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PubMed1984

The impact of prospective payment: a multi-dimensional analysis of New Jersey's SHARE program.

The SHARE program, which set per diem prospective rates for New Jersey hospitals during the period 1975-1982, is evaluated. Analysis suggests that this program did contain hospital cost increase. However, the program threatened the viability of most inner-city hospitals. Indirect evidence suggests that there was cost-shifting in response to this program, which regulated payment for only Blue Cross and Medicaid patients. Structural features of this program and its successor, the New Jersey DRG program, are analyzed; and implications for the Medicare prospective payment system are examined.

Cost Allocation↗
PubMed1984

Cost-shifting: the discount dilemma.

Cost-shifting, the practice by hospitals of raising their prices to make up for reimbursement shortfalls from payers that do not pay full charges, is an important and controversial issue. Concerns about cost-shifting, particularly its effects on payment equity and cost escalation, have led many insurers, business groups, and legislators to advocate rate-setting regulation for hospitals. This article seeks to clarify the definition of cost-shifting, and quantifies its magnitude in Minneapolis/St. Paul. We believe that cost-shifting is the consequential result of the failure of both public and private payers to structure payment policies that reward cost-effective hospitals, and we outline a market-oriented alternative to rate-setting to address the discount dilemma caused by cost-shifting.

Charities↗
PubMed2003

Variation in unit costs of hospitals in the English National Health Service.

OBJECTIVES: In England, the Department of Health places high priority on reducing the variation in unit costs of National Health Service (NHS) hospitals. Efficiency targets are set for hospitals to create incentives for relatively high cost hospitals to reduce their costs and shift performance closer to that of their lower cost counterparts. We examine empirically the dispersion in unit costs to assess the extent of variation in the productivity of hospitals and trends over time. METHODS: We use econometric panel data techniques on data from 235 NHS acute hospital trusts over a six-year period, 1994/95 to 1999/00, supplemented with information from semi-structured interviews with key individuals in hospitals and purchasing bodies. RESULTS: There appears to have been no reduction in variation during this period. Relative unit costs for individual trusts also appear stable, with little movement from relatively high cost to low cost. Judging from limited quantitative evidence outside health care, the variation in costs between NHS hospitals may be comparatively low. CONCLUSIONS: Given all the other aspects of hospital performance that government is seeking to change, reduction in the dispersion of unit costs per se should not be a major policy objective. It is far more important to examine variation in quality-adjusted unit costs.

Cost Allocation↗
PubMed2001

An attributable cost model for a telecare system using advanced community alarms.

We have developed an attributable cost model for a city-based telecare scheme involving 11,618 community alarm users. The equipment was assumed to cost 500 Pounds-1000 Pounds per installation, compared with 175 Pounds for the current system. Because of the significant additional capital cost of the proposed system, it would be necessary to borrow to finance it. For example, if the home equipment cost 500 Pounds per unit, an additional 2.2 million Pounds would be required. Nonetheless, it would be possible to achieve a return on the investment after 10 years. The principal savings would arise from reduced hospital bed costs and reduced residential care. The model suggests that the financial benefits of the proposed system would occur in the ratio of 4% to the local authority housing department, 43% to the National Health Service and 53% to the residential care provider.

Aged↗
PubMed1979

Industrial emission of cadmium in Japan.

Direct emission of cadmium into air and water in Japan has been controlled on the basis of the Emission and Effluent Standards. Environmental quality in these media has been improved, but delayed effects of these emissions in the past are now manifest by contamination of agricultural acreage in various parts of this country. Special land improvement projects are therefore required, and cost allocation should be made on the basis of scientific assessment of natural background. An impact assessment on accidental release of potential sources of cadmium dispersed in the water system should be made on the basis of inventory surveillance. Assessment of natural background can practically be made by two means. One is to examine the vertical distribution of cadmium in a soil profile and to search for a subsurface layer in which there can be no contamination. Another is the use of the Zn/Cd ratio as an index of pollution, a value of 400 being suggested as a screening level. The transport of cadmium was found to occur principally in particulate form, and sampling and analysis of water together with suspended solid after a heavy rainfall is suggested as a useful means for assessing the character of a catchment area and for planning the improvement of land surface in mining districts.

Agriculture↗
PubMed1985

Costing nonprofit services: developments, problems, and issues.

The author reviews the current status of cost accounting in the nonprofit sector. Major conceptual, methodological, and practical problems which impede use are discussed, and approaches for advancing knowledge in nonprofit financial management are presented. While much of the information applies to nonprofit organizations in general, the focus is on voluntary health and welfare organizations.

Accounting↗
PubMed2006

Health insurance coverage of direct support workers in the developmental disabilities field.

There is mounting evidence that employer-provided health insurance is an important factor in recruiting and retaining a competent and motivated direct support workforce within health and human services occupations. A review of the literature in this area, including new information related to the developmental disabilities field, is presented to assist nonprofit employers and government officials in designing initiatives to address increasing health care costs. Approaches to financing health coverage for frontline staff and a new program in New York that will provide subsidies to agencies to enhance existing coverage are discussed.

Adult↗
PubMed1994

Patients at risk: health reform and risk adjustment.

The Clinton proposal recognizes the need for successful risk adjustment and calls for the National Health Board to promulgate a risk adjustment formula by 1 April 1995. Unfortunately, risk adjustment technology is primitive; using observable characteristics such as age only slightly ameliorates the flawed incentives of not adjusting at all. Without major improvements in risk adjustment technology we face a trade-off between giving plans an incentive to select good risks and an incentive to produce at lowest cost. Pure capitation maximizes both incentives; pure fee-for-service minimizes both. I suggest experimentation with paying plans partly on the basis of risk-adjusted capitation and partly on the basis of a fee schedule reflecting actual use (partial capitation). In the draft Clinton plan, the option given to alliances not to offer plans priced above 120 percent of the weighted average premium appears to assume better risk adjustment ability than is now possible. This option should be relaxed or abandoned.

Actuarial Analysis↗
PubMed1994

The Clinton plan: what happened to the tough choices?

This paper points out four difficult choices embedded in the Clinton plan. First, universal coverage is achieved, but with regressive head-tax financing on many workers-since the cost of the employer mandate ultimately will fall on workers' wages. Perhaps such an approach can be made politically acceptable. Second, cost containment is entrusted to global spending limits, which will limit the rate of improvement in quality. Third, the offering of choice among a variety of health plans of different costs and quality, although desirable in itself, may lead to inequity. Finally, the plan's financing will make it difficult for voters to tell what trade-offs they are making, because employer mandates and budget cuts disguise choices.

Community Participation↗
PubMed1994

Employer-based health insurance in a changing work force.

The loss of manufacturing jobs and the expansion of service jobs and part-time employment have contributed to a decline in the rate of employer-sponsored health insurance among workers. Not only does manufacturing provide more of its own workers with coverage compared with other industry groups, but it also is a significant net "exporter" of coverage to dependent workers in other industries. In 1991 the net export of coverage represented a 20 percent tax on manufacturing employers per covered worker, while professional services--the fastest-growing industry group-collected a subsidy from other industry groups equal to more than 12 percent per covered worker. Similarly, larger firms--those that employed 100 workers or more--paid a self-imposed tax of as much as 13 percent per covered worker to support dependent workers employed in smaller firms.

Cost Allocation↗
PubMedDate not supplied

Implementing employer and individual mandates.

As is true of automobile insurance, a strong case can be made for a mandate that requires individuals to purchase health insurance rather than shifting costs to others. A mandate by itself, however, is likely to be regressive. By dealing with individual needs through the back door, an employer mandate generally keeps costs hidden and raises employment problems, while an employer subsidy will be poorly targeted. An individual mandate, in turn, raises other difficult administrative issues of collection and enforcement. No employer mandate is sufficient without an individual mandate, and millions of Americans will fall outside of any mandated system.

Community Participation↗
PubMedDate not supplied

Medicare's end-stage renal disease program: current status and future prospects.

The twenty-five years of the end-stage renal disease (ESRD) program have been characterized by remarkable clinical achievements, which have prolonged and improved the quality of life for thousands of patients. As the program enters the next millennium, it faces considerable challenges: As the number and acuity of patients increase, the availability of trained nephrologists will decrease, and total costs will continue to rise. Policymakers will need to work closely with the renal professional and patient communities to develop creative approaches to delivering and financing ESRD care that is of the highest quality, yet is affordable.

Capitation Fee↗
PubMedDate not supplied

Mental health/medical care cost offsets: opportunities for managed care.

Health services researchers have long observed that outpatient mental health treatment sometimes leads to a reduction in unnecessary or excessive general medical care expenditures. Such reductions, or cost offsets, have been found following mental health treatment of distressed elderly medical inpatients, some patients as they develop major medical illnesses, primary care outpatients with multiple unexplained somatic complaints, and nonelderly adults with alcoholism. In this paper we argue that managed care has an opportunity to capture these medical care cost savings by training utilization managers to make mental health services more accessible to patients whose excessive use of medical care is related to psychological factors. For financial reasons, such policies are most likely to develop within health care plans that integrate the financing and management of mental health and medical/surgical benefits.

Cost Allocation↗