E THNICITY, race, religion, and socioeconomic status (SES) impact therapists' and family members' beliefs and behaviors regarding illness and health. Working with low-income African American youth in whom sickle cell disease (SCD) has been diagnosed, our work is influenced by our sociodemographic backgrounds that differentiate us from the families with whom we work.1 In devising, implementing, and evaluating a family intervention for pediatric SCD

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Prompted by the growth of managed care and the American Psychological Association's recent guidelines for treatment efficacy studies, we have struggled with the challenges associated with devising and implementing manualized family intervention programs for pediatric patients. This manuscript outlines the strengths and challenges of controlled manual-based family interventions for medically ill children, using pediatric sickle cell disease (SCD) as an example. A culturally and developmentally sensitive intervention program, designed for the researcher's subject population (African American, low SES, inner city) is discussed. Possible solutions to the challenges of conducting family-oriented intervention efficacy studies with pediatric populations are presented.

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Rapid health care consolidation has led to rising health care prices, diminished access to care, and reduced incentives for quality improvement. States have a variety of tools to address these adverse consequences of the loss of health care competition, ranging from state antitrust enforcement to global budgets or provider rate-regulation. One of the tools is a “certificate of public advantage” (COPA) or cooperative agreement under which the state approves a health care merger and shields it from antitrust enforcement in exchange for state oversight and supervision of the merged entities’ conduct. COPAs are controversial. The Federal Trade Commission and economists vehemently oppose COPAs, citing evidence that health care consolidation leads to higher prices and does not yield efficiencies, savings, or improved quality. The risks of COPAs are that they create, in essence, a state-sanctioned monopoly that could significantly raise prices, reduce consumer choice and access, and disinvest in essential services that may be less profitable but are critical for population health. Nevertheless, particularly in rural areas, health care providers seek to consolidate to weather mounting financial challenges. In response, states are exploring COPAs as a tool to exercise oversight over the merging parties’ health care prices, secure commitments for investments in population health, promote beneficial health care integration, and maintain access to rural health care providers. This report, published by the Milbank Memorial Fund, describes the twin COPAs approved by Tennessee and Virginia in 2017 to allow health systems, Wellmont Health System and Mountain States Health Alliance, to merge to form Ballad Health System, a combined entity that holds a near-monopoly in southwest Virginia and northeast Tennessee. This case study highlights the unique features of the Ballad Health COPA, involving two states’ COPA laws, and describes the legal authority, factors and commitments secured for approval, and the states’ resources and coordination for ongoing supervision. It remains to be seen whether the states can implement the COPAs with sufficient rigor and oversight to ensure the benefits of COPAs outweigh their risks. COPAs are a risky policy solution because they permit health care mergers that would not pass antitrust scrutiny and may result in untenable price increases and other adverse effects. On the other hand, COPAs may offer potential benefits in terms of population health and access particularly for struggling rural communities. Stringent, well-resourced, and long-term state oversight is key to avoiding the risks of monopoly and enforcing the commitments to population health and cost control. Whether states can prevent the adverse outcomes and reap the potential benefits under a COPA remains an open question, but Tennessee and Virginia are poised to try.Suggested citation: ERIN C. FUSE BROWN, MILBANK MEMORIAL FUND, HOSPITAL MERGERS AND PUBLIC ACCOUNTABILITY: TENNESSEE AND VIRGINIA EMPLOY A CERTIFICATE OF PUBLIC ADVANTAGE (2018), https://www.milbank.org/publications/hospital-mergers-and-public-accountability-tennessee-and-virginia-employ-a-certificate-of-public-advantage/.