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In 2010 Maryland replaced fee-for-service payment for some rural hospitals with "global budgets" for hospital-provided services called Total Patient Revenue (TPR). A principal goal was to incentivize hospitals to manage resources efficiently. Using a difference-in-differences design, we compared eight TPR hospitals to seven similar non-TPR Maryland hospitals to estimate how TPR affected hospital-provided services. We also compared health care use by "treated" patients in TPR counties to that of patients in counties containing control hospitals. Inpatient admissions and outpatient services fell sharply at TPR hospitals, increasingly so over the period that TPR was in effect. Emergency department (ED) admission rates declined 12 percent, direct (non-ED) admissions fell 23 percent, ambulatory surgery center visits fell 45 percent, and outpatient clinic visits and services fell 40 percent. However, for residents of TPR counties, visits to all Maryland hospitals fell by lesser amounts and Medicare spending increased, which suggests that some care moved outside of the global budget. Nonetheless, we could not assess the efficiency of these shifts with our data, and some care could have moved to more efficient locations. Our evidence suggests that capitation models require strong oversight to ensure that hospitals do not respond by shifting costs to other providers.

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The Affordable Care Act encourages workplace wellness programs, chiefly by promoting programs that reward employees for changing health-related behavior or improving measurable health outcomes. Recognizing the risk that unhealthy employees might be punished rather than helped by such programs, the act also forbids health-based discrimination. We reviewed results of randomized controlled trials and identified challenges for workplace wellness programs to function as the act intends. For example, research results raise doubts that employees with health risk factors, such as obesity and tobacco use, spend more on medical care than others. Such groups may not be especially promising targets for financial incentives meant to save costs through health improvement. Although there may be other valid reasons, beyond lowering costs, to institute workplace wellness programs, we found little evidence that such programs can easily save costs through health improvement without being discriminatory. Our evidence suggests that savings to employers may come from cost shifting, with the most vulnerable employees--those from lower socioeconomic strata with the most health risks--probably bearing greater costs that in effect subsidize their healthier colleagues.

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La aceleración del gasto sanitario en el Servicio Nacional de Salud (SNS), postulada como insostenible hace 21 años en el "informe Abril"1 de 1991 y de nuevo en el "informe McKinsey & Company" (M&C)2 de 2009, se basó entre otros motivos en la mala gestión y el envejecimiento poblacional. Ambos contienen errores de bulto, y tal vez forzados, para abrir puertas a la progresiva privatización, que sólo han servido para encarecer, cual diezmo, los costes de la asistencia sanitaria allí donde se implantaron. El Servicio de Salud de Castilla-La Mancha (SESCAM), como en general el SNS, demuestra altos grados de eficiencia año tras año, con mejores resultados, alta satisfacción de la población y mayor esperanza de vida que la media de los países de la Unión Europea y de la OCDE. Las medidas estrella propugnadas en ambos informes, copago y autogestión, se desestiman aquí por los fracasos cosechados en otros Países y algunas Comunidades Autónomas Españolas. Proponemos introducir reformas e innovaciones, pero dentro de los márgenes saludables de mejora de la eficiencia en gestión sanitaria (AU)

The escalation of healthcare expenditure in the National Health Service (NHS), postulated as unsustainable 21 years ago in the 1991 April report1 and again in the 2009 McKinsey & Company" (M&c) report2, was based on bad management and the aging population, amongst other reasons. Both reports contain blunders, perhaps coerced, in order to lead the way to gradual privatisation, which has only served to increase the cost of healthcare where it was implemented. The Castilla-La Mancha Healthcare Service (SESCAM) and the NHS in general, have shown a high level of efficiency year after year, with better results, a high level of population satisfaction and a longer mean life expectancy than that of other EU and OCDE countries. The star measures advocated in both reports, co-payment and self-management, are rejected here due to their failure in other countries and in some Spanish autonomous communities. We propose the implementation of reforms and innovations, but those that are within the healthy margins of improving the efficiency of healthcare management (AU)

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There is mounting evidence that employer-provided health insurance is an important factor in recruiting and retaining a competent and motivated direct support workforce within health and human services occupations. A review of the literature in this area, including new information related to the developmental disabilities field, is presented to assist nonprofit employers and government officials in designing initiatives to address increasing health care costs. Approaches to financing health coverage for frontline staff and a new program in New York that will provide subsidies to agencies to enhance existing coverage are discussed.

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With a host of other expensive issues leading President Bush's agenda, officials fear Medicaid could suffer some hard blows. States are already carving out efficiencies, even as enrollment swells. New HHS Secretary Mike Leavitt, left, last week said he saw an opportunity to revamp coverage for some Medicaid recipients. "Wouldn't it be better to give Chevys to everyone, rather than Cadillacs to a few?" he asked.

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A cost-segregation study is an asset-reclassification strategy that accelerates tax-depreciation deductions. By using this strategy, healthcare facility owners can lower their current income-tax liability and increase current cash flow. Simply put, certain real estate is reclassified from long-lived real property to shorter-lived personal property for depreciation purposes. Depreciation deductions for the personal property then can be greatly accelerated, thereby producing greater present-value tax savings. An analysis of costs can be conducted from either detailed construction records, when such records are available, or by using qualified appraisers, architects, or engineers to perform the allocation analysis.

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