From 2004, Vol. 4, No. 8: At the University of Florida, they report that their lab is extremely cost conscious and has focused on efficiency and utilization while continuing to provide high quality care for all patients. They write that they are also very aggressive with vendor negotiations and inventory management to help reduce costs. From 2004, Vol. 4, No. 7: At Lenox Hill Hospital in New York, they try to deliver excellent quality of care to patients and feel that patient care should never be compromised. However, this has become more and more difficult given the pressures placed on the hospital, physicians and nursing staff by managed care. Maintaining a high level of quality in the current managed care environment has required working much harder with fewer resources. From 2004, Vol. 4, No. 6: At Porter Adventist Hospital in Littleton, Colorado, managed care has affected where a patient can be admitted or have outpatient procedures performed. This has limited access to electrophysiologists in their community because the patient frequently will require a referral from a primary care physician that may not be aware of the procedures an electrophysiologist can perform. This limitation obviously can and does affect patient volume. However, the level of care provided once the patient enters the electrophysiology realm does not seem to be affected by managed care. From 2004, Vol. 4, No. 5: At St. Peter's Hospital in Albany, New York, they are doing more outpatient procedures, and the physician groups work closely with the health insurance companies to keep them informed and educate them in all areas of electrophysiology. From 2004, Vol. 4, No. 4: At Medical City Heart, Dallas, Texas, they are doing more outpatient procedures, and the physician groups work closely with the health insurance companies to keep them informed and educate them in all areas of electrophysiology. From 2004, Vol. 4, No. 3: At Tufts-New England Medical Center, Cardiac Arrhythmia Center, Boston, Massachusetts, managed care has had a small impact on their lab. From 2003, Vol. 3, No. 9: Emory Crawford Long Hospital in Atlanta, Georgia (in conjunction with Emory University Hospital) negotiates managed care contracts on their behalf. Patients in managed care plans require pre-certification prior to their procedure to ensure payment, and this has increased their office staff responsibilities. Beyond this, however, it is rare that a patient cannot receive care in the lab. From 2003, Vol. 3, No. 8: At St. John Hospital and Medical Center, Detroit, Michigan, they encounter occasional patients who are not permitted to have their procedures done at the facility for insurance purposes, although they make every effort to accommodate as many of these patients as possible. From 2003, Vol. 3, No. 7: At the UCLA Cardiac Arrhythmia Center in Los Angeles, they serve an area that has extensive managed care presence. However, this trend is on the decline in Southern California, and they anticipate that this will not adversely affect care in the future. From 2003, Vol. 3, No. 6: At the University of Massachusetts Medical Center in Worcester, they note that Massachusetts is tightly governed by manage care contracts. Occasionally, certain procedures such as tilt table testing can present a difficult challenge in getting insurance carriers to reimburse these tests. Their greatest challenge remains the need for more resources, i.e. EP lab space, staff and equipment. With expanding indications for ICDs and catheter ablation, there are instances where patients can wait four to six weeks for elective procedures. They are constantly faced with the challenge of meeting the clinical needs of our patients while maintaining our own commitments toward academic pursuits. From 2003, Vol. 3, No. 5: At the University of Iowa Hospitals in Iowa City, Iowa, changes in insurance/hospital affiliation have had a significant impact on their referrals. In fact, many of these issues are out of their hands. From 2003, Vol. 3, No. 4: At the University of California - San Diego in California, managed care has not impacted their patient volume, only the reimbursement received from each case. In fact, they have had to make a concerted effort to renegotiate their contracts recently, especially to increase reimbursement for devices, since their case load and charges in this area has grown dramatically. From 2003, Vol. 3, No. 3: At the University of Rochester Medical Center at Strong Memorial Hospital in New York, their community has an aggressive managed care organization and their market is such that they compete with other hospitals. They receive many referrals from other geographic regions for EP procedures. From 2003, Vol. 3, No. 2: At Advocate Illinois Masonic Medical Center in Chicago, Illinois, there is a greater emphasis on getting patients scheduled and treated in a timely manner. Sometimes, if a patient s arrhythmia is tolerated well, they may opt to come back as an outpatient to be treated rather than stay if it means waiting a day. From 2003, Vol. 3, No. 1: At the Carle Heart Center in Urbana, Illinois, managed care directs the flow of patients to different centers, but does not affect how they provide care to their patients. From 2002, Vol. 2, No. 6: At Mercy Heart Institute in Sacramento, California, they have not changed their commitment to excellence despite the penetration of managed care and changes in revenue. Their EP Program located at Mercy General Hospital continues to be one of the largest in the country, listed in the top 5% for volume. They continue to bring new technology and quality regardless of diminishing reimbursement. From 2002, Vol. 2, No. 5: At Einstein Heart Institute in Philadelphia, Pennsylvania, managed care has not affected the care of their patients, but instead has resulted in their becoming a more efficient lab. From 2002, Vol. 2, No. 4: At the Georgia Heart Center in Macon, Georgia, they write that managed care has not had an impact on their program. From 2002, Vol. 2, No. 3: At Riverside Methodist Hospital in Columbus, Ohio, most of the changes they reported were related to the recent cuts in reimbursement. There has been increased pressure to contain the costs in the lab. From 2002, Vol. 2, No. 2: At Saint Vincent Heart Center in Erie, Pennsylvania, managed care has provided them with the challenge of providing a higher degree of care to their patients while at the same time reducing costs. In their area, they have been able to improve care, increase volumes and offer new services, despite changes in the reimbursement arena. From 2001, Vol. 1, No. 2: At Walter Reed Army Medical Center in Washington D.C., because of managed care, all health care institutions have changed the way they purchase supplies and manage inventory. At WRAMC, they have managed to do this through innovative contracts with suppliers with no deleterious effect on patient outcomes. From 2001, Vol. 1, No. 1: At Morristown Memorial Hospital in Morristown, New Jersey, managed care has required that procedures be performed more promptly than ever, with extreme attention to maintain costs, but with no compromise in patient outcomes and safety. The laboratory has consistently contained costs by using only the necessary equipment, well thought out in advance, to perform procedures safely, minimizing waste. Furthermore, high-ticket items such as implantable devices are selected based upon patient need (i.e., single versus dual chamber devices) and not on a routine basis. Device manufacturers must remain competitive with respect to pricing.