The Cost Shifting Economics of United States Emergency Department Professional Services (2016-2019)

STUDY OBJECTIVE

We estimate the economics of US emergency department (ED) professional services, which is increasingly under strain given the longstanding effect of unreimbursed care, and falling Medicare and commercial payments.

METHODS

We used data from the Nationwide Emergency Department Sample (NEDS), Medicare, Medicaid, Health Care Cost Institute, and surveys to estimate national ED clinician revenue and costs from 2016 to 2019. We compare annual revenue and cost for each payor and calculate foregone revenue, the amount clinicians may have collected had uninsured patients had either Medicaid or commercial insurance.

RESULTS

In 576.5 million ED visits (2016 to 2019), 12% were uninsured, 24% were Medicare-insured, 32% Medicaid-insured, 28% were commercially insured, and 4% had another insurance source. Annual ED clinician revenue averaged $23.5 billion versus costs of $22.5 billion. In 2019, ED visits covered by commercial insurance generated $14.3 billion in revenues and cost $6.5 billion. Medicare visits generated $5.3 billion and cost $5.7 billion; Medicaid visits generated $3.3 billion and cost $7 billion. Uninsured ED visits generated $0.5 billion and cost $2.9 billion. The average annual foregone revenue for ED clinicians to treat the uninsured was $2.7 billion.

CONCLUSION

Large cost-shifting from commercial insurance cross-subsidizes ED professional services for other patients. This includes the Medicaid-insured, Medicare-insured, and uninsured, all of whom incur ED professional service costs that substantially exceed their revenue. Foregone revenue for treating the uninsured relative to what may have been collected if patients had health insurance is substantial.

Cost Sharing and Cost Shifting Mechanisms under a per Diem Payment System in a County of China

Cost sharing and cost shifting mechanisms are of vital importance in a prospective payment system. This paper employed the difference-in-differences method to estimate the impacts of a per diem system with inverted-U-shape rates on medical costs and the length of stay based on data from a health insurance institution. The supply side cost sharing mechanism worked so that the new payment system significantly reduced medical costs by 17.59 percent while the average length of stay varied little. After further analyzing the mechanism, we found that heterogeneous effects emerged mainly due to the special rates design. The reform decreased the cases that incurred relatively high medical costs and lengths of stay. However, cost shifting existed so that physicians could be motivated to provide unnecessary services to the patients who should have been discharged before the average length of stay. Therefore, payment rates in the per diem system require a sophisticated design to constrain its distortion to medical service provision even though medical expenditures were successfully contained.

Cost-benefit allocation of collaborative carbon emissions reduction considering fairness concerns-A case study of the Yangtze River Delta, China

As the country with the highest carbon emissions, the main focus of China has become carbon reduction. At present, the governance of carbon reduction is mainly based on the division of administrative regions, which leads to the governance inefficiency and high costs because of spatial spillover and regional mobility of carbon emissions. The need for collaborative governance to promote carbon reduction performance has been recognized. However, because of differences in both costs and benefits between developed and less developed regions, a clear cost and benefit allocation mechanism must be established first. Fairness is very important when all members are to actively participate in collaborative carbon emission reduction efforts. In this paper, one of the regions renowned for collaborative governance-the Yangtze River Delta region-is used as example, and a cost-benefit allocation mechanism is constructed that incorporates members' fairness concerns. The carbon emission efficiency, carbon reduction efforts, and total carbon emission amount are compared under two scenarios: a cost-sharing scenario and a centralized decision-making scenario. The results indicate that, compared with the centralized decision-making scenario, the cost-sharing scenario achieved greater regional carbon reduction efforts, a higher carbon emission efficiency, and more total emissions. Furthermore, under the cost-sharing scenario, in less developed regions, fairness concerns increase carbon emission efficiency and total carbon emissions. The fairness concern in developed regions reduces the profit proportion, while the fairness concern in less developed region increases the profit proportion. The impact of fairness concern on carbon reduction is stronger in developed regions.

Water pollutant discharge permit allocation based on DEA and non-cooperative game theory

Against the background of the ecological civilization system reform in the new era, the appropriate allocation of water pollutant discharge permits is an important policy for controlling the amount of wastewater discharge. Traditional allocation methods have disadvantages, such as high additional costs, an unfair allocation scheme, and market distortion. In the present study, a fixed-cost allocation model based on data envelopment analysis (DEA) and the Nash non-cooperative game theory is employed to allocate water pollutant discharge permits of totally 31 provinces in China from 2008 to 2017. The allocation scheme considers environmental efficiency. The results demonstrate regional differences in the allocation of water pollutant discharge permits. The eastern region has abundant allocations. The northeastern and central regions have insufficient allocations. Besides, the western region has a significant shortage of allocations. It indicates the higher the utilization efficiency of the water pollutant discharge permits, the higher the region's sustainable development is. Based on the analysis, we propose guidelines for industrial wastewater discharge reduction.

Mixed Bag: Some Payers Capitalize on COVID Chaos; Others Help Make Care Easier

Physicians believe some payers are taking advantage of COVID chaos with their drug policies, but also see some plans taking steps to make care easier during the pandemic.

Air Ambulance Turbulence: Consolidation, Cost Shifting, and Surprise Billing

It is a heroic part of the American health system. Lives are saved, the dire consequences avoided. But the air ambulance industry is consolidating, prices are soaring, and insurers and providers continually fight over network issues. One consequence: Surprise billing that leaves patients owing tens of thousands of dollars.

The Effect of Medical Technology Innovations on Patient Outcomes, 1990-2015: Results of a Physician Survey

BACKGROUND

Developments in diagnostics, medical devices, procedures, and prescription drugs have increased life expectancy and quality of life after diagnosis for many diseases. Previous research has shown that, overall, increased investment in medical technology has led to increased health outcomes. In addition, the value of investment in specific innovations, particularly in new pharmaceuticals or biopharmaceuticals, has frequently been shown through an evaluation of the associated health outcomes and costs. Value assessments for all medical technologies and interventions are an important consideration in current debates on access and affordability of health care in the United States.

OBJECTIVE

To identify practicing physician impressions of the historical effect of postdiagnosis innovations in medical technology on patient outcomes within the 8 health conditions that have the largest effect on health in the United States.

METHODS

National statistics were used to identify the 8 conditions responsible for the most mortality and morbidity within the United States between 1990 and 2014. A physician survey was developed for each major condition to obtain physician opinion on the extent to which pharmaceuticals and biopharmaceuticals, medical devices, diagnostics, and surgical procedures contributed to improvements in postdiagnosis mortality and morbidity outcomes over the evaluated period. Respondents were provided with a fifth category, "cannot allocate," to account for postdiagnosis outcome gains resulting from other factors such as public health interventions.

RESULTS

The conditions identified as having the greatest effect on morbidity and mortality since 1990 were breast cancer, ischemic heart disease, human immunodeficiency virus infection, diabetes, unipolar depression, chronic obstructive pulmonary disease, cerebrovascular disease, and lung cancer. After excluding other factors, physicians specializing in these conditions, with a mean of 21.4 years in practice, considered pharmaceuticals and biopharmaceuticals as having the greatest postdiagnosis effect across all 8 conditions, with 56% of outcome gains attributed to this innovation category. Diagnostics was the second biggest contributor at 20%.

CONCLUSIONS

Physician perceptions indicated that attention should be paid to value assessments of innovative diagnostics, devices, and surgical procedures, as well as to pharmaceuticals and biopharmaceuticals, before goals for allocating health care expenditures among the different innovations are determined.

DISCLOSURES

Funding for this study was provided by the National Pharmaceutical Council, a health policy research group that receives its funding from biopharmaceutical manufacturers. Wamble is employed by RTI Health Solutions, which received funding from the National Pharmaceutical Council to conduct this research. Ciarametaro and Dubois are employed by the National Pharmaceutical Council.

Global budgets in Maryland: early evidence on revenues, expenses, and margins in regulated and unregulated services

Maryland implemented one of the most aggressive payment innovations the nation has seen in several decades when it introduced global budgets in all its acute care hospitals in 2014. Prior to this, a pilot program, total patient revenue (TPR), was established for 8 rural hospitals in 2010. Using financial hospital report data from the Health Services Cost Review Commission from 2007 to 2013, we examined the hospitals' financial results including revenue, costs, and profit/loss margins to explore the impact of the adoption of the TPR pilot global budget program relative to the remaining hospitals in the state. We analyze financial results for both regulated (included in the global budget and subject to rate-setting) and unregulated services in order to capture a holistic image of the hospitals' actual revenue, cost and margin structures. Common size and difference-in-differences analyses of the data suggest that regulated profit ratios for treatment hospitals increased (from 5% in 2007 to 8% in 2013) and regulated expense-to-gross patient revenue ratios decreased (75% in 2007 and 68% in 2013) relative to the controls. Simultaneously, the profit margins for treatment hospitals' unregulated services decreased (- 12% in 2007 and - 17% in 2013), which reduced the overall margin significantly. This analysis therefore indicates cost shifting and less profit gain from the program than identified by solely focusing on the regulated margins.

Implementation of Robotic Surgery in a Pediatric Hospital: Lessons Learned

BACKGROUND

Since the late 1980s, minimally invasive surgery (MIS) has been one of the fastest growing approaches for surgical procedures. However, its development has reached a plateau. One of the reasons is the difficulty to operate on more complex cases, such as neonatal procedures. Some experts report outstanding outcomes for complex operations, but not all surgeons may be able to achieve the same results. Is robotic surgery (RS) a solution?

METHODS

To answer this question, we reviewed the current indications of RS for the pediatric population and the steps needed to incorporate the robotic surgical system in a children's hospital. We reported our experience and presented our first results and the encountered problems.

RESULTS

After a year and a half of experience with RS, several lessons were learned: (1) the current robotic surgical system cannot yet be considered a replacement to conventional MIS, (2) docking is less time consuming than expected, (3) postoperative pain is significantly decreased, (4) the absence of haptic feedback is still a matter of concern, and (5) costs can be afforded by sharing the RS with adult surgeons.

CONCLUSIONS

Based on our experience, the advantages seem to outweigh the drawbacks as it encourages team building and increases overall comfort for the surgeon. However, the current literature fails to prove that RS gives better results for pediatric patients. New advances in technology will probably help to overcome the encountered difficulties and the high costs.

Cost shifting and other perverse incentives in biodiversity offsetting in India

Biodiversity offsetting aims to compensate for development-induced biodiversity loss through commensurate conservation gains and is gaining traction among governments and businesses. However, cost shifting (i.e., diversion of offset funds to other conservation programs) and other perverse incentives can undermine the effectiveness of biodiversity offsetting. Additionality-the requirement that biodiversity offsets result in conservation outcomes that would not have been achieved otherwise-is fundamental to biodiversity offsetting. Cost shifting and violation of additionality can go hand in hand. India's national offsetting program is a case in point. Recent legislation allows the diversion of offset funds to meet the country's preexisting commitments under the United Nations Framework Convention on Climate Change (UNFCCC) and United Nations Convention on Biological Diversity (CBD). With such diversions, no additional conservation takes place and development impacts remain uncompensated. Temporary additionality cannot be conceded in light of paucity of funds for preexisting commitments unless there is open acknowledgement that fulfillment of such commitments is contingent on offset funds. Two other examples of perverse incentives related to offsetting in India are the touting of inherently neutral offsetting outcomes as conservation gains, a tactic that breeds false complacency and results in reduced incentive for additional conservation efforts, and the clearing of native vegetation for commercial plantations in the name of compensatory afforestation, a practice that leads to biodiversity decline. The risks accompanying cost shifting and other perverse incentives, if not preempted and addressed, will result in net loss of forest cover in India. We recommend accurate baselines, transparent accounting, and open reporting of offset outcomes to ensure biodiversity offsetting achieves adequate and additional compensation for impacts of development.

The hidden costs: Identification of indirect costs associated with acute gastrointestinal illness in an Inuit community

BACKGROUND

Acute gastrointestinal illness (AGI) incidence and per-capita healthcare expenditures are higher in some Inuit communities as compared to elsewhere in Canada. Consequently, there is a demand for strategies that will reduce the individual-level costs of AGI; this will require a comprehensive understanding of the economic costs of AGI. However, given Inuit communities' unique cultural, economic, and geographic contexts, there is a knowledge gap regarding the context-specific indirect costs of AGI borne by Inuit community members. This study aimed to identify the major indirect costs of AGI, and explore factors associated with these indirect costs, in the Inuit community of Rigolet, Canada, in order to develop a case-based context-specific study framework that can be used to evaluate these costs.

METHODS

A mixed methods study design and community-based methods were used. Qualitative in-depth, group, and case interviews were analyzed using thematic analysis to identify and describe indirect costs of AGI specific to Rigolet. Data from two quantitative cross-sectional retrospective surveys were analyzed using univariable regression models to examine potential associations between predictor variables and the indirect costs.

RESULTS/SIGNIFICANCE

The most notable indirect costs of AGI that should be incorporated into cost-of-illness evaluations were the tangible costs related to missing paid employment and subsistence activities, as well as the intangible costs associated with missing community and cultural events. Seasonal cost variations should also be considered. This study was intended to inform cost-of-illness studies conducted in Rigolet and other similar research settings. These results contribute to a better understanding of the economic impacts of AGI on Rigolet residents, which could be used to help identify priority areas and resource allocation for public health policies and programs.

Joint pollution control in the Lake Tai Basin and the stabilities of the cost allocation schemes

This paper provides insights into the allocation of benefits derived from joint wastewater treatment in the Lake Tai Basin of China and the acceptability and stability of different cost allocation schemes in a trans-jurisdictional water system context. First, the wastewater treatment cost function is estimated and coalition costs are compared to the cost of stand-alone wastewater treatment in each province. Second, two standard and five game theoretical cost allocation schemes are applied to the grand coalition. Results suggest that a cost savings of US $46.46 million can be obtained by forming a grand coalition. All allocation schemes were found to be acceptable. Results also suggest that both Shanghai and Jiangsu Province would prefer a proportional allocation scheme based on pollutant discharge, because it would offer them the largest cost savings. But this allocation scheme is the least stable one. Based on the criterion of stability, the Nash-Harsanyi scheme emerges as providing the optimal allocation. Finally, calculation of power and stability indexes suggests Jiangsu Province as an agent is critical to the success of grand coalition formation.

Hybrid averaging offers high-flow contrast by cost apportionment among imaging time, axial, and lateral resolution in optical coherence tomography angiography

The current temporal, wavelength, angular, and spatial averaging approaches trade imaging time and resolution for multiple independent measurements that improve the flow contrast in optical coherence tomography angiography (OCTA). We find that these averaging approaches are equivalent in principle, offering almost the same flow contrast enhancement as the number of averages increases. Based on this finding, we propose a hybrid averaging strategy for contrast enhancement by cost apportionment. We demonstrate that, compared with any individual approach, the hybrid averaging is able to offer a desired flow contrast without severe degradation of imaging time and resolution. Making use of the extended range of a VCSEL-based swept-source OCT, an angular averaging approach by path length encoding is also demonstrated for flow contrast enhancement.

Pollution control costs of a transboundary river basin: Empirical tests of the fairness and stability of cost allocation mechanisms using game theory

With rapid economic growth, transboundary river basin pollution in China has become a very serious problem. Based on practical experience in other countries, cooperation among regions is an economic way to control the emission of pollutants. This study develops a game theoretic simulation model to analyze the cost effectiveness of reducing water pollutant emissions in four regions of the Jialu River basin while considering the stability and fairness of four cost allocation schemes. Different schemes (the nucleolus, the weak nucleolus, the Shapley value and the Separable Cost Remaining Benefit (SCRB) principle) are used to allocate regionally agreed-upon water pollutant abatement costs. The main results show that the fully cooperative coalition yielded the highest incremental gain for regions willing to cooperate if each region agreed to negotiate by transferring part of the incremental gain obtained from the cooperation to cover the losses of other regions. In addition, these allocation schemes produce different outcomes in terms of their fairness to the players and in terms of their derived stability, as measured by the Shapley-Shubik Power Index and the Propensity to Disrupt. Although the Shapley value and the SCRB principle exhibit superior fairness and stabilization to the other methods, only the SCRB principle may maintains full cooperation among regions over the long term. The results provide clear empirical evidence that regional gain allocation may affect the sustainability of cooperation. Therefore, it is implied that not only the cost-effectiveness but also the long-term sustainability should be considered while formulating and implementing environmental policies.

Health insurance and the demand for medical care: Instrumental variable estimates using health insurer claims data

This paper takes a different approach to estimating demand for medical care that uses the negotiated prices between insurers and providers as an instrument. The instrument is viewed as a textbook "cost shifting" instrument that impacts plan offerings, but is unobserved by consumers. The paper finds a price elasticity of demand of around -0.20, matching the elasticity found in the RAND Health Insurance Experiment. The paper also studies within-market variation in demand for prescription drugs and other medical care services and obtains comparable price elasticity estimates.

A Comparison of Costs Between Medical and Surgical Patients in an Academic Pediatric Intensive Care Unit

OBJECTIVE

To estimate the impact of patient type on costs incurred during a pediatric intensive care unit (PICU) hospitalization.

PATIENTS AND METHODS

Retrospective cohort study at an academic PICU located in the United States that examined 850 patients admitted to the PICU from January 1 to December 31, 2009. Forty-eight patients were excluded due to lack of financial data. Primary service was defined by the attending physician of record. Outcome measures were total and daily pediatric intensive care costs (2009 US dollars).

RESULTS

Of 802 patients in the sample, there were 361 medical and 441 surgical patients. Comparing medical to surgical patients, severity of illness as defined by Pediatric Risk of Mortality (PRISM) III scores was 4.53 vs 2.08 (P < 0.001), length of stay was 7.37 vs 5.00 days (P < 0.001), total pediatric intensive care hospital costs were $34,786 vs $30,598 (P < 0.001), and mean daily pediatric intensive care hospital costs were $3985 vs $6616 (P < 0.001).

CONCLUSIONS

Medical patients had higher severity of illness and length of stay resulting in higher total pediatric intensive care costs when compared to surgical patients. Interestingly, when accounting the length of stay, surgical patients had higher daily pediatric intensive care costs despite lower severity of illness.

A lot of mental illness starts in adolescence. Therefore should we shift some of the spending from adult to adolescent mental health services?

In May 2015 the UK elected a new government. In election campaigns, health is one of the most important areas of debate and over the preceding 12 months, the state of child and adolescent mental health services (CAMHS) had held a particularly high profile in the media and in political debate. Many had suggested that the rate of mental illness starting in adolescence is increasing and that service provision is not of sufficient quality or scale to meet this need. A brief review of the sources for these statistics reveals that whilst this may be true, there is a dearth of accurate and up to date data on the scale of the need for CAMHS or the extent to which it is being met. Nonetheless, members of all parties claimed to support improvements in mental health service provision for children and adolescents through increases in funding. A key question for policy makers has therefore become, from where any additional funding might be derived. One suggestion has been that funding be transferred from spending on adult mental health services. The exact practical nature of such a policy is yet to be explored in detail by government or stakeholders. The primary purpose of the present discussion is therefore to consider the possible ethical implications of such a policy in principle. The discussion forms part of a wider and evolving political and professional discourse on society's and government's attitude towards mental illness, towards the balance of individual and societal needs and towards the balance between preventative and supportive interventions to improve health.

Modelling of nuclear power plant decommissioning financing

Costs related to the decommissioning of nuclear power plants create a significant financial burden for nuclear power plant operators. This article discusses the various methodologies employed by selected European countries for financing of the liabilities related to the nuclear power plant decommissioning. The article also presents methodology of allocation of future decommissioning costs to the running costs of nuclear power plant in the form of fee imposed on each megawatt hour generated. The application of the methodology is presented in the form of a case study on a new nuclear power plant with installed capacity 1000 MW.

Reduction of Baltic Sea nutrient inputs and allocation of abatement costs within the Baltic Sea catchment

The Baltic Sea Action Plan (BSAP) requires tools to simulate effects and costs of various nutrient abatement strategies. Hierarchically connected databases and models of the entire catchment have been created to allow decision makers to view scenarios via the decision support system NEST. Increased intensity in agriculture in transient countries would result in increased nutrient loads to the Baltic Sea, particularly from Poland, the Baltic States, and Russia. Nutrient retentions are high, which means that the nutrient reduction goals of 135 000 tons N and 15 000 tons P, as formulated in the BSAP from 2007, correspond to a reduction in nutrient loadings to watersheds by 675 000 tons N and 158 000 tons P. A cost-minimization model was used to allocate nutrient reductions to measures and countries where the costs for reducing loads are low. The minimum annual cost to meet BSAP basin targets is estimated to 4.7 billion Euro.

Cost-control mechanisms in Canadian private drug plans

Approximately 68% of Canadians receive prescription drug coverage through an employer-sponsored private plan. However, we have very limited data on the structure of these plans. This study aims to identify and describe the use of cost-control mechanisms in private drug plans in Canada and describe what private coverage looks like for the average Canadian. Using 2010 data from over 113,000 different private drug plans, provided by Applied Management Consultants, we determined the overall use of key cost-control measures, and the cost-control tools that appear to be gaining currency compared to a report on benefits coverage in 1998. We found that the use of common cost-control measures is relatively low among Canadian private benefits programs. Co-insurance is much more common in private coverage plans than co-payments. Deductibles are uncommon in Canada and, when in place, are very small. The use of annual and lifetime maximums is increasing. Canadian private benefits programs use few cost-control measures to respond to increasing costs, particularly in comparison to their public counterparts. These results suggest there are ample opportunities for greater efficiency in private sector drug coverage plans.

Cost accounting in a surgical unit in a teaching hospital - a pilot study

INTRODUCTION

Economic constraints remain one of the major limitations on the quality of health care even in industrialised countries. Improvement of quality will require optimising facilities within available resources. Our objective was to determine costs of surgery and to identify areas where cost reduction is possible.

PATIENTS AND METHODS

80 patients undergoing routine major and intermediate surgery during a period of 6 months were selected at random. All consumables used and procedures carried out were documented. A unit cost was assigned to each of these. Costing was based on 3 main categories: preoperative (investigations, blood product related costs), operative (anaesthetic charges, consumables and theatre charges) and post-operative (investigations, consumables, hospital stay). Theatre charges included two components: fixed (consumables) and variable (dependent on time per operation).

RESULTS

The indirect costs (e.g. administration costs, 'hotel' costs), accounted for 30%, of the total and were lower than similar costs in industrialised nations. The largest contributory factors (median, range) towards total cost were, basic hospital charges (30%; 15 to 63%); theatre charges fixed (23%; 6 to 35%) and variable (14%; 8 to 27%); and anaesthetic charges (15%; 1 to 36%).

CONCLUSION

Cost reduction in patients undergoing surgery should focus on decreasing hospital stay, operating theatre time and anaesthetic expenditure. Although definite measures can be suggested from the study, further studies on these variables are necessary to optimise cost effectiveness of surgical units.

[A cost-benefit analysis of a Mexican food-support program]

Objective Presenting an estimate of a Mexican food-support program (FSP) program's cost transfer ratio (CTR) from start-up (2003) to May 2005. Methods The program's activities were listed by constructing a time allocation matrix to ascertain how much time was spent on each of the program's activities by the personnel so involved. Another cost matrix was also constructed which was completed with information from the program's accountancy records. The program's total cost, activity cost and the value of given FSP transfers were thus estimated. Results Food delivery CRT for 2003, 2004 and 2005 was 0.150, 0.218, 0.230, respectively; cash CTR was 0.132in 2004 and 0.105 in 2005. Conclusion Comparing CTR values according to transfer type is a good way to promote discussion related to this topic; however, the decision for making a transfer does not depend exclusively on efficiency but on both mechanisms' effectiveness.

Cost of wind energy: comparing distant wind resources to local resources in the midwestern United States

The best wind sites in the United States are often located far from electricity demand centers and lack transmission access. Local sites that have lower quality wind resources but do not require as much power transmission capacity are an alternative to distant wind resources. In this paper, we explore the trade-offs between developing new wind generation at local sites and installing wind farms at remote sites. We first examine the general relationship between the high capital costs required for local wind development and the relatively lower capital costs required to install a wind farm capable of generating the same electrical output at a remote site,with the results representing the maximum amount an investor should be willing to pay for transmission access. We suggest that this analysis can be used as a first step in comparing potential wind resources to meet a state renewable portfolio standard (RPS). To illustrate, we compare the cost of local wind (∼50 km from the load) to the cost of distant wind requiring new transmission (∼550-750 km from the load) to meet the Illinois RPS. We find that local, lower capacity factor wind sites are the lowest cost option for meeting the Illinois RPS if new long distance transmission is required to access distant, higher capacity factor wind resources. If higher capacity wind sites can be connected to the existing grid at minimal cost, in many cases they will have lower costs.

The determinants of hospital cost: a cost-volume-profit analysis of health services in the occupied territories: Palestine

OBJECTIVE

The purpose of this study is to examine the unit costs of a multi-service hospital in Palestine for the period 2005-2007. We investigate the cost structure of the Rafidya Hospital located in Nablus city, for both inpatient and outpatient departments.

METHODS

This study uses cost-volume-profit (CVP) analysis, also known as breakeven analysis. CVP analysis requires examining total costs, along with fixed and variable costs. CVP analysis illuminates how changes in assumptions about cost behaviour and the relevant range in which those assumptions are valid affect the relationships among revenues, variable costs and fixed costs at various production levels.

KEY FINDINGS

For the hospital of interest, we find that fixed costs account for 70% of total costs, and variable costs were 30% of total costs. Inpatient departments accounted for 86% of total costs, and outpatient departments were 14% of total costs. Results of the breakeven analysis illustrate that several departments charge sufficient fees to cover all unit costs.

CONCLUSIONS

Results provide useful information about unit cost based on four categories: (1) unit cost per admission of each department, (2) unit cost per patient day of each department, (3) unit cost per admission with annual capital cost of each department and (4) unit cost per patient day with annual capital cost. Our results provide hospital cost information that can be used by decision-makers to provide and expand healthcare services, in an effort to increase sustainability and profitability. The use of cost analysis by administrators and regulators will improve the quality of financial information, as well as enhance the efficient use of scarce resources.

[Shift-share analysis on regional industrial pollution growth]

Based on the statistical calculation of industrial pollution charge, an extended shift share analysis method was employed to study the regional industrial pollution growth in Jilin Province, and the preferred action for regional industrial ecological transition was discussed from a view point of pollution treatment. The results could be summarized as follows: 1) Proportional shift could suggest some ways to promote industrial ecological transition from the aspect of industrial organization, while differential shift can provide some enlightenment for pollution treatment in terms of technology. The variation coefficients of proportional shift and differential shift at regional scale are 15.78 and 34.05 respectively, and the difference between them implies that production technology plays a much more important role than that of industrial organization in the course of regional industrial ecological transition. 2) Comparing the corresponding components at regional scale and neighborhood scale is meaningful to discover the area which has a dominant effect on regional pollution. As to Jilin Province, it should pay more attention on the pollution reducing in Changchun City and Jilin City. 3) By means of identifying sectoral linkage influence and non-linkage influence on pollutants output, regional pollution types can be grouped into compound category and monomial category, and relevant countermeasures could be adopted to control industrial pollution through industrial organization. 4) The spatial structure of industrial ecological transition in Jilin Province can be divided into four regions which are central area, southeast area, western area and eastern area.

Economic assessment of central cancer registry operations, Part III: Results from 5 programs

In this article, we report results from the cost analysis of 5 central cancer registries funded by the National Program of Cancer Registries (NPCR). To estimate the true economic costs of operating a cancer registry, we used a cost-assessment tool (CAT) to collect data on all registry activities, not just those funded by the NPCR. Data were collected on actual, rather than budgeted, expenditures, including personnel, consultants, information technology (IT) support, and other factors influencing costs. Factors that can affect registry costs include the amount of consolidation from abstract to incident cases, the method of data reporting, the number of edits that must be performed manually versus electronically, and the amount of interstate data exchange required of a registry. Expenditures were allocated to specific surveillance and data enhancement and analysis activities. Our study confirmed that cost per case varies across registry activities. The cost of surveillance activities per case ranges from $24.79 to $95.78 while the cost of data enhancement and analysis registry activities per reported cancer case ranges from $2.91 to $9.32. Total cost per reported cancer case also varies, ranging from $30 to slightly more than $100, with a median of $45.84. Further research using data from all NPCR-funded registries is required to assess reasons for this variation. Information gained from such an assessment will improve efficiency in registry operations and provide data to better quantify the funding requirements for expanding registry activities.

Conservation through the economics lens

Although conservation is an inherently transdisciplinary issue, there is much to be gained from examining the problem through an economics lens. Three benefits of such an approach are laid out in this paper. First, many of the drivers of environmental degradation are economic in origin, and the better we understand them, the better we can conserve ecosystems by reducing degradation. Second, economics offers us a when-to-stop rule, which is equivalent to a when-to-conserve rule. All economic production is based on the transformation of raw materials provided by nature. As the economic system grows in physical size, it necessarily displaces and degrades ecosystems. The marginal benefits of economic growth are diminishing, and the marginal costs of ecological degradation are increasing. Conceptually, we should stop economic growth and focus on conservation when the two are equal. Third, economics can help us understand how to efficiently and justly allocate resources toward conservation, and this paper lays out some basic principles for doing so. Unfortunately, the field of economics is dominated by neoclassical economics, which builds an analytical framework based on questionable assumptions and takes an excessively disciplinary and formalistic approach. Conservation is a complex problem, and analysis from individual disciplinary lenses can make important contributions to conservation only when the resulting insights are synthesized into a coherent vision of the whole. Fortunately, there are a number of emerging transdisciplines, such as ecological economics and environmental management, that are dedicated to this task.

A waste load allocation method based on unfairness factors and its application in the Zhangweinan Watershed, northern China

A waste load allocation method was developed for industrial wastewater management based on unfairness factors, an industrial allocation factor and pollution reduction discounts. Three unfairness factors were defined to assess the relative efficiencies of energy consumption, pollution discharge and waste treatment costs for different industries. The overall effect of these factors was described by an industrial allocation factor. Based on the values of these factors, industries were classified into three types, after which waste load allocation proportions among different industries were determined using different pollution reduction discounts. This waste load allocation method was then applied in the Zhangweinan Watershed, which is one of the most seriously polluted watersheds in northern China. The results revealed that extractive, mechanical and food industries comprise the type I industries, which had the lowest pollution reduction discounts of 0, 0.25 and 0.5, respectively. The metallurgical industry and other industries were characterized as type II and discounts of 0.5 and 0.6 were given to their primary reductions. Textile, pharmaceutical, oil and pyrogenic, chemical and paper industries were classified as type III industries and had a waste load reduction of more than 80% of the pollution discharge in 2004.

[Performance-oriented allocations of financial resources at medical schools: an overview]

During the last 15 years, the performance-based allocation of funds (Leistungsorientierte Mittelvergabe, LOM) has become remarkably important at medical schools in Germany. In the meantime, all medical schools have established procedures adopting LOM to research. More recently, several medical schools have also begun to use LOM for teaching. The procedures used for both research and teaching are still very heterogeneous. For research, the DFG and the Wissenschaftsrat made suggestions to the medical schools, which were appreciated in a very normative way. The DFG is currently revising its recommendations in cooperation with the AWMF. In some federal states, LOM is also used to control the allocation of funds between different medical schools. Medical schools very often use the impact factor for the evaluation of individuals (postdoctoral qualification (habilitation), appointments), although the impact factor is not suitable for that purpose. In these cases, citation systems should be preferred.