The Affordable Care Act and the Transformation of US Health Care

The neoliberal period was accompanied by a momentous transformation within the US health care system.  As the result of a number of political and historical dynamics, the healthcare law signed by President Barack Obama in 2010 ‑the Affordable Care Act (ACA)‑ drew less on universal models from abroad than it did on earlier conservative healthcare reform proposals. This was in part the result of the influence of powerful corporate healthcare interests. While the ACA expands healthcare coverage, it does so incompletely and unevenly, with persistent uninsurance and disparities in access based on insurance status. Additionally, the law accommodates an overall shift towards a consumerist model of care characterized by high cost sharing at time of use. Finally, the law encourages the further consolidation of the healthcare sector, for instance into units named “Accountable Care Organizations” that closely resemble the health maintenance organizations favored by managed care advocates. The overall effect has been to maintain a fragmented system that is neither equitable nor efficient. A single payer universal system would, in contrast, help transform healthcare into a social right.

Usage-Based versus Measure-Based Unit Pricing: Is There a Better Index of Value?

In many product categories, unit prices facilitate price comparisons across brands and package sizes; this enables consumers to identify those products that provide the greatest value. However in other product categories, unit prices may be confusing. This is because there are two types of unit pricing, measure-based and usage-based. Measure-based unit prices are what the name implies; price is expressed in cents or dollars per unit of measure (e.g. ounce). Usage-based unit prices, on the other hand, are expressed in terms of cents or dollars per use (e.g., wash load or serving). The results of this study show that in two different product categories (i.e., laundry detergent and dry breakfast cereal), measure-based unit prices reduced consumers’ ability to identify higher value products, but when a usage-based unit price was provided, their ability to identify product value was increased. When provided with both a measure-based and a usage-based unit price, respondents did not perform as well as when they were provided only a usage-based unit price, additional evidence that the measure-based unit price hindered consumers’ comparisons. Finally, the presence of two potential moderators, education about the meaning of the two measures and having to rank order the options in the choice set in terms of value before choosing, did not eliminate these effects.

Exergetic, energetic, economic and environmental evaluation of concentrated solar power plants in Libya

The PhD project addresses the potential of using concentrating solar power (CSP) plants as a viable alternative energy producing system in Libya. Exergetic, energetic, economic and environmental analyses are carried out for a particular type of CSP plants. The study, although it aims a particular type of CSP plant – 50 MW parabolic trough-CSP plant, it is sufficiently general to be applied to other configurations. The novelty of the study, in addition to modeling and analyzing the selected configuration, lies in the use of a state-of-the-art exergetic analysis combined with the Life Cycle Assessment (LCA). The modeling and simulation of the plant is carried out in chapter three and they are conducted into two parts, namely: power cycle and solar field. The computer model developed for the analysis of the plant is based on algebraic equations describing the power cycle and the solar field. The model was solved using the Engineering Equation Solver (EES) software; and is designed to define the properties at each state point of the plant and then, sequentially, to determine energy, efficiency and irreversibility for each component. The developed model has the potential of using in the preliminary design of CSPs and, in particular, for the configuration of the solar field based on existing commercial plants. Moreover, it has the ability of analyzing the energetic, economic and environmental feasibility of using CSPs in different regions of the world, which is illustrated for the Libyan region in this study. The overall feasibility scenario is completed through an hourly analysis on an annual basis in chapter Four. This analysis allows the comparison of different systems and, eventually, a particular selection, and it includes both the economic and energetic components using the “greenius” software. The analysis also examined the impact of project financing and incentives on the cost of energy. The main technological finding of this analysis is higher performance and lower levelized cost of electricity (LCE) for Libya as compared to Southern Europe (Spain). Therefore, Libya has the potential of becoming attractive for the establishment of CSPs in its territory and, in this way, to facilitate the target of several European initiatives that aim to import electricity generated by renewable sources from North African and Middle East countries. The analysis is presented a brief review of the current cost of energy and the potential of reducing the cost from parabolic trough- CSP plant. Exergetic and environmental life cycle assessment analyses are conducted for the selected plant in chapter Five; the objectives are 1) to assess the environmental impact and cost, in terms of exergy of the life cycle of the plant; 2) to find out the points of weakness in terms of irreversibility of the process; and 3) to verify whether solar power plants can reduce environmental impact and the cost of electricity generation by comparing them with fossil fuel plants, in particular, Natural Gas Combined Cycle (NGCC) plant and oil thermal power plant. The analysis also targets a thermoeconomic analysis using the specific exergy costing (SPECO) method to evaluate the level of the cost caused by exergy destruction. The main technological findings are that the most important contribution impact lies with the solar field, which reports a value of 79%; and the materials with the vi highest impact are: steel (47%), molten salt (25%) and synthetic oil (21%). The “Human Health” damage category presents the highest impact (69%) followed by the “Resource” damage category (24%). In addition, the highest exergy demand is linked to the steel (47%); and there is a considerable exergetic demand related to the molten salt and synthetic oil with values of 25% and 19%, respectively. Finally, in the comparison with fossil fuel power plants (NGCC and Oil), the CSP plant presents the lowest environmental impact, while the worst environmental performance is reported to the oil power plant followed by NGCC plant. The solar field presents the largest value of cost rate, where the boiler is a component with the highest cost rate among the power cycle components. The thermal storage allows the CSP plants to overcome solar irradiation transients, to respond to electricity demand independent of weather conditions, and to extend electricity production beyond the availability of daylight. Numerical analysis of the thermal transient response of a thermocline storage tank is carried out for the charging phase. The system of equations describing the numerical model is solved by using time-implicit and space-backward finite differences and which encoded within the Matlab environment. The analysis presented the following findings: the predictions agree well with the experiments for the time evolution of the thermocline region, particularly for the regions away from the top-inlet. The deviations observed in the near-region of the inlet are most likely due to the high-level of turbulence in this region due to the localized level of mixing resulting; a simple analytical model to take into consideration this increased turbulence level was developed and it leads to some improvement of the predictions; this approach requires practically no additional computational effort and it relates the effective thermal diffusivity to the mean effective velocity of the fluid at each particular height of the system. Altogether the study indicates that the selected parabolic trough-CSP plant has the edge over alternative competing technologies for locations where DNI is high and where land usage is not an issue, such as the shoreline of Libya.

Acompanhamento da construção do edifício "Castilho 15"

Relatório de Estágio para obtenção do grau de Mestre em Engenharia Civil

Aspectos econômicos da produção de bovinos de corte

O Brasil ocupa as posições de maior produtor e exportador mundial de carne bovina, com a região Centro-Oeste respondendo por 35% do abate nacional, em 2010. Entretanto, faz-se necessário valorizar o planejamento, o controle e a gestão empresarial nas propriedades produtoras, visando ao lucro na atividade. O presente estudo objetivou analisar e avaliar a viabilidade econômica da produção de bovinos de corte, em Camapuã (MS), a fim de identificar os itens relevantes aos custos da atividade. Como direcionador dos custos variáveis, no custo operacional efetivo, o suplemento mineral fornecido aos animais e a mão de obra mostraram-se relevantes para a gestão do sistema de produção, representando, aproximadamente, 71% dos custos. Com base nos resultados apresentados, pôde-se concluir que a propriedade apresenta boa lucratividade (superior a 20%). Verificou-se, ainda, com base no fluxo de caixa, taxa interna de retorno de 13,13% e capital inicial investido retornando em, aproximadamente, 7 anos, com resultados atrativos para o investimento, neste segmento agropecuário. O estudo proporcionou um parâmetro de custo para o produtor pecuarista, podendo contribuir para um melhor planejamento de atividades, em que, apesar dos altos investimentos iniciais, possivelmente, poderá reduzir seus custos, com o manejo racional no sistema produtivo, o que seria mais atrativo para o mercado, tornando mais viáveis as suas atividades de produção e comercialização do produto.

A systematic review of the cost-effectiveness of targeted therapies for metastatic non-small cell lung cancer (NSCLC)

Background: Non-small cell lung cancer (NSCLC) imposes a substantial burden on patients, health care systems and society due to increasing incidence and poor survival rates. In recent years, advances in the treatment of metastatic NSCLC have resulted from the introduction of targeted therapies. However, the application of these new agents increases treatment costs considerably. The objective of this article is to review the economic evidence of targeted therapies in metastatic NSCLC. Methods: A systematic literature review was conducted to identify cost-effectiveness (CE) as well as cost-utility studies. Medline, Embase, SciSearch, Cochrane, and 9 other databases were searched from 2000 through April 2013 (including update) for full-text publications. The quality of the studies was assessed via the validated Quality of Health Economic Studies (QHES) instrument. Results: Nineteen studies (including update) involving the MoAb bevacizumab and the Tyrosine-kinase inhibitors erlotinib and gefitinib met all inclusion criteria. The majority of studies analyzed the CE of first-line maintenance and second-line treatment with erlotinib. Five studies dealt with bevacizumab in first-line regimes. Gefitinib and pharmacogenomic profiling were each covered by only two studies. Furthermore, the available evidence was of only fair quality. Conclusion: First-line maintenance treatment with erlotinib compared to Best Supportive Care (BSC) can be considered cost-effective. In comparison to docetaxel, erlotinib is likely to be cost-effective in subsequent treatment regimens as well. The insights for bevacizumab are miscellaneous. There are findings that gefitinib is cost-effective in first- and second-line treatment, however, based on only two studies. The role of pharmacogenomic testing needs to be evaluated. Therefore, future research should improve the available evidence and consider pharmacogenomic profiling as specified by the European Medicines Agency. Upcoming agents like crizotinib and afatinib need to be analyzed as well. © Lange et al.

Heritage assets : procedimentos para o reconhecimento e a mensuração adotados pelos museus

Este artigo teve como objetivo principal efetuar a análise das demonstrações contábeis de museus localizados nos cinco continentes, visando identificar o tratamento contábil relacionado ao reconhecimento e à mensuração dos heritage assets (HAs). Para tanto, aborda as definições de heritage assets, bem como o tratamento contábil discutido na literatura e definido pelas normas aplicáveis aos museus dos países foco deste estudo. Trata-se de uma pesquisa aplicada, qualitativa, descritiva e documental, conduzida a partir da análise do conteúdo dos relatórios anuais, demonstrações contábeis e respectivas notas explicativas de nove museus localizados na Nova Zelândia, Austrália, Reino Unido, África do Sul, Brasil, Canadá, Peru, Argentina e Estados Unidos. A partir da análise dos documentos, verificaram-se práticas heterogêneas, sendo o HA evidenciado em apenas uma parcela dos Balanços Patrimoniais, com destaque para as entidades situadas na Nova Zelândia e na Austrália, as quais apresentam o detalhamento mais completo e robusto. Quanto aos critérios de mensuração adotados pelos museus, o custo histórico é adotado principalmente para o reconhecimento inicial, enquanto outros critérios (valor justo, valor de mercado, custo de reposição e julgamento de profissionais especializados) são utilizados na mensuração subsequente. ______________________________________________________________________________ ABSTRACT

Diseño de un sistema de control de costos para el proceso de construcción de vivienda popular

El objetivo,para el desarrollo de este proyecto de graduación, es establecer un control de costos en las viviendas de interés social que se desarrollan en el Ecuador, a nivel de proyectos, ejecutados por empresas constructoras o contratistas. Se tomarán datos de la ejecución en campo de viviendas de 42 m2 de construcción, en la comunidad de Macas provincia del Cañar. Se verificarán materiales reales, rendimiento de mano de obra reales y rendimientos de equipo y transporte reales, con el afán de determinar el costo real de la obra. Todos estos datos se registrarán en el modelo desarrollado con lo que se comparará lo ejecutado contra lo programado. En el caso de existir un desfase entre estos dos parámetros, el modelo proyectará un nuevo presupuesto, asegurándose de que los gastos no excedan el financiamiento autorizado para el proyecto. El modelo almacenará datos de rendimientos de mano de obra, precios de materiales, equipos y transporte. Esto permitirá plantear presupuestos para futuros proyectos con precios cada vez más cercanos a los reales en la ejecución del proyecto, ayudando, de manera permanente, a instituciones gubernamentales profesionales de la construcción dedicadas a la proyección de viviendas.

A Formação de Oficiais de Administração: Especificidades, Oportunidades e Contingências na senda de uma Carreira Profissional

Face ao paradigma atual onde são constantemente impostas às entidades públicas medidas para a racionalização de recursos, os Estabelecimentos de Ensino Superior Público Universitário Militar não são exceção tornando-se cada vez mais premente a aposta numa gestão eficiente e eficaz. Neste âmbito, a Contabilidade Analítica assume de forma crescente um papel dominante na análise e controlo dos custos por atividade. O presente Trabalho de Investigação Aplicada encontra-se subordinado ao tema “A Formação de Oficiais de Administração: Oportunidades, Especificidades e Contingências na senda de uma Carreira Profissional”. Assim, o objetivo geral do presente trabalho passa pelo cálculo do custos de formação dos alunos de Administração dos três ramos das Forças Armadas e desta forma, optar pelo modelo mais rentável economicamente. Para o cálculo do custo, de entre as inúmeras opções existentes relativamente a sistemas de custeio, baseámo-nos no método das Secções Homogéneas ou Centros de Custos. A estrutura do trabalho pode ser dividida em duas partes, a primeira de cariz teórico e a segunda uma vertente prática. A metodologia adotada teve como referência o método de investigação em Ciência Sociais, isto é, partindo de uma pergunta central de investigação, que origina perguntas derivadas, procuram-se respostas através da formulação, exploração e teste de hipóteses. De acordo com os resultados do presente estudo podemos verificar que é o modelo de formação utilizada na Academia Militar o mais rentável economicamente. Desta forma, dadas as evidentes afinidades científicas existentes entre os cursos seria pertinente uma reconfiguração da estrutura científica, durações e do perfil formativo dos diferentes cursos. Assim, uma reorganização que elimine redundâncias e promova a partilha de recursos possibilitará ganhos de eficiência na gestão e consequentemente redução de custos.

Análisis de la gestión de inventarios en las pequeñas empresas manufactureras de muebles de madera en la ciudad de Cuenca. Caso práctico: Muebles “Chelita”

La Gestión y Administración de Inventarios son de gran importancia para el funcionamiento económico, administrativo y de control de la empresa, por lo que realizamos este trabajo de investigación denominado: “Análisis de la Gestión de Inventarios en las Pequeñas Empresas Manufactureras de Muebles de Madera en la ciudad de Cuenca. Caso Práctico: Muebles “Chelita”. En el capítulo I, se describe los antecedentes del Sector Económico Manufacturero de muebles en la ciudad de Cuenca, los antecedentes preliminares, normativa e información Contable, Administrativa y de Control de la Empresa de Muebles “Chelita”, En el capítulo II, se desarrolló las bases teóricas de grandes autores y legislación ecuatoriana vigente para la adecuada administración, por lo que lleva una serie de procesos, análisis y control para poder obtener la óptima gestión de los inventarios y poder salvaguardar intereses de la empresa y del sector manufacturero de muebles. En el capítulo III, se desarrolló dos secciones de las cuales detallamos a continuación; en la primera sección se describe los análisis de los Estados Financieros, la parte contable y de control de la empresa de muebles “Chelita” y en la segunda sección describimos la parte investigativa mediante la muestra tomada del sector manufacturero de muebles con la adecuada tabulación de datos y de las encuestas para analizar la situación actual que vive hoy en día el sector manufacturero de muebles en la ciudad de Cuenca. En el capítulo IV, finalmente encontramos las respectivas conclusiones y recomendaciones de nuestro trabajo de investigación generando un valor agregado tanto a nivel de la empresa de Muebles “Chelita” como a nivel de sector manufacturero de muebles.

Assessing the potential of inter-organisational shared services

Shared Services (SS) involves the convergence and streamlining of an organisation’s functions to ensure timely service delivery as effectively and efficiently as possible. As a management structure designed to promote value generation, cost savings and improved service delivery by leveraging on economies of scale, the idea of SS is driven by cost reduction and improvements in quality levels of service and efficiency. Current conventional wisdom is that the potential for SS is increasing due to the increasing costs of changing systems and business requirements for organisations and in implementing and running information systems. In addition, due to commoditisation of large information systems such as enterprise systems, many common, supporting functions across organisations are becoming more similar than not, leading to an increasing overlap in processes and fuelling the notion that it is possible for organisations to derive benefits from collaborating and sharing their common services through an inter-organisational shared services (IOSS) arrangement. While there is some research on traditional SS, very little research has been done on IOSS. In particular, it is unclear what are the potential drivers and inhibitors of IOSS. As the concepts of IOSS and SS are closely related to that of Outsourcing, and their distinction is sometimes blurred, this research has the first objective of seeking a clear conceptual understanding of the differences between SS and Outsourcing (in motivators, arrangements, benefits, disadvantages, etc) and based on this conceptual understanding, the second objective of this research is to develop a decision model (Shared Services Potential model) which would aid organisations in deciding which arrangement would be more appropriate for them to adopt in pursuit of process improvements for their operations. As the context of the study is on universities in higher education sharing administrative services common to or across them and with the assumption that such services were homogenous in nature, this thesis also reports on a case study. The case study involved face to face interviews from representatives of an Australian university to explore the potential for IOSS. Our key findings suggest that it is possible for universities to share services common across them as most of them were currently using the same systems although independently.

Multi-output buck-boost converter with enhanced dynamic response to load and input voltage changes

This paper presents a new multi-output DC/DC converter topology that has step-up and step-down conversion capabilities. In this topology, several output voltages can be generated which can be used in different applications such as multilevel converters with diode-clamped topology or power supplies with several voltage levels. Steady state and dynamic equations of the proposed multi-output converter have been developed, that can be used for steady state and transient analysis. Two control techniques have been proposed for this topology based on constant and dynamic hysteresis band height control to address different applications. Simulations have been performed for different operating modes and load conditions to verify the proposed topology and its control technique. Additionally, a laboratory prototype is designed and implemented to verify the simulation results.

Fuzzy logic power system stabilizer in multimachine stability studies

Power system stabilizers (PSS) work well at the particular network configuration and steady state conditions for which they were designed. Once conditions change, their performance degrades. This can be overcome by an intelligent nonlinear PSS based on fuzzy logic. Such a fuzzy logic power system stabilizer (FLPSS) is developed, using speed and power deviation as inputs, and provides an auxiliary signal for the excitation system of a synchronous motor in a multimachine power system environment. The FLPSS's effect on the system damping is then compared with a conventional power system stabilizer's (CPSS) effect on the system. The results demonstrate an improved system performance with the FLPSS and also that the FLPSS is robust

The effect of rhBMP-2 on canine osteoblasts seeded onto 3D bioactive polycaprolactone scaffolds

Our strategy entails investigating the influence of varied concentrations (0, 10, 100 and 1000 ng/ml) of human recombinant bone morphogenetic protein-2 (rhBMP-2) on the osteogenic expression of canine osteoblasts, seeded onto poly-caprolactone 20% tricalcium phosphate (PCL-TCP) scaffolds in vitro. Biochemical assay revealed that groups with rhBMP-2 displayed an initial burst in cell growth that was not dose-dependent. However, after 13 days, cell growth declined to a value similar to control. Significantly less cell growth was observed for construct with 1000 ng/ml of rhBMP-2 from 20 days onwards. Confocal microscopy confirmed viability of osteoblasts and at day 20, groups seeded with rhBMP-2 displayed heightened cell death as compared to control. Phase contrast and scanning electron microscopy revealed that osteoblasts heavily colonized surfaces, rods and pores of the PCL-TCP scaffolds. This was consistent for all groups. Finally, Von Kossa and osteocalcin assays demonstrated that cells from all groups maintained their osteogenic phenotype throughout the experiment. Calcification was observed as early as four days after stimulation for groups seeded with rhBMP-2. In conclusion, rhBMP-2 seems to enhance the differentiated function of canine osteoblasts in a non-dose dependent manner. This resulted in accelerated mineralization, followed by death of osteoblasts as they underwent terminal differentiation. Notably, PCL-TCP scaffolds seeded only with canine osteoblasts could sustain excellent osteogenic expression in vitro. Hence, the synergy of PCL with bioactive TCP and rhBMP-2 in a novel composite scaffold, could offer an exciting approach for bone regeneration.

From expert to tasks, expert nursing practice redefined?

Aim The aim of this paper was to explore the concept of expertise in nursing from the perspective of how it relates to current driving forces in health care in which it discusses the potential barriers to acceptance of nursing expertise in a climate in which quantification of value and cost containment run high on agendas. Background Expert nursing practice can be argued to be central to high quality, holistic, individualized patient care. However, changes in government policy which have led to the inception of comprehensive guidelines or protocols of care are in danger of relegating the ‘expert nurse’ to being an icon of the past. Indeed, it could be argued that expert nurses are an expensive commodity within the nursing workforce. Consequently, with this change to the use of clinical guidelines, it calls into question how expert nursing practice will develop within this framework of care. Method The article critically reviews the evidence related to the role of the Expert Nurse in an attempt to identify the key concepts and ideas, and how the inception of care protocols has implications for their role. Conclusion Nursing expertise which focuses on the provision of individualized, holistic care and is based largely on intuitive decision making cannot, should not be reduced to being articulated in positivist terms. However, the dominant power and decision-making focus in health care means that nurses must be confident in articulating the value of a concept which may be outside the scope of knowledge of those with whom they are debating. Relevance to clinical practice The principles of abduction or fuzzy logic may be useful in assisting nurses to explain in terms which others can comprehend, the value of nursing expertise.