Small surgeries, huge markups

A Southern California surgery center charged teacher Lynne Nielsen $87,500 for a routine, 20-minute knee operation that normally costs about $3,000.

Despite the huge markup, the Long Beach Unified School District and its insurer, Blue Shield of California, paid virtually all of the bill from Advanced Surgical Partners in Costa Mesa. Blue Shield mailed the $84,800 check to the high school Spanish teacher last month and told her to sign it over to the surgery center.

Nielsen said she was outraged and refused to send the check. Instead, she asked the California attorney general's office to investigate the matter. "This is insane," she said.

The 61-year-old is the latest patient caught up in a growing battle nationwide over billing by outpatient surgery centers. Industry experts say some of these surgery centers seek out well-insured patients such as Nielsen, sometimes by waiving their copays and deductibles, and then bill their insurers exorbitant amounts for out-of-network care.

All too often, critics say, insurers pay these large sums and then cite high medical bills for why insurance premiums keep rising for businesses and consumers.

"This bill is so outrageous it almost takes my breath away," said Gerald Kominski, director of the UCLA Center for Health Policy Research. "This is an example of what's wrong with our healthcare system, and employees and taxpayers of the school district are paying the price here."

In response to questions from The Times, Blue Shield defended its $84,800 payment as proper. Advanced Surgical Partners, through its lawyer, said the bill was excessive. Amid the scrutiny, the two sides agreed to a lower amount this week.

Nationwide, some insurers have begun to challenge these bills from outpatient centers. Last year, a unit of insurance giant Aetna Inc. sued several surgery centers in Northern California and accused them of overbilling the insurer more than $20 million. It has pursued similar actions against providers in New Jersey and Texas. Other insurers such as UnitedHealth Group Inc. have filed similar suits in California.

In one instance, Aetna said, a California surgery center charged $73,536 for a kidney stone procedure when the average in-network charge was $7,612. Aetna said it paid some of these bills before disputing them in court.

Doctors and surgery centers say the criticism is unjustified. Surgery centers say they have helped reduce healthcare costs by offering convenient care at a fraction of what hospitals charge for colonoscopies, cataract surgeries and other outpatient procedures. These facilities now handle up to 40% of all outpatient surgeries, according to the Ambulatory Surgery Center Assn.

Nielsen went to Advanced Surgical Partners in November at the recommendation of her surgeon even though it was out of her insurance network. She checked beforehand with the facility and it assured her they would accept whatever Blue Shield offered to pay.

The surgery center's $87,500 bill was just for use of its facility and supplies. Nielsen's orthopedic surgeon and anesthesiologist billed separately and were paid about $1,200 combined.

Henry Fenton, an attorney for the surgery center, said this bill "was excessive and not correct. I'm sure they will be more careful in the future."

Blue Shield said its typical rate for this arthroscopic knee procedure in Southern California is about $3,000 among in-network providers.

"This surgery center is charging 30 times the average by remaining out of network to advance this outrageous and anti-consumer practice," said Blue Shield spokesman Steve Shivinsky. "This is a national problem."

Yet the company said it was obligated to pay nearly all of Advanced Surgical's bill because it is bound by the health plan rules set by the teacher's employer, the Long Beach school district. The school system is self-insured, meaning it pays its own medical bills and uses Blue Shield to administer its benefits and process claims.

In other situations involving out-of-network care, it's common for insurers to pay only about 60% of what's deemed to be "usual and customary" charges or some percentage of Medicare rates. Insurers and out-of-network medical providers routinely spar over what constitutes a reasonable amount.

Kominski, the UCLA professor, said he faulted both Blue Shield and the school district for "dropping the ball on this. There were lots of opportunities for red flags to go off on such an outlandish bill."

After defending its handling of the claim, Blue Shield reversed course this week and stopped payment on its $84,800 check. It told Nielsen that the surgery center had agreed to accept $15,000 instead.

"We are very pleased that Advanced Surgical Partners agreed to accept a more competitive rate," Shivinsky said.

Overall, Blue Shield said, it expects to have new measures in place by next month to better address these out-of-network billing issues for certain employer health plans. It also said employers should do more to encourage workers to use in-network facilities that are paid negotiated rates.

The Long Beach school district expressed frustration at the teacher's bill, but it echoed Blue Shield's explanation that it will incur additional costs at times because it has promised employees out-of-network benefits.

"This out-of-network issue regarding surgery centers is one that we want to explore with our employee groups in the next bargaining cycle," said Chris Eftychiou, a district spokesman.

Joe Boyd, executive director of the Teachers Assn. of Long Beach, said there is nothing in the employee contract to prevent the school district and Blue Shield from rejecting inflated medical bills.

"That's absurd. It isn't a requirement of the contract to pay fees that are five or 10 times what's customary," Boyd said. "We don't want the school district or our members ripped off."

Nielsen said she remains angry that Blue Shield declined to do anything when she first complained about the situation in December. She plans to continue pursuing the matter with the attorney general's office, which records show has begun an inquiry.

"Our insurance premiums wouldn't keep increasing," she said, "if they paid a fair amount for these procedures."

chad.terhune@latimes.com

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South Korea successfully launches satellite into orbit

SEOUL -- In danger of falling behind in the space race on the Korean peninsula, the South Korean government announced Wednesday that it had successfully launched a rocket into space.

Pressure had been mounting ever since mid-December when communist arch-rival North Korea managed to launch a multi-stage rocket and put a satellite into orbit.

South Korea's Satellite Launch Vehicle-1, also known as Naro, blasted off at 4 p.m. local time from a space center in Jeolla province on the southwestern coast.

"Five hundred forty seconds after the launch, Naro successfully separated the satellite," South Korean Science and Technology Minister Lee Joo-ho said at a news briefing Wednesday. "After analyzing various data, we have confirmed that [the satellite] has been successfully put into orbit." 

Officials said the launch made South Korea the 13th country to get a satellite into orbit from its own territory. Iran on Monday announced that it had launched a monkey into space using its own technology.

The sky was clear and the weather had warmed up on Wednesday afternoon at the space center, where about 3,000 people gathered to observe the latest attempt to launch Naro. The crowd excitedly cheered and waved national flags during the countdown.

Two attempts to launch a space vehicle, in 2009 and 2010, ended in failures. The third attempt was to take place in October but was delayed due to a damaged rubber seal that caused a fuel leak. The next try came in November, but it was canceled 17 minutes before the rocket set to be launched due to a technical glitch.

The failures looked all the more embarrassing after the successful Dec. 12 launch of the Unha-3 rocket by North Korea, which has an economy less than one-twentieth the size of South Korea's. What North Koreans have dubbed a "peaceful satellite launch" was a part of the legacy of North Korean leader Kim Jong Il, who died in December 2011.

The international community condemned North Korea as its rocket launch was suspected to be a cover for a test of ballistic missile technology.

Lee Sang-ryul, a South Korean scientist with the Korea Aerospace Research Institute, said the launches seven weeks apart were not comparable because the South Korean objective was purely scientific.

"The exterior of Unha-3 and Naro seems to be very much alike. It is about the same weight, the shapes are similar, and the fact that it puts a satellite in the orbit is the same. However, I believe North Korea's purpose is not to develop a satellite launch vehicle but a weapons development," South Korean television quoted Lee as saying Wednesday.

North Korea said earlier this month it would also conduct a nuclear test and that "the various satellites and long-range rockets that we will fire ... are targeted at the United States, the archenemy of the Korean people."

Independent scientists say the North Korean satellite was not a complete success because its transmitter failed during the launch, but that it achieved a reasonably accurate orbit.

"Most countries when they launch their first satellite don't get too close," Jonathan McDowell of the Harvard-Smithsonian Center for Astrophysics said in a recent interview.

He added that South Koreans shouldn't feel that North Korea has beaten them.

"It is difficult, but it is basically high-tech plumbing," McDowell said. "It is not as sophisticated as creating the industrial base to make a Samsung monitor."

South Korea's Naro program began in 2002 with the help of Russian technology. Before Wednesday's launch, the country had sent about 10 satellites into space, but they were all launched from foreign rockets overseas.

ALSO:

Egyptian general warns against continued unrest

Dozens of corpses found along river in Aleppo, Syria

Controversial Spanish doctor testifies in huge sports doping trial

-- Barbara Demick reported from Beijing.

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Yandex puts mobile app blocked by Facebook on hold

MOSCOW (Reuters) – Russian internet company Yandex has put an experimental application that allows users to search social networking sites from mobile devices on hold after it was blocked by Facebook.

Facebook, which launched its own search tool earlier this month, blocked the Wonder app three hours after its launch on January 24 for U.S. users.

The application allows users to look for recommendations on, for example, music or restaurants based on information from their friends on social network sites.

Facebook believes Wonder violates its policies, which state that no data obtained from Facebook can be used in any search engine without the company’s written permission, Yandex said on Wednesday, adding access to Facebook would not be restored.

“Since this access was revoked, we decided to put our application on hold for the time being,” the Russian firm said, adding it would consider partnership with other social networks and services.

Existing Wonder users are still able to search in Instagram, Foursquare and Twitter, a Yandex spokeswoman said, but marketing and further development of the application is on hold.

(Reporting by Maria Kiselyova; Editing by Mark Potter)

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Roseanne Barr to guest star on NBC's 'The Office'

LOS ANGELES (AP) — Roseanne Barr is dropping into NBC's "The Office."

The network said Barr will guest star as a talent agent named Carla Fern in scenes set to tape Wednesday. The agent agrees to help office manager Andy Barnard realize his show business dream. Series regular Ed Helms plays Andy.

Barr is taking a break from her stand-up comedy act in Las Vegas for "The Office" visit. The workplace comedy is in its final season, and producer Greg Daniels has promised a memorable end after nine years.

"The Office," adapted from the British series of the same name, ranks among NBC's most popular shows. Barr knows something about bringing a long-running hit to an end: Her sitcom "Roseanne" aired from 1988 to 1997.

___

Online:

http://www.nbc.com/the-office/

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The New Old Age Blog: For Some Caregivers, the Trauma Lingers

Recently, I spoke at length to a physician who seems to have suffered a form of post-traumatic stress after her mother’s final illness.

There is little research on this topic, which suggests that it is overlooked or discounted. But several experts acknowledge that psychological trauma of this sort does exist.

Barry Jacobs, a clinical psychologist and author of “The Emotional Survival Guide for Caregivers” (The Guilford Press, 2006), often sees caregivers who struggle with intrusive thoughts and memories months and even years after a loved one has died.

“Many people find themselves unable to stop thinking about the suffering they witnessed, which is so powerfully seared into their brains that they cannot push it away,” Dr. Jacobs said.

Flashbacks are a symptom of post-traumatic stress disorder, along with feelings of numbness, anxiety, guilt, dread, depression, irritability, apathy, tension and more. Though one symptom or several do not prove that such a condition exists — that’s up to an expert to determine — these issues are a “very common problem for caregivers,” Dr. Jacobs said.

Dolores Gallagher-Thompson, a professor of psychiatry at the Stanford University School of Medicine who treats many caregivers, said there was little evidence that caregiving on its own caused post-traumatic stress. But if someone is vulnerable for another reason — perhaps a tragedy experienced earlier in life — this kind of response might be activated.

“When something happens that the individual perceives and reacts to as a tremendous stressor, that can intensify and bring back to the forefront of consciousness memories that were traumatic,” Dr. Gallagher-Thompson said. “It’s more an exacerbation of an already existing vulnerability.”

Dr. Judy Stone, the physician who was willing to share her mother’s end-of-life experience and her powerful reaction to it, fits that definition in spades.

Both of Dr. Stone’s Hungarian parents were Holocaust survivors: her mother, Magdus, called Maggie by family and friends, had been sent to Auschwitz; her father, Miki, to Dachau. The two married before World War II, after Maggie left her small village, moved to the city and became a corset maker in Miki’s shop.

Death cast a long shadow over the family. During the war, Maggie’s first baby died of exposure while she was confined for a time to the Debrecen ghetto. After the war, the family moved to the United States, where they worked to recover a sense of normalcy and Miki worked as a maker of orthopedic appliances. Then he died suddenly of a heart attack at the age of 50.

“None of us recovered from that,” said Dr. Stone, who traces her interest in medicine and her lifelong interest in fighting for social justice to her parents and trips she made with her father to visit his clients.

Decades passed, as Dr. Stone operated an infectious disease practice in Cumberland, Md., and raised her own family.

In her old age, Maggie, who her daughter describes as “tough, stubborn, strong,” developed macular degeneration, bad arthritis and emphysema — a result of a smoking habit she started just after the war and never gave up. Still, she lived alone, accepting no help until she reached the age of 92.

Then, in late 2007, respiratory failure set in, causing the old woman to be admitted to the hospital, then rehabilitation, then assisted living, then another hospital. Maggie had made her preferences absolutely clear to her daughter, who had medical power of attorney: doctors were to pursue every intervention needed to keep her alive.

Yet one doctor sent her from a rehabilitation center to the hospital during respiratory crisis with instructions that she was not to be resuscitated — despite her express wishes. Fortunately, the hospital called Dr. Stone and the order was reversed.

“You have to be ever vigilant,” Dr. Stone said when asked what advice she would give to families. “You can’t assume that anything, be it a D.N.R. or allergies or medication orders, have been communicated correctly.”

Other mistakes were made in various settings: There were times that Dr. Stone’s mother had not received necessary oxygen, was without an inhaler she needed for respiratory distress, was denied water or ice chips to moisten her mouth, or received an antibiotic that can cause hallucinations in older people, despite Dr. Stone’s request that this not happen. “People didn’t listen,” she said. “The lack of communication was horrible.”

It was a daily fight to protect her mother and make sure she got what she needed, and “frankly, if I hadn’t been a doctor, I think I would have been thrown out of there,” she said.

In the end, when it became clear that death was inevitable, Maggie finally agreed to be taken off a respirator. But rather than immediately arrange for palliative measures, doctors arranged for a brief trial to see if she could breathe on her own.

“They didn’t give her enough morphine to suppress her agony,” Dr. Stone recalled.

Five years have passed since her mother died, and “I still have nightmares about her being tortured,” the doctor said. “I’ve never been able to overcome the feeling that I failed her — I let her down. It wasn’t her dying that is so upsetting, it was how she died and the unnecessary suffering at the end.”

Dr. Stone had specialized in treating infectious diseases and often saw patients who were critically ill in intensive care. But after her mother died, “I just could not do it,” she said. “I couldn’t see people die. I couldn’t step foot in the I.C.U. for a long, long time.”

Today, she works part time seeing patients with infectious diseases on an as-needed basis in various places — a job she calls “rent a doc” — and blogs for Scientific American about medical ethics. “I tilt at windmills,” she said, describing her current occupations.

Most important to her is trying to change problems in the health system that failed her mother and failed her as well. But Dr. Stone has a sense of despair about that: it is too big an issue, too hard to tackle.

I’m grateful to her for sharing her story so that other caregivers who may have experienced overwhelming emotional reactions that feel like post-traumatic stress realize they are not alone.

It is important to note that both Dr. Jacobs and Dr. Gallagher-Thompson report successfully treating caregivers beset by overwhelming stress. It is hard work and it takes time, but they say recovery is possible. I’ll give a sense of treatment options they and others recommend in another post.

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Makeup artist is a go-to guy for gore

Hunched over half a naked body, Barney Burman uses a hand rake to shave chunks of molten clay from the skull, while a co-worker scrapes air bubbles from a severed hand.

On a separate table, two men are working on the other half, sawing through the foam legs of a victim who has been cut in two for an upcoming episode of the NBC series "Grimm."

Burman, an Oscar-winning, third-generation makeup effects artist, had just a few days to create the severed cadaver, which he personally delivered this week to Portland, Ore., where the supernatural series shoots.

PHOTOS: On Location - Creating cadavers

"We get the best of both words," said Burman, owner of B2FX in North Hollywood. "We get to make monsters and dead people on a weekly basis — it's fantastic."

Thanks to a plethora of crime dramas and supernatural shows such as "Grimm," as well as a continued appetite for physical effects — as opposed to those created on a computer screen — makeup artists like Burman remain very much in demand in Hollywood. They use old-school techniques and materials to fashion monsters from clay, foam, paint and silicone.

Burman has designed and created all manner of dead bodies and creatures for "Grimm," a popular series inspired by classic Grimm's fairy tales that is now in its second season. "Grimm" stars David Giuntoli as a detective, descended from an elite line of criminal profilers, who faces off against various ancient evils and mythic monsters.

Although the drama uses some computer generated effects, it equally relies on Burman and his team to design and create as many as three dead bodies and four creatures per episode.

"He's good, he's fast ... and he makes these creatures look very real," said David Greenwalt, creator and executive producer of "Grimm" with Jim Kouf.

The shelves of Burman's studio are lined with heads of various human-monster hybrids — including a pigman and a wolfman — beside a stack of freshly painted eyeballs, along with an assortment of aliens. The company employs as many as a dozen mostly freelance artists, each of whom has specialties, such as sculpting hands or attaching hair.

PHOTOS: Hollywood Backlot moments

Burman's job is often a race against the clock. First, an actor sits for about an hour, as Burman and his crew create a cast of his head and body. From the cast, the crew sculpts a clay model of the body, which is used to form a mold that is filled with a silicone compound.

"I would like to do this in three weeks," he said of his latest cadaver, a mold of actor Quinn Franzen. "Instead, I have just seven to eight days."

A 46-year-old Los Angeles native, Burman comes from a family of makeup artists. His grandfather Ellis Burman worked with the renowned makeup effects artist Jack Pierce on classic monster films, including 1941's "The Wolf Man" with Lon Chaney.

His father, Tom Burman, joined John Chambers — the makeup effects artist depicted in the Oscar-nominated movie "Argo" — in creating the groundbreaking makeup for "Planet of the Apes."

Burman is self-taught, having learned the business as a child, visiting sets with his father, who often used him to test makeup or try out masks. He once modeled for a small alien in "Close Encounters of the Third Kind."

"I would test things on him. He was always game," recalled Tom Burman. "He had a real propensity for it. I'm really proud of him."

After flirting with a career as an actor, the younger Burman entered the family trade and opened his first studio in 2004, initially operating out of his garage in Van Nuys.

PHOTOS: On Location - Creating cadavers

It was partly a practical decision. Acting jobs were scarce, but Burman could make decent money as a makeup effects artist once his father got him his first job, which allowed him to join the makeup artists union.

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Sheriff's response time is longer in unincorporated areas, audit finds

It took Los Angeles County sheriff's deputies a minute longer to respond to emergency calls from unincorporated parts of the county than from cities that contract with the department for police services, according to a county audit.

The finding comes days after Supervisor Gloria Molina accused Sheriff Lee Baca of "stealing" police resources from residents in unincorporated neighborhoods and threatened to hire "independent private patrol cars" to backfill cuts in sheriff's patrols. She has accused Baca of providing better service to contract cities than to unincorporated areas.

According to the audit, which examined the last fiscal year, it took deputies, on average, 4.8 minutes to respond to emergency calls in contract cities compared with 5.8 minutes in unincorporated areas.

Sheriff's officials said the extra minute was because neighborhoods in unincorporated areas are more spread out and have more difficult road conditions.

The audit also found that Baca provided 91% of promised patrol hours to unincorporated areas, compared with 99% for cities and agencies that buy his services. Sheriff's officials blamed the difference on deep budget cuts imposed by the board that caused the department to leave dozens of deputy positions unfilled.

Adjusted for those cuts, the department was much closer to its goal — averaging 98.5% fulfillment of its pledged patrol hours, according to the audit.

The findings by the county's auditor-controller are expected to add more fuel to the ongoing debate between the sheriff and the board about whether the sheriff is shortchanging county residents who live outside city borders.

Baca and his predecessors have long wrangled with supervisors over funding and patrol resources.

Although the board sets the sheriff's budget, Baca, an elected official, has wide discretion on how to spend it. The Sheriff's Department polices about three-fourths of the county. Along with the unincorporated areas, Baca's deputies patrol more than 40 cities within the county that don't have their own police forces. The patrol obligations for those cities are set in contracts with the department, so county budget cuts are more likely to affect unincorporated areas.

On Tuesday, the board is expected to discuss Molina's idea to empower unincorporated neighborhoods to negotiate police contracts with the Sheriff's Department or some other agency — the same way incorporated cities do.

According to the audit, it costs the sheriff about $552 million to provide police services for contract cities and agencies, but the department gets approximately $371 million back. The auditor-controller suggested pursuing changes in state law or board policy to allow the sheriff to recoup more.

State law prohibits sheriffs from billing contract cities for non-patrol services provided countywide. So the department has provided a broad range of services — such as homicide and narcotics detectives, bomb squads and the county crime lab — at no extra charge.

Sheriff's spokesman Steve Whitmore said those rigid agreements — with contract cities, the county's courts, community colleges and public transit lines — limited where the sheriff could slash in the face of county budget woes.

The board has cut the sheriff's budget — now at $2.8 billion — by $128 million in 2010, $96 million in 2011 and $140 million last year, according to Whitmore.

The sheriff has already reassigned about two dozen gang enforcement deputies to patrol in unincorporated areas and has identified more than 90 other deputies to do the same, Whitmore said.

Molina's spokeswoman declined to suggest other areas where sheriff's officials should slash in light of funding cuts from the board but said that services to unincorporated areas should not be one of them.

"We respectfully request they go back to the drawing board," spokeswoman Roxane Márquez said.

robert.faturechi@latimes.com

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Rupert Sanders' wife files for divorce in LA

LOS ANGELES (AP) — Rupert Sanders' wife has filed for divorce five months after it was revealed the director had a brief affair with actress Kristen Stewart.

Liberty Ross, Sanders' wife of more than nine years, filed for divorce Friday in Los Angeles citing irreconcilable differences.

Ross' filing cites irreconcilable differences for the couple's breakup. They have two children, an 8-year-old daughter and 6-year-old son.

The model-actress is seeking joint custody of the children and spousal support from her estranged husband, who directed Stewart in "Snow White and the Huntsman."

TMZ, which first reported the filing, stated that Sanders also filed divorce paperwork but it was not available on Monday.

Stewart, who has been dating "Twilight" co-star Robert Pattinson, apologized for her fling with Sanders in July after it was revealed by US Weekly.

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Rescuer Appears for New York Downtown Hospital

Manhattan’s only remaining hospital south of 14th Street, New York Downtown, has found a white knight willing to take over its debt and return it to good health, hospital officials said Monday.

NewYork-Presbyterian Hospital, one of New York City’s largest academic medical centers, has proposed to take over New York Downtown in a “certificate of need” filed with the State Health Department. The three-page proposal argues that though New York Downtown is projected to have a significant operating loss in 2013, it is vital to Lower Manhattan, including Wall Street, Chinatown and the Lower East Side, especially since the closing of St. Vincent’s Hospital after it declared bankruptcy in 2010.

The rescue proposal, which would need the Health Department’s approval, comes at a precarious time for hospitals in the city. Long Island College Hospital, just across the river in Cobble Hill, Brooklyn, has been threatened with closing after a failed merger with SUNY Downstate Medical Center, and several other Brooklyn hospitals are considering mergers to stem losses.

New York Downtown has been affiliated with the NewYork-Presbyterian health care system while maintaining separate operations.

“We are looking forward to having them become a sixth campus so the people in that community can continue to have a community hospital that continues to serve them,” Myrna Manners, a spokeswoman for NewYork-Presbyterian, said.

Fred Winters, a spokesman for New York Downtown, declined to comment.

Presbyterian’s proposal emphasized that it would acquire New York Downtown’s debt at no cost to the state, a critical point at a time when the state has shown little interest in bailing out failing hospitals.

The proposal said that if New York Downtown were to close, it would leave more than 300,000 residents of Lower Manhattan, including the financial district, Greenwich Village, SoHo, the Lower East Side and Chinatown, without a community hospital. In addition, it said, 750,000 people work and visit in the area every day, a number that is expected to grow with the construction of 1 World Trade Center and related buildings.

The proposal argues that New York Downtown is essential partly because of its long history of responding to disasters in the city. One of its predecessors was founded as a direct result of the 1920 terrorist bombing outside the J. P. Morgan Building, and the hospital has responded to the 1975 bombing of Fraunces Tavern, the 1993 and 2001 attacks on the World Trade Center, and, this month, the crash of a commuter ferry from New Jersey.

Like other fragile hospitals in the city, New York Downtown has shrunk, going to 180 beds, down from the 254 beds it was certified for in 2006, partly because the more affluent residents of Lower Manhattan often go to bigger hospitals for elective care.

The proposal says that half of the emergency department patients at New York Downtown either are on Medicaid, the program for the poor, or are uninsured.

NewYork-Presbyterian would absorb the cost of the hospital’s maternity and neonatal intensive care units, which have been expanding because of demand, but have been operating at a deficit of more than $1 million a year, the proposal said.

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Automakers in alliance to speed fuel-cell development

Ford Motor Co. is joining with Daimler and Renault-Nissan to speed development of cars that run on hydrogen, with hopes of bringing a vehicle to market in as little as four years.

Hydrogen fuel-cell vehicles generate electricity after a chemical reaction between hydrogen and oxygen. Hydrogen is stored in special high-pressure tanks, and the only emissions are water vapor and heat.

Under the alliance, each company will invest equally in the technology. They plan to develop a common fuel cell system that the companies will use to power their own vehicles. The companies also plan to take advantage of their combined size to reduce costs.

Many automakers have been testing the hydrogen fuel-cell vehicles for years but haven't been able to bring costs down enough to sell the vehicles in mass markets. The zero-emissions cars have the potential to cut pollution and reduce the world's reliance on oil for transportation.

"Working together will significantly help speed this technology to market at a more affordable cost to our customers," Raj Nair, Ford's group vice president for global product development, said in a statement issued Monday. "We will all benefit from this relationship, as the resulting solution will be better than any one company working alone."

The companies said engineering work on the individual fuel cells and the overall hydrogen system will be done jointly by the companies at several locations around the world. They also are studying joint development of other parts for fuel-cell vehicles in an effort to bring down costs.

Work will be done at the site of a previous fuel-cell joint venture between Ford and Daimler in Vancouver, Canada, as well as at a Daimler facility in Nabern, Germany, and a Nissan operation in Oppama, Japan, Ford spokesman Alan Hall said. He was not aware of an executive being appointed to run the joint venture.

The automakers each have several years of experience developing fuel-cell vehicles. Their test vehicles have traveled more than 6.2 million miles.

The alliance among Ford of Dearborn, Mich., Mercedes-Benz maker Daimler of Germany, and the joint operations of France's Renault and Japan's Nissan Motor Co. is another example of global automakers combining forces to develop engines and other new technologies. The companies are trying to share expensive development costs yet keep their products different.

Nissan and Renault have had combined operations for years. Toyota Motor Corp. and BMW said this month that they are working together on next-generation batteries for green vehicles called lithium-air. Their collaboration, first announced in late 2011, also is working on fuel cells, with hopes of completing a vehicle by 2020.

French carmaker PSA Peugeot Citroen and General Motors Co. have a deal to share in purchases of parts and services to cut costs. Toyota has a joint venture with Peugeot Citroen to make small cars in Europe.

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