Improving government health services through contract management: a case from Cambodia.
(9/42)
Most government health facilities in Cambodia perform poorly, due to lack of funds, inadequate management and inefficient use of resources, but mostly due to poor motivation of staff. This paper describes contracting as a possible tool for Ministries of Health to improve health service delivery more rapidly than the more traditional reform approaches. In Cambodia, the Ministry of Health started an experiment with contracting in eight districts, covering 1 million people. Health care management in five districts was sub-contracted to private sector operators, and their results were compared with three control districts. Both internal and external reviews showed that after 3 years of implementation, the utilization of health services in the contracted districts improved significantly, in comparison with the control districts. There was adequate competition in awarding the contracts. A Ministry of Health Project Co-ordinating Unit measured the performance of the contractors, and contributed pro-actively. There was no evidence of rent-seeking practices by either the contracting agency or the contractors. This paper describes in more detail the successes and failures in one of the contracted districts, where HealthNet International applied the contracting approach. Despite significantly increased official user fees, constituting 16% of recurrent costs, the utilization of services was equally increased. Patients thought the fees were reasonable because they were still lower than the fees demanded if government health workers charged informally. They also thought that the services were of better quality than in the unregulated private sector. Another important result was that combining strict monitoring with performance-based incentives demonstrates a decrease in total family health expenditure of some 40% from US dollars 18 to US dollars 11 per capita per year. Innovative and decisive management proved to be essential, which is more likely to be achieved by a contracted manager than by regular government managers with life-long employment. This paper discusses how the contractor addressed the deeply rooted problems of informal private activities of government health workers. The NGO district management experimented with two management systems: first by individual contracts with health workers, and secondly by sub-contracting directly with the health centre chiefs and hospital directors. A reason for concern is that poli-pharmacy and excessive use of injectables continued. Also, the participation of the central level of the Ministry of Health was positive in the contracting process, but the role and participation of the provincial level of the Ministry was more tentative. (+info)
Reducing costs and improving outcomes of percutaneous coronary interventions.
(10/42)
OBJECTIVE: To describe cost reduction and quality improvement efforts in our percutaneous coronary intervention (PCI) program and how risk adjustment was used to assess the effects of these changes. STUDY DESIGN: Single center registry analysis. PATIENTS AND METHODS: Data were collected on 2158 PCIs performed between July 1, 1994, and June 30, 1997. Of these, 1126 PCIs reflected care provided after implementation of competitive bidding for catheterization lab supplies, and efforts to reduce the use of postprocedure heparin and to implement early arterial sheaths removal (postbidding period). Hospital costs were estimated using a microcost accounting method. In-hospital mortality rates during the 2 time periods were compared using standardized mortality ratio estimated with a previously validated risk adjustment model for in-hospital mortality. RESULTS: Compared with the prebidding period, the postbidding period was characterized by a significantly higher utilization of new technology (coronary stents and atherectomy devices 46% vs 25%; abciximab 19.1% vs 3.7, P<.01), and an overall increase in case complexity. Despite these changes, the average and median postbidding cost per case was dollars 1223 and dollars 1444 lower, respectively, than in the prebidding period. After adjustment for comorbidities, procedure variables, complications, and length of hospital stay, multivariate regression modeling identified the postbidding period as an independent predictor of lower hospital costs (P<.001) with an estimated adjusted cost savings of dollars 460. These cost savings were associated with trends toward a lower observed mortality rate, a higher predicted mortality rate, and a significantly lower standardized mortality ratio (SMR .71; 95% CI 0.48-0.9; P<.05). CONCLUSION: Despite an increase in case complexity and utilization of new technology, cost reductions can be achieved through competitive bidding for supplies and modifications of periprocedure care. Risk adjustment appears to be a valid tool for assessing the effectiveness of these efforts independently from changes in case mix. (+info)
The Medicare world from both sides: a conversation with Tom Scully. Interview by Uwe E. Reinhardt.
(11/42)
Tom Scully, administrator of the Centers for Medicare and Medicaid Services (CMS), the nation's largest health insurer, discusses the Medicare program with Princeton University economist Uwe Reinhardt. Scully's previous appointments in both the public and private sectors have given him a diverse set of experiences from which to draw in his current position. He praises the agency's staff for devising innovations to cope with a changing health care environment, praises the program for continuing to meet most seniors' needs, and staunchly defends the Bush administration's focus on the private sector as the way forward for Medicare. (+info)
A synthetic peptide blocking the apolipoprotein E/beta-amyloid binding mitigates beta-amyloid toxicity and fibril formation in vitro and reduces beta-amyloid plaques in transgenic mice.
(12/42)
Alzheimer's disease (AD) is associated with accumulation of beta-amyloid (Abeta). A major genetic risk factor for sporadic AD is inheritance of the apolipoprotein (apo) E4 allele. ApoE can act as a pathological chaperone of Abeta, promoting its conformational transformation from soluble Abeta into toxic aggregates. We determined if blocking the apoE/Abeta interaction reduces Abeta load in transgenic (Tg) AD mice. The binding site of apoE on Abeta corresponds to residues 12 to 28. To block binding, we synthesized a peptide containing these residues, but substituted valine at position 18 to proline (Abeta12-28P). This changed the peptide's properties, making it non-fibrillogenic and non-toxic. Abeta12-28P competitively blocks binding of full-length Abeta to apoE (IC50 = 36.7 nmol). Furthermore, Abeta12-28P reduces Abeta fibrillogenesis in the presence of apoE, and Abeta/apoE toxicity in cell culture. Abeta12-28P is blood-brain barrier-permeable and in AD Tg mice inhibits Abeta deposition. Tg mice treated with Abeta12-28P for 1 month had a 63.3% reduction in Abeta load in the cortex (P = 0.0043) and a 59.5% (P = 0.0087) reduction in the hippocampus comparing to age-matched control Tg mice. Antibodies against Abeta were not detected in sera of treated mice; therefore the observed therapeutic effect of Abeta12-28P cannot be attributed to an antibody clearance response. Our experiments demonstrate that compounds blocking the interaction between Abeta and its pathological chaperones may be beneficial for treatment of beta-amyloid deposition in AD. (+info)
Medicare program; competitive acquisition of outpatient drugs and biologicals under Part B. Interim final rule with comment period.
(13/42)
This interim final rule with comment period implements provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 that require the implementation of a competitive acquisition program for certain Medicare Part B drugs not paid on a cost or prospective payment system basis. Beginning January 1, 2006, physicians will generally be given a choice between obtaining these drugs from vendors selected through a competitive bidding process or directly purchasing these drugs and being paid under the average sales price system. (+info)
Nicotinic cholinergic receptors in the rat cerebellum: multiple heteromeric subtypes.
(14/42)
Nicotinic receptors (nAChRs) in the cerebellum have been implicated in the pathology of autism spectrum disorders (Lee et al., 2002; Martin-Ruiz et al., 2004). The subtypes of nAChRs in the cerebellum are not known in any detail, except that, in addition to the homomeric alpha7 subtype, there appears to be one or more heteromeric subtypes consisting of combinations of alpha and beta subunits. To begin to better understand the potential roles of these heteromeric nAChRs in cerebellar circuitry and their potential as targets for nicotinic drugs, we investigated their subunit composition. Using subunit-selective antibodies in sequential immunoprecipitation assays, we detected six structurally distinct heteromeric nAChR populations in the rat cerebellum. Among these were several subtypes that have not been encountered previously, including alpha3alpha4beta2 and alpha3alpha4beta4 nAChRs. This diversity suggests that nAChRs play multiple roles in cerebellar physiology. (+info)
Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2006 and certain provisions related to the Competitive Acquisitions Program of outpatient drugs and biologicals under Part B. Final rule with comment.
(15/42)
This rule addresses Medicare Part B payment policy, including the physician fee schedule that are applicable for calendar year (CY) 2006; and finalizes certain provisions of the interim final rule to implement the Competitive Acquisition Program (CAP) for Part B Drugs. It also revises Medicare Part B payment and related policies regarding: Physician work; practice expense (PE) and malpractice relative value units (RVUs); Medicare telehealth services; multiple diagnostic imaging procedures; covered outpatient drugs and biologicals; supplemental payments to Federally Qualified Health Centers (FQHCs); renal dialysis services; coverage for glaucoma screening services; National Coverage Decision (NCD) timeframes; and physician referrals for nuclear medicine services and supplies to health care entities with which they have financial relationships. In addition, the rule finalizes the interim RVUs for CY 2005 and issues interim RVUs for new and revised procedure codes for CY 2006. This rule also updates the codes subject to the physician self-referral prohibition and discusses payment policies relating to teaching anesthesia services, therapy caps, private contracts and opt-out, and chiropractic and oncology demonstrations. As required by the statute, it also announces that the physician fee schedule update for CY 2006 is -4.4 percent, the initial estimate for the sustainable growth rate for CY 2006 is 1.7 percent and the conversion factor for CY 2006 is $36.1770. (+info)
The HSPGs Syndecan and Dallylike bind the receptor phosphatase LAR and exert distinct effects on synaptic development.
(16/42)
The formation and plasticity of synaptic connections rely on regulatory interactions between pre- and postsynaptic cells. We show that the Drosophila heparan sulfate proteoglycans (HSPGs) Syndecan (Sdc) and Dallylike (Dlp) are synaptic proteins necessary to control distinct aspects of synaptic biology. Sdc promotes the growth of presynaptic terminals, whereas Dlp regulates active zone form and function. Both Sdc and Dlp bind at high affinity to the protein tyrosine phosphatase LAR, a conserved receptor that controls both NMJ growth and active zone morphogenesis. These data and double mutant assays showing a requirement of LAR for actions of both HSPGs lead to a model in which presynaptic LAR is under complex control, with Sdc promoting and Dlp inhibiting LAR in order to control synapse morphogenesis and function. (+info)