Individual choices and universal rights for drinking water in rural Africa.

More than 500 million rural Africans lack safe drinking water. The human right to water and United Nations Sustainable Development Goal SDG6.1 promote a policy shift from building water infrastructure to sustaining water services. However, the financial calculus is bleak with the costs of "safely managed"' or "basic" water services in rural Africa beyond current government budgets and donor funds. The funding shortfall is compounded by the disappointing results of earlier policy initiatives in Africa. This is partly because of a failure to understand which attributes of water services rural people value. We model more than 11,000 choice observations in rural Kenya by attributes of drinking water quality, price, reliability, and proximity. Aggregate analysis disguises alternative user priorities in three choice classes. The two larger choice classes tolerate lower service levels with higher payments. A higher water service level reflects the smallest choice class favored by women and the lower wealth group. For the lower wealth group, slower repair times are accepted in preference to a lower payment. Some people discount potable water and proximity, and most people choose faster repair times and lower payments. We argue policy progress needs to chart common ground between individual choices and universal rights. Guaranteeing repair times may provide a policy lever to unlock individual payments to complement public investment in water quality and waterpoint proximity to support progressive realization of a universal right.

The Effects of Global Budgeting on Emergency Department Admission Rates in Maryland.

STUDY OBJECTIVE: In 2014, Maryland launched a population-based payment model that replaced fee-for-service payments with global budgets for all hospital-based services. This global budget revenue program gives hospitals strong incentives to tightly control patient volume and meet budget targets. We examine the effects of the global budget revenue model on rates of admission to the hospital from emergency departments (EDs). METHODS: We used medical record and billing data to examine adult ED encounters from January 1, 2012, to December 31, 2015, in 25 hospital-based EDs, including 10 Maryland global budget revenue hospitals, 10 matched non-Maryland hospitals (primary control), and 5 Maryland Total Patient Revenue hospitals (secondary control). Total Patient Revenue hospitals adopted global budgeting in 2010 under a pilot Maryland program targeting rural hospitals. We conducted difference-in-differences analyses for overall ED admission rates, ED admission rates for ambulatory-care-sensitive conditions and non-ambulatory-care-sensitive conditions, and for clinical conditions that commonly lead to admission. RESULTS: In 3,175,210 ED encounters, the ED admission rate for Maryland global budget revenue hospitals decreased by 0.6% (95% confidence interval -0.8% to -0.4%) compared with that for non-Maryland controls after global budget revenue implementation, a 3.0% relative decline, and decreased by 1.9% (95% confidence interval -2.2% to -1.7%) compared with that for Total Patient Revenue hospitals, a 9.5% relative decline. Relative declines in ED admission rates were similar for ambulatory-care-sensitive-condition and non-ambulatory-care-sensitive-condition encounters. Admission rate declines varied across clinical conditions. CONCLUSION: Implementation of the global budget revenue model led to statistically significant although modest declines in ED admission rates within its first 2 years, with declines in ED admissions most pronounced among certain clinical conditions.

Standardized Cost Estimates for Home Visiting: Pilot Study of the Home Visiting Budget Assistance Tool (HV-BAT).

Purpose Using a standardized approach and metrics to estimate home visiting costs across multiple evidence-based models and regions could improve the consistency and accuracy of cost estimates, allow stakeholders to observe trends in cost allocation, analyze how home visiting costs vary, and develop future program budgets. Between October 2015 and December 2018, we developed and pilot-tested the Home Visiting Budget Assistance Tool (HV-BAT) to standardize the collection of home visiting program costs and analyze costs for local implementing agencies (LIAs). Methods We recruited LIAs that implemented at least one of nine evidence-based home visiting models in 15 states implementing the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program. LIAs reported their costs to implement a home visiting model using the HV-BAT and provided feedback on the tool. We estimated annual total cost and cost per family served for each LIA, examined cost summary statistics for the sample, and analyzed whether and how LIA characteristics affected home visiting costs using regression analyses. Results Of the 168 LIAs invited to participate in the HV-BAT pilot study, 75 agreed to participate, and 45 across 14 states completed the HV-BAT. We estimated home visiting costs of approximately $8500 per family per year, but costs varied across LIAs (range $1970-$39,770; standard deviation = $5794). The marginal cost of adding a family declined as the number of families served by an LIA increased. Feedback from LIAs indicated that users had difficulty providing some details on costs (e.g., mileage for specific services), needed more detailed instructions, and desired a summary of subtotals and total costs reported in the HV-BAT. Conclusions The HV-BAT provides an approach to standardize cost data collection for home visiting programs. Pilot study results indicate that there may be significant economies of scale for home visiting services. This study provides preliminary estimates of costs that can help in program planning and budgeting.

Sharing and the Provision of "Cost-Ineffective" Life-Extending Services to Less Severely Ill Patients.

BACKGROUND: Cost-utility analysis prioritizes services using cost, life-years, and the health state utility of the life-years. Nevertheless, a significant body of evidence suggests that the public would prefer more variables to be considered in decision making and at least some sharing of the budget with services for severe conditions that are not cost-effective because of their high cost. OBJECTIVES: To examine whether this preference for sharing persists for less severe conditions when both cost effectiveness and illness severity would indicate that resources should be allocated to other services. METHODS: Survey respondents were asked to divide a budget between two patients facing life-threatening illnesses. The severity of the illnesses differed and the price of treatment was varied. RESULTS: Sharing occurred in all scenarios including scenarios in which the illness was less severe and services were not cost-effective. Results are consistent with behavior commonly observed in other contexts. CONCLUSIONS: Results suggest that sharing per se is important and that the public would support some funding of cost-ineffective services for less severe health problems.

Resolving the "Cost-Effective but Unaffordable" Paradox: Estimating the Health Opportunity Costs of Nonmarginal Budget Impacts.

Considering whether or not a proposed investment (an intervention, technology, or program of care) is affordable is really asking whether the benefits it offers are greater than its opportunity cost. To say that an investment is cost-effective but not affordable must mean that the (implicit or explicit) "threshold" used to judge cost-effectiveness does not reflect the scale and value of the opportunity costs. Existing empirical estimates of health opportunity costs are based on cross-sectional variation in expenditure and mortality outcomes by program budget categories (PBCs) and do not reflect the likely effect of nonmarginal budget impacts on health opportunity costs. The UK Department of Health regularly updates the needs-based target allocation of resources to local areas of the National Health Service (NHS), creating two subgroups of local areas (those under target allocation and those over). These data provide the opportunity to explore how the effects of changes in health care expenditure differ with available resources. We use 2008-2009 data to evaluate two econometric approaches to estimation and explore a range of criteria for accepting subgroup specific effects for differences in expenditure and outcome elasticities across the 23 PBCs. Our results indicate that health opportunity costs arising from an investment imposing net increases in expenditure are underestimated unless account is taken of likely nonmarginal effects. They also indicate the benefits (reduced health opportunity costs or increased value-based price of a technology) of being able to "smooth" these nonmarginal budget impacts by health care systems borrowing against future budgets or from manufacturers offering "mortgage" type arrangements.

Use of programme budgeting and marginal analysis to set priorities for local NHS dental services: learning from the north east of England.

Background: Priority setting is necessary where competing demands exceed the finite resources available. The aim of the study was to develop and test a prioritization framework based upon programme budgeting and marginal analysis (PBMA) as a tool to assist National Health Service (NHS) commissioners in their management of resources for local NHS dental services. Methods: Twenty-seven stakeholders (5 dentists, 8 commissioners and 14 patients) participated in a case-study based in a former NHS commissioning organization in the north of England. Stakeholders modified local decision-making criteria and applied them to a number of different scenarios. Results: The majority of financial resources for NHS dental services in the commissioning organization studied were allocated to primary care dental practitioners' contracts in perpetuity, potentially constraining commissioners' abilities to shift resources. Compiling the programme budget was successful, but organizational flux and difficulties engaging local NHS commissioners significantly impacted upon the marginal analysis phase. Conclusions: NHS dental practitioners' contracts resemble budget-silos which do not facilitate local resource reallocation. 'Context-specific' factors significantly challenged the successful implementation and impact of PBMA. A local PBMA champion embedded within commissioning organizations should be considered. Participants found visual depiction of the cost-value ratio helpful during their initial priority setting deliberations.

Staff planning for operating rooms with different surgical services lines.

We present a two-phase model for a staff planning problem in a surgical department. We consider the setting where staff, in particular nurse circulators and surgical scrub technicians, are assigned to one of different service lines, and while they can be 'pooled' and temporally assigned to other service line if needed, these re-assignments should belimited. In Phase I, we decide on the number of staff hours to budget for each service line, considering policies limiting staff pooling and overtime, and different demand scenarios. In Phase II, we determine how these budgeted staff hours should be allocated across potential work days and shifts, given estimated staff requirements and shift-related scheduling restrictions. We propose a heuristic to speed the model's Phase II solution time. We implement the model using a hospital's surgical data and compare the model's results with the hospital's current practices. Using a simulation model for the surgical operations, we find that our two-phase model reduces the delays caused by staff unavailability as well as staff pooling, without increasing the workforce size. Finally, we briefly describe a decision-support tool we developed with the objective of fine-tuning staff planning decisions.

Strategic Provider Behavior Under Global Budget Payment with Price Adjustment in Taiwan.

Global budget payment is one of the most effective strategies for cost containment, but its impacts on provider behavior have not been explored in detail. This study examines the theoretical and empirical role of global budget payment on provider behavior. The study proposes that global budget payment with price adjustment is a form of common-pool resources. A two-product game theoretic model is derived, and simulations demonstrate that hospitals are expected to expand service volumes, with an emphasis on products with higher price-marginal cost ratios. Next, the study examines the early effects of Taiwan's global budget payment system using a difference-in-difference strategy and finds that Taiwanese hospitals exhibited such behavior, where the pursuit of individual interests led to an increase in treatment intensities. Furthermore, hospitals significantly increased inpatient service volume for regional hospitals and medical centers. In contrast, local hospitals, particularly for those without teaching status designation, faced a negative impact on service volume, as larger hospitals were better positioned to induce demand and pulled volume away from their smaller counterparts through more profitable services and products such as radiology and pharmaceuticals.

Health spending and political influence: the case of earmarks and health care facilities.

Earmarks, otherwise known as Congressionally directed spending requests, are a historically significant means of political influence over budgets. In this brief, we report on the results of a longitudinal study of federal earmarks affecting health care facilities and public health. We analyzed 10 years of earmark for health care facilities and examined the correlates of being in the top 50% of earmark recipients for each year. Having representatives or senators serving on the respective Appropriations committees were shown to have increased odds of being a top earmark recipient, as was being in jurisdictions with greater poverty. However, health-related measures of need were not significantly associated with being a top earmark recipient.

[Concept of budget-based remuneration system for the fields of psychiatry and psychotherapy, psychosomatic medicine and psychotherapy, child and adolescent psychiatry and psychotherapy]. / Konzept eines budgetbasierten Entgeltsystems für die Fachgebiete Psychiatrie und Psychotherapie, Psychosomatische Medizin und Psychotherapie, Kinder- und Jugendpsychiatrie und -psychotherapie.

A new remuneration system is currently being developed for the hospital care of people with mental disorders. Last year, because of sharp criticism the option phase of the planned Flat-rate Charges in Psychiatry and Psychosomatics (Pauschalierende Entgelte Psychiatrie und Psychosomatik, PEPP) was extended by 2 years. During this time the Federal Ministry of Health wants to look for alternatives and possible starting points for the further development of care. Now, 16 scientific professional associations and organisations have presented a joint concept for a sustainable solution: the budget-based remuneration system. The system is suitable for ensuring that people with mental disorders are treated according to their particular needs and for promoting the appropriate further development of regional care in all treatment settings. It corresponds with the objectives as formulated in Section 17d of the Hospital Finance Act (Krankenhausfinanzierungsgesetz, KHG) and translates the PEPP system, which is currently being developed and focusses on average prices, into a performance-oriented, transparent budgetary system. The fundamental principle is the separation of the individual hospitals' budgeting on the basis of evidence-based, feature- and performance-related modules and billing in the form of advance payments from the agreed budget.

Beyond feedback control: the interactive use of performance management systems. Implications for process innovation in Italian healthcare organizations.

This paper shows how the use of performance management systems affects managers' perception of satisfaction, the effectiveness of the control system and the performance related to process innovation. An exploratory empirical research has been conducted on 85 managers operating in Italian healthcare organizations. Empirical findings put forward that the interactive--as opposed to diagnostic--use of performance management systems enhances managerial satisfaction with the control system and managerial perception of effectiveness. The present study then showed that it is not the control itself that is an obstacle to innovation in organizations in general (and in health organizations in particular) but the diagnostic use of the control mechanisms, which impedes the interaction between the control personnel and those subject to the control. Finally, this paper addresses managerial implications and further research avenues.

Antenatal cardiotocography in primary midwife-led care: a budget impact analysis.

OBJECTIVES: In many countries, the healthcare sector is dealing with important challenges such as increased demand for healthcare services, capacity problems in hospitals and rising healthcare costs. Therefore, one of the aims of the Dutch government is to move care from in-hospital to out-of-hospital care settings. An example of an innovation where care is moved from a more specialised setting to a less specialised setting is the performance of an antenatal cardiotocography (aCTG) in primary midwife-led care. The aim of this study was to assess the budget impact of implementing aCTG for healthy pregnant women in midwife-led care compared with usual obstetrician-led care in the Netherlands. METHODS: A budget impact analysis was conducted to estimate the actual costs and reimbursement of aCTG performed in midwife-led care and obstetrician-led care (ie, base-case analysis) from the Dutch healthcare perspective. Epidemiological and healthcare utilisation data describing both care pathways were obtained from a prospective cohort, survey and national databases. Different implementation rates of aCTG in midwife-led care were explored. A probabilistic sensitivity analysis was conducted to estimate the uncertainty surrounding the budget impact estimates. RESULTS: Shifting aCTG from obstetrician-led care to midwife-led-care would increase actual costs with €311 763 (97.5% CI €188 574 to €426 072) and €1 247 052 (97.5% CI €754 296 to €1 704 290) for implementation rates of 25% and 100%, respectively, while it would decrease reimbursement with -€7 538 335 (97.5% CI -€10 302 306 to -€4 559 661) and -€30 153 342 (97.5% CI -€41 209 225 to -€18 238 645) for implementation rates of 25% and 100%, respectively. The sensitivity analysis results were consistent with those of the main analysis. CONCLUSIONS: From the Dutch healthcare perspective, we estimated that implementing aCTG in midwife-led care may increase the associated actual costs. At the same time, it might lower the healthcare reimbursement.

General budget support: has it benefited the health sector?

There has been recent controversy about whether aid directed specifically to health has caused recipient governments to reallocate their own funds to non-health areas. At the same time, general budget support (GBS) has been increasing. GBS allows governments to set their own priorities, but little is known about how these additional resources are subsequently used. This paper uses cross-country panel data to assess the impact of GBS programmes on health spending in low-income and middle-income countries, using dynamic panel techniques to estimate unbiased coefficients in the presence of serial correlation. We found no clear evidence that GBS had any impact, positive or negative, on government health spending derived from domestic sources. GBS also had no observed impact on total government health spending from all sources (external as well as domestic). In contrast, health-specific aid was associated with a decline in health expenditures from domestic sources, but there was not a full substitution effect. That is, despite this observed fungibility, health-specific aid still increases total government health spending from all sources. Finally, increases in total government expenditure led to substantial increases in domestic government health expenditures.

Evaluating public health resources: what happens when funding disappears?

INTRODUCTION: Although various factors affect the sustainability of public health programs, funding levels can influence many aspects of program continuity. Program evaluation in public health typically does not assess the progress of initiatives after discontinuation of funding. The objective of this study was to describe the effect of funding loss following expiration of a 5-year federal grant awarded to state health departments for development of statewide obesity prevention partnerships. METHODS: The study used qualitative methods involving semistructured key informant interviews with state health departments. Data were analyzed using thematic analysis for effect of funding loss on staffing, programs, partnerships, and implementation of state plans. RESULTS: Many of the programs that continued to run after the grant expired operated at reduced capacity, either reaching fewer people or conducting fewer program activities for the same population. Although many states were able to leverage funding from other sources, this shift in funding source often resulted in priorities changing to meet new funding requirements. Evaluation capacity suffered in all states. Nearly all states reported losing infrastructure and capacity to communicate widely with partners. All states reported a severe or complete loss of their ability to provide training and technical assistance to partners. Despite these reduced capacities, states reported several key resources that facilitated continued work on the state plan. CONCLUSIONS: Decisions regarding continuation of funding are often dependent on budget constraints, evidence of success, and perceived ability to succeed in the future. Evaluating public health funding decisions may help guide development of best practice strategies for supporting long-term program success.

Solve the puzzle of electronic health record implementation budgeting.

Health care organizations need to adopt an electronic health record (EHR) system for compliance with the Health Information Technology for Economic and Clinical Health Act. How to budget the EHR implementation is a challenging issue to the chief financial officers in health care organizations. This article uses a mock hospital to illustrate how to prepare an EHR implementation budget step by step in a hospital setting. After the project budget baseline is set, the budgeting steps are as follows: (1) estimating the cost for each project element, (2) aggregating all costs, and (3) revising budget to meet the budget baseline. Several budgeting techniques are discussed, including analogue, parametric, and unit cost based on effort. The budgeting methodology can also be applied to a physician/clinic EHR implementation budget.

How rolling forecasting facilitates dynamic, agile planning.

Rolling forecasting may be used to replace or supplement the annual budget process. The rolling forecast typically builds on the organization's strategic financial plan, focusing on the first three years of plan projections and comparing the strategic financial plan assumptions with the organization's expected trajectory. Leaders can then identify and respond to gaps between the rolling forecast and the strategic financial plan on an ongoing basis.

'Placement budgets' for supported employment--improving competitive employment for people with mental illness: study protocol of a multicentre randomized controlled trial.

BACKGROUND: Vocational integration of people with mental illness is poor despite their willingness to work. The 'Individual Placement and Support' (IPS) model which emphasises rapid and direct job placement and continuing support to patient and employer has proven to be the most effective vocational intervention programme. Various studies have shown that every second patient with severe mental illness was able to find competitive employment within 18 months. However, the goal of taking up employment within two months was rarely achieved. Thus, we aim to test whether the new concept of limited placement budgets increases the effectiveness of IPS. METHODS/DESIGN: Six job coaches in six out-patients psychiatric clinics in the Canton of Zurich support unemployed patients of their clinic who seek competitive employment. Between June 2010 and May 2011 patients (N=100) are randomly assigned to three different placement budgets of 25h, 40h, or 55h working hours of job coaches. Support lasts two years for those who find a job. The intervention ends for those who fail to find competitive employment when the respective placement budgets run out. The primary outcome measure is the time between study inclusion and first competitive employment that lasted three months or longer. Over a period of three years interviews are carried out every six months to measure changes in motivation, stigmatization, social network and social support, quality of life, job satisfaction, financial situation, and health conditions. Cognitive and social-cognitive tests are conducted at baseline to control for confounding variables. DISCUSSION: This study will show whether the effectiveness of IPS can be increased by the new concept of limited placement budgets. It will also be examined whether competitive employment leads in the long term to an improvement of mental illness, to a transfer of the psychiatric support system to private and vocational networks, to an increase in financial independence, to a reduction of perceived and internalized stigma, and to an increase in quality of life and job satisfaction of the patient. In addition, factors connected with fast competitive employment and holding that job down in the long term are being examined (motivation, stigmatization, social and financial situation). TRIAL REGISTER: ISRCTN89670872.

Credit use: psychological perspectives on a multifaceted phenomenon.

Consumer borrowing is a highly topical and multifaceted phenomenon as well as a popular subject for study. We focus on consumer credit use and review the existing literature. To categorize what is known we identify four main psychological perspectives on the phenomenon: credit use as (1) a reflection of the situation, (2) a reflection of the person, (3) a cognitive process, and (4) a social process. On top of these perspectives we view credit use as a process that entails three distinct phases: (1) processes before credit acquisition, (2) processes at credit acquisition, and (3) processes after credit acquisition. We review the international literature along a two-tier structure that aligns the psychological perspectives with a process view of credit. This structure allows us to identify systematic concentrations as well as gaps in the existing research. We consolidate what is known within each perspective and identify what seems to be most urgently missing. Some of the most important gaps relate to research studying credit acquisition from the perspective of credit use as a reflection of the person or as a social process. In particular, research on credit use as a reflection of the person appears to focus exclusively on the first stage of the credit process. We conclude with a discussion that reaches across perspectives and identifies overarching gaps, trends, and open questions. We highlight a series of implicit linkages between perspectives and the geographical regions in which studies related to the perspectives were conducted. Beyond diagnosing a geographical imbalance of research, we argue for future research that systematically addresses interrelations between perspectives. We conclude with a set of global implications and research recommendations.

Notes from the Director, National Heart, Lung, and Blood Institute: transitions.

During this time of transition in the federal government and the National Institutes of Health, I write to assure the Blood community of the National Heart, Lung, and Blood Institute's (NHLBI) commitment to new and established investigators as outlined in the NHLBI Strategic Plan. This perspective discusses the NHLBI budget for the fiscal year 2009 and new policies for funding early stage investigators and revised grant applications.