Funding Accountable Care in Oregon: Financial Models in Two Coordinated Care Organizations.

EXECUTIVE SUMMARY: Oregon's coordinated care organizations (CCOs) are an integral part of a massive statewide reform that brings accountable care to Medicaid. CCOs are regional collaboratives among health plans, providers, county public health, and communitybased organizations that administer a single global budget covering physical, mental, and dental healthcare for low-income Oregonians. CCOs have been given freedom within the global budget to implement reforms that might capture efficiencies in cost and quality. For this study-fielded between 2012 and 2015-we traced the path of the global budget through the interior structures of two of Oregon's most promising CCOs. Using document review and in-depth qualitative interviews, we synthesized and summarized descriptive narrative data to produce case studies of the financial models in each CCO. We found that the CCOs feature substantially different market contexts, governance models, organizational structures, and financial systems.

Access to dental public services by disabled persons.

BACKGROUND: According to the World Health Organization, one in every 10 people has a disability, and more than two-thirds of them do not receive any type of oral dental care. The Brazilian Constitution of 1988 guarantees all civilians including disabled people the right to healthcare, shaping the guidelines of the Brazilian National Health Care System (Sistema Único de Saúde--SUS). However, there is limited information about the true accessibility of dental services. This study evaluated the accessibility of public dental services to persons with disabilities in Fortaleza, Ceará, which has the third highest disability rate in Brazil. METHODS: A cross-sectional quantitative study using structured questionnaires was administered to dentists (n = 89) and people with disabilities (n = 204) to evaluate the geographical, architectural, and organizational accessibility of health facilities, the communication between professionals and patients with disabilities, the demand for dental services, and factors influencing the use of dental services by people with motor, visual, and hearing impairments. RESULTS: 43.1% of people with disabilities do not recognize their service as a priority of Basic Health Units (BHU), 52.5% do not usually seek dental care, and of those who do (n = 97), 76.3% find it difficult to receive care and 84.5% only seek care on an emergency basis. Forty-five percent are unaware of the services offered in the BHU. Of the dentists, 56.2% reported difficulty in communicating with deaf patients, and 97.8% desired interpreters stationed in the BHU. People with disabilities gave better accessibility ratings than dentists (p = 0.001). 37.3% of the patients and 43.8% of dentists reported inadequate physical access infrastructure (including doors, hallways, waiting rooms, and offices). Dentists (60%) reported unsafe environments and transportation difficulties as geographical barriers, while most people with disabilities did not report noticing these barriers. CONCLUSIONS: While access to dental services has increased in Fortaleza, the lack of accessibility of health units and their surroundings does not promote the treatment of people with disabilities. Cultural, organizational, architectural, geographical, and communication barriers constrain the demand for and use of oral dental care services by this social segment.

Cost analysis of periodontitis management in public sector specialist dental clinics.

BACKGROUND: The objective of this paper is to quantify the cost of periodontitis management at public sector specialist periodontal clinic settings and analyse the distribution of cost components. METHODS: Five specialist periodontal clinics in the Ministry of Health represented the public sector in providing clinical and cost data for this study. Newly-diagnosed periodontitis patients (N = 165) were recruited and followed up for one year of specialist periodontal care. Direct and indirect costs from the societal viewpoint were included in the cost analysis. They were measured in 2012 Ringgit Malaysia (MYR) and estimated from the societal perspective using activity-based and step-down costing methods, and substantiated by clinical pathways. Cost of dental equipment, consumables and labour (average treatment time) for each procedure was measured using activity-based costing method. Meanwhile, unit cost calculations for clinic administration, utilities and maintenance used step-down approach. Patient expenditures and absence from work were recorded via diary entries. The conversion from MYR to Euro was based on the 2012 rate (1€ = MYR4). RESULTS: A total of 2900 procedures were provided, with an average cost of MYR 2820 (€705) per patient for the study year, and MYR 376 (€94) per outpatient visit. Out of this, 90% was contributed by provider cost and 10% by patient cost; 94% for direct cost and 4% for lost productivity. Treatment of aggressive periodontitis was significantly higher than for chronic periodontitis (t-test, P = 0.003). Higher costs were expended as disease severity increased (ANOVA, P = 0.022) and for patients requiring surgeries (ANOVA, P < 0.001). Providers generally spent most on consumables while patients spent most on transportation. CONCLUSIONS: Cost of providing dental treatment for periodontitis patients at public sector specialist settings were substantial and comparable with some non-communicable diseases. These findings provide basis for identifying potential cost-reducing strategies, estimating economic burden of periodontitis management and performing economic evaluation of the specialist periodontal programme.

The representation of health professionals on governing boards of health care organizations in New York City.

The Representation of Health Professionals on Governing Boards of Health Care Organizations in New York City. The heightened importance of processes and outcomes of care-including their impact on health care organizations' (HCOs) financial health-translate into greater accountability for clinical performance on the part of HCO leaders, including their boards, during an era of health care reform. Quality and safety of care are now fiduciary responsibilities of HCO board members. The participation of health professionals on HCO governing bodies may be an asset to HCO governing boards because of their deep knowledge of clinical problems, best practices, quality indicators, and other issues related to the safety and quality of care. And yet, the sparse data that exist indicate that physicians comprise more than 20 % of the governing board members of hospitals while less than 5 % are nurses and no data exist on other health professionals. The purpose of this two-phased study is to examine health professionals' representations on HCOs-specifically hospitals, home care agencies, nursing homes, and federally qualified health centers-in New York City. Through a survey of these organizations, phase 1 of the study found that 93 % of hospitals had physicians on their governing boards, compared with 26 % with nurses, 7 % with dentists, and 4 % with social workers or psychologists. The overrepresentation of physicians declined with the other HCOs. Only 38 % of home care agencies had physicians on their governing boards, 29 % had nurses, and 24 % had social workers. Phase 2 focused on the barriers to the appointment of health professionals to governing boards of HCOs and the strategies to address these barriers. Sixteen health care leaders in the region were interviewed in this qualitative study. Barriers included invisibility of health professionals other than physicians; concerns about "special interests"; lack of financial resources for donations to the organization; and lack of knowledge and skills with regard to board governance, especially financial matters. Strategies included developing an infrastructure for preparing and getting appointed various health professionals, mentoring, and developing a personal plan of action for appointments.

Considering the health care entity C corporation conversion to tax pass-through entity status.

The double taxation of C corporation income from operations and from the ultimate sale of its assets makes the C corporation an inefficient tax status for many health care entities. At the time of this writing, the changes in the federal tax law that are scheduled to take effect in 2013 will increase this level of double-taxation inefficiency. The owners of a C corporation practice can avoid the C corporation status tax inefficiency by converting the practice to either (1) S corporation status or (2) LLC status. The conversion of the health care C corporation to an S corporation may be accomplished without a current tax cost. However, the conversion of a health care C corporation to an LLC status can result in a current tax at both the corporation level and the shareholder level. Nonetheless, the current conversion tax cost may be less than the future tax cost (1) of operating the practice as a C corporation and incurring double taxation at what may be higher tax rates or (2) of incurring the higher tax cost (or reduced price) on the ultimate disposition of the practice assets and the attendant double taxation of the appreciation in the value of the practice assets. Since individual income tax rates on qualifying dividends from C corporations and on capital gains are currently at very low rates, this may be a good time for C corporation practice owners to consider the costs and benefits of a conversion to either S corporation status or LLC status. The practice owners should consult with their accounting, legal, and valuation advisors in order to consider all of the costs and benefits of a possible corporate tax status conversion. An estimation of both the costs and benefits of the corporate tax status conversion depends on the concluded fair market values of the medical practice, dental practice, or other health care entity assets. And, that practice asset appraisal should encompass all of the practice assets, both tangible assets and intangible assets.

[Use of statistical analysis methods in the management of treatment-and-prophylactic organizations (example of the dental clinic)].

Experience in calculation of the capacity of basic equipment used in a dental clinic is described. Two models for evaluation of treatment activities in clinics are suggested.

A descriptive survey of management and operations at selected sports medicine centers in the United States.

No uniform guidelines for operations or accreditation standards for sports medicine center were available and, at the time of this study, little information on the management and operation of sports medicine centers was available in the literature. The purpose of the study was to determine the management structure and function of selected sports medicine centers in the United States. Questionnaires were mailed to 200 randomly selected centers throughout the United State from a directory of sports medicine centers published in Physician and Sportsmedicine (1992) to gather descriptive information on eight areas, including 1) general background, 2) staffing, 3) services, facilities, and equipment, 4) billing, collections, and revenue, 5) clientele, caseloads, and referrals, 6) ownership and financing, 7) school and club outreach contracts, and 8) marketing strategies and future trends. A total of 71 surveys (35.5%) were returned in the allotted time frame. Data were analyzed using ranges, means, medians, modes, and percentages. Results yielded several conclusions about sports medicine centers. Nearly all (93%) of the centers employed physical therapists; physical therapists were clinical directors at 70.2% of centers; orthopaedists were most often medical directors; rehabilitation was the most frequently offered service (93%); physical therapy produced the highest revenue; sports injuries accounted for a mean 34.5% of patients, who were mostly recreational or high school athletes between 13-60 years of age; primary shareholders were most often physical therapists or physicians; most were involved in outreach services for schools; marketing strategies primarily involved communication with referral sources; and managed care was identified most frequently as a trend affecting the future of sports medicine centers. Findings identified common aspects of sports medicine centers and may assist in establishing guidelines for operations or accreditation of sports medicine centers.

Eficiente administración sanitaria? Caso clínica estomatológica / Efficient sanitary administration? The Stomatologic Clinic Case

La administración en las instituciones de salud es un tema importante para el logro de la satisfacción de los pacientes y familiares, a la par de la correcta utilización de los recursos disponibles. El sistema de salud en Cuba es presupuestado, y por ello, una gestión eficiente es vital para distribuir los recursos en función de los mejores resultados. Un importante indicador a considerar en este tema lo constituyen los costos de calidad. Dentro del sistema nacional de salud, las clínicas estomatológicas son organizaciones donde resulta muy novedoso el tema de mejoramiento continuo de su gestión a partir de los costos de calidad. En el presente trabajo se realizó una evaluación de los costos de calidad en la Clínica Estomatológica Docente III Congreso del PCC, lo cual constituyó la base del programa de mejoras. El costo total de calidad fue de 22 394.15 pesos en el año 2011, siendo el 62,69 por ciento por fallos relacionados esencialmente a reelaboraciones, desperdicios, paralización parcial por poco instrumental, entre otras causas que fueron la base del programa de mejora.

The administration of health care institutions is an important theme for achieving the patients and relatives satisfaction, and the right usage of the available resources at the same time. Health Care System in Cuba is budgeted and for that, an efficient management is vital in distributing the resources for better results. Quality costs are an important indicator to consider in this theme. Inside the national Health Care System, stomatologic clinics are organizations where it is fashionable the theme of the continuous management improvement on the basis of the quality costs. In the current work we carried out an evaluation of the quality costs at the Teaching Stomatologic Clinic III Congreso del Partido, took as the basis of the improvement program. The total quality cost was 22 394.15 pesos in 2011. 62,69 percent was caused by mistakes essentially related with re-elaboration, wastes, partial paralyzing because of few instrumental, among other causes that were the base of the improvement program.

Steel can recycling: how to cut costs and support the environment.

This is the first in a series of three articles regarding steel can recycling from foodservice operations of healthcare facilities. This article highlights the benefits of recycling and how steel is recycled across the country; the second will focus on the basic methods of recycling steel cans, and will include information on conducting a waste audit and negotiating with a hauler; the final article will convey a case history of actual foodservice recycling practice from a healthcare facility.