Co-commissioning of public services and outcomes in the UK: Bringing co-production into the strategic commissioning cycle

Commissioning as a planning, resource mobilization and prioritization activity needs to harness user and community co-production of public services and outcomes. Based on a public value model, we map how commissioners can go beyond traditional consultation and participation processes to achieve co-commissioning with citizens. Moreover, we discuss how public sector organizations can use their strategic commissioning process to support and embed citizen voice and action in their problem prevention, treatment and rehabilitation strategies to achieve the quality of life outcomes desired by both citizens and public service commissioners.     

Walking the contractual tightrope: a transaction cost economics perspective on social impact bonds

ABSTRACT

Transaction cost economics is applied in this paper to social impact bonds to explore how public service commissioners could improve outcomes-based contracts. The authors supply a framework for assessing the quality of outcomes specifications and clarify the trade-off between a robust value case for government and the transaction costs associated with specifying such a deal. Illustrated by two examples, the authors suggest that commissioners aim for a ‘requisite’ contract: one that minimizes opportunism while balancing the costs of developing a more robust outcomes specification.     

The financial manager's role in the Voluntary Effort

"Voluntary Effort" hopes to duplicate its first year success by further reducing the annual rate of increase of hospital costs by another two percent. The financial manager will play a key role in the achievement of this goal. Mr. Shelton views the financial manager as part of the hospital management team with the responsibility to review the operating goals and management effectiveness of the institution. The Hospital Financial Management Association has developed a Code of Action to assist the financial manager in dealing with his/her assignments and goals. Ultimately, "Voluntary Effort" is striving to establish a cost-effective health care financing and delivery system. The financial manager is encouraged to initiate in-service training programs for support staff to develop a management team capable of creating such a system. The success of the "Voluntary Effort" is dependent upon the effectiveness of hospital managers in dealing with the 1979 minimum wage and social security tax increases, cost containment and inflation. The financial manager can help by determining the financial feasibility of institutional decisions, interpreting government regulations and supplying written facts and figures to the rest of the hospital management team and community.     

The price effects of cross‐market mergers: theory and evidence from the hospital industry

We consider the effect of mergers between firms whose products are not viewed as direct substitutes for the same good or service, but are bundled by a common intermediary. Focusing on hospital mergers across distinct geographic markets, we show that such combinations can reduce competition among merging hospitals for inclusion in insurers' networks, leading to higher prices (or lower‐quality care). Using data on hospital mergers from 1996–2012, we find support that this mechanism operates within state boundaries: cross‐market, within‐state hospital mergers yield price increases of 7%–9 % for acquiring hospitals, whereas out‐of‐state acquisitions do not yield significant increases.     

Gauging the financial impact of physicians on hospitals

A study evaluated the impact of physicians on hospital finances in four basic areas of physician care: primary care, medical specialties, surgical specialties, and other specialties. The study highlighted inherent differences in the activity and revenue-generating patterns of physicians to provide insight into the financial implications of the clinical enterprise. The findings offer a useful perspective on hospitalist programs, particularly regarding the point at which a hospitalist program is likely to be financially self-sustaining. Such data could be used to determine the number of physicians needed to support a new or expanded clinical service.     

FINANCING SATELLITE OUTPATIENT CARE IN RURAL HOSPITALS

Providing health care to low income or elderly residents of rural areas remains a serious national health care problem in the United States. This case study evaluates an intervention for primary outpatient care to a particular class of patients – veterans – and shows how it can benefit them. Locating the outpatient clinic in a struggling rural hospital makes an outreach by the urban veterans hospital financially feasible and is profitable for the rural hospital.     

Hospital use behaviors and associated costs in a health insurance organization, Japan

Physicians are known to play an important role in the rise of health care costs. But patients--the other side of the chain of health care systems--have been given little attention. The present study utilized the outpatient claims (in the belief that the outpatient hospital visits are mainly decided by the patients) from a health insurance organization in Japan (the Fukuoka Prefecture public service mutual aid association for government employees who serve in small cities, towns, and villages) to analyze the employee behaviors in the use of hospital care and the costs associated with these behaviors. Number of diseases diagnosed for an employee, number of claims an employee submitted for one disease, number of hospitals an employee visited, number of claims an employee had from one hospital, and the total number of claims an employee submitted were used to describe the hospital use behaviors. Results showed that some employees exhibited unusual behaviors, characterized by having an extremely large number of diseases diagnosed, visiting a large number of different hospitals, having a large number of claims, etc. Higher medical expenditures were associated with such behaviors. The findings of this study suggest that the patients' role in the rise of health care costs cannot be ignored, and cost-containment strategies targeting modification of patient behaviors in the use of hospital care may prove to be very useful.     

The ins and outs of outsourcing and insourcing: what have we learnt from the past 30 years?

This paper explores recent experience with outsourcing of public services. It highlights how approaches to outsourcing have evolved during the past 30 years, moving through phases of competitive tendering, partnership working, strategic commissioning, prime contracting and, more recently, insourcing. The paper finishes with 10 lessons for commissioners and service providers which can be drawn from these experiences.     

Public Support for Older Disabled People: Evidence from the English Longitudinal Study of Ageing on Receipt of Disability Benefits and Social Care Subsidy

In England, state support for older people with disabilities consists of a national system of non‐means‐tested cash disability benefits and a locally administered means‐tested system of social care. Evidence on how the combination of the two systems targets those in most need is lacking. We estimate a latent factor structural equation model of disability and receipt of one or both forms of support. The model integrates the measurement of disability and its influence on receipt of state support, allowing for the socio‐economic gradient in disability, and adopts income and wealth constructs appropriate to each part of the model. We find that receipt of each form of support rises as disability increases, with a strong concentration on the most disabled, especially for local‐authority‐funded care. The overlap between the two programmes is confined to the most disabled. Less than half of recipients of local‐authority‐funded care also receive a disability benefit; a third of those in the top 10 per cent of the disability distribution receive neither form of support. Despite being non‐means‐tested, disability benefits display a degree of income and wealth targeting, as a consequence of the socio‐economic gradient in disability and likely disability benefit claims behaviour. The scope for improving income/wealth targeting of disability benefits by means testing them, as some have suggested, is thus less than might be expected.     

Medicare on the critical list. Understanding the etiology of the disease will help in the search for a cure.

Medicare, and its companion program Medicaid, came into being as part of Lyndon Johnson's Great Society. Their purpose was to provide the elderly with equal access to high-quality medical care. Though the goals were laudable, the magnitude of the costs and of the effects was unforeseen. As the two programs made medical care available to a large segment of the population, the demand grew. At the same time, private industry became more generous with its health insurance plans. Because of their emphasis on hospital care, the governmental and private industry plans helped push hospital prices up. Now that both sectors are finding the cost of medical care unacceptably high, Congress is proposing remedial legislation and corporations are trying alternative health care plans. These authors explore how well the maladies of Medicare may respond to the various cures that are being proposed.     

An examination,through roles of accounting,of the commissioning of public services from the third sector: the case of a DWP funded initiative

The commissioning of public services from the third sector is explored. The article is based on a qualitative review of pilots for a Department for Work and Pensions (DWP) project— ‘LinkAge Plus’—for people aged over 50. The article offers organizations and policy-makers new insights into the issues faced by the third sector and commissioners of services. The main issue identified is the fragility of the accounting information used to make decisions and monitor progress.     

上海老年长期照护服务供需矛盾分析

随着人口的老龄化以及家庭抚养老年人功能的不断弱化,老年人长期照护服务机制必须尽快完善。上海是我国人口老龄化程度最高的地区,老年人对长期照护服务的需求不断增长。在这种背景下,本文分析上海老年长期照护服务供需状况及其原因,最终提出解决矛盾的基本思路和具体对策。     

农村空巢老年人长期照护体系建设的困境与出路——基于湖南省15个县市的调查

摘要：建立和完善农村老年人长期照护体系,是应对银色浪潮的必然选择。我国农村老年人长期照护体系还处于起步阶段,长期照护的供需矛盾、潜在需求与现实需求的矛盾、资源短缺与服务能力低的矛盾十分突出。借鉴西方经验,建立适合我国农村实际的融经济供养、医疗照护、日常生活护理、精神慰藉于一体的老年人长期照护体系,已迫在眉睫。老年长期照护既是一种制度体现,也是一种服务体系,必须整合各方面力量。其中,政府是主导,家庭是基础,社区是载体、专业服务机构是主体。     

The impact of the managed care backlash on health care spending

The health spending slowdown associated with the managed care revolution in the 1990s suggests that managed care may have been successful in controlling health care spending. I exploit the passage of state regulation during the “managed care backlash” as well as geographic variation in managed care intensity to measure the impact of managed care on spending. I find that restricting managed care causes a large and significant increase in hospital spending, which cannot be explained by changes in hospital market concentration, other regulatory activity, and multiple other possible explanations. I also do not find effects of the backlash on mortality.     

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.     

Propuesta de un índice para evaluar la gestión del control interno

Derived from its humanitarian mission, to pay quality health care to the population, in hospitals and health facilities is needed reduce the occurrence of events that may threaten the physical and psychological integrity of the patients they serve. One of the strategies to consider to overcome this challenge is the proper implementation of the internal control system, to ensure the sustainability of insurers, by increasing efficiency in the care of people, feasible only within a care model that quantifies and management on population identified and addressed. The objective of this paper was to propose a coefficient to evaluate the internal control management for a hospital entity. This was conceived under the guidelines of the multi-criteria modeling in conjunction with the detection of critical points through Petri nets. For this, the order of importance and fulfillment of the components of Internal Control and in unison the unreliability of critical processes in the entity being identified practical application was determined.     

New Jersey's health care system reforms

As New Jersey grappled with the huge burden of uncompensated hospital care, a diverse group of organizations banded together to develop a unique private sector response to the immediate crisis and a long-term strategy for comprehensive reform of the state's health care system.     

What can Canada teach us about health care financing?

Canada now spends proportionally more on health care than any other country except the U.S., Sweden and the Netherlands - about 7.2% of its GNP or about $500 per capita. Almost all Canadians (99%) are insured against the cost of all hospital and physician expenses through government health insurance programs administered by the provinces. Hospitals are reimbursed by the government 26 times per year and must work within annual budgets formulated by the Ministry of Health. The fiscal restraints imposed upon hospitals have caused them to look at expansion of shared services, regionalization and a slowed rate of growth. As in the U.S., hospital administrators complain about government regulation on the grounds that individual physicians have a much greater influence over utilization than do hospital administrators. Further hospital cutbacks will have the effect of reducing services and therefore, costs. However, there is concern that these kinds of modifications will result in services among communities which would affect the very principle of universal health insurance for Canadians.     

The supply of charity services by nonprofit hospitals: motives and market structure

This article studies provision of charity care by private, nonprofit hospitals. We demonstrate that in the absence of large positive income effects on charity care supply, convex preferences for the nonprofit hospital imply crowding out by other private or government hospitals. Extending our model to include impure altruism (rivalry) provides a possible explanation for the previously reported empirical result that both crowding out and income effects on indigent care supply are often weak or insignificant. Empirical analysis of data for hospitals in Maryland provides evidence of rivalry on the supply of charity care.     

Frequent-user patients: reducing costs while making appropriate discharges

Homeless patients who lack access to the health resources they need to maintain their health on their own pose a challenge for hospitals: Premature discharge of such patients can result in their being readmitted to the hospital in a short time, leading to higher costs for the hospital. Hospitals can address this problem by developing clear, effective homeless discharge policies and by developing ongoing relationships with appropriate medical respite care providers. A hospital also can benefit from spearheading an initiative to develop a medical respite program, enlisting the assistance of other community stakeholders.