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PubMed1984

Return to nursing home investment: issues for public policy.

Because Government policy does much to determine the return available to nursing home investment, the profitability of the nursing home industry has been a subject of controversy since Government agencies began paying a large portion of the Nation's nursing home bill. Controversy appears at several levels. First is the rather narrow concern, often conceived in accounting terms, of the appropriate reimbursement of capital-related expense under Medicaid and Medicare. Second is the concern about how return to capital affects the flow of investment into nursing homes, leading either to inadequate access to care or to over-capacity. Third is the concern about how sources of return to nursing home investment affect the pattern of nursing home ownership and the amount of equity held by owners since the pattern of ownership and amount of equity have been linked to quality of care.

Capital Financing↗
PubMed1999

Characterization and observation of animals responsible for rabies post-exposure treatment in Phnom Penh, Cambodia.

In order to provide relevant therapeutic answers to human patients exposed to risk of rabies infection who visit the Institut Pasteur du Cambodge for post-exposure treatment and to improve control of rabies in Cambodia, a pilot study was carried out in Phnom Penh Province in November and December 1997 with three objectives: characterization of the population of animals responsible for the exposure to rabies, observation of the animals concerned, and confirmation of the presence of rabies virus in the province. Between 18 November 1997 and 19 December 1997, 409 of the 741 patients treated at the Institut Pasteur du Cambodge because of an exposure to a known rabies vector were included in the study. The animals concerned were: 401 dogs (98%), six monkeys (1.5%) and two cats (0.5%). Three-hundred-and-seventy of the animals (90.5%) were owned, 4 (1%) were unowned but were available for characterization and observation, and 35 (8.6%) had an unknown ownership status and were not available for further study. The exposures occurred on private property in 84% of the cases, and 80 of the 370 owned animals (22%) lived in the same home as had the patient. The 374 animals with known ownership status were examined. Five were already dead and two of these five dogs had presented clinical signs typical of those of rabies. The male:female sex ratio of the dogs was 2.1:1. The 369 live animals were placed under observation for 10 d immediately after exposure of the humans had taken place. At the end of the period none of the animals had developed clinical signs of rabies, three had died of diseases other than rabies, and one was lost. Tests for the rabies nucleocapsid antigen were positive in two cases (the two suspected rabid dogs), confirming the presence of rabies in Phnom Penh Province. Consequently, we recommend measures to improve the control of rabies in Cambodia.

Animals↗
PubMed2000

The financial performance of hospitals belonging to health networks and systems.

The U.S. health industry is experiencing substantial restructuring through ownership consolidation and development of new forms of interorganizational relationships. Using an established taxonomy of health networks and systems, this paper develops and tests four hypotheses related to hospital financial performance. Consistent with our predictions, we find that hospitals in health systems that had unified ownership generally had better financial performance than hospitals in contractually based health networks. Among health network hospitals, those belonging to highly centralized networks had better financial performance than those belonging to more decentralized networks. However, health system hospitals in moderately centralized systems performed better than those in highly centralized systems. Finally, hospitals in networks or systems with little differentiation or centralization experienced the poorest financial performance. These results are consistent with resource dependence, transaction cost economics, and institutional theories of organizational behavior, and provide a conceptual and empirical baseline for future research.

American Hospital Association↗
PubMed2000

Community orientation in hospitals: an institutional and resource dependence perspective.

OBJECTIVE: To conceptualize community orientation-defined as the generation, dissemination, and use of community health-need intelligence-as a strategic response to environmental pressures, and to test a theoretically justified model of the predictors of community orientation in hospitals. DATA SOURCES: The analysis used data for 4,578 hospitals obtained from the 1994 and 1995 American Hospital Association (AHA) Annual Survey and the 1994 Medicare Hospital Cost Report data sets. Market-level data came from the Area Resource File. STUDY DESIGN: Multiple regression analysis was used to examine the effects of hospital size, dependence on managed care, ownership, network, system and alliance memberships, and level of diffusion of community-orientation practices in the area on the degree of community orientation in hospitals. The model, based on Oliver's (1991) framework of organizational responsiveness to environmental pressures, controlled for the effects of industry concentration and lagged profitability. PRINCIPAL FINDINGS: Degree of community orientation is significantly related to hospital size; ownership; dependence on managed care; and membership in a network, system, or alliance. It is also significantly related to the diffusion of community-orientation practices among other area hospitals. CONCLUSIONS: Degree of community orientation is influenced by the nature of environmental pressures and by hospital interests. It is higher in hospitals that are large, nonprofit, or members of a network, system, or alliance; in hospitals that are more dependent on managed care; and in hospitals that operate in areas with higher diffusion of community-orientation activities.

American Hospital Association↗
PubMed2001

Medicare and Medicaid programs; physicians' referrals to health care entities with which they have financial relationships. Health Care Financing Administration (HCFA), HHS. Final rule with comment period.

This final rule with 90-day comment period (Phase I of this rulemaking) incorporates into regulations the provisions in paragraphs (a), (b), and (h) of section 1877 of the Social Security Act (the Act). Under section 1877, if a physician or a member of a physician's immediate family has a financial relationship with a health care entity, the physician may not make referrals to that entity for the furnishing of designated health services (DHS) under the Medicare program, unless an exception applies. The following services are DHS: clinical laboratory services; physical therapy services; occupational therapy services; radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment, and supplies; prosthetics, orthotics, and prosthetic devices and supplies; home health services; outpatient prescription drugs; and inpatient and outpatient hospital services. In addition, section 1877 of the Act provides that an entity may not present or cause to be presented a Medicare claim or bill to any individual, third party payer, or other entity for DHS furnished under a prohibited referral, nor may we make payment for a designated health service furnished under a prohibited referral. Paragraph (a) of section 1877 of the Act includes the general prohibition. Paragraph (b) of the Act includes exceptions that pertain to both ownership and compensation relationships, including an in-office ancillary services exception. Paragraph (h) includes definitions that are used throughout section 1877 of the Act, including the group practice definition and the definitions for each of the DHS. We intend to publish a second final rule with comment period (Phase II of this rulemaking) shortly addressing, to the extent necessary, the remaining sections of the Act. Phase II of this rulemaking will address comments concerning the ownership and investment exceptions in paragraphs (c) and (d) and the compensation exceptions in paragraph (e) of section 1877 of the Act. Phase II of this rulemaking will also address comments concerning the reporting requirements and sanctions provided by paragraphs (f) and (g) of the Act, respectively, and include further consideration of the general exception to the referral prohibition related to both ownership/investment and compensation for services furnished in an ambulatory surgical center (ASC), end-stage renal dialysis facility, or by a hospice in section 411.355(d) of the regulations (this exception presently is in force and effect as to clinical laboratory services). In addition, Phase II of this rulemaking will address section 1903(s) of the Act, which extends aspects of the referral prohibition to the Medicaid Program. Phase II will also address comments received in response to this rulemaking, as appropriate, and certain proposals for new exceptions to section 1877 of the Act not included in the 1998 proposed rulemaking, but suggested in the public comments.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2002

Firearm availability and female homicide victimization rates among 25 populous high-income countries.

OBJECTIVE: to determine the association between firearm availability and female homicide victimization among high-income countries. METHODS: Data were assembled for the most recent available year (1994-1999) from the official reports of the ministries of health for those countries that had more than 2 million inhabitants and were dassified as high income by the World Bank. Twenty-five nations provided sufficient information for the analysis. Rates of female victimization from homicide, firearm homicide, and nonfirearm homicide were compared with a validated proxy for household firearm ownership (the percentage of total national suicides that are committed with firearms). Possible confounding variables included in the analysis were the percentage of the population living in urban areas and income inequality. RESULTS: The United States is an outlier. It had the highest level of household firearm ownership and the highest female homicide rate. The United States accounted for 32% of the female population in these high-income countries, but for 70% of all female homicides and 84% of all female firearm homicides. Female homicide victimization rates were significantly associated with firearm availability largely because of the United States. CONCLUSION: Among high-income countries, where firearms are more available, more women are homicide victims. Women in the United States are at higher risk of homicide victimization than are women in any other high-income country.

Adult↗
PubMedDate not supplied

Digital image archiving: challenges and choices.

In the last five years, imaging exam volume has grown rapidly. In addition to increased image acquisition, there is more patient information per study. RIS-PACS integration and information-rich DICOM headers now provide us with more patient information relative to each study. The volume of archived digital images is increasing and will continue to rise at a steeper incline than film-based storage of the past. Many filmless facilities have been caught off guard by this increase, which has been stimulated by many factors. The most significant factor is investment in new digital and DICOM-compliant modalities. A huge volume driver is the increase in images per study from multi-slice technology. Storage requirements also are affected by disaster recovery initiatives and state retention mandates. This burgeoning rate of imaging data volume presents many challenges: cost of ownership, data accessibility, storage media obsolescence, database considerations, physical limitations, reliability and redundancy. There are two basic approaches to archiving--single tier and multi-tier. Each has benefits. With a single-tier approach, all the data is stored on a single media that can be accessed very quickly. A redundant copy of the data is then stored onto another less expensive media. This is usually a removable media. In this approach, the on-line storage is increased incrementally as volume grows. In a multi-tier approach, storage levels are set up based on access speed and cost. In other words, all images are stored at the deepest archiving level, which is also the least expensive. Images are stored on or moved back to the intermediate and on-line levels if they will need to be accessed more quickly. It can be difficult to decide what the best approach is for your organization. The options include RAIDs (redundant array of independent disks), direct attached RAID storage (DAS), network storage using RAIDs (NAS and SAN), removable media such as different types of tape, compact disks (CDs and DVDs) and magneto-optical disks (MODs). As you evaluate the various options for storage, it is important to consider both performance and cost. For most imaging enterprises, a single-tier archiving approach is the best solution. With the cost of hard drives declining, NAS is a very feasible solution today. It is highly reliable, offers immediate access to all exams, and easily scales as imaging volume grows. Best of all, media obsolescence challenges need not be of concern. For back-up storage, removable media can be implemented, with a smaller investment needed as it will only be used for a redundant copy of the data. There is no need to keep it online and available. If further system redundancy is desired, multiple servers should be considered. The multi-tier approach still has its merits for smaller enterprises, but with a detailed long-term cost of ownership analysis, NAS will probably still come out on top as the solution of choice for many imaging facilities.

Capital Expenditures↗
PubMed2002

Are for-profit hospital conversions harmful to patients and to Medicare?

We examine how changes in hospital ownership to and from for-profit status affect quality and Medicare payments per hospital stay. We hypothesize that hospitals converting to for-profit ownership boost post acquisition profitability by reducing dimensions of quality not readily observed by patients and by raising prices. We find that 1-2 years after conversion to for-profit status, mortality of patients, which is difficult for outsiders to monitor, increases while hospital profitability rises markedly and staffing decreases. Thereafter, the decline in quality is much lower. A similar decline in quality is not observed after hospitals switch from for-profit to government or private nonprofit status.

Diagnosis-Related Groups↗
PubMedDate not supplied

Medical school financial support, faculty composition, and selection of family practice by medical students.

OBJECTIVE: This study examines the relationship between the choice of family practice by medical students in the 1986-1987 academic year and nine variables: ownership of school, weeks of required family medicine clinical training, age of school, and six variables related to medical school financial support and faculty composition. METHODS: In multivariate analysis, three variables were found to be significantly related to choice of family practice (R2 = .441): weeks of required family medicine clinical training, proportion of faculty in family practice, and ownership of the school. A cluster analysis was performed using nine variables. RESULTS: Along with the multivariate analysis, the resulting nine clusters demonstrate that additional variables need to be identified to explain the variance in percentage of students choosing family practice at different schools.

Career Choice↗
PubMed1992

Pharmaceutical services in U.S. hospitals in 1989.

The results of a spring 1989 national survey of hospital-based pharmacy services are reported. The study group (n = 2112) comprised half of U.S. acute-care general surgical or medical hospitals with 50 or more licensed beds. Pharmacy directors were asked about their hospital's provision of 14 clinical pharmacy services. The survey had a response rate of 56% (1174 usable responses). Provision levels varied significantly with the pharmacy drug delivery system for 14 services, pharmacy director's education for 12 services, hospital teaching affiliation for 12 services, hospital ownership for 9 services, hospital size for 9 services, and geographic region for 5 services. The following percentages of respondents offered specific services: drug-use evaluation, 90%; inservice education, 66%; adverse drug reaction (ADR) management, 46%; drug therapy monitoring, 41%; pharmacokinetic consultations, 40%; parenteral-enteral nutrition team participation, 28%; patient medication counseling, 26%; drug therapy protocol management, 25%; cardiopulmonary resuscitation (CPR) team participation, 25%; clinical research, 22%; drug information, 16%; participation in medical rounds, 13%; poison information, 9%; and medication histories, 2%. Pharmacist staffing requirements for clinical services usually centralized within the department were highest for drug information and poison information. Within hospitals offering the services, four of nine patient-specific services were potentially available to more than half the patients: ADR management, CPR team participation, drug therapy monitoring, and nutrition team participation. Drug therapy protocol management required the most pharmacist staff time. Only one service, pharmacokinetic consultations, was justified by more than half of the providers of that service. Respondents expected all the services to undergo net growth during 1989-90. The 1989 National Clinical Pharmacy Services Survey showed that provision of clinical pharmacy services varied with the pharmacy drug delivery system, pharmacy director's education, hospital teaching affiliation, hospital ownership, hospital size, and geographic region.

Adverse Drug Reaction Reporting Systems↗
PubMed2005

Batterers' use of guns to threaten intimate partners.

OBJECTIVES: To present the prevalence of gun ownership among batterers and describe their self-reported use of guns to threaten intimate partners. METHODS: We used multivariate methods to analyze data from 8529 men enrolled in Massachusetts certified batterer intervention programs between 1999 and 2003. RESULTS: Seven percent of the sample reported owning guns during the past 3 years. Recent gun owners were 7.8 times more likely than non-gun-owners to have threatened their partners with guns. Gun owners and non-gun-owners were equally likely to have threatened their partners with knives. Batterers reported using guns to threaten their partners in 4 ways, including 1) threatening to shoot them; 2) cleaning, holding, or loading a gun during an argument; 3) threatening to shoot a pet or person the victim cared about; and 4) shooting a gun during an argument with a victim. Identified risk markers for threatening an intimate partner with a gun included substance abuse, homicidal behavior, making knife threats, and gun ownership in the 3 years preceding assessment. CONCLUSION: Among batterers, owning a gun is highly correlated with using a gun to threaten an intimate partner. Legal restrictions that prohibit batterers from owning and possessing firearms should be enforced consistently. Detailed contextual information about the circumstances in which batterers use guns to threaten intimate partners and potential protective and risk factors relevant to firearm use by batterers should be explored.

Coercion↗
PubMed1991

Private health insurance and medical care utilization: evidence from the Medicare population.

This paper examines the impact of supplemental health insurance policy ownership on the use of health care services by the elderly. It employs a data base consisting of Medicare claims data from over 2,000 beneficiaries in six states, actual copies of their supplemental insurance policies, and detailed survey information. The results show that policy ownership has a substantial, positive impact on service usage and costs, particularly for beneficiaries in fair or poor health. The greatest impact was found for policies that provide first-dollar coverage.

Aged↗
PubMed1991

Differences in hospital resource allocation among sick newborns according to insurance coverage.

OBJECTIVE: To assess whether newborns' insurance coverage was associated with differences in the allocation of hospital services. DESIGN: Retrospective analysis of computerized hospital discharge data, comparing resource allocation among newborns according to insurance status, controlling for race/ethnicity, diagnoses, hospital characteristics (ownership, teaching status, nursery level), and disposition. SETTING: All California civilian acute-care hospitals. PATIENTS: Population-based sample, excluding out-of-hospital and military hospital births. Resource allocation was studied among all newborns discharged in 1987 with evidence of serious problems (N = 29,751). MAIN OUTCOME MEASURES: Length of stay, total charges, and charges per day. RESULTS: Sick newborns without insurance received fewer inpatient services than comparable privately insured newborns with either indemnity or prepaid coverage. This pattern was observed across all hospital ownership types. Mean stay was 15.7 days for all privately insured newborns (15.6 days for those with indemnity and 15.7 days for those with prepaid coverage), 14.8 days for Medicaid-covered newborns, and 13.2 days for uninsured newborns (P less than .001). Length of stay, total charges, and charges per day were 16%, 28%, and 10% less, respectively, for the uninsured than for all privately insured newborns (P less than .001). Resources for newborns covered by Medicaid were generally greater than for the uninsured and less than for the privately insured. Both uninsured and Medicaid-covered newborns were found to have more severe medical problems than the privately insured. CONCLUSIONS: The findings cannot be explained by differences in medical need or by differences in non-medically indicated services; they constitute prima facie evidence of inequities that need to be addressed by policy changes.

California↗
PubMedDate not supplied

Rural community hospitals and factors correlated with their risk of closing.

The issue of rural hospital closings in the United States in recent years has become of increasing concern to health care policy analysts. Rural communities face unique health needs, necessitating access to local health care. Much has been written about the social, economic, legislative, and technological changes that have increased the stress on rural hospitals in the 1980s. However, quantifiable models have been lacking with which to examine in detail factors associated with rural hospitals and to correlate such factors with individual hospitals' risks of closing. In this study, we identify variables correlated with rural community hospital closures in the period 1980-87. Using epidemiologic case-control methods, 161 closed rural hospitals were matched 1 to 3 with a control group of 483 rural hospitals which remained open during the same period. A series of hospital performance indicators and demographic, economic, and social community variables were entered into a multiple logistic regression model. Four variables were found to be positively correlated with risk of closure. They are for-profit ownership; nongovernment, not-for-profit ownership; presence of a skilled nursing or other longterm care unit; and the number of other hospitals in the county. Variables negatively correlated with risk of closure were accreditation by the Joint Commission on the Accreditation of Healthcare Organizations, the number of facilities and services, and membership in a multihospital system. Policy and research implications at the Federal, State, and local levels are discussed.

Accreditation↗
PubMedDate not supplied

A cost and production analysis of hospital dental care programs.

To provide hospital dental programs with useful information about the expansion of dental services and the identification of pertinent financial information, a production function and cost function analysis was performed. Results showed that hospital ownership (public or private) and size of the dental clinics were associated with the cost of providing dental services and the volume of services provided. Among 23 hospitals studied, private hospitals had a much lower cost per visit, had more paid attending dentist staff, paid their resident dentists less, and had significantly more billings paid by Medicaid and by patients than public hospitals. When stratified by ownership and size, these basic differences were accentuated for the small clinics. Except for primarily the Medicaid and self-pay billings, the characteristics of large public and private hospital dental clinics were extremely similar. Multiple regression analysis found that a decrease in cost per visit was associated with more visits to dentists and more to hygienists. Production of dental services could be increased by increasing the number of attending dentists, hygienists, and residents. Preliminary econometric analysis reveals that the optimal mix of attending dentists to resident dentists should be approximately 1.8 full-time equivalent (FTE) resident for every 1 attending FTE dentist to produce the most dental services at the lowest cost.

Costs and Cost Analysis↗
PubMed1988

[Owner-dog relationships--a decade later].

The first cynological study in South Africa was done in 1976. To establish possible new tendencies in dog ownership, the study was repeated a decade later. The questionnaire included questions on breed, nutrition, care, reproduction, behaviour, training and replacement, and the information was gathered by door to door visits. External factors such as the need for specific breeds for specific situations (security, economics) in the country, availability of reading matter about dogs, the convenience of commercial dog foods, the growing tendency for mothers to enter into fixed employment, campaigns against undesired breeding, improved veterinary services, reports on canine heroism in the media, could all have influenced the patterns of dog ownership. The awareness of these tendencies could be of importance to the companion animal veterinarian.

Animal Welfare↗
PubMed1986

[Nutritional status and land tenure. A study in adults of the rural area of the northeastern Brazil].

The present study was carried out in the rural areas of four municipalities in the North-East of Brazil as part of a broader survey which covered a sample of families living in the area. A subsample of adults (453 women and 126 men) was obtained from individuals who attended the survey's post for clinical and anthropometric evaluation. According to land tenure, they were stratified into four categories: those with-without land (W.L.); small land owner (S.O.); medium land owners (M.O.); and large land owners (L.O.). Means for anthropometric variables (height, weight, middle arm circumference and skinfold thickness) were calculated for each stratum. The differences between groups were statistically significant (p less than 0.05). Findings revealed that the larger the property, the greater the mean value for height; extreme values attained a difference of 7 and 6 cm in men and women, respectively. Mean weight increased as land ownership grew reaching a difference of 9 and 11 kg in men and women, respectively (p less than 0.01). Skinfold thickness and middle arm circumference showed significant differences between strata. To evaluate their present nutritional status, the adequacy of weight to height was obtained. In spite of the low proportion of individuals who exhibited less than 90%, adequate improvement was detected as land tenure increased. The study discusses the precariousness of criteria and patterns for the nutritional evaluation of adults, and suggests the existence of a relationship between nutritional status and land ownership.

Adolescent↗
PubMed1985

Assessing the financial characteristics of multi-institutional organizations.

The prospective pricing of health services is precipitating greater attention to financial characteristics and greater development of multi-institutional organizations (MIOs). This study compares the financial characteristics of 1,590 MIO hospitals with 2,819 freestanding hospitals by ownership type: church-operated, other not-for-profit, and investor-owned. Using 1981 data from the American Hospital Association, the hospitals' capital structure and profitability are measured using three financial ratios: total assets-to-equity, return on equity, and operating margin. The results indicate both greater leverage and greater profitability among MIO hospitals, particularly in the investor-owned sector. The implications of these findings are discussed relative to financial performance by hospital ownership type in the future.

Capital Financing↗