Establishing an osteoporosis service.
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Ambulatory Care Facilities↗
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The role of the specialist in community medicine with a special interest in capital development.
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Capital Financing↗
Unified general internal medicine training programs: a path for general medicine.
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Ambulatory Care↗
Pre-anesthetic assessment clinics in Ontario.
PURPOSE: To survey the provision of pre-anesthetic assessment clinics in hospitals in Ontario during the summer of 1997. METHODS: Mail survey questionnaire of all 300 hospitals in Ontario. RESULTS: Replies were received from 260 hospitals (86.7%) of which 131 provide anesthesia. Of these, 86% are community and 14% teaching hospitals. Regular clinics are held in 63% of these hospitals, most commonly daily. As to location, 73% are held in the outpatient department. Written guidelines detailing which patients should be referred are issued by 77% of departments. The attending surgeon is the most common source of referral (64%). Referred patients are most commonly seen by a nurse (52%) who decides on onward referral to an anesthesiologist. Services generating the most referrals are general surgery (83%), orthopedics (64%) and obstetrics/gynecology (49%). In 47% of hospitals 10-50 patients are seen per month and they travel most commonly up to 100 km. The average "no show" rate is 6.2%. Only 36% of departments assess patients the same day as seen by the surgeon. On attending the clinic, 51% can see an internist the same day in contrast to 30% being able to see a cardiologist. Pre-admission testing is available to 97% on the same day. Direct funding is available for the nurse (87%), physician (1%) and secretarial help (43%). Remuneration of the anesthesiologist is fee for service (99%) and sessional (1%). CONCLUSION: Pre-anesthetic assessment clinics are common in Ontario. More development is required to enable patients to receive all aspects of their preoperative assessment during one visit.
Anesthesia Department, Hospital↗
Reengineering the picture archiving and communication system (PACS) process for digital imaging networks PACS.
Prior to June 1997, military picture archiving and communications systems (PACS) were planned, procured, and installed with key decisions on the system, equipment, and even funding sources made through a research and development office called Medical Diagnostic Imaging Systems (MDIS). Beginning in June 1997, the Joint Imaging Technology Project Office (JITPO) initiated a collaborative and consultative process for planning and implementing PACS into military treatment facilities through a new Department of Defense (DoD) contract vehicle called digital imaging networks (DIN)-PACS. The JITPO reengineered this process incorporating multiple organizations and politics. The reengineered PACS process administered through the JITPO transformed the decision process and accountability from a single office to a consultative method that increased end-user knowledge, responsibility, and ownership in PACS. The JITPO continues to provide information and services that assist multiple groups and users in rendering PACS planning and implementation decisions. Local site project managers are involved from the outset and this end-user collaboration has made the sometimes difficult transition to PACS an easier and more acceptable process for all involved. Corporately, this process saved DoD sites millions by having PACS plans developed within the government and proposed to vendors second, and then having vendors respond specifically to those plans. The integrity and efficiency of the process have reduced the opportunity for implementing nonstandard systems while sharing resources and reducing wasted government dollars. This presentation will describe the chronology of changes, encountered obstacles, and lessons learned within the reengineering of the PACS process for DIN-PACS.
Administrative Personnel↗
Technology assessment and requirements analysis: a process to facilitate decision making in picture archiving and communications system implementation.
In a time of decreasing resources, managers need a tool to manage their resources effectively, support clinical requirements, and replace aging equipment in order to ensure adequate clinical care. To do this successfully, one must be able to perform technology assessment and capital equipment asset management. The lack of a commercial system that adequately performed technology needs assessment and addressed the unique needs of the military led to the development of an in-house Technology Assessment and Requirements Analysis (TARA) program. The TARA is a tool that provides an unbiased review of clinical operations and the resulting capital equipment requirements for military hospitals. The TARA report allows for the development of acquisition strategies for new equipment, enhances personnel management, and improves and streamlines clinical operations and processes.
Capital Financing↗
[The changing role of intraoperative mammary frozen sections in breast cancer: comparison of data from East and West Germany before and after reunification].
The goal of the present study lies in the comparison of differently funded health care structures, with emphasis on certain aspects regarded to be essential for medical progress. For this purpose, mammary intraoperative frozen sections pooled from a total of 4163 intraoperative frozen sections obtained from representatively selected departments of pathology from East and West Germany before and after reunification were analysed comparatively. Our results clearly demonstrate a profound change in the role of intraoperative mammary frozen sections, with a predominantly diagnostic function in the former German Democratic Republic as a tool for histopathologically evaluating "questionable" mammary lesions. The use of such sections changed towards a predominantly therapeutic function during surgical treatment as a means of organ preservation after the German reunification.
Breast Neoplasms↗
Meeting the mammography screening needs of underserved women: the performance of the National Breast and Cervical Cancer Early Detection Program in 2002-2003 (United States).
OBJECTIVE: To examine the extent to which the National Breast and Cervical Cancer Early Detection Program (Program) has helped to meet the mammography screening needs of underserved women. METHODS: Low-income, uninsured women aged 40-64 are eligible for free mammography screening through the Program. We used data from the U.S. Census Bureau to estimate the number of women eligible for services. We obtained the number of women receiving Program-funded mammograms from the Program. We then calculated the percentage of eligible women who received mammograms through the Program. RESULTS: In 2002-2003, of all U.S. women aged 40-64, approximately 4 million (8.5%) had no health insurance and had a family income below 250% of the federal poverty level, meeting Program eligibility criteria. Of these women, 528,622 (13.2%) received a Program-funded mammogram. Rates varied substantially by race and ethnicity. The percentage of eligible women screened in each state ranged from about 2% to approximately 79%. CONCLUSIONS: Although the Program provided screening services to over a half-million low-income, uninsured women for mammography, it served a small percentage of those eligible. Given that in 2003 more than 2.3 million uninsured, low-income, women aged 40-64 did not receive recommended mammograms from either the Program or other sources, there remains a substantial need for services for this historically underserved population.
Adult↗
A fourth year of training in ambulatory medicine: the University of Washington experience.
Postresidency training in ambulatory general internal medicine has been proposed as a means to enhance the generalist skills of internal medicine graduates. At the University of Washington, a fourth year of training in ambulatory medicine has been offered since 1967. The resident training year provides a core experience in general internal medicine as well as the opportunity for elective experiences in subspecialties and other allied specialties. Graduates of this year of experience in ambulatory training were surveyed to determine current practice patterns and retrospective evaluation of the program; responses were received from 36 of 52 graduates (69%). Among respondents, 50% are general internists, 39% subspecialists, and 11% in other practice specialties. Eight respondents (22%) are practicing in rural communities. Respondents identified the specialized training in outpatient medicine as the primary strength of the additional training year. Many reported using the year to gain additional training tailored to their future practice. The fourth year of ambulatory training thus represents an efficient means to provide additional training to internists planning careers in general internal medicine. It can serve a variety of purposes, including preparation for practice in rural and other settings with unique clinical demands, training of clinician educators, and retraining of subspecialists seeking to shift to generalist practice.
Ambulatory Care↗
Estimating debt capacity of New York State Health facilities.
A measure of the capacity to take on new debt is developed for health facilities. This measure is a function of the current financial position of the facility, future financial market conditions (interest rates and bond/loan maturities), and a policy variable (the debt service coverage ratio) to be set by state health policy makers. The quality of this measure was shown to depend on the quality of current health facility financial accounting data, on the quality of forecasts of interest rates and future cashflow, and on the appropriateness of the criterion debt service coverage ratio. Some of the limitations of the estimate are discussed. Consideration of the debt capacity estimate serves to highlight some crucial issues in imposing capital expenditure limits, namely the interrelationships between financial viability, interest rates and access to capital markets.
Capital Financing↗
Capital budgeting in hospital management using the analytic hierarchy process.
In recent years, the health care industry has been experiencing change to a degree unprecedented since the inception of the Medicare program. With traditional in-hospital care on the decline, hospitals are being forced to compete for business. They must identify within their own systems feasible alternatives for dealing with these changes and then determine which ones will best accomplish the goals of the organization. This paper offers a procedure that utilizes the analytic hierarchy process--a multicriteria decision-making tool that helps arrange the possible alternatives in hierarchical order given the priorities of relevant decision makers. An application of the method to a mid-sized hospital is presented. Although the procedure is structured, it is flexible enough to be updated for the realities of any health care institution.
Budgets↗
Cost of capital to the hospital sector.
This paper provides estimates of the cost of equity and debt capital to for-profit and non-profit hospitals in the U.S. for the years 1972-83. The cost of equity is estimated using, alternatively, the Capital Asset Pricing Model and Arbitrage Pricing Theory. We find that the cost of equity capital, using either model, substantially exceeded anticipated inflation. The cost of debt capital was much lower. Accounting for the corporate tax shield on debt and capital paybacks by cost-based insurers lowered the net cost of capital to hospitals.
Capital Expenditures↗
Determinants of interest rates on tax-exempt hospital bonds.
The aim of this paper is to examine the determinants of interest rates on tax-exempt hospital bonds. The results highlight the potential and actual roles of Federal and state policy in the determination of these rates. The shift to a Prospective Payment System under Medicare has subsidized the borrowing costs of some hospitals at the expense of others. The selection of underwriters by negotiation rather than by competitive bidding results in higher interest rates. The Federal tax act of 1986 raised the cost of hospital debt by encouraging bond issues to contain call features.
Capital Financing↗
Profitability of HMOs: does non-profit status make a difference?
This study, based on 163 HMOs, tests the hypothesis that the rates of return on assets (ROA) are not significantly different between for-profit and non-profit HMOs. It finds no statistical support for rejecting the hypothesis. The marked similarity in profitability is fully explained by analyzing methods of cost control and accounting, operational incentives and constraints, and price determination. The paper concludes that profitability is not a defining distinction in the operation of managed care.
Capital Financing↗
The fruits of empire rot on the vine: United States health policy in the austerity era.
Since 1970--with the decline in the hegemonic empire--the U.S. economy has entered a period of lower profitability, producing a major shift in the economic behavior of corporate capital. In contrast to the demand stimulation (New Deal) programs of the earlier period of prosperity capitalism, capital has moved toward a profit stimulation strategy in the current era of austerity capitalism. Fundamental to this austerity strategy is the drive to reduce costs of production. Both governmental and employee health benefits represent a cost of production. Thus in the health field, austerity strategy signifies a reduction in the provision of health benefits to employees and cuts in governmental health programs. An effect of austerity capitalism may be that health patterns now mainly confined to the underdeveloped world will become more prominent among the low-wage and unemployed sectors of the working class in the United States.
Capital Financing↗
Meeting production: the economics of contracting mental illness.
This article presents a case study which illustrates the impact that economic forces can have on organizational structure and clinical practice. Specifically, the stresses and double-binds which staff experience as a result of having to manipulate different sources of funding in order to 'meet production' are examined. Ethnographic fieldwork conducted at a day treatment center connected with a Community Mental Health Center revealed that contracts are made and quotas are set each year to 'produce' different kinds of services. The two main types of services, habilitative and socialization, are not funded equally. Funding agencies pay the most for habilitative services because these are meant to be directed toward the most symptomatic clients requiring the highest level of care. However, who is billed habilitative at any one time may or may not have anything to do with who is actually symptomatic and receiving a higher level of care. The reasons for this are explored, with special attention paid to how staff must adjust to constantly changing funding requirements. Despite the obstacles, staff attempt to provide clients with the level of care that they need, regardless of whether or not this is reflected in production quotas. Taken together, these two elements--the efforts of staff to conform to funding agency requirements plus their attempts to provide clients with the level of care that they need--require that staff engage in a constant and very wearisome juggling act. It is concluded that as a consequence of the demands of meeting production, both staff morale and the treatment of clients is adversely affected.
Capital Financing↗
Can they get along without us? Sustainability of donor-supported health projects in Central America and Africa.
This article presents a synthesis of five country studies of the sustainability of U.S. government-funded health projects in Central America and Africa. The studies reviewed health projects with a comparative framework to determine which project activities had continued after the donor funding ceased. This review found that health projects in Africa were less firmly sustained than those in Central America. The studies then evaluated context factors and project characteristics that were related to the sustainability of the projects. The weak economic and political context of the African cases was found to inhibit sustainability in those countries, suggesting that broader development issues be addressed before donors expect significant sustainability of health projects in Africa. Even in Central America it was found that the strength of the institution implementing the project was an important variable for sustainability, suggesting that donor attention also be shifted toward strengthening institutional development in order to assure sustainability. In addition to context factors, several project characteristics were related to sustainability in most cases and suggest sustainability guidelines for project design and implementation. The article concludes that projects should be designed and managed so as to: (1) demonstrate effectiveness in reaching clearly defined goals and objectives; (2) integrate their activities fully into established administrative structures; (3) gain significant levels of funding from national sources (budgetary and cost-recovery) during the life of the project; (4) negotiate project design with a mutually respectful process of give and take: and (5) include a strong training component.
Africa↗
Industry-university collaborations: a necessity for the future.
OBJECTIVES: The aim of this discussion document is to consider the potential benefits of collaborations between universities and industry. Universities and industry now exist in a harsh and competitive economic climate. Indeed, their very survival depends increasingly on their ability and willingness to adapt to an unprecedented pace of change. There are a number of compelling reasons for universities and industry to undertake collaborative research. The costs of research have escalated. Universities, of necessity, are increasingly seeking financial support from industry as conventional sources of funding have been systematically reduced. Companies can no longer be self sufficient in terms of the science and technology needed for success. The strength of universities is their science base, and industry recognizes that the rapid exploitation of scientific advances is the key to its survival. Both organizations can benefit from collaborative research programmes. Universities are able to make additional staff appointments which add to their intellectual resource and reputation. In addition the purchase of equipment enhances their infrastructure. CONCLUSIONS: Industry has the opportunity to recognize the potential relevance and value of funded research and must harness and commercially exploit new knowledge as rapidly as possible. Ultimately such collaboration will give rise to new approaches to the prevention, diagnosis and treatment of dental diseases with benefits to all concerned.
Capital Financing↗