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PubMed1982

Decentralized budgeting: holding the purse strings, part 1.

A decentralized nursing structure allows the head nurse to become actively involved in the planning and budgeting process. In Nursing Decentralization: The El Camino Experience (published in November 1981 by Nursing Resources) the authors describe the development of a budgeting system that supports autonomy, accountability, and authority at the practitioner level. For JONA readers, we present, in two parts, an abridged version of the chapter "Budgeting: Holding the Purse Strings." Part 1, which follows, outlines important steps for the development of a successful and efficient budgeting program that can be adapted to meet the needs of other decentralized organizations. Part 2, which details a typical budget session, will appear in the next issue of JONA.

Budgets↗
PubMed2003

Dynamic energy and time budgets in hummingbirds: a study in Sephanoides sephaniodes.

Temperature and diet quality are two of the most important factors affecting the dynamic regulation of animal energy budgets. Because hummingbirds are very sensitive to energy stress, we used Green-backed Firecrowns (Sephanoides sephaniodes) to test the dynamics of their energy budget under different energetic challenges in chronic conditions (20 days). Experimental groups were: HQ-TNZ (high quality diet and thermoneutrality), HQ-LT (high quality diet and low temperature), LQ-TNZ (low quality diet and thermoneutrality), and LQ-LT (low quality diet and low temperature). Analysis of behavioral, morphological, and physiological variables revealed that thermal and dietary factors affect time and energy budgets independently. Hummingbirds increased energy intake during the first day of acclimation at LT, but after second day, the LQ-LT group did not maintain their energy intake and began to loose body mass. Moreover, diet quality affected digestive organs. The intestine, gizzard, liver and kidneys all increased in size when food quality was lowest, probably to obtain more food per feeding event and to more efficiently process the ingested food. Exposure to low ambient temperatures affected the most metabolically productive organs such as the heart, lungs, and muscular mass. Lower temperature increased basal and daily energy expenditure, and changed the time budget. Sephanoides sephaniodes spent more time perching when their energy balance was close to be negative. We suggest that energy budget regulation in hummingbirds does not reside exclusively in the energy output nor in the energy-input but in both pathways.

Acclimatization↗
PubMed2003

Ion budgets and sediment-water interactions during the experimental acidification and recovery of Little Rock Lake, Wisconsin.

Ion budgets for the two basins of experimentally acidified Little Rock Lake (Vilas County, WI, U.S.A.) indicate that Ca2+, Mg2+, and K+ were released from the bottom sediments to the water column during 1984-1994, and NH4+, NO3-, and SO4(2-) were removed for a net internal alkalinity generation (IAG). Sulfate removal contributed approximately 50% of the IAG in the reference basin, and cation production generated approximately 40%. In-lake processes in the reference basin removed approximately 38% of the sulfate input; 58% was lost to outflow, and 4% remained in the water column. As a result of acid additions that stimulated sulfate reduction and lower pH that enhanced ion exchange, sulfate removal and Ca2+ production were more important for IAG in the treatment basin. During 1984-1994, sulfate removal contributed about 61% of the IAG, and Ca2+ production contributed about half of the IAG from cation production. In the treatment basin, in-lake processes removed about 46% of the total input of sulfate (including acid additions); 36% was lost to outflow and 18% remained in the water column (representing approximately 25% of the added acid). In both basins of LRL, NH4+ consumption roughly balanced NO3- consumption, and net N transformations provided only 3-12% of the IAG. Overall, Na+ and Cl- were conservative in both basins during 1984-1994. Most ion budget components, including calculated internal reaction terms, showed fairly large interannual variations; e.g., ion inputs (dominated by atmospheric deposition) varied by a factor of about two. Over the 10-year period, ANC terms calculated from the budgets as the difference between base cation and acid anion terms agreed well with measured ANC terms for the budget components, indicating that the budgets accounted for all important IAG constituents.

Acid Rain↗
PubMedDate not supplied

Activity budget and positional behavior of the Mysore slender loris (Loris tardigradus lydekkerianus): implications for slow climbing locomotion.

Both predator defense and feeding ecology models have been proposed to explain the relatively slow climbing locomotion of the Lorisinae. During a study of the socioecology of the Mysore slender loris (Loris tardigradus lydekkerianus) in Tamil Nadu, India, six categories of behavior and eleven different postures were recorded to estimate a general activity budget for the slender loris, and are examined here particularly in relation to slow climbing locomotor strategies. Reactions to potential predators are also described. The main study population was composed of 15 animals. Activity budgets were compiled in three ways: all instantaneous point samples collected over 1,173 h pooled (n = 13,717), the means of individual lorises (n = 15) and behavior at the moment of first contact (n = 357). No significant difference was found between these three data sets. Approximately 45% of the activity budget was spent in inactive behaviors including sitting vigilant, resting and sleeping. Foraging and traveling comprised nearly half the activity budget, with the rest of the time spent grooming. The most common postures assumed by lorises were sitting and quadrupedal walking. Individual lorises were relatively gregarious and spent up to half their activity budget with other animals. Unlike pottos and angwantibos, lorises did not freeze, head butt or drop from branches in reaction to potential predators, but either ignored them, fled or made loud calls. Cryptic and slow climbing locomotion were used before traveling on open ground between discontinuous substrates, thereby supporting hypotheses relating to predator pressure, and also before capturing fast moving insect prey, supporting hypotheses relating to diet. It is proposed that a divergence in foraging strategies between bushbabies and lorisines may be the best adaptive explanation for their behavioral and morphological differences, including predator defense mechanisms.

Animals↗
PubMed1975

Input-output analysis and the hospital budgeting process.

Two hospitals budget systems, a conventional budget and an input-output budget, are compared to determine how they affect management decisions in pricing, output, planning, and cost control. Analysis of data from a 210-bed not-for-profit hospital indicates that adoption of the input-output budget could cause substantial changes in posted hospital rates in individual departments but probably would have no impact on hospital output determination. The input-output approach promises to be a more accurate system for cost control and planning because, unlike the conventional approach, it generates objective signals for investigating variances of expenses from budgeted levels.

Accounting↗
PubMedDate not supplied

Error budgets: a system to characterize error source in health care experimentation.

OBJECTIVE: In the design of an experiment, it is important that all significant sources of error be identified and characterized accurately before the experiment is executed. For many experiments, the experiment designer is less inclined to ignore significant error factors when he adopts the use of an error budget in his experiment design process. A plan for generating an accurate error budget is presented along with a discussion concerning the disposition of significant error sources. METHODS: Specific methods discussed to generate the error budget are the fishbone diagram, factor weighing and Pareto analysis. Specific dispositions suggested are to eliminate, attenuate, characterize or to simply acknowledge the error with no remedy. These procedures, adhered to by most successful experiment design teams in industry, have evolved over recent decades and seem to be of use as they are applied to health care research. RESULTS: Use of the outlined method forces the experimenter to become familiarized with the most significant variables of the experiment he or she is designing through the deliberate examination of experimental noise contributors and through the comparison of the experimental noise to the magnitudes of the measurements in the experiment. CONCLUSION: The design of health care research experiments may be streamlined by incorporating the methods outlined in the generation of an error budget and by properly using the error budget to dispose of each source of error properly.

Chiropractic↗
PubMedDate not supplied

Global budgets and excess demand for hospital care.

Excess demand is a pervasive feature of health care systems that use global budgets to pay for hospital care, regardless of the amount of money spent by those systems. This paper presents a theory that explains this feature of global budgets. The theory emphasizes that hospital administrators control the allocation of their budget, and that they choose quantity and resource intensity to maximize their own utility. The equilibrium quantity of care provided may be less than quantity demanded by consumers, leading to excess demand for admissions. An increase in the hospital's budget may even be associated with an increase in excess demand.

Budgets↗
PubMed1998

[Performance-related income budget. A means for reorganizing hospital financing].

Performance-related budgets are the result of negotiated performance units per hospital multiplied by state-wide negotiated prices. Such hospital budgets contain profit chances and loss risks. Exceeding the contractual fixed amount leads to price reductions, falling below that amount leads to lower reimbursement. A consistent pricing system for basic and department performance units could solve the present problem of cost separation in Germany. A step in this direction is the definition of hospital department groups and the construction of an average department treatment case, which could be priced on an average cost base. In the long run, more flexibility according to pricing and budgeting can be developed. Competitive insurance companies should be free to find their own budgets so that a hospital can have several independent contractors.

Budgets↗
PubMed2006

Fixed budgets as a cost containment measure for pharmaceuticals.

In Västerbotten County, Sweden, there are two health centers which (in contrast to all other health centers in the region) bear strict responsibility over their pharmaceutical budget. This study examined whether the prices and quantities of pharmaceuticals prescribed by physicians working at these health centers differ significantly from those prescribed by physicians at health centers with open-ended budgets. Estimation results using matching methods, which allows us to compare similar patients at the different health centers, show that the introduction of fixed pharmaceutical budgets did not affect physicians' prescription behavior, indicating that fixed budgets may not be an efficient measure to reduce costs. Another explanation is that the health centers under study already had taken measures to contain costs, making it hard to further reduce costs.

Budgets↗
PubMed1990

GP budget holding in the United Kingdom: learning from American HMOs.

A key component of the 1989 British National Health Service White Paper, 'Working for Patients', is the so-called budget holding plan for general practitioners. This controversial proposal calls on GPs to manage their patients' budgets for consultant (specialist) services and hospital care. Most aspects of the scheme, now only contemplated in the U.K., have functioned for years in American health maintenance organisations (HMOs). The thesis of this article is that an analysis of the GP budget holding proposal, in light of the many years of experience with HMOs, will provide valuable insight into how the British innovation might (or might not) function. Moreover, we believe the U.S. HMO experience has a high degree of relevance for the design, implementation and management of budget holding practices in the NHS of the 1990s, as well as other similar proposals being considered across the European continent.

Budgets↗
PubMed1995

Clearing the fog on the Tyne: programme budgeting in Newcastle and North Tyneside Health Authority.

When the internal market was introduced, the National Health Service Management Executive envisaged purchasing as a process by which contracts would be developed from information concerning current services, modified in the light of strategic purchasing objectives, epidemiological needs assessment and indicators of comparative performance and efficiency. Our concern in this paper is with the promotion of efficiency. We distinguish between three levels and, in particular, discuss how the programme budgeting and marginal analysis framework can be used in the promotion of efficiency at 'top-level' decision making. PB/MA can be used to give a focus to needs assessment and forge explicit links between individual contracts within a well defined health strategy. The objectives of the current research and development ongoing within Newcastle and North Tyneside Health Authority are outlined. The intention is to achieve programme budgeting which is more responsive to decision makers' needs and is consistent with the contracting cycle. However, a number of constraints are expected to impede development. They include transferability of national and international information; absence of local information on epidemiology, effectiveness and cost-effectiveness; limitations on the accuracy and precision of programme budgets; and whether purchasers make strategic decisions based on macro budgets. The contribution of each of these constraints is explored.

Budgets↗
PubMed2006

A software tool to aid long-term care budget planning at local authority level.

OBJECTIVE: Local authorities face real challenges when it comes to annual budget planning for funding the system of long-term care. Uncertainty about the long-term cost of caring for current residents in the system, in addition to unknown future admissions, have made the tasks of local authority budget managers very complex and demanding. In this paper, we present a software implementation of a novel forecasting framework developed by the authors to provide useful information to local authority budget planners involved in long-term care. METHODS: The tool is built upon a forecasting framework, which combines unit costs of care with an estimated underlying survival model for publicly funded residents in long-term care, to provide forecasts of the cost of maintaining the group of elderly people who are currently in long-term care (referred to as known commitments) for a period of time. A prototype version of the software tool, which was created and tested in collaboration with an English borough, allows user interaction via a friendly graphical interface that guides through a set of screens of options in a familiar wizard fashion. RESULTS AND DISCUSSION: Feedback from care planners and managers show that the tool helps them gain better understanding of the patterns of length-of-stay of residents under their care, and provides quantitative inputs into their decision making on budget planning for long-term care. The development of the software tool brings advanced modelling techniques out of research papers into the hands of decision makers in the public sector and contributes to improving the delivery of long-term care.

Activities of Daily Living↗
PubMed1998

Primary care reform: a three country comparison of 'budget holding'.

Governments in most developed nations have been looking to organisational and financial reform of health systems over the last decade. Although the structure and problems of the health care sector in each country may differ, with countries correspondingly adopting different reform agendas, there has been some element of commonality in reforms: that of (managed) competition. Of particular importance in such reforms has been the strengthening of primary care. General practitioners and primary care physicians, as 'gatekeepers' to the health system, are increasingly being called upon to be accountable; not only for their patients' health but also for the wider resource implications of any treatments prescribed. In some countries this role has been formalised through establishing 'budget holding' for general practitioners and primary care physicians, for example, through general practice 'fund holding' in the UK, Health Maintenance Organisations in the USA, and Independent Practice Associations in New Zealand. This paper examines: (i) what such budget holding seeks to achieve; (ii) the effectiveness of the budget holding experience to date in achieving these objectives; and (iii) factors which appear to determine the success of budget holding in achieving its objectives.

Budgets↗
PubMed2000

Implications of the Balanced Budget Act of 1997.

The sweeping and challenging changes in the health care industry emanating from the Balanced Budget Act of 1997 have exceeded those experienced by health care providers and consumers under the Tax Equity and Fiscal Responsibility Act of 1982, the Diagnosis Related Groupings in 1984, and the Resource-Based Relative Value Scale in 1992. To understand and cope with these changes, the financial impact of the Balanced Budget Act is examined in depth, particularly in terms of reimbursement or funding for all health care settings, providers, and medical education. The dramatic changes in the health care delivery process that have caused havoc and turmoil also are examined. For survival and growth under the Balanced Budget Act, reengineering strategies are presented. The ethical and social responsibilities that underlie the current and future impact of the Balanced Budget Act are analyzed to foster the principles of justice, fairness, and best interests of the public.

Budgets↗
PubMed2005

[The regional budget for mental health care: a new approach to combine inpatient and outpatient care].

OBJECTIVE: Due to increasing health care expenditures the discussion about advantages and disadvantages of new methods for resource allocation in mental health care has been intensified. A promising model is the Regional Budget for Mental Health Care, which is currently being examined in Schleswig-Holstein. The present paper describes first experiences with the new resource allocation model. BASIC CONDITIONS: An annual budget, provided for the treatment of a fixed number of patients, makes it possible to reduce inpatient capacity in favour of improved community-integrated approaches for the treatment of acute psychiatric illness. RESULTS: In a first step inpatient capacity will be reduced by 8 percent. By the end of 2007 capacity for hospital day care shall be increased by 87 percent and a home treatment will be implemented. The previous working method, orientated to treatment setting, will be replaced by an approach specialized in diagnostic groups. CONCLUSIONS: The Regional Budget could improve the continuity and flexibility of patient care. Service providers become motivated to treat in a way, which with little resource consumption achieves a long lasting health status improvement. For health insurances the Regional Budget is an opportunity to limit cost increases.

Ambulatory Care↗
PubMed1986

Funding human services: fixed utility versus fixed budget.

It is argued in this paper that government allocations for human services based on inputs rather than outcomes, reduce efficiency in social and health service provision. An alternative system of budgeting or contracting on the basis of cost-per-closed case and case outcome is discussed. An interdependency between fixed budget and fixed utility models of allocation is affirmed. The locus of decision-making for operationalizing this interdependency is seen as the program and budget review panel to which operating agencies and government departments must submit financial and program accounting information from year to year. In isolation, the fixed budget approach degenerates into routine allocation or contract renewal with a focus on such input and output variables as volume of service and unit cost, and the fixed utility approach, into political stalemate. Simulated examples are given to demonstrate how allocation on the basis of inputs and outputs alone provides an incentive to inefficiency, and a fixed utility orientation to efficiency.

Budgets↗
PubMed1999

Mission-based budgeting: removing a graveyard.

Many activities in today's medical schools no longer have medical students' education as their central reason for existence. Faculty are hired primarily to provide clinical service or to make discoveries, with the role of educator of secondary importance. Budgeting in medical schools has not evolved in concert with these changing roles of faculty. The cost of medical students' education is still calculated as if all faculty were hired primarily to teach medical students and their other activities were to support this "central" mission. Most medical schools still mix revenues without regard to intent and cannot accurately determine costs because they confuse expenses with costs. At the University of Florida College of Medicine, a group of administrators, chairpersons, and faculty developed a budgeting process now called mission-based budgeting. This is a three-step process: (1) revenues are prospectively identified for each mission and then aligned with intended purposes; (2) faculty productivity, i.e., faculty effort and its quality, is measured for each of the missions; and (3) productivity is linked to the prospective budget for each mission. This process allows the institution to understand the intent of its revenues, to measure how productive its faculty are, to learn the true costs of its missions, to make wise investment decisions (subsidies), and to justify to various constituents its use of revenues. The authors describe this process, focusing particularly on methods used to develop a comprehensive database for assessment of faculty productivity in education.

Academic Medical Centers↗
PubMed2002

Optimal resource allocation for curing Chlamydia trachomatis infection among asymptomatic women at clinics operating on a fixed budget.

GOAL: The goal was to determine the optimal strategy for screening coverage, test selection, and treatment for infection in asymptomatic women for a given family-planning-program budget. STUDY DESIGN: We developed a resource allocation model to determine the optimal strategy using data from 5078 visits by women universally screened for infection in a publicly funded family planning clinic system in Philadelphia. We maximized the number of infected women cured from the clinic perspective and maximized the cost-savings from the healthcare system perspective. The model incorporated the following age distributions: <20 years (27%), 20 to 24 years (30%), and >24 years (43%), with prevalences of 10.6%, 6.9%, and 2.3%, respectively. We modeled two screening test assays (DNA probe and ligase chain reaction [LCR] for cervical specimens) and two treatments (doxycycline and azithromycin). The model allowed for different test and treatment choices by age group. RESULTS: At the baseline annual budget of $6 per visit, the strategy that maximized both the number of infected women cured and cost savings would be to screen all women with DNA probe and to treat all women with positive tests with azithromycin. This strategy would result in 183 women cured at a cost-savings of $140,176. Sensitivity analysis showed that the total budget had a great impact on the optimal strategy, incorporating screening coverage, test selection, and treatment. CONCLUSIONS: Using resource allocation models enables clinic managers operating with a fixed budget to identify a strategy that maximizes the number of asymptomatic women cured and cost savings when the clinic age distribution and age-specific prevalences are known.

Ambulatory Care Facilities↗