Disparities in Colorectal Cancer Treatment Delay Within Appalachia--The Role of For-Profit Hospitals.

BACKGROUND: Appalachian residents have a higher overall cancer burden than the rest of the United States because of the unique features of the region. Treatment delays vary widely within Appalachia, with colorectal cancer patients undergoing median treatment delays of 5 days in Kentucky compared to 9 days for patients in Pennsylvania, Ohio, and North Carolina combined. OBJECTIVE: This study identified the source of this disparity in treatment delay using statistical decomposition techniques. METHODOLOGY: This study used linked 2006 to 2008 cancer registry and Medicare claims data for the Appalachian counties of Kentucky, Pennsylvania, Ohio, and North Carolina to estimate a 2-part model of treatment delay. An Oaxaca Decomposition of the 2-part model revealed the contribution of the individual determinants to the disparity in delay between Kentucky counties and the remaining 3 states. RESULTS: The Oaxaca Decomposition revealed that the higher percentage of patients treated at for-profit facilities in Kentucky proved the key contributor to the observed disparity. In Kentucky, 22.3% patients began their treatment at a for-profit facility compared to 1.4% in the remaining states. Patients initiating treatment at for-profit facilities explained 79% of the observed difference in immediate treatment (<2 days after diagnosis) and 72% of Kentucky's advantage in log days to treatment. CONCLUSIONS: The unique role of for-profit facilities led to reduced treatment delay for colorectal cancer patients in Kentucky. However, it remains unknown whether for-profit hospitals' more rapid treatment converts to better health outcomes for colorectal cancer patients.

Does a global budget superimposed on fee-for-service payments mitigate hospitals' medical claims in Taiwan?

Taiwan's global budgeting for hospital health care, in comparison to other countries, assigns a regional budget cap for hospitals' medical benefits claimed on the basis of fee-for-service (FFS) payments. This study uses a stays-hospitals-years database comprising acute myocardial infarction inpatients to examine whether the reimbursement policy mitigates the medical benefits claimed to a third-payer party during 2000-2008. The estimated results of a nested random-effects model showed that hospitals attempted to increase their medical benefit claims under the influence of initial implementation of global budgeting. The magnitudes of hospitals' responses to global budgeting were significantly attributed to hospital ownership, accreditation status, and market competitiveness of a region. The results imply that the regional budget cap superimposed on FFS payments provides only blunt incentive to the hospitals to cooperate to contain medical resource utilization, unless a monitoring mechanism attached with the payment system.

Diversification in the hospital industry.

An institution life cycle hypothesis is advanced to explain hospital behavior: boom and bust, diversification and divestiture, occasionally leading to closure or merger. Hospital diversification and its impact on the operating ratio are studied for 172 hospitals during the period 2002-2007. Diversification and operating ratio are modeled in a two-stage least squares (TSLS) framework as being jointly dependant. Institutional diversification is found to yield better financial position, and the better operating profits allow the institution the wherewithal to diversify. The impact of external government planning and hospital competition is also measured. Some services are in a growth phase, like bariatric weight loss surgery and sleep disorder clinics. Management's attitude concerning risk and reward is considered.

A gestão em saúde e as ferramentas gerenciais: a experiência com o SISPLAN do Instituto Nacional do Câncer / Health management and managerial tools: the SISPLAN experience at the Brazilian National Cancer Institute

A gestão na área de saúde vem sofrendo modificações ao longo do tempo. As últimas duas décadas foram voltadas para o crescimento e implementação da gestão profissional neste setor, com o suporte do uso de sistemas de planejamento informatizados como apoio à gestão. Assim, este estudo tem como principal fio condutor as premissas da Gestão e do uso de ferramentas gerenciais. Embora não seja um estudo de caso, apóia-se em uma experiência concreta de gestão no Instituto Nacional de Câncer do Rio de Janeiro. Nesta pesquisa é observado que as organizações de saúde sempre estiveram voltadas para a assistência sem preocupação com a gestão em si, mas que a partir da crise econômica mundial dos anos 80 houve mudanças neste cenário. Estas alterações ocorreram não somente na gestão da saúde, como também na profissionalização do gestor. O uso de ferramentas gerenciais também é contemplado nesta pesquisa, porquanto hoje se debate a sua importância no auxílio do planejamento e da estratégia a ser orientada para estas organizações. Paralelamente à discussão sobre os sistemas mais usados nas empresas e organizações de saúde, é discutida como ferramenta gerencial principal nesta tese o Sistema de Planejamento (SISPLAN) do Instituto Nacional de Câncer do Rio de Janeiro, um instrumento desenvolvido na Instituição e que vem redesenhando os espaços institucionais de decisão e de discussão de políticas. Este estudo demonstra que a aplicação desta ferramenta gerencial possibilitou a implementação dos projetos prioritários e mais relevantes. Como ferramenta gerencial, o SISPLAN facilitou o desenvolvimento de uma gestão participativa e compartilhada em todos os níveis. Apesar das melhorias que ainda são necessárias para o aperfeiçoamento deste instrumento, são inegáveis as conquistas obtidas no transcorrer deste processo...

A gestão em saúde e as ferramentas gerenciais: a experiência com o SISPLAN do Instituto Nacional do Câncer

A gestão na área de saúde vem sofrendo modificações ao longo do tempo. As últimas duas décadas foram voltadas para o crescimento e implementação da gestão profissional neste setor, com o suporte do uso de sistemas de planejamento informatizados como apoio à gestão. Assim, este estudo tem como principal fio condutor as premissas da Gestão e do uso de ferramentas gerenciais. Embora não seja um estudo de caso, apóia-se em uma experiência concreta de gestão no Instituto Nacional de Câncer do Rio de Janeiro. Nesta pesquisa é observado que as organizações de saúde sempre estiveram voltadas para a assistência sem preocupação com a gestão em si, mas que a partir da crise econômica mundial dos anos 80 houve mudanças neste cenário. Estas alterações ocorreram não somente na gestão da saúde, como também na profissionalização do gestor. O uso de ferramentas gerenciais também é contemplado nesta pesquisa, porquanto hoje se debate a sua importância no auxílio do planejamento e da estratégia a ser orientada para estas organizações. Paralelamente à discussão sobre os sistemas mais usados nas empresas e organizações de saúde, é discutida como ferramenta gerencial principal nesta tese o Sistema de Planejamento (SISPLAN) do Instituto Nacional de Câncer do Rio de Janeiro, um instrumento desenvolvido na Instituição e que vem redesenhando os espaços institucionais de decisão e de discussão de políticas. Este estudo demonstra que a aplicação desta ferramenta gerencial possibilitou a implementação dos projetos prioritários e mais relevantes. Como ferramenta gerencial, o SISPLAN facilitou o desenvolvimento de uma gestão participativa e compartilhada em todos os níveis. Apesar das melhorias que ainda são necessárias para o aperfeiçoamento deste instrumento, são inegáveis as conquistas obtidas no transcorrer deste processo...

The management in the health area has been experiencing changes through time. The last two decades were concerned only to the growth and implementation of the staffing management system, with the use of computerized planning system as a kind of support to the management itself. Thus, this thesis takes the premises of the Management and the use of Managerial Tools as the basis of its research. Although, it is not a study of case, it is supported on a real managerial experience applied at National Cancer Institute of Rio de Janeiro. In this study, we observe that the health organizations used to be concerned only to the assistance, without worrying about the management itself. This thought has changed following the World Economical Crises in the 80’s, and after that, the health industry became concerned not only in the health management, but also in the professionalism of the manager. The usage of managerial tools in the heath system is also discussed in this thesis, due to the importance that is given to this subject. Nowadays, we debate a lot, the importance of a managerial tool in helping the planning and strategy to be presented as a model to the health organizations. In parallel to the discussion about the most used managerial systems in the companies and organizations of health, this study also discusses, as the most important focus, a managerial tool called SISPLAN of National Cancer Institute of Rio de Janeiro, a tool developed by this institution which has been restructuring the institutional spaces of decision and of politics discussion This research also shows that the application of SISPLAN made able the implementation of more relevant and priority projects. As a managerial tool, SISPLAN facilitated the development of a management system which was both participative and shared in all levels. Despite of improvements that are still necessary for the improvement of this tool, they are undeniable the achievements obtained in the course of this process. It can be realized, however, that spite of its features, SISPLAN doesn’t seem to be a managerial tool which express the institution strategy, because it behaves as a planning tool. So, we concluded that according to balanced scorecard features, it must be associated to SISPLAN as a complementary managerial tool which allows the construction of the strategy, based on a chain of cause and effect relations and on booster factors. This thesis aims to demonstrate, how essential is the availability of a managerial tool is essential for the success of the heath management.

A modified method of activity-based costing for objectively reducing cost drivers in hospitals.

OBJECTIVES: Activity-based costing (ABC) is widely used to precisely allocate indirect costs to medical services. In the ABC method, the indirect cost is divided among the medical services in proportion to the volume of "cost drivers", for example, labor hours and the number of hours of surgery. However, the workload of data collection of cost drivers can be time-consuming and a considerable burden if there are many cost drivers. The authors aim to develop a method for objectively reducing the cost drivers used in the ABC method. METHODS: In the ABC method, the cost driver is assigned for each activity. We assume that these activities and cost drivers are the best combination. Our method, that is cost driver reduction (CDR), can objectively select surrogates of the cost drivers for each activity in ABC from candidate cost drivers. Concretely, the total indirect cost of an activity is temporarily allocated to the medical services using each candidate of cost drivers. The difference between the costs calculated by each candidate and the proper cost driver used in ABC is calculated to evaluate the similarity by the evaluation function. RESULTS: We estimated the cost of laboratory tests using our method and revealed that the number of cost drivers could be reduced from seven in the ABC to four. Similarly, the results of cost estimation obtained by our method were as accurate as those calculated using the ABC. CONCLUSIONS: Our method provides two advantages compared to the ABC method: 1) it provides results that are as accurate as those of the ABC method, and 2) it is simpler to perform complicated estimation of hospital costs.

Egresos hospitalarios por cáncer urogenital en Chile: segunda parte / Hospital discharges due to urogenital cancer in Chile: second part

El siguiente trabajo comprendió el análisis de los Egresos Hospitalarios por cáncer urogenital (CUG) para los años 1993, 1996 y 2001. Estos antecedentes permitirán establecer una tendencia que refleje más fielmente el verdadero rol del cáncer urogenital dentro de los egresos hospitalarios totales y más específicamente dentro de las patologías que afectan al aparato génitourinario. Se analizó la base de datos correspondiente al Boletín de Egresos Hospitalarios del MINSAL para los años 1993, 1996 y 2001. Se obtuvo para cada año información concerniente a los egresos hospitalarios totales, por patología génitourinaria y específicamente por cáncer de próstata, testículo, vejiga y riñón. Estos fueron caracterizados según sexo, edad y región del país desde donde egresaron. En 1993, 1996 y 2001 hubo respectivamente: 1.870, 2.745 y 3.544 egresos por cáncer prostático, 964, 964 y 1.071 por cáncer testicular, 826, 962 y 1.195 por cáncer vesical y 469, 535 y 905 egresos por cáncer renal. Estas patologías abarcaron, en su conjunto, el 0,29; 0,36 y 0,43 porciento de los Egresos Hospitalarios totales, y el 6,6, 7,5 y 10,4 porciento de los egresos hospitalarios por patología génitourinaria. Casi la mitad de los egresos corresponde a cáncer prostático, el que se ubica, lejos, como la primera causa de egresos hospitalarios por cáncer urogenital en Chile.

Egresos hospitalarios por patología genitourinaria en Chile: segunda parte / Hospital discharges by pathologies of the genitourinary tract in Chile: second part

Utilizando el Boletín de Egresos Hospitalarios del MINSAL para los años 1993, 1996 y 2001 se analizaron aquellos códigos correspondientes a Patologías del Sistema Génitourinario (PGU) según el sistemade Clasificación Internacional de Enfermedades OMS CIE-9 y CIE-10, caracterizándolos según su composición geográfica y demográfica.En 1993, 1996 y 2001 se registraron en Chile: 1.404.478, 1.441.374 y 1.566.187 egresos hospitalarios, respectivamente. Los egresos por PGU en esos años fueron 62.978, 70.207 y 64.648, lo que correspondea 4,48 porciento, 4,87 porciento y 4,13 porciento de los egresos hospitalarios totales para ese año. La ITU, HPB, litiasis y fimosisse mantienen como las patologías más prevalentes que requirieron hospitalización. Durante el año 2001,se observó una disminución entre 6 porciento y 7 porciento de los egresos por infección urinaria. Destaca el comportamientode los egresos por cánceres urológicos, los que fueron 4.129 en 1993, 5.206 en 1996 y 6.715 en 2001. Esto corresponde a 6,6 porciento, 7,5 porciento y 10,4 porciento del total de egresos por PGU para cada año respectivo. La patología génitourinaria continúa siendo una contribución menor al total de egresos hospitalarios en el país. Destaca la disminución en el número de egresos por infección urinaria registrado el año 2001. Además, es posible observar un aumento sostenido de los egresos por cáncer urogenital durante estos 8 años de seguimiento.

The funding of private hospitals in Australia.

Private hospitals are an essential component of Australia's complex mix of public and private health funding and provision. Private hospitals account for 34.3 per cent of all hospital separations, and over half (56.2%) of all same-day separations. The revenue (funding) of the sector approached $4 billion by 1998/99, and as a result of its recent rapid growth capital expenditure in the sector was nearly $550 million in the same year. Private casemix of private hospitals is distinctive, and characterised by a high proportion of surgical procedures in general (48.1 per cent), and more than a majority of all services in such areas as rehabilitation, orthopaedics (shoulder, knee, spinal fusion, and hand surgery), alcohol disorders, same day colonoscopy and sleep disorders. This chapter synthesizes data from a multitude of sources to produce a comprehensive picture of Australia's private hospital sector and its funding. It examines the funding (revenue) sources of private hospitals, and considers how and why private hospitals approach the issue of funding from a different perspective than their public sector colleagues. To illustrate how Australian private hospitals approach revenue (funding) strategically, a series of indicative types of hospitals is explored.

"Voluntary" user fees in Buenos Aires hospitals: innovation or imposition?

Voluntary user fees in hospitals in Buenos Aires, which operate outside official controls, have not featured in other studies of health care in Argentina. After providing a historical overview of different hospital funding sources, the authors focus on the activity of cooperadoras--the organizations responsible for levying voluntary fees. Using detailed data from two case-study hospitals and more general financial sources, they assess the importance of these fees, identifying sharp variations between different hospitals, serious problems of under-reporting, and potential abuses. The authors also examine the means by which fees are levied and the degree of coercion involved. Voluntary fees are not a particularly successful funding strategy: the income they generate is variable; they are almost entirely unregulated; and they sometimes conflict with other, more legitimate funding sources. Most importantly, their voluntaristic aspect is largely notional: most patients are heavily pressured to make payments. The main motivation for continuing with voluntary fees is to avoid the political fallout that would probably result from introduction of a formal user fees policy.

Sistema de información hospitalaria integrada: una propuesta / Integral informaton system for hospital: a proposal

La existencia de sistemas de informacion integrales para los hospitales es una preocupacion constante para quienes deben tomar deciciones en forma oportuna. Este trabajo traduce la necesidad de desarrollar un sistema de informacion que cubra todos los elementos y actividades de un hospital como herramienta básica para una mejora continua de la calidad de la atención médica y como medio de contencion de costos.(au)

Financing reforms in the German hospital sector: from full cost cover principle to prospective case fees.

OBJECTIVES: The authors provide an overview of the hospital sector in Germany with a focus on the impact of recent reform legislation on this sector. METHODS: Data from the Federal Statistics Office, the Ministry of Health, and the Federal Association of Physicians are synthesized with information obtained from a general review of the literature. RESULTS: Before the implementation of recent health-care reforms, the German health-care system has been sharply divided into inpatient and ambulatory care sectors, resulting in a fragmented system of care delivery. All hospital operating costs were fully covered through per diem charges. The 1992 Health Care Structure Act and subsequent pieces of legislation have introduced new mechanisms to improve cost efficiency in the hospital sector and increase coordination between the inpatient and outpatient care. These measures notably include implementing an inpatient prospective payment system and permitting ambulatory surgery and care services to be offered in inpatient settings. CONCLUSIONS: Whereas prospective payments have greatly reduced the length of stay, hospitals were reluctant to offer ambulatory surgery due to budgetary constraints and the high level of ambulatory surgery by office-based physicians. The reforms passed have not yielded substantial cost savings. These reforms offer a natural experiment that could benefit from national and international studies on the impact of hospital sector redesign on management, financing, and patient outcomes.

How do Canadian hospitals do it? A comparison of utilization and costs in the United States and Canada.

In 1990 Canadian hospitals provided more services at less cost than did acute care facilities in the United States. Canadians spent $2,720 less per discharge for 48 percent longer stays. If U.S. acute care facilities had achieved an average discharge cost comparable to that in Canada, the annual savings among hospitals in the United States would have totalled $84.3 billion. In a comparative study of volumes and costs in medium-size and teaching hospitals, it was found that U.S. hospitals had greater costs for delivering services than Canadian acute care facilities did in almost every department.

Hospital and community characteristics in closures of urban hospitals, 1980-87.

Characteristics of 190 urban community hospitals that were closed during the period 1980-87 and characteristics of the communities that they served were analyzed and compared to a control group of 380 urban hospitals that remained open. A negative association was found between hospital closure and four hospital characteristics: the presence of a cancer program approved by the American College of Surgeons, the combined characteristics of for-profit status and membership in a multi-institutional chain, the number of admissions, and the number of facilities and services offered. A positive association was found between hospital closure and the percentage of black residents in the community. These findings are discussed in the context of political and economic trends in health care and urban development. Implications for future research are noted, including managerial strategy for hospital administrators and the socioeconomic implications of hospital survival in declining urban communities.