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PubMed1989

[Addiction treatment services in the Russian Federation].

The purpose of this paper is to address issues pertaining to the substantiation of trends in improving the narcological service with regard to the present restructuring of antialcohol policy. It is necessary to give up the practice of locating narcological facilities in accommodated premises and to develop the network of dispensaries by constructing new types of buildings. It is advisable to drastically expand the basis for post-graduate training of psychiatrists-narcologists by establishing in each economic region chairs of narcology at faculties of post-graduate training of physicians within medical schools, as well as departments of post-graduate training of personnel at scientific research institutes. There is a need to dramatically strengthen the structural subdivisions of narcological service, providing curative and preventive care to drug addicts. Narcological service for teenagers is also in need of improvement, right up to the introduction of posts of psychiatrists-narcologists for teenagers at all narcological institutions. Another task of high priority is the creation of legal mechanism for organising within narcological service, on the cooperative basis, one's own industrial and rural enterprises capable of improving social and labour rehabilitation of patients and, in the and, to ensure the transfer of narcological service to cost-accountable and self-financing practice.

Adolescent↗
PubMed2002

SWAp dynamics in a decentralized context: experiences from Uganda.

This paper examines the role of the Ministry of Health (MoH) in Uganda in the process of developing a Sector-Wide Approach (SWAp) within the health sector. Power dynamics are integral to any understanding of development assistance, and SWAps bring with them new opportunities for the deployment of influence. The SWAp process has changed the interaction between the donors and the Government, and the perspective of this interaction has shifted from various technical areas to the entire health sector. It is argued that although the decentralization of the public sector has transferred considerable responsibilities and duties from the central level to the districts, significant power, defined as a social construct, has been generated by the MoH in the very process of developing SWAps. The MoH has been able to exercise significant influence on defining the content and boundaries of the SWAp process, as well as the direction it is taking. This development has largely followed blueprints drawn by donors. Through the institutional framework associated with SWAps, the MoH has redefined the interaction between the central level and the districts as well as between the MoH and the donors. While the SWAp process is now moving from the planning to the implementation phase in Uganda, we see a number of new, changing, ambiguous and contradictory strategies emerging.

Financing, Organized↗
PubMed1997

Social theory and social class.

Concepts of class developed with the emergence of industrial society in the nineteenth century. For an understanding of current divisions, theories must reflect the advances of capitalism and the global economy that characterize the late twentieth century. In industrialized societies, reductions in the industrial workforce and the growth of finance, investment and real-estate industries worldwide have produced a new, largely female, service workforce. Large sectors of industry have departed in search of cheaper labour in poorer countries, which also have a rising number of women workers. In those areas, as a result, a new industrial workforce has emerged. Concomitantly, accumulation of land in less developed agricultural regions for production for the world market has led to an increase in mobile agricultural labour and a shift of landless labourers to the cities of less developed countries. In addition, both upward and downward mobility have occurred for individuals and groups in specific populations, as well as for particular diseases in developed and less developed countries. All these processes have precipitated fundamental changes in class, gender and family relationships and transformed the living conditions of populations in both developed and less developed societies. These changes have major implications for the patterns of health and disease in the world today. Objective measures of social change may be difficult to construct and use in epidemiological cancer research. Since questions of class and shifting social relations are directly implicated in the patterns of disease, they must be assessed in future research as accurately as possible.

Developed Countries↗
PubMed1998

Mining hidden value through strategic real estate plans.

Healthcare providers can get the most from their real estate investments if they manage them strategically rather than view them as a cost of doing business. Organizations that develop strategic real estate plans can optimize the cost-effectiveness of their assets, reduce operating costs, and create cash through disposition strategies. The cost-effectiveness of assets can be optimized by using off-balance-sheet financing structures, such as outright sale, sale-lease-back arrangements, synthetic leases, and beneficial occupancy agreements. Opportunities for cost reduction can be found by conducting operations, administrative, and maintenance reviews and cost-segregation studies. Cost-reduction efforts also should focus on ensuring space is used in the most productive manner possible and that the organization pays no more than the minimum required property tax. Disposition strategies should begin with inventorying real estate assets to identify surplus assets. Such assets then can be moved off the balance sheet or converted into commercial or public uses.

Capital Expenditures↗
PubMed1980

Health Care Financing Administration--Adoption of the National Bureau of Standards fire safety evaluation system for health care facilities. Final notice.

The Department of Health, Education, and Welfare proposed extending the new Fire Safety Evaluation sSystem (FSES) to all hospitals participating in the Medicare and Medicaid programs in a Notice of comment period publishedon June 28, 1979 in the Federal Register (44 FR 37818). The Department also sought public comment on whether to apply the FSES to skilled nursing facilities (SNFs) and intermediate care facilities (ICFs) in this same Notice. After a careful review and analysis of the public comments received, the Department has decided to adopt the FSES as a means of evaluating alternative arrangements used to achieve compliance with the provisions of the Life Safety Code for hospitals, skilled nursing facilities, and intermediate care facilities participating in the Medicare and Medicaid programs.

Accident Prevention↗
PubMed1994

Influences on the use of capital by public hospitals.

This paper examines key influences on the volume of capital employed by public hospitals. Empirical models are constructed and analysed separately for total capital employed and for plant and equipment only, using data from 68 Victorian hospitals. Such data provide an empirical base to guide government decisions on funding capital expenditure in hospitals. The analysis finds that the proportion of hospital expenditure devoted to outpatients and teaching, and the proportion of funding derived from government all influence the level of capital utilised per inpatient. The model provided a reasonable fit for plant and equipment, but much improved data coverage and consistent valuation of land and buildings are required to adequately explain influences on total capital.

Ambulatory Care↗
PubMed2005

Building new hospitals: a UK infection control perspective.

Infection control input is vital throughout the planning, design and building stages of a new hospital project, and must continue through the commissioning (and decommissioning) process, evaluation and putting the facility into full clinical service. Many hospitals continue to experience problems months or years after occupying the new premises; some of these could have been avoided by infection control involvement earlier in the project. The importance of infection control must be recognized by the chief executive of the hospital trust and project teams overseeing the development. Clinical user groups and contractors must also be made aware of infection control issues. It is vital that good working relationships are built up between the infection control team (ICT) and all these parties. ICTs need the authority to influence the process. This may require their specific recognition by the Private Finance Initiative National Unit, the Department of Health or other relevant authorities. ICTs need training in how to read design plans, how to write effective specifications, and in other areas with which they may be unfamiliar. The importance of documentation and record keeping is paramount. External or independent validation of processes should be available, particularly in commissioning processes. Building design in relation to infection control needs stricter national regulations, allowing ICTs to focus on more local usage issues. Further research is needed to provide evidence regarding the relationship between building design and the prevalence of infection.

Cross Infection↗
PubMed2003

Marker vaccines and companion diagnostic tests for classical swine fever.

For Classical Swine Fever (CSF) a subunit vaccine consisting of the E2 protein is commercially available. The discriminatory ELISAs detect antibodies against another viral protein, the E(rns). As CSF has already been eradicated from many countries the use of a marker vaccine in these regions can only be contemplated as emergency vaccination after a new introduction of virus. Therefore, a Large Scale Marker Vaccine Trial was financed by the EU Commission and organised by the EU Reference Laboratory for CSF in 1999. When tested under the conditions of emergency vaccination, e.g. challenge before full immunity had developed, it was shown, that most CSF challenge infections took a subclinical course with reduced virus shedding. Transplacental transmission in pregnant sows could not be prevented after an application of a single vaccine dose. The most serious deficiencies have been found in the discriminatory ELISAs. Both available tests have shown deficiencies in sensitivity and specificity compared to conventional CSF antibody ELISAs. At the time, when the trial was performed, no confirmatory test was available to verify the results of the discriminatory ELISAs. Currently two new developments of marker vaccines for CSF are in progress. A chimaeric vaccine is based on infectious clones of the conventional live vaccine (C-strain) where a gene is replaced with the corresponding gene of the closely related pestivirus Bovine Viral Diarrhoea (BVD) virus. Conversely, the E2 gene of a BVD virus can be replaced by the E2 of a virulent CSF virus. The other principle is the construction of a DNA vaccine, expressing the E2 gene after entering the host cell. Deletion mutants of the E2 gene have also been constructed and tested for their induction of immunity. Both new developments are based on the same discriminatory tests as mentioned previously and developments of other principles for discrimination are rare.

Animals↗
PubMedDate not supplied

The Massachusetts program for reducing the risk of formaldehyde exposure.

Urea formaldehyde foam insulation in homes has caused increasing concerns about the adverse health effects associated with residential exposure to formaldehyde emissions. These health effects cover a broad spectrum of symptoms, including neurophysiological effects, respiratory irritations, and eye and skin irritations. Recent studies have also suggested a possible correlation between exposure to formaldehyde vapors and cancer. In 1979, following hundreds of complaints of adverse health effects from occupants of dwellings insulated with urea formaldehyde foam insulation (UFFI), the Massachusetts Department of Public Health issued regulations banning the new installation of UFFI in Massachusetts. New State legislation was adopted in 1986 which reformulated UFFI policy. The law established a minimum concentration of formaldehyde of 0.1 parts per million (ppm) below which removal of the insulation is not required or encouraged. A trust fund financed by industry was established to pay for air testing and for the removal of UFFI from homes if the formaldehyde level exceeds the statutory minimum of 0.1 ppm or if an occupant experiences adverse health effects attributable to the insulation. Based on the Massachusetts experience, these requirements have been identified: the need for flexibility and midcourse corrections in the development of health policy to allow for the incorporation of new scientific information or changes in the economic or political environment, the need for close coordination with all affected parties, and the need for scientific and technical policy development to be joined with economic and political perspectives to ensure smooth implementation of health policies.

Construction Materials↗
PubMed1995

The development of the Hill-Burton legislation: interests, issues and compromises.

The Hill-Burton Hospital Survey and Construction Act has its roots in the social health and welfare programs of the New Deal. This paper traces its development and the positions of three groups-the hospital industry, the U.S. Public Health Service, and the Senate Subcommittee on Wartime Health and Education-on four issues: the nature of federal funding to states, the use of public funds by private hospitals, the oversight powers of a Federal Hospital Council, and health services for the poor. The analysis involves two lines of thought: the political strategy of incrementalism and the roles of the three interest groups in reaching compromises to quickly pass an "unsponsored" bill. Relevance to the current effort to pass a single payer national health insurance is explored.

Financing, Government↗
PubMed1992

Considerations in setting up a positron emission tomography center.

Clinically oriented imaging with position emission tomography (PET) has come of age. Given an adequate referral base and physician interest, a compelling argument can be made at all levels of the review process for setting up a PET program in a clinical setting. PET is expensive. It is obvious that the cost of running a PET service depends heavily on an institution's ability to obtain reasonable financing. Educational institutions have the opportunity to acquire special funding through a variety of sources. On the other hand, money can be expensive for private entrepreneurs. It appears that in the near future PET centers will probably remain at educational institutions or large well-financed community hospitals able to raise money at reasonable rates until reimbursement issues are better resolved. Finally, the future of clinical PET may hinge significantly on the ability of commercial radiopharmaceutical suppliers to provide regional fluorodeoxyglucose distribution. As an institutional program development, PET offers opportunities by providing unique clinical data aiding the referral pattern. PET may serve as a magnet for recruitment in many areas and may promote interdisciplinary cooperation. A clinical PET center serves both as a model for future and more widespread use of PET and as a training ground for medical personnel. Finally, the unique capabilities of PET may facilitate grant opportunities.

Facility Design and Construction↗
PubMedDate not supplied

Using disease management and market reforms to address the adverse economic effects of drug budgets and price and reimbursement regulations in Germany.

OBJECTIVE: Germany spends the highest share (10.4%) of its gross domestic product on health care among European Union countries. The majority of this financing comes from an earmarked tax on labor earnings. Drug spending, as a share (12.7%), is relatively low, as is per-capita drug spending. Over the past decade, a number of specific budgeting initiatives were introduced to control drug spending-with some success, at least until the 11% increase in the first 6 months of 2001. METHODS: This article describes and analyzes these governmental initiatives as well as other market reforms. RESULTS: Germany has had a "drug budget silo mentality" throughout this period. But the focus of the mentality moved rapidly from the central budget to regional budgets and to drug budgets per physician based on historical data. These amounts do not correspond to either medical necessity or economic considerations. An analysis of the health-care system as a whole shows that the efforts to constrain spending with budget in one area can lead to higher total costs. This article also considers the impact of introducing other actual or proposed reforms such as a positive list to replace the negative list, generic substitution, retail price competition among pharmacies, and E-health commerce. There is also a new national institute constructing a database of information on health technology assessments. CONCLUSIONS: To overcome the strong segmentation of the health system in physician, drug, and hospital budgets, we recommend using this information from proper cost-effectiveness evaluations to develop clear guidelines for disease management programs, reinforced by appropriate financial incentives.

Budgets↗
PubMed1989

Development and implementation of a strategic-planning process at a university hospital.

The development and implementation of a long-range strategic plan for the pharmacy department at a university hospital is described. Because of rapidly occurring changes in health-care delivery, financing, and education, the pharmacy department at the University of Illinois Hospitals decided to create a strategic plan that would stimulate growth, be responsive to a changing health-care environment, and emphasize the department's philosophy of striving for professional leadership in education, research, and innovation. Actual strategy development was done during a three-day administrative retreat, which was conducted according to a structured agenda that facilitated extensive brainstorming and discussion. As a result, the department developed eight major strategies that have been directing its growth and development over the last four years. Each strategy had an implementation plan that included substrategies with statements of specific results that were expected, an action plan (a list of specific tasks to be accomplished), and a general statement summarizing the benefits of each substrategy. Annual meetings were held to review the continued appropriateness of these strategies. Implementation of the strategic plan has resulted in major improvements in drug cost containment, improved ambulatory-care pharmaceutical services, a results-oriented performance-appraisal system, more support for clinical education programs, and a substantial increase in support for research. The strategic plan has allowed the department to constructively participate in two downsizing events within the hospital without major adverse effects on its own services and programs. Use of the strategic-planning process should be considered by other hospital pharmacy departments as a means of responding to the external and internal forces of change that currently affect most hospitals.

Chicago↗
PubMed1999

Social Security, retirement incentives, and retirement behavior: an international perspective.

Escalating rates of early retirement are imposing fiscal pressure on retirement systems around the world. In some developed countries, the labor-force participation rates of men ages 60-64 have fallen by 75 percent over the last three decades. One explanation for this striking decline is social security program provisions which create disincentives to continued labor-force participation by older workers. There are substantial differences among developed nations in the labor-force participation of older workers. While two-thirds of 60-year-old American males are working, only one-quarter of men that age are working in Belgium. Over the entire 55-65 age range, 63 percent of American males are working, compared with only 40 percent of French males and 33 percent of Belgians males. There is strong evidence that the early retirement provisions of social security systems in developed countries determine the modal age of retirement. There is a strong relationship between early retirement ages and labor-force withdrawal rates; for example, in France, 60 percent of those working at the early entitlement age of 60 leave the labor force at that age. The core of this analysis is the construction of "implicit tax/subsidy rates" on additional work at older ages through each nation's social security system. These rates measure the change in a worker's retirement wealth entitlement from delaying retirement for one year, relative to the amount that would have been earned over that year. The U.S. Social Security system has an actuarial adjustment for delayed benefits claiming and other features that avoid financial incentives to leave the labor force at age 62 for a married worker, there is a slight disincentive to work for single workers and high wage earners. However, at ages 65 and older there is a stronger incentive to leave the labor force, with implicit tax rates on work of 19 percent for married workers and 33 percent for single workers. By comparison, other nations do not have actuarially fair adjustments, and as a result impose substantial taxes on additional work at older ages. In several countries, implicit tax rates on work at older ages approach or exceed 100 percent. This is because by delaying retirement, workers forgo benefits which often replace close to their full wage, in addition to having to pay the high payroll taxes required to finance generous social security benefits. There is a striking correlation across nations between high implicit tax rates on additional work and low labor-force participation rates among older workers. This suggests that social security program incentives are an important determinant of retirement. These findings have important policy implications for reforming social security programs in the United States and abroad. Policymakers must consider how program reforms will affect incentives for continued work at older ages.

Actuarial Analysis↗
PubMed1992

Cost containment and new priorities in the European community.

This article reports on the author's survey of the cost-control measures for health care in 12 European countries during the period from 1983 to 1990. Among these countries the greatest convergence was in the use of the budget as a system of control, reinforced by manpower controls. Budgets were constructed to restrict hospital costs and payments to doctors practicing outside of hospitals. Another strategy was cost sharing for purchase of drugs and, in some cases, for dentistry. Most countries took steps to control expensive medical equipment; others, to restrict entry to medical schools. The European experience demonstrates the technical feasibility of the government's controlling health care costs by regulating supply rather than demand. The key to Europe's success in the use of monopsony power, whereby one purchaser dominates the market. The author contends that regulation works in Europe and questions whether the United States can exert similar control over its coalition of insurers and providers in order to rein in its health care expenses.

Ambulatory Care↗
PubMed1996

A cost-utility analysis of second-line chemotherapy in metastatic breast cancer. Docetaxel versus paclitaxel versus vinorelbine.

The aim of this study was to determine the incremental effectiveness, the incremental health-related quality of life (differences in quality-adjusted progression-free survival between treatments), the incremental cost and the incremental cost-effectiveness and cost-utility ratios, for docetaxel, paclitaxel and vinorelbine, when these drugs were used as second-line treatment in patients with metastatic breast cancer. In the absence of comparative direct evidence of the relative efficacy of docetaxel, paclitaxel and vinorelbine in this setting, a model was designed to determine the effects of the 3 interventions on health outcome and cost. A Markov process model, based on 53 disease states, was thus constructed to evaluate the socioeconomics of the 3 treatment regimens. The model allows assessments from the start of second-line chemotherapy until death. Costs were evaluated from the combined view of the healthcare system and the patient. Direct nonmedical and indirect costs were excluded. Consumption per episode of care was estimated by retrospective analysis of 153 medical reports from 5 different hospitals. Hospital costs were allocated values from the national accounting costs by diagnosis-related group (DRG). The content of the health states was based on the multiattribute health states classification system (MASH). Preference values were assigned by application of a standard reference lottery using 20 oncological nurses as proxies for the patients. The health-related quality-of-life score was used as a quality adjustment weighting factor to calculate quality-adjusted progression-free survival associated with the 3 different regimens. Docetaxel reduces the time spent in progression, decreases the number of complications due to progressive disease and thereby provides better quality of life. It provides a benefit of 57 disease- and discomfort-free days compared with vinorelbine and 22 days compared with paclitaxel. Docetaxel may be thought of as self-financing as a result of savings in hospital admissions, providing net savings of 6800 French francs (FF; 1993 values) compared with expenditure associated with vinorelbine treatment and FF700 compared with the equivalent figures for paclitaxel.

Antineoplastic Agents↗
PubMed2002

Willingness to pay for treated mosquito nets in Surat, India: the design and descriptive analysis of a household survey.

For willingness to pay (WTP) studies to have an appropriate impact on policy making, it is essential that the design and analysis are undertaken carefully. This paper aims to describe and justify the design of the survey tool used to assess hypothetical WTP for treated mosquito nets (TMN) in rural Surat, India and report its findings. Results from qualitative work were used as an input for developing the WTP questionnaire. A total of 1200 households belonging to 80 villages in rural Surat were selected for the study. A bidding format was used to elicit WTP values, using three different starting bids. The scenario was constructed in a way to reduce the possibility of respondents acting strategically. The response rate was 100%. About 79% of the respondents were willing to buy TMNs and the mean WTP was Rs57. Descriptive results of economic and other taste and preference variables are also presented, which include preventive measures used by households and treatment seeking behaviour for malaria. It is observed that WTP as well as demographic variables and prevention methods differ significantly across arms of the trial. This paper suggests that policy-makers could use the evidence following further analysis, along with information on costs of implementation, to ascertain the levels of subsidy that may be needed at different levels of coverage.

Adult↗
PubMed1994

Using Medicaid claims data to evaluate a large physician fee increase.

OBJECTIVE: This study demonstrates the use of Medicaid claims data in order to evaluate a threefold fee increase in physician fees for deliveries ($265 to $795), which the Maryland Medicaid program implemented in 1986. DATA SOURCES AND STUDY SETTING: The study used Maryland Medicaid claims data for years of service 1985-1988, and was done at the Maryland Department of Health and Mental Hygiene with the help of a Robert Wood Johnson, Health Care Financing and Organization (HCFO) grant. STUDY DESIGN: Overall, our design is that of a pre-test, post-test with multiple observation points both before and after the fee increase. We measured participation in three ways, corresponding to three different units of analysis. With the county-quarter year as unit of analysis, we followed a panel of providers over 16 quarters for each county in the state to determine changes in the number of delivering providers. With the individual provider as the unit of analysis, we identified effects on their Medicaid caseload between years that may have been influenced by the fee increase. Finally, we looked at continuously enrolled Medicaid women who delivered to determine the effects of the fee increase on site and volume of prenatal care. DATA COLLECTION/EXTRACTION METHODS: Analytic files for each unit of analysis were compiled from previously extracted Medicaid claims files using standard statistical software packages. PRINCIPAL FINDINGS: Using techniques described, we were able to get an in-depth picture of overall responsiveness to the intervention. We found a moderate influence of the fee increase on overall participation, less than what we would have predicted. CONCLUSIONS: Administrative data can be used to construct efficient, yet sophisticated evaluations of major policy changes. Findings from our evaluation suggest a moderate effect of the fee increase on overall participation. However, raising fees to the level of private third party payers does not in itself guarantee equal access to private physician health care for Medicaid mothers.

Adolescent↗