METHODOLOGICAL ASPECTS IN EFFICIENCY EVALUATION OF PUBLIC HOSPITALS

The specific characteristics of the public health care sector prevent the normal working of the market and the trend toward the efficient provision of services. The present study was carried out to offer the Audit Office of the Basque Country and Navarra an objective point of reference from which to measure the efficiency of clinical services. This study consists of an evaluation of the efficient production and utilization of the resources—intermediate services—that hospitals provide to medical staff for carrying out the diagnosis and treatment of patients, together with the efficient use of these intermediate services by the aforementioned medical staff.     

基于平等主义文化的瑞典养老服务体系的形成及其对中国的启示

瑞典作为斯堪的纳维亚福利体系的代表国家之一,其养老服务体系被打上了平等主义文化的烙印。瑞典平等主义文化的形成得益于土地改革、贸易联盟和积极的劳动力市场政策等一系列事件。受到平等主义文化的影响,瑞典养老服务体系的演进分为四个阶段:1918年以前,瑞典以家庭养老服务为主,政府只为贫困老年人提供养老服务;1918—1949年,以老年之家为代表的机构养老服务为主,覆盖全体老年人;1950—1989年,居家养老服务成为瑞典最主要的养老服务方式;1990年至今,“消费者选择”提升了瑞典居家养老服务的质量,政府成为养老服务的唯一责任主体。瑞典基于平等主义文化的养老服务体系的发展经验为我国带来以下启示:大力推进城乡养老服务设施与养老服务津贴的全覆盖;以服务质量为导向推动养老服务供给侧竞争;创造平等的就业环境,为养老服务提供人员保障;充分发挥第三方组织在养老服务中的作用。     

Health care in Australia 1980–2000

Subjective information, collected in this case by a modified Delphi method, can reduce uncertainty and clarify priorities for decision makers. Although Australian health care is likely to face increasing costs and a restriction of some services, a more flexible system will emerge—with community-based care, continuing professional education, and greater use of paramedical staff.     

Evolve and integrate: a new imperative for ambulatory care

A highly evolved ambulatory care delivery system possesses four key attributes: high-quality care, exceptional levels of access, outstanding patient and staff satisfaction, and cost-effective delivery of care. Such a system seeks to ease management of the patient care continuum by delivering as many services as possible under one umbrella. High-quality, cost-effective care is achieved through improved care coordination and cost management, resulting from a tight connection between physicians and hospitals and between inpatient and outpatient settings. Improved access is an important means to improving patient satisfaction.     

Physicians and administrators can work together

This article describes the working relationship between the administration and medical staff of the Mid-Maine Medical Center which is comprised of two separate modern hospitals. The authors advocate the philosophy that "a hospital which harnesses the medical staff's considerable talent and expertise through sound organizational input will be a stronger institution." They explain that patient care is becoming increasingly complex and that management decisions impact heavily on the care provided. In 1973, the Medical Center changed from its traditional organizational form of having a full-time medical director and an administrator report to the board of directors, to a modified corporate model designed to increase physician involvement. In the new organization, the vice president of finance and a part-time chief of staff (acting as vice president for medical affairs) report to the president (former medical director) who, in turn, is responsible to the board of trustees. The authors attribute the success of the reorganization to the CEO's willingness to delegate and share authority, not to the CEO's physician background. Planning at the institution involves a committee of six physicians, four administrators, and one full-time planner. A budgeting committee of three physicians and three administrators is responsible for the review of the budget as well as for making recommendations for the executive board for the expected volume of services. It is concluded that there is no perfect way to run a hospital, but the involvement of doctors in hospital decisions is necessary.     

Design thinking

In the past, design has most often occurred fairly far downstream in the development process and has focused on making new products aesthetically attractive or enhancing brand perception through smart, evocative advertising. Today, as innovation's terrain expands to encompass human-centered processes and services as well as products, companies are asking designers to create ideas rather than to simply dress them up. Brown, the CEO and president of the innovation and design firm IDEO, is a leading proponent of design thinking--a method of meeting people's needs and desires in a technologically feasible and strategically viable way. In this article he offers several intriguing examples of the discipline at work. One involves a collaboration between frontline employees from health care provider Kaiser Permanente and Brown's firm to reengineer nursing-staff shift changes at four Kaiser hospitals. Close observation of actual shift changes, combined with brainstorming and rapid prototyping, produced new procedures and software that radically streamlined information exchange between shifts. The result was more time for nursing, better-informed patient care, and a happier nursing staff. Another involves the Japanese bicycle components manufacturer Shimano, which worked with IDEO to learn why 90% of American adults don't ride bikes. The interdisciplinary project team discovered that intimidating retail experiences, the complexity and cost of sophisticated bikes, and the danger of cycling on heavily trafficked roads had overshadowed people's happy memories of childhood biking. So the team created a brand concept--"Coasting"--to describe a whole new category of biking and developed new in-store retailing strategies, a public relations campaign to identify safe places to cycle, and a reference design to inspire designers at the companies that went on to manufacture Coasting bikes.     

The Employer's Role in Reforming the U.S. Health Care System

In 2005 large U.S. employers spent an average of almost $7,400 per head on health care benefits, a 73% increase in the last five years. If the current trend continues, American companies may find it difficult to compete in a global marketplace where international competitors provide labor with heath care at a fraction of U.S. costs. This article argues that effective reform of the U.S. health care system will require major efforts from all major “stakeholders,” starting with the federal government and state and local governments and including insurance companies and the “consumers” of health care services. By far the important role, however, is reserved for private‐sector employers, which have been the incubator for recent innovations in American health care and are in the best position to coordinate and drive health care reform. But incremental steps in cost‐sharing, small‐scale pilot projects of consumer‐based designs, and employee awareness campaigns will not be enough. Employers need to take radical steps to break through the inertia that has built up among all stakeholders over the past 50 years. Chief among the author's proposals for employers are the following:

• ? In choosing a health care plan for employees, use value‐based purchasing criteria that consider more than just the price and access to services.
• ? Help consumers by demanding information from providers and insurers about the cost and efficacy of health care services, and of alternative treatments, before the choices are made.
• ? Encourage “consumerism” by setting up benefit plans that have a Health Reimbursement Arrangement (HRA) or a Health Savings Account (HSA) component.

As the author states in closing, “Let these reforms begin with employers as the organizing force to drive needed change across the system. That may very well be the only way to save our employment‐based model.”     

Improving the delivery of clinic care

There has been an increasingly widespread movement toward the delivery of health care in outpatient settings. Hospitals must start to prepare for the shift from inpatient to outpatient services. Reductions in reimbursement and increasing costs will force hospitals to collect and obtain more data on outpatient services. Projecting future demands and assessing current utilization rates are two of the key factors in maintaining stability. This article is a case study of a major urban medical center's outpatient clinic. It includes a summary of observations on the clinic's daily operations and several recommendations for improvement. While the original analysis was highly specific to the actual facility observed, this article has been structured so that it may be applied to other institutions.     

The Wider Impacts of the Coronavirus Pandemic on the NHS*

The coronavirus pandemic has had huge impacts on the National Health Service (NHS). Patients suffering from the illness have placed unprecedented demands on acute care, particularly on intensive care units (ICUs). This has led to an effort to dramatically increase the resources available to NHS hospitals in treating these patients, involving reorganisation of hospital facilities, redeployment of existing staff and a drive to bring in recently retired and newly graduated staff to fight the pandemic. These increases in demand and changes to supply have had large knock-on effects on the care provided to the wider population. This paper discusses likely implications for healthcare delivery in the short and medium term of the responses to the coronavirus pandemic, focusing primarily on the implications for non-coronavirus patients. Patterns of past care suggest those most likely to be affected by these disruptions will be older individuals and those living in more deprived areas, potentially exacerbating pre-existing health inequalities. Effects are likely to persist into the longer run, with particular challenges around recruitment and ongoing staff shortages.     

How companies tackle health care costs: Part II.

In this continuing examination of responses to the growing costs of health care, based on a survey of more than 200 large companies, the author discusses the results of employers' efforts to trim these expenses. Most companies have chosen to meet the cost-cutting challenge by changing demand--that is, by redesigning their health insurance policies--and by changing the suppliers of health care services. After a critical analysis of these mechanisms, the author concludes that most of these strategies do little more than shift the costs from one payer to the next. To affect the total cost of the system, she maintains the business sector must use its power to bring about changes in the reimbursement of providers and in the underlying structure of the health care system.     

EFFECTS OF NEW CONTROL SYSTEMS IN SWEDISH HEALTH CARE ORGANIZATIONS

Organizations that are radically changing their control systems provide interesting arenas for studies of the effects of such systems. Research on public organizations have shown reforms in some cases to have effects but in other cases they have had no effects. The aim of our study is to describe the introduction and effects of a new control system in the Swedish health care sector. Basically a traditional budget system is replaced with a system according to which hospitals are paid for services made. We found that the new system had functional but also some dysfunctional effects. The major functional effect was an increased productivity. This was possible due to an earlier low level of productivity. However, increased productivity demands capacity reductions given a certain production level. Such decisions must be taken by politicians but they are, however, very reluctant to reduce capacity, which may cause serious disturbances in the system and dysfunctional consequences.     

中国央行数字货币的设计机制及潜在影响研究--基于央行数字货币专利申请的分析

本文基于央行数字货币专利申请信息和相关专家公开论述,系统分析了央行数字货币的设计演变、双层投放体系及其对金融体系、政策调控的潜在影响。研究认为,央行数字货币在中心化、双层投放体系设计下,定位于现金替代,对商业银行存款挤出及货币乘数影响较小。央行数字货币在保护用户隐私、提高监管能力、降低交易成本和简化跨境支付方面有着显著优势,对现有第三方支付业务产生替代效应。央行数字货币也会影响以支付为重要入口的金融科技业务和数字金融解决方案输出业务的发展,但若数字货币支付交易数据能够在保证安全和隐私的前提下,向金融科技企业和金融机构开放数据分析接口,则有利于打破数据孤岛,推动金融科技业务和金融数字化转型更好更快发展。     

Aligning managed care contracts, compensation plans, and incentive models

Today's pure production-based compensation and incentive models are lagging behind new, third-party, "value based" payment models, such as shared savings, bundled payments, and pay for performance. Financial executives are struggling with the emerging disconnects between new, external payment models and traditional methods providers use to distribute funds internally. To begin to align internal payment models with emerging third-party payment models, providers should inventory the misaligned incentives within their own organizations, engage their physicians and payers in a dialogue on what needs to be paid and how, and learn from past mistakes. No perfect payment distribution model exists. Rather, providers should choose a best-fit model based on their market position, culture, and readiness for change. Ultimately, finance executives should take the lead in aligning their organization's internal and external payment models.     

Professional vs financial capital in the field of health care—struggles for the redistribution of power and control

The field of health care, like all fields of social life, is a site of continuous games for power and control. This paper applies the conceptual tools of the French sociologist Pierre Bourdieu—in particular the notions of field and capital—to analyse the diverse roles, and partially divergent objectives of the various institutions and individuals involved in the functions of financing, production, and consumption of health services. Participants in these struggles are seen to have different chances of winning or losing, depending on their relative power, which is determined by the distribution of differently valued capitals in this specific field. The expectations associated with the transition to market based control mechanisms in the field of Finnish health care, and the experiences of those directly involved in this transition are analysed. The nature and implications of the process of transition from a planning allocation system to a competition based resource allocation system are studied on the basis of extensive interviews and observations conducted in one university hospital and two central hospitals in Finland.     

Profits with a purpose: an interview with Tom Chapman. Interview by Nancy A. Nichols

Greater Southeast Community Hospital is located in the center of one of Washington, D.C.'s most troubled and isolated neighborhoods. Like so many inner-city hospitals, it serves a population struggling with high rates of poverty, crime, and illiteracy. As a result, the area suffers from the highest rates of infant mortality, cancer, and coronary disease in the D.C. area. When Tom Chapman joined the hospital in 1984, it was giving away roughly 11% of its care-or about $11.5 million worth of medical services to indigent residents. If things continued at that rate, the hospital would soon go out of business. His challenge: to keep Greater Southeast solvent while shoring up the community that surrounds it. Chapman, who grew up in a housing project himself, understands the problems of inner cities innately. Working in tandem with community residents, Greater Southeast has developed a broad range of preventive and supportive programs, such as housing, day care for children and the elderly, nursing home services, and literacy training. Last year, Chapman was promoted to CEO of Greater Southeast Health Care, a broad network comprising two hospitals, three nursing homes, a physician care network, and over 50 community programs. He remains true to his original mission: "I want to create a network of participants, stringing together various organizations and players, each of whom have something special to contribute to urban problems.... What we are really doing is creating a community."     

农村社区居家养老服务需求强度的实证分析——基于辽宁省S镇农村老年人的问卷调查

基于辽宁省S镇农村社区老年人居家养老服务需求调查发现,农村社区居家养老更加符合农村老年人的养老意愿。依据克雷顿·奥尔德弗"ERG"需求层次理论,将农村老年人需求分为生活照料、医疗保健、精神赡养三个层次。通过李克特量表法衡量居家养老服务需求强度得出,农村老年人所需的医疗保健和精神赡养与生活照料相比需求强度较高。运用spearman相关系数模型测算了年龄、性别、生活自理能力、婚姻状况、健康自评等因素对居家养老服务需求强度的影响程度。为此,我国发展农村居家养老服务需要尊重老年人的养老意愿,以居家养老服务需求强度为依据实施精准供给,积极完善农村社会化养老服务政策支持体系,逐步满足农村社区老年人的养老需求。     

第三方合作存款与商业银行风险承担

近年来与第三方互联网平台合作推出存款产品一度成为部分中小银行吸收存款的重要手段,监管部门对此高度关注并出台监管措施,但相关的学术研究较为匮乏。本文基于国内上市银行2012—2020年的面板数据,实证分析开展第三方合作存款业务对银行风险承担的影响并考察内在机理。研究发现,开展该业务显著提高了银行风险承担水平,表现为加权风险资产的扩张及高风险行业信贷资产配置的提升。机制研究表明,合作银行的储蓄存款规模显著扩张,流动性资金的过快增长刺激银行信贷向高利率贷款、高风险行业倾斜。本文研究对完善互联网存款监管,防控商业银行风险具有一定的启示意义。     

老年人“美好生活”水平测度与政策洞见——基于主成分分析的三指数模型

基于中国老年健康影响因素跟踪调查2014年的数据,使用主成分分析法从9个测量指标中提取测度老年人“美好生活”的3个一级指数——安全指数、生存指数和享受指数,并合成老年人“美好生活”综合指数(BLI-E)。分项来看,生存指数、综合指数呈对称的正态分布,安全指数右偏分布水平较高,享受指数左偏分布水平偏低;分地区来看,各省份的老年人“美好生活”指数差异不大,养老服务供给不充分问题更突出;分组来看,老年人中女性比男性、农村比城镇、高龄与低龄、居家养老比独居或机构养老的“美好生活”水平更低。当前制约我国老年人实现“美好生活”的主要瓶颈是养老资源供给不足情况下的共享不均衡问题。建议加大力度解决我国老年人“美好生活”发展不充分的问题,着重解决不平衡问题,打造综合性、全方位的老年人“美好生活”保障体系。     

Diversification of External Accountants Serving Small and Medium‐sized Enterprises: Evidence from Belgium

The purpose of this study is: (1) to discover which services are offered by external accountants serving small and medium‐sized enterprises (SMEs); (2) to study the factors that are associated with the degree of diversification of the services offered by these accountants; and (3) to investigate if there are differences between self‐employed accountants and accounting firms on the previous two points. This study has some interesting conclusions: (1) the heterogeneity of internal staff is not significantly associated with the degree of diversification; (2) a homogeneous internal staff with an accounting background is particularly important for accounting firms that diversify their services in the accounting and tax area; (3) collaboration with other service providers is an important factor associated with more diversification of the services; (4) marketing is only important for self‐employed accountants; (5) accounting firms offer fewer non‐accounting‐related services if they serve more micro clients (fewer than 10 employees), whereas self‐employed accountants offer more accounting and tax services if they serve more micro clients (fewer than 10 employees); and (6) accounting firms that diversify in accounting and tax services mainly serve more micro clients (fewer than 10 employees), whereas accounting firms that diversify in non‐accounting areas serve more larger clients (more than 10 employees).     

Family planning and health: the Narangwal experiment

The findings of a 7-year field experiment conducted in the Indian Punjab show that integrating family planning with health services is more effective and efficient than providing family planning separately. The field experiment was conducted between 1968 and 1974 at Narangwal in the Indian State of Punjab. It involved 26 villages, with a total population of 35,000 in 1971-72. The demographic characteristics of the villages were found to be typical of the area. 5 groups of villages were provided with different combinations of services for health, nutrition and family planning. A control group received no project services. A population study was made of the effects of integrating family planning with maternal and child health services. A nutritional study looked at the results of integrating nutritional care and health services. The effectiveness of integration was evaluated by identifying it both with increased use of family planning and improved health. Efficiency was judged by relating effectiveness to input costs. Distribution of the benefits was also examined. The effectiveness of these different combinations of services on the use of family planning was measured: 1) by all changes in the use of modern methods of family planning, 2) by the number of new acceptors, 3) by the changes in the proportion of eligible women using contraceptives, and 4) by how many people started to use the more effective methods. Results showed the use of family planning increased substantially in the experimental groups, whereas the control group remained constant. It was also found that, though the services combining family planning with maternal health care stimulated more use of family planning, they were more costly than the more integrated srevices. The Narangwal experiment provides significant evidence in favor of combining the provision of family planning and health services, but its potential for replication on a large scale needs to be studied.