Agency problems in hospitals participating in self-management project under global budget system in Taiwan

Emergency department visits and associated factors among people with dementia residing in nursing homes in Taiwan: a one-year cohort study

BACKGROUND

Residing in a nursing home (NH) may increase emergency department (ED) utilization in patients with dementia; however, evidence regarding the status of and predictors for ED utilization of NH residents with dementia remains unclear, especially in Asia. This study aimed to assess the incidence density of ED visits and associated factors for the risk of ED utilization among NH residents with dementia.

METHODS

This one-year cohort study followed 6595 NH residents with dementia aged ≧ 40 years from Taiwan's National Health Insurance Research Database between 2012 and 2014. The Andersen-Gill extension of Cox regression analysis with death as a competing risk was applied to investigate the association of the risk of all causes and the most common causes of ED utilization with the predisposing, enabling, and need factors as defined by the Andersen model.

RESULTS

All participants encountered 9254 emergency visits in the 5371.49 person-years observed, representing incidence densities of ED visits of 1722.80 per 1000 person-years. Among them, respiratory disease was the most common cause of ED visits. The significant predictors for the risk of all-cause and respiratory-cause ED visits included: (1) predisposing factors (i.e., age and gender); (2) enabling factors (i.e., regional variables); and (3) need factors (i.e., prolonged ventilator dependence and comorbidity status).

CONCLUSIONS

Predisposing, enabling, and need factors could influence ED visits among studies patients. NH providers should consider these factors to develop strategies for reducing ED utilization.

Intraorganization conflicts of interest in hospitals adapting to a changing ecosystem

PURPOSE

Health systems function in an ecosystem that is turbulent and competitive because of demographic, economic, political, technological and lifestyle changes and sociopolitical influences, requiring hospitals to adopt comprehensive business strategies. Failure to do so may result in duplication, waste and deficits. This original article uses the prism of agency theory to examine differences in approach at two levels of hospital management and the consequent problems in the incorporation of necessary changes. Agency theory posits an inherent conflict of interest in organizations, including health organizations: the managers (agents) always aim to maximize their profit or personal interest instead of that of the owner or organization (principal), potentially causing difficulty in managing the organization. The aim is to generate recommendations for policymakers.

DESIGN/METHODOLOGY/APPROACH

The study is based on 30 semi-structured, in-depth interviews with key figures in the health system and on two levels of hospital management: senior managers and heads of selected departments. The analysis used a categorical qualitative methodology.

FINDINGS

The main findings are five key themes: views of business behavior, asymmetry of interests, asymmetry of information, transparency and cooperation between various levels of management and ambivalence toward business in hospitals. The two levels of management are clearly divided in terms of interests, information and activity, leading to difficulty in cooperation, efficiency and achievement of organizational goals.

ORIGINALITY/VALUE

Using agency theory, this study provides a systemic and organizational view of hospitals' management and environmental adaptation. Understanding the processes and increasing cooperation at various managerial levels can help make the system more efficient and ensure its survival in a dynamic market.

Agency problems of global budget system in Taiwan's National Health Insurance

The main purpose of this study was to investigate the agency problem presented by the global budget system followed by hospitals in Taiwan. In this study, we examine empirically the interaction between the principal: Bureau of National Health Insurance (BNHI) and agency: medical service providers (hospitals); we also describe actual medical service provider and hospital governance conditions from a agency theory perspective. This study identified a positive correlation between aversion to agency hazard (self-interest behavior, asymmetric information, and risk hedging) and agency problem risks (disregard of medical ethics, pursuit of extra-contract profit, disregard of professionalism, and cost orientation). Agency costs refer to BNHI auditing and monitoring expenditures used to prevent hospitals from deviating from NHI policy goals. This study also found agency costs negatively moderate the relationship between agency hazards and agency problems The main contribution of this study is its use of agency theory to clarify agency problems and several potential factors caused by the NHI system. This study also contributes to the field of health policy study by clarifying the nature and importance of agency problems in the health care sector.

ICU service in Taiwan

Background

The aim of the study was to understand the current status of intensive care unit (ICU) in order to optimize the resources achieving the best possible care.

Methods

The study analyzed the status of ICU settings based on the Taiwan National Health Insurance database between March 2004 and February 2009.

Results

A total of 1,028,364 ICU patients were identified. The age was 65 ± 18 years, and 61% of the patients were male. The total ICU bed occupancy rate was 83.8% which went up to 87.3% during winter. The ICU bed occupancy was 94.4% in major medical centers. The ICU stay was 6.5 ± 0.5 days, and the overall ICU mortality rate was 20.2%. The hospital stay was 16.4 ± 16.8 days, and the average cost of total hospital stay was approximately US$5,186 per patient.

Conclusions

The rate of ICU bed occupancy was dependent on seasonal changes, and it reached near full capacity in major medical centers in Taiwan. The ICU beds were distributed based on the categories of hospitals in order to achieve a reasonable cost efficiency. ICU faces many challenges to maintain and improve quality care because of the increasing cost of state-of-the-art technologies and dealing with aging population.