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Medicare takes into account that private practice clinics pay for their own overhead and therefore provides a higher payment to assist in these costs. The average wholesale costs of medications for the treatment modalities reviewed were obtained from the 2001 Drug Topics Red Book (18) (Table 4).A hypothetical cost model was then constructed for each of the five treatment modalities by combining the average number of estimated treatments required to achieve wart clearance, physician costs, and medication costs (Table 5). Utilizing this cost model based on the Arkansas Medicare non-facility fee schedule, the CPT codes were added to the cost of medication to determine the final cost for the treatment of a patient with a moderate wart burden as previously defined.

We believe that the issues surrounding finder''s fees and other recruitment incentives merit more careful scrutiny. The payment of finder''s fees for subject recruitment can be seen as a paradigmatic example of other problematic phenomena in an increasingly commercial research environment. When situated within this context, it becomes clear that the actual and potential impact of finder''s fees is more significant than has been presumed. The problems resulting from finder''s fees are part of the wider encroachment of commercial interests on research, the provision of health-care services, and the priorities of researchers and health-care professionals. These issues ought to receive more attention from regulatory and funding agencies, professional organizations, academic institutions, institutional review boards ORBs)--known in Canada as research ethics boards (REBs)--and researchers. Representatives of each of these interests have an important role to play in addressing the tensions generated by financial interests in research.

Similar approaches, although limited in number, have been applied to nursing homes. Several clinical trials of QI have not been encouraging (Schnelle et al. 1998; McKenna, Moyers, and Feurberg 1998). Additionally, Zinn et al. (1997) found no association between QI adoption as determined from a survey of nursing home administrators, and two outcome measures: percent of residents with pressure ulcers and percent with contractures. However, these outcome measures were limited in that prevalence (as opposed to incidence) of these conditions may be more influenced by admission patterns than by care actually provided in the nursing home, and the measures were not risk-adjusted. We address this issue in testing the hypothesis: [H.sub.5]: Quality improvement implementation in nursing homes is associated with better risk-adjusted patient outcomes.

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