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We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs to implement changes arising from our continuing experience with these systems, and to implement a number of changes made by the Deficit Reduction Act of 2005 (Pub. L. 109-171). In addition, in the Addendum to this final rule, we describe the changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs. We also are setting forth rate-of-increase limits as well as policy changes for hospitals and hospital units excluded from the IPPS that are paid in full or in part on a reasonable cost basis subject to these limits. These changes are applicable to discharges occurring on or after October 1, 2006. In this final rule, we discuss public comments we received on our proposals to refine the diagnosis-related group (DRG) system under the IPPS to better recognize severity of illness among patients--to use a hospital-specific relative value (HSRV) cost center weighting methodology to adjust DRG relative weights; and to implement consolidated severity-adjusted DRGs or alternative severity adjustment methods. Among the other policy changes that we are making are those changes related to: limited revisions of the reclassification of cases to DRGs; the long-term care (LTC)-DRGs and relative weights; the wage data, including the occupational mix data, used to compute the wage index; applications for new technologies and medical services add-on payments; payments to hospitals for the direct and indirect costs of graduate medical education; submission of hospital quality data; payments to sole community hospitals and Medicare-dependent, small rural hospitals; and provisions governing emergency services under the Emergency Medical Treatment and Labor Act of 1986 (EMTALA). We are responding to requested public comments on a number of other issues that include performance-based hospital payments for services and health information technology, as well as how to improve health data transparency for consumers. In addition, we are responding to public comments received on a proposed rule issued in the Federal Register on May 17, 2006 that proposed to revise the methodology for calculating the occupational mix adjustment to the wage index for the FY 2007 hospital inpatient prospective payment system by applying an adjustment to 100 percent of the wage index using new 2006 occupational mix survey data collected from hospitals. We are finalizing two policy documents published in the Federal Register relating to the implementation of the Health Care Infrastructure Improvement Program, a hospital loan program for cancer research, established under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. This final rule also revises the definition of the term "unit" to specify the exclusion of units of drugs sold to approved Medicare Competitive Acquisition Program (CAP) vendors for use under the CAP from average sales price (ASP) calculations for a period of up to 3 years, at which time we will reevaluate our policy.
This study used program location and program reputation to describe two important faculty characteristics: academic reputation and research reputation. The study involved 44 graduate programs in health administration representing four program locations: schools of public health, business, medicine/allied health, and graduate/independent. Fourteen programs were identified as ranked programs and the remaining 30 programs were identified as unranked programs. While the study identifies many differences, few are significant, thus adding credence to the argument for diversity in program location and diminishing credence in the argument for program reputation.
This study investigated program directors' perspectives on Didactic Program in Dietetics graduates' inability to secure positions in Supervised Practice Programs. The sample included all 229 program directors listed in the Directory of Dietetics Programs 1997-98. Directors contacted by electronic mail or fax completed a 4-part survey instrument including 3 Likert scale sections exploring the effects of the situation and strategies suggested to lessen them. The fourth part reported current practices. Response rate was 56%. Graduates' failure to secure Supervised Practice Program positions was found to be a significant or somewhat significant problem regardless of program size or affiliation. Strategies to increase the likelihood of Supervised Practice Program acceptance included work experience, application coaching, graduate coursework, and reapplication. We found that program directors have a high level of concern about their graduates' futures and are frustrated by their limited ability to improve the situation. Helping graduates who do not secure Supervised Practice Program assignments identify career options is essential.
Over the past quarter-century, evaluation researchers have recognized the importance of documenting implementation practices of programs as they are transferred from controlled to real-world settings. As programs become widely disseminated in the general population, there is a tendency for practitioners to alter programs in a manner more conducive to their immediate needs, which may adversely affect program outcomes. The current paper uses findings from an ongoing evaluation of a school-based victimization prevention program to highlight some of the difficulties in maintaining a high degree of fidelity when providing prevention programming in a school-based setting. The results, based on observations of program delivery and program provider descriptions of implementation, allow for the examination of fidelity based on different data collection techniques.
We developed a questionnaire regarding issues in psychiatric residency training and distributed it to the chief residents at all United States general psychiatry residency training programs. We hoped to examine psychiatry residency program characteristics and see if any particular characteristics had a significant relationship to improved success in the 1994 National Residency Matching Program (NRMP) results. We found that those programs with six or more PGY-1 positions available in the NRMP, those programs with an associated child and adolescent psychiatry residency training program, and those programs offering a research elective had a higher PGY-1 match through the NRMP than programs without these features.
Many approaches can be used to develop understanding of service programs. These approaches vary in how much they rely on technical vs. political procedures, who controls them, purpose, scope of content, and generality of results. Only some of these approaches are usually considered program evaluation. This diversity is illustrated by a description of the history of 10 program evaluation-like approaches to understanding as they operated during the 18-year life of the federal Community Mental Health Centers (CMHC) Program. When services were funded in federal categorical programs, information-gathering approaches focused narrowly on the program and its activities. It now appears that more widely useful information would result by shifting from the evaluation of "programs" to comparative analysis and evaluation of service systems.
Major programs of the College of American Pathologists (CAP) are directed toward improvement of laboratory practices through peer review, interlaboratory comparison, education, and development of practice standards and guidelines. Two programs provided to cytopathology laboratories, the Laboratory Accreditation Program and the Interlaboratory Comparison Program in Cervicovaginal Cytology, are dedicated to these laboratory improvement principles. In 1996, each of these programs served over 2100 laboratories that provide cytopathology services. This paper reviews the peer development, structure, and administration of the Laboratory Accreditation Program and the Interlaboratory Comparison Program in Cervicovaginal Cytology, focusing on recent and ongoing initiatives to enhance their contribution to continued improvement of gynecologic cytopathology laboratory practices.
The financing and delivery of long-term care (LTC) need substantial reform. Many cannot afford essential services; age restrictions often arbitrarily limit access for the nonelderly, although more than a third of those needing care are under 65 years old; Medicaid, the principal third-party payer for LTC, is biased toward nursing home care and discourages independent living; informal care provided by relatives and friends, the only assistance used by 70% of those needing LTC, is neither supported nor encouraged; and insurance coverage often excludes critically important services that fall outside narrow definitions of medically necessary care. We describe an LTC program designed as an integral component of the national health program advanced by Physicians for a National Health Program. Everyone would be covered for all medically and socially necessary services under a single public plan, federally mandated and funded but administered locally. An LTC payment board in each state would contract directly with providers through a network of local public agencies responsible for eligibility determination and care coordination. Nursing homes, home care agencies, and other institutional providers would be paid a global budget to cover all operating costs and would not bill on a per-patient basis. Alternatively, integrated provider organizations could receive a capitation fee to cover a broad range of LTC and acute care services. Individual practitioners could continue to be paid on a fee-for-service basis or could receive salaries from institutional providers. Support for innovation, training of LTC personnel, and monitoring of the quality of care would be greatly augmented. For-profit providers would be compensated for past investments and phased out. Our program would add between $18 billion and $23.5 billion annually to current spending on LTC. Polls indicate that a majority of Americans want such a program and are willing to pay earmarked taxes to support it.
"Nothing in biology makes sense except in the light of evolution", wrote Theodosius Dobzhansky, one of the founders of the Modern Synthesis that led to the unification of evolutionary theory and genetics in the midst of the 20th century. Programmed cell death is a genetically regulated process of cell suicide that is central to the development, homeostasis and integrity of multicellular organisms. Conversely, the dysregulation of mechanisms controlling cell suicide plays a role in the pathogenesis of a wide range of diseases. While great progress has been achieved in the unveiling of the molecular mechanisms of programmed cell death, a new, and somehow puzzling level of complexity has recently begun to emerge, suggesting i) that several different self destruction pathways may exist and operate in parallel in our cells, and ii) that molecular effectors of cell suicide might also perform other functions unrelated to cell death induction and crucial to cell survival, such as cell differentiation, metabolism, and the regulation of the cell cycle. These new findings, with important physiopathological and therapeutic implications, seem at odds with the paradigm of programmed cell death derived from the studies of Caenorhabditis elegans, which led to the concept of the existence of selective, bona fide death genes that emerged and became selected for their sole capacity to execute or repress cell death. In this review, I will argue that this new level of complexity might only make sense and be understood when considered in a broader evolutionary context than that of our phylogenetic divergence from C. elegans. A new view of the regulated cell death pathways emerges when one attempts to ask the question of when and how they may have become selected during a timeline of 4 billion years, at the level of ancestral single-celled organisms, including the bacteria. I will argue that there may be no such thing as a bona fide genetic cell death program. Rather, in the framework of a model that I have termed the "original sin" hypothesis, I have proposed the existence of an initial pleiotropy of the molecular tools involved in the control and execution of self-destruction--an ancestral involvement in both pro-life and pro-death activities. I will discuss how this hypothesis may be reconciled with the C. elegans paradigm of programmed cell death. Finally I will discuss how an ancestral level of pleiotropic functions of the molecular tools involved in the control of cell death, aging and genetic diversification might have favored their initial selection, their constant availability for de novo selection, and their progressive propagation in most--if not all--species during the course of evolution.
It has been shown in the for-profit sector (business, service, and manufacturing) that the success of an organization depends on its ability to satisfy customer requirements while eliminating waste and reducing costs. The purpose of this article was to examine the impact of current practices in customer focus on program participation rates in the Virginia WIC Program. The results of this study showed that the use of customer-focused strategies was correlated to program participation rates in the WIC Program. The mean data showed that teamwork and accessibility were at unsatisfactory levels in Virginia.
Many researchers have shown a link between employee job satisfaction and customer satisfaction in the private sector. Customer satisfaction is the end result of whether the particular service and/or a product meet the customer's needs. The purpose of this research project was to assess the level of employee job satisfaction in the Virginia WIC Program and to determine whether a correlation exists between the level of employee job satisfaction and program participation rates. The results of this study showed that high levels of employee job satisfaction were positively correlated to high program participation rates in the Virginia WIC Program.
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This final rule establishes requirements and procedures for implementation of the TRICARE Program, the purpose of which is to implement a comprehensive managed health care delivery system composed of military medical treatment facilities and CHAMPUS. Principal components of the final rule include: establishment of a comprehensive enrollment system; creation of a triple option benefit, including a Uniform HMO Benefit required by law; a series of initiatives to coordinate care between military and civilian delivery systems, including Resource Sharing Agreements, Health Care Finders, PRIMUS and NAVCARE Clinics, and new prescription pharmacy services; and a consolidated schedule of charges, incorporating steps to reduce differences in charges between military and civilian services. This final rule also includes provisions establishing a special civilian provider program authority for active duty family members overseas. The TRICARE Program is a major reform of the MHSS that will improve services to beneficiaries while helping to contain costs.
This rule finalizes the interim final rule with comment period published in the Federal Register November 24, 1999 (64 FR 66234) and the interim final rule with comment period published in the Federal Register on October 1, 2002 (67 FR 61496). The November 1999 interim final rule implemented sections 4801 through 4803 of the Balanced Budget Act of 1997 (Pub. L. 105-33) and established requirements for Programs of All-inclusive Care for the Elderly (PACE) under the Medicare and Medicaid programs. The interim final rule with comment period published on October 1, 2002 (67 FR 61496) implemented section 903 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Pub. L. 106-554).
This final rule simplifies the administration of benefits under the CHAMPUS Program for the Handicapped (PFTH) and changes the name of this benefit to Program for Persons with Disabilities (PFPWD); adds occupational therapists in independent practice to the list of authorized individual professional providers; provides criteria for cost-sharing certain procedures when data is transferred electronically from the patient's home to a medical practitioner; defines and limits plans recognized as supplemental insurance under CHAMPUS; and adopts the Federal Claims Collection Act and the Federal Claims Collection Standards by reference.