Types and Distribution of Payments From Industry to Physicians in 2015.

IMPORTANCE: Given scrutiny over financial conflicts of interest in health care, it is important to understand the types and distribution of industry-related payments to physicians. OBJECTIVE: To determine the types and distribution of industry-related payments to physicians in 2015 and the association of physician specialty and sex with receipt of payments from industry. DESIGN, SETTING, AND PARTICIPANTS: Observational, retrospective, population-based study of licensed US physicians (per National Plan & Provider Enumeration System) linked to 2015 Open Payments reports of industry payments. A total of 933 295 allopathic and osteopathic physicians. Outcomes were compared across specialties (surgery, primary care, specialists, interventionalists) and between 620 166 male (66.4%) and 313 129 female (33.6%) physicians using regression models adjusting for geographic Medicare-spending region and sole proprietorship. EXPOSURES: Physician specialty and sex. MAIN OUTCOMES AND MEASURES: Reported physician payment from industry (including nature, number, and value), categorized as general payments (including consulting fees and food and beverage), ownership interests (including stock options, partnership shares), royalty or license payments, and research payments. Associations between physician characteristics and reported receipt of payment. RESULTS: In 2015, 449 864 of 933 295 physicians (133 842 [29.8%] women), representing approximately 48% of all US physicians were reported to have received $2.4 billion in industry payments, including approximately $1.8 billion for general payments, $544 million for ownership interests, and $75 million for research payments. Compared with 47.7% of primary care physicians (205 830 of 431 819), 61.0% of surgeons (110 604 of 181 372) were reported as receiving general payments (absolute difference, 13.3%; 95% CI, 13.1-13.6; odds ratio [OR], 1.72; P < .001). Surgeons had a mean per-physician reported payment value of $6879 (95% CI, $5895-$7862) vs $2227 (95% CI, $2141-$2314) among primary care physicians (absolute difference, $4651; 95% CI, $4014-$5288). After adjusting for geographic spending region and sole proprietorship, men within each specialty had a higher odds of receiving general payments than did women: surgery, 62.5% vs 56.5% (OR, 1.28; 95% CI, 1.26-1.31); primary care, 50.9% vs 43.0% (OR, 1.38; 95% CI, 1.36-1.39); specialists, 36.3% vs 33.4% (OR, 1.15; 95% CI, 1.13-1.17); and interventionalists, 58.1% vs 40.7% (OR, 2.03; 95% CI, 1.97-2.10; P < .001 for all tests). Similarly, men reportedly received more royalty or license payments than did women: surgery, 1.2% vs 0.03% (OR, 43.20; 95% CI, 25.02-74.57); primary care, 0.02% vs 0.002% (OR, 9.34; 95% CI, 4.11-21.23); specialists, 0.08% vs 0.01% (OR, 3.67; 95% CI, 1.71-7.89); and for interventionalists, 0.13% vs 0.04% (OR, 7.98; 95% CI, 2.87-22.19; P < .001 for all tests). CONCLUSIONS AND RELEVANCE: According to data from 2015 Open Payments reports, 48% of physicians were reported to have received a total of $2.4 billion in industry-related payments, primarily general payments, with a higher likelihood and higher value of payments to physicians in surgical vs primary care specialties and to male vs female physicians.

Factors affecting home gardens ownership, diversity and structure: a case study from Benin.

BACKGROUND: Home gardens (HGs) provide perspectives for conservation of plant genetic resources while contributing to improving livelihoods. However, knowledge of local factors shaping their ownership, plant diversity (PD) and structure is still limited especially in West-Africa, where food insecurity is acute. This is critical to ensure effective mainstreaming of HGs into future biodiversity conservation and food production policies. METHODS: Socio-economic and PD data were obtained from individual interviews (n = 470) and gardens inventories (n = 235) spanning humid, sub-humid and semi-arid zones of Benin. Generalised Linear Models, Hierarchical Cluster Analysis, Principal Component Analysis and Simple Correspondence Analysis were performed to examine socio-economic characteristics (age, gender, education level and main economic activity) affecting HGs ownership, and their effect coupled with intrinsic HGs characteristics (size, age) on PD and structure within HGs, across contrasting bio-geographical regions. RESULTS: HG ownership was significantly dependent upon a complex relationship between age, gender and education level of the farmers. The probability to own HG increased with age with an early involvement in home gardening for women. Similarly, with increasing age, it was more likely to find a male owner than a female owner among the uneducated informants and those of primary school. Inversely, it was more likely to find female owner than a male owner among secondary school level or more. PD increased with increasing owner age and size of the HG. Larger and more diversified HGs were found in sub-humid and semi-arid zones while smaller and less diversified HGs were encountered in the humid zone. HGs were multi-layered. Based on the prevailing plant groups, three categories of HG were distinguished: Herb based gardens, Herb and Shrub/Trees based gardens, and Palm and Liana based gardens. Their prevalence was dependent upon bio-geographical zones and HG owner socio-economic characteristics, with herbs based HGs being mainly associated to women. CONCLUSION: Results suggest effects of complex interactions between socio-economic factors on HG ownership, and influence of these effects combined with intrinsic characteristics of HGs on PD. The early involvement of women in home gardening and their particular interest in herbs and shrubs are important assets for future conservation strategies based on HG and food production. Interventions are required to interfere with declining PD in HG across generations to accommodate multiple ecosystem service benefits.

[Acute pain therapy in German hospitals as competitive factor. Do competition, ownership and case severity influence the practice of acute pain therapy?]. / Akutschmerztherapie in deutschen Krankenhäusern als Wettbewerbsfaktor. Wird die Praxis der Akutschmerztherapie von Wettbewerb, Trägerschaft und Fallschwere beeinflusst?

BACKGROUND: Due to the implementation of the diagnosis-related groups (DRG) system, the competitive pressure on German hospitals increased. In this context it has been shown that acute pain management offers economic benefits for hospitals. The aim of this study was to analyze the impact of the competitive situation, the ownership and the economic resources required on structures and processes for acute pain management. MATERIAL AND METHODS: A standardized questionnaire on structures and processes of acute pain management was mailed to the 885 directors of German departments of anesthesiology listed as members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin). RESULTS: For most hospitals a strong regional competition existed; however, this parameter affected neither the implementation of structures nor the recommended treatment processes for pain therapy. In contrast, a clear preference for hospitals in private ownership to use the benchmarking tool QUIPS (quality improvement in postoperative pain therapy) was found. These hospitals also presented information on coping with the management of pain in the corporate clinic mission statement more often and published information about the quality of acute pain management in the quality reports more frequently. No differences were found between hospitals with different forms of ownership in the implementation of acute pain services, quality circles, expert standard pain management and the implementation of recommended processes. Hospitals with a higher case mix index (CMI) had a certified acute pain management more often. The corporate mission statement of these hospitals also contained information on how to cope with pain, presentation of the quality of pain management in the quality report, implementation of quality circles and the implementation of the expert standard pain management more frequently. There were no differences in the frequency of using the benchmarking tool QUIPS or the implementation of recommended treatment processes with respect to the CMI. CONCLUSION: In this survey no effect of the competitive situation of hospitals on acute pain management could be demonstrated. Private ownership and a higher CMI were more often associated with structures of acute pain management which were publicly accessible in terms of hospital marketing.

A systematic approach to the planning, implementation, monitoring, and evaluation of integrated health services.

BACKGROUND: Because of the current emphasis and enthusiasm focused on integration of health systems, there is a risk of piling resources into integrated strategies without the necessary systems in place to monitor their progress adequately or to measure impact, and to learn from these efforts. The rush to intervene without adequate monitoring and evaluation will continue to result in a weak evidence base for decision making and resource allocation. Program planning and implementation are inextricability linked to monitoring and evaluation. Country level guidance is needed to identify country-specific integrated strategies, thereby increasing country ownership. DISCUSSION: This paper focuses on integrated health services but takes into account how health services are influenced by the health system, managed by programs, and made up of interventions. We apply the principles in existing comprehensive monitoring and evaluation (M&E) frameworks in order to outline a systematic approach to the M&E of integration for the country level. The approach is grounded by first defining the country-specific health challenges that integration is intended to affect. Priority points of contact for care can directly influence health, and essential packages of integration for all major client presentations need to be defined. Logic models are necessary to outline the plausible causal pathways and define the inputs, roles and responsibilities, indicators, and data sources across the health system. Finally, we recommend improvements to the health information system and in data use to ensure that data are available to inform decisions, because changes in the M&E function to make it more integrated will also facilitate integration in the service delivery, planning, and governance components. SUMMARY: This approach described in the paper is the ideal, but its application at the country level can help reveal gaps and guide decisions related to what health services to prioritize for integration, help plan for how to strengthen systems to support health services, and ultimately establish an evidence base to inform investments in health care. More experience is needed to understand if the approach is feasible; similarly, more emphasis is needed on documenting the process of designing and implemented integrated interventions at the national level.

Contested visions of American democracy: citizenship, public housing, and the international arena.

This essay reexamines the history of public housing and the controversy it generated from the Great Depression to the Cold War. By recasting that history in the global arena, it demonstrates that the debate over public housing versus homeownership was also a debate over the meaning of American citizenship and democracy, pointing up starkly divergent notions about what was and was not American. Through an examination of national conflicts and neglected local struggles, this article further shows that the fight over public housing was far more meaningful and volatile than traditionally assumed. Both critics and advocates of public housing drew from international experiences and imagery in positioning the home as a constitutive feature of citizenship in American democracy. Fears of Bolshevism, fascism, and communism served to internationalize issues of race, space, and housing and together shaped the decision of whether a decent home was an American right or privilege.

Landlords and tenants in the wake of abolition and ecological devastation in Brazil's Middle Paraíba Valley.

This article uses Barra do Piraí as a case study of rural land tenure, production, consumption, and labor in Brazil's Middle Paraíba Valley during the half century following abolition of slavery in 1888. Dairy farming and railroad development distinguished Barra do Piraí from other coffee-producing areas that suffered from ecological devastation. By 1900 the land's loss of fertility precluded further plantation agriculture in Barra do Piraí, leading to the transition from lucrative coffee cultivation to dairy farming based on meager capital inputs. Compared to the earlier coffee culture, dairy farms produced only modest wealth for landlords and required fewer laborers, compelling impoverished tenants to migrate in search of employment. Since Barra do Piraí was an important railroad junction, many rural laborers ended up in the locale after using the railroad as a migratory path. At the same time, the railroad and proto-industries that it stimulated provided alternative employment for rural laborers, thereby partially mitigating the leverage landlords had over the abundant labor force. The availability of industrial and proto-industrial employment created occupational diversity among rural tenants and introduced them to work routines that would become commonplace when the region more fully industrialized after 1940.

Association of hospital ownership with patient transfers to outpatient care under a prospective payment system in Taiwan.

Case payment, a prospective payment system akin to diagnosis-related groups (DRGs) has in-built incentives for hospitals to transfer inpatients to their own ambulatory care units following early discharge. This study used nation-wide inpatient claims data on a total of 100,730 patients treated in 2000 in (Taiwan): cesarean section (59,364 cases), femoral/inguinal hernia operation (18,675 cases), and hemorrhoidectomy (22,691 cases), all reimbursed by case payment, to explore the relationship between hospital ownership and patient transfers to outpatient treatment. For all three diagnoses, for-profit (FP) hospitals not only had lower lengths of stay (LOS) compared to public hospitals, but also showed very high odds of patient transfer to their own outpatient units, after controlling for institutional variables, (hospital level, teaching status, and geographic location), hospital competitive environment (the Herfindal-Hirschman index), and patient variables (gender, age, length of stay, and number of secondary diagnoses, a proxy for severity of illness). Similar, though slightly lower odds were observed with not-for-profit (NFP) hospitals relative to public hospitals. The findings support the property rights theory, suggesting that in Taiwan, institutional profit maximization motives may be driving patient transfers under the case payment diagnoses, rather than medical care needs. In NFP hospitals, their physician compensation mechanism, driven largely by care volumes provided by each physician, appears to be driving the disproportionately greater likelihood of patient transfer to outpatient care.

Off-balance-sheet financing can generate capital for strategic development.

To manage their real estate portfolios effectively and obtain funding for strategic development, IDSs should consider adopting off-balance-sheet financing strategies, such as sale-and-leaseback transactions, synthetic leases, and joint-venture arrangements. Under these approaches, real estate assets are moved off of the organization's balance sheet via a partial or complete transfer of ownership to a third-party entity. The organization typically retains a satisfactory degree of control over the assets as lessee in sale-and-leaseback and synthetic-lease arrangements, or limited or minority partner in a joint venture, while freeing up cash to use for other strategic purposes.

IDS conversions to for-profit status: structuring the deal.

Not-for-profit integrated delivery systems (IDSs) may convert assets to for-profit status in a variety of ways, but typically choose from three basic conversion structures: sale of assets, joint ventures, and lease or management agreements. To select the optimal conversion structure, not-for-profit IDS executives should understand the forces driving their organization's desire or need to effect such a conversion and examine the legal, business, and political implications of each option in light of the organization's particular circumstances.

Health care markets in Australia: ownership of the private hospital sector.

Over the past decade, the Australian hospital sector has undergone a massive economic and administrative reorganization with ramifications for both the private and the public sectors. Changes such as privatization, deregulation, and the entry of foreign capital into the hospital sector are occurring in the hospital systems of many countries, including Australia, the United States, and the United Kingdom. These developments are radically transforming the hospital sector, altering established relationships between the state, the medical profession, the consumer, and the corporate investor, and raising important questions about the future of hospital services in regard to equity, accessibility, and quality.