduct against undergraduate students are governed solely by the university honor code, except for sponsored research activities which are governed by this policy. Honor Committee the Honor Committee is selected to promote academic integrity as a core value for our university community. Members of the committee also serve on hearing panels established to investigate and resolve alleged violations of the code. George Mason University 2016-2017 Official University Catalog 194 A chair and vice chair will be elected in April of each year by the members of the committee. The Office provides administrative oversight for the Honor Committee and the integrity process at Mason. Student Responsibilities Students are responsible for ensuring the work they are submitting is their own work. This includes checking to make sure that any information that was not their own creation is properly attributed to the original source, as well as working within the guidelines provided by the professor of the class regarding submitted work. Facilitating misconduct in the form of providing unauthorized resources, tests, or solutions for others is a violation of the honor code and will be dealt with as such. Students have an obligation to encourage respect among their fellow students for the provisions of the code. This includes an obligation to report violations by other students to the Honor Committee. Faculty Responsibilities At the beginning of each semester, faculty members have the responsibility of explaining to their classes their policy regarding the Honor code. They must also explain the extent to which aid, if any, is permitted in academic work. Additional language should include what constitutes acceptable behavior for the course they are teaching. Procedures for Reporting Violations and Record Keeping All suspected violations must be reported to the Office of Academic Integrity in a timely manner. The student will be notified in writing that an accusation has been made and meet with a staff member in the office to review the case materials and decide the next course of action. Findings of responsibility in Honor Code cases are maintained by the Office of Academic Integrity in accordance with the Library of Virginia Records Management schedule. George Mason University 2016-2017 Official University Catalog 195 Living Learning Communities Housing and Residence Life Phone: 703-993-2720 Fax: 703-993-2744 Email: housing@gmu. Our goal is to help these students in a number of capacities including counseling and advising on benefits, academic and admissions advising, and career transition. Few schools have a dedicated staff to help transition from a military environment to college life and we are proud to be able to assist our students in any way. Located within the Office of Admissions, the Office of Military Services understands personally that the transition to student life can be challenging, yet rewarding. Along with the entire university community, we are grateful to you and your family members for your service to our country. We are dedicated to providing the services you need to successfully navigate this transition. If you would like to schedule a time to meet with a Transition Coordinator, please email military@gmu. George Mason University 2016-2017 Official University Catalog 197 Learning Solutions Return to: General Information Arlington Campus Founders Hall, Suite 448 Phone: 703-993-2109 Web: ls. George Mason University 2016-2017 Official University Catalog 198 Office of the Ombudsman Return to: General Information Phone: 703-993-3306 Email: jcaetano@gmu. When appropriate, the Ombudsman may recommend changes in processes and policies at the university. Meetings with the Ombudsman are confidential, except when there is imminent risk of serious physical harm to anyone. The Office of the Ombudsman does not serve as an office of notice or record for the University.

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Carey, 2009: Preliminary development and evaluation of lightning jump algorithms for the real-time detection of severe weather. Ali-Mehenni, 2000: the rain profiling algorithm applied to polarimetric weather radar. Short, 1996: Evidence from tropical raindrop spectra of the origin of rain from stratiform versus convective clouds. Perreira, 2002: Measurements of drop size distribution in southwestern Amazon region. Vandenberghe, 2003: A multichannel radiometric profiler of temperature, humidity, and cloud liquid. Vecchi North Atlantic tropical cyclones are responsible for major flooding over large areas of the continental United States. At each stream gage station, we then compute the 10-yr flood peak, which represents the flood peak that is expected to occur, on average, once every 10 years and corresponds to the 90th percentile of the flood peak distribution. The 10-yr flood peaks are computed only over the past 31 years to mitigate potential effects due to anthropogenic modifications of these catchments. The whiskers represent the 10th and the 90th percentiles, the limits of the boxes the 25th and 75th percentiles, and the horizontal line and square inside the boxes the median and mean, respectively. Recently, Rowe and Villarini (2013) used this approach to characterize flooding associated with six predecessor rain events over the central United States. Keeping in mind the variability within each category, these results are helpful in interpreting the values of the. Flood ratio maps for (a) Hurricane Floyd (1999), (b) Hurricane Irene (2011), (c) Hurricane Katrina (2005), and (d) Hurricane Ike (2008). The darker shades of green represent the 500-km buffer around the center of circulation. For each of these storms, we have created flood ratio maps by interpolating the values among the different stream gage stations using the inverse distance weighting method. Figure 2 shows the spatial extent of flooding associated with two hurricanes making landfall along the U. East Coast [Hurricanes Floyd (1999) and Irene (2011)] and two hurricanes making landfall in the Gulf of Mexico [Katrina (2005) and Ike (2008)]. The darker shades of gray represent the extent of the 500-km buffer around the center of circulation for all the storms during the study period. Some of the largest flood ratios over the past 30 years are associated with Hurricane Irene, with flood ratio values larger than 3. Moreover, as is shown by creating the flood ratio maps for the recent Hurricanes Isaac (2012) and Sandy (2012). There are large areas of the study region with flood peak values exceeding the 10-yr flood peaks. Most of the largest flood ratio values are located along the eastern seaboard, from North Carolina to Vermont. The Appalachian Mountains represent a natural divide, shielding the western part of the domain. Other areas with flood ratios larger than 1 are the coastal regions, in particular from coastal Louisiana to Florida. This secondary swath is generally associated with storms making landfall along the Gulf of Mexico and then moving northward over the U. These differences highlight the role of land use/land cover properties and antecedent soil moisture conditions to flooding. This flood ratio values in excess of 1 over most of the study study focused on flooding over the continental United region. This is generally over the central United States, as far north and west as consistent with Elsner (2003), who found that during Illinois, Wisconsin, and Michigan. Because the inland impacts are much larger than previously thought based on rainfall analyses, they indicate that for large areas of the United States awareness about this flood hazard should potentially be increased.

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Lecture will concentrate on how to design experiments with proper controls for statistical analysis, as well as obtaining permits and approvals from appropriate agencies. Students will have the opportunity to propose and carry out a small independent project using zebrafish as a model organism. Topics include intercellular communication (nervous and endocrine), metabolism, water and solute balance, and cardiovascular and respiratory physiology. The course will cover the systematics, anatomy, paleogeography, and ecology of extinct vertebrates. Discussions will include fishes, early tetrapods & amniotes, dinosaurs, birds and mammals. The use and presentation of this information from such investigations in court room proceedings will be discussed. Lectures, field trips, and lab exercises teach physical and chemical aspects of aquatic systems and life cycles, and adaptations of aquatic organisms. Describes general system ecology, ecosystem restoration, and the utilization of natural processes to provide ecosystem services to society and benefits to George Mason University 2016-2017 Official University Catalog 2026 nature. Students will study principles in general system ecology and ecological engineering and explore practices in sustainable ecological design by carrying out a hands-on experimental design project with field microcosms/meocosms in a newly established Wetland Mesocosm Compound on the campus. Includes food production, spoilage and preservation, fermentation technology, waste disposal, water purification, biodeterioration, and decomposition. Nutrition, growth, transport, and anabolic and catabolic processes are emphasized. Laboratory includes quantification of cellular macromolecules, enzyme purification and kinetics, column chromatography, and bacterial responses to environmental stimuli. Stresses evolution of microbial species, biochemical cycling, and species interactions. Laboratory stresses use of cultural, biochemical, and phylogenetic methods to study microbial isolation, metabolism, and identification. Both monogenic and complex human genetic diseases, as well as principles of genetic screening and counseling, will be presented. The functional roles stem cells play in regulating normal development and contributing to disease-state pathologies. An examination of the therapeutic potential of stem cells through "regenerative medicine. The relative contributions of genetic and environmental factors influencing weight gain will be covered as well as recent trends in obesity research. Detailed discussion of anatomical structures and their functions of the endocrine, nervous, muscular, skeletal, and integumentary systems following introduction to the cellular and tissue levels of organization. Topics also include selected pathology for each organ system; current therapeutic interventions are addressed. Detailed discussion of George Mason University 2016-2017 Official University Catalog 2034 anatomical structures and their functions of the cardiovascular, lymphatic, respiratory, urinary, digestive and reproductive organ systems. Topics also include selected disorders for each organ system to illustrate disruption of homeostasis. Topics vary but include design of field manipulations, data collection and analysis, and introduction to organisms of study site. The course emphasizes evolution, taxonomic diversity, and plant-animal interactions in terrestrial tropic forests. This course focuses on methods for testing hypotheses related to tropical plant and animal biology. Responses to temperature, salinity, low oxygen levels and diet will be covered from a phylogenetic and energetic perspective. The course also provides an overview of marine environmental law and policy issues related to marine conservation policy. Marine mammal conservation and policy is also a major component of the course; several, lecture sessions are devoted to the issue of whaling, threats to marine mammal populations, and recent conservation issues such as marine mammals and noise pollution. Covers topics from the evolution of sex and gender to the evolution of complex reproductive strategies involving behaviors such as mate recognition, courtship displays, territoriality, polygamy, and offspring care. Lectures focus primarily on multi-cellular animals but also include discussions of unicellular prokaryotes and eukaryotes as well as plants.

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Uniform licensure standards and reciprocity compacts could operate both to protect consumers and to reduce barriers to telemedicine. Similar considerations apply to the potential for licensure to restrict competition from out-ofstate providers who wish to move in-state. Recommendation 3: Governments should reexamine the role of subsidies in health care markets in light of their inefficiencies and potential to distort competition. Competitive markets compete away the higher prices and supra-competitive profits necessary to sustain such subsidies. Such competition holds both the promise of consumer benefits and the threat of 23 undermining an implicit policy of subsidizing certain consumers and types of care. Competition cannot provide resources to those who lack them; it does not work well when certain facilities are expected to use higher profits in certain areas to cross-subsidize uncompensated care. In general, it is more efficient to provide subsidies directly to those who should receive them, rather than to obscure cross subsidies and indirect subsidies in transactions that are not transparent. Recommendation 4: Governments should not enact legislation to permit independent physicians to bargain collectively. Physician collective bargaining will harm consumers financially and is unlikely to result in quality improvements. There are numerous ways in which independent physicians can work together to improve quality without violating the antitrust laws. Recommendation 5: States should consider the potential costs and benefits of regulating pharmacy benefit manager transparency. When deciding whether to mandate particular benefits, governments should consider that such mandates are likely to reduce competition, restrict consumer choice, raise the cost of health insurance, and increase the number of uninsured Americans. Proponents argue that mandates can correct insurance market failures, and that the required inclusion of some benefits in all health insurance plans can be welfare enhancing. Opponents argue that the case for many mandates is anecdotal, and that mandates raise premium costs, leading employers to opt out of providing health insurance and insured individuals to drop their coverage. Opponents also note that providers of the mandated benefit are usually the most vigorous proponents of such legislation, making it more likely that the mandated benefits may constitute "provider protection" and not "consumer protection. For mandates to improve the efficiency of the health insurance market, state and federal legislators must be able to identify services the insurance market is not currently covering for which consumers are willing to pay the marginal costs. In practice, mandates are likely to limit consumer choice, eliminate product diversity, raise the cost of health insurance, and increase the number of uninsured Americans. Perspective on Physician-Related Issues Physician Joint Ventures and Multiprovider Networks. Attempts to achieve clinical integration were discussed at length at the Hearings. Panelists described a wide variety of factors as possibly relevant to evaluating clinical integration. Panelists and commentators asked the Agencies to define the criteria that the Agencies will consider sufficient to demonstrate that a particular venture is clinically integrated. The Agencies do not suggest particular structures with which to achieve clinical integration that justifies a rule of reason analysis of joint pricing, because of the risk that it would channel market behavior, instead of encouraging market participants to develop structures responsive to their particular goals and the market conditions they face. As an aid to analysis, Chapter 2 of the Report includes a broad outline of some of the kinds of questions that the Agencies are likely to ask when analyzing whether a physician network joint venture is clinically integrated. The Agencies will continue carefully to evaluate proposed hospital mergers and to challenge those with likely anticompetitive effects. In most cases, the Agencies have analyzed hospital product markets as a broad group of acute, inpatient medical conditions where the patient must remain in a health care facility for at least 24 hours for treatment, recovery or observation. The Agencies continue to examine whether smaller markets exist within the traditional cluster product market definition or other product market adjustments might be warranted, and encourage research on these matters. The Agencies encourage research on whether services provided in outpatient settings may constitute additional relevant product markets, and if so, whether those services might be adversely affected by a hospital merger. The Agencies encourage additional research to validate or refute the analytical techniques for defining product markets suggested by various commentators and panelists. In connection with this Report, the Agencies undertook a substantial analysis of how best to determine the contours of the relevant geographic market in which hospitals operate, consistent with the process described in the 1992 Horizontal Merger Guidelines (Merger Guidelines).

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It frees regulators from restrictions imposed by legislatures, and reduces opportunities for challenges to their behavior in the courts. This phenomenon should worry any lawyer engaged in regulatory practice and concerned with limited government. Regulation Regulation occurs when agencies (or private actors) compel firms and individuals to change their future behavior by threatening them with sanctions for non-compliance. It is thus forward-looking, rather than a backward-looking attempt to obtain compensation for a past harm or punishment for past actions. But the incentive effects of damage awards or fines differ from the impact of substantive restrictions on future behavior in three ways. First, regulations cover many firms and individuals who may not be parties to the controversy that inspired the regulations; damage awards and fines are awarded against individual firms or persons. Third, a fine or damage award can be imposed only when there is a recognized duty and breach; a regulation can be imposed governing behavior that was previously seen as legal. When governments regulate, they displace the mixture of markets and tort and contract law that would otherwise govern the relationships between private individuals. In particular, unregulated outcomes are more heterogeneous than regulated ones, as local knowledge and diverse individual preferences will lead different individuals and firms to different solutions to the same problem. At least in theory, regulation occurs because those private law institutions have failed for one reason or another. A key reason is that there is no a priori assurance that regulatory solutions will be welfare-increasing, an assurance we possess for private transactions. Because contracts are voluntary, for example, we know that they leave the parties to the contract at least as well off as not entering into the contract would have. For example, we frequently observe regulators behaving in ways that advance the interests of organized interest groups at the expense of the general public. Madison also offered a solution to the ills of factions: he insisted that our governing institutions make it difficult for political actors to serve the interests of factions at the expense of the nation as a whole. Ross & Helen Workman Professor of Law and Business at the University of Illinois and Senior Associate at the Mercatus Center at George Mason University. Bruce Yandle is Alumni Distinguished Professor of Economics Emeritus at Clemson University and a Senior Scholar at the Mercatus Center. Andrew Dorchak is Head of Reference and Foreign & International Specialist at Case Western Reserve University School of Law. February 2008 109 If a faction consists of less than a majority, relief is supplied by the republican principle, which enables the majority to defeat its sinister views by regular vote. It may clog the administration, it may convulse the society; but it will be unable to execute and mask its violence under the forms of the Constitution. When a majority is included in a faction, the form of popular government, on the other hand, enables it to sacrifice to its ruling passion or interest both the public good and the rights of other citizens. To secure the public good and private rights against the danger of such a faction, and at the same time to preserve the spirit and the form of popular government, is then the great object to which our inquiries are directed. The Benefits and Costs of Regulation by Litigation There are no public benefits to imposing regulation through litigation. Any regulatory measures achieved in a settlement could be obtained through conventional rulemaking or legislation. Which regulator will have to act may be different, but the outcome could be achieved without litigation. For example, the tobacco Master Settlement Agreement effectively imposed a tax on future sales of cigarettes in all fifty states through settlement of litigation between the major U. The state legislatures could have passed tax increases, as could Congress, which would have had the same effect, but the attorneys general and private lawyers could not have. No state attorney general, and no private attorney, has the authority under any state constitution to tax tobacco (or anything else). The key to the attractiveness of regulation by litigation is exactly this-that it enables regulators to assume powers that they otherwise lack. It should be seen as a negative, not a positive, attribute of regulation by litigation that it enables government and private actors to evade constitutional restraints on their powers. Further, regulations imposed by litigation are less comprehensive than regulations imposed by rulemaking.

References:

  • https://www.prismsports.org/UserFiles/file/KOS-ADL-PDFandScoring.pdf
  • https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/palliative-care-tools_technical-brief-2017.pdf
  • http://www.survivorlibrary.com/library/merck_manual_1901.pdf
  • https://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf