Oikeudenkäyntikulut kannustimena : taloustieteellinen analyysi oikeudenkäyntikulujen korvausvelvollisuuden vaikutuksista

English summary: Legal costs as incentive: An economic analysis of cost-shifting (s. 192.)

Qualité et économies: vont-elles de pair [Quality and saving: do they run together?]

In the healthcare debate, it is often stated that better quality leads to savings. Quality systems lead to additional costs for setting up, running and external evaluations. In addition, suppression of implicit rationing leads to additional costs. On the other hand, they lead to savings by procedures simplification, improvement of patients' health state and quicker integration of new collaborators. It is then logical to imagine that financial incentives could improve quality. First evidences of pay for performances initiatives show a positive impact but also some limitations. Quality and savings are linked together and require all our attention.

Effect of religion on suicide attempts in outpatients with schizophrenia or schizo-affective disorders compared with inpatients with non-psychotic disorders

Little is known of the relations between psychosis, religion and suicide. One hundred and fifteen outpatients with schizophrenia or schizo-affective disorder and 30 inpatients without psychotic symptoms were studied using a semi-structured interview assessing religiousness/spirituality. Their past suicide attempts were examined. Additionally, they were asked about the role (protective or incentive) of religion in their decision to commit suicide. Forty-three percent of the patients with psychosis had previously attempted suicide. Religiousness was not associated with the rate of patients who attempted suicide. Twenty-five percent of all subjects acknowledged a protective role of religion, mostly through ethical condemnation of suicide and religious coping. One out of ten patients reported an incentive role of religion, not only due to negatively connotated issues but also to the hope for something better after death. There were no differences between groups (i.e. psychotic vs. non-psychotic patients). Religion may play a specific role in the decisions patients make about suicide, both in psychotic and non-psychotic patients. This role may be protective, a finding particularly important for patients with psychosis who are known to be at high risk of severe suicide attempts. Interventions aiming to lower the number of suicide attempts in patients with schizophrenia should take these data into account.

2015-16 Student Loan Repayment and Forgiveness Programs

Many loan repayment and incentive programs are available to encourage college students and graduates to enter into and continue to work in designated high-need careers. More and more Iowans are reaping the rewards of these federal, state and private programs that help reduce student loan debt while allowing them to pursue their career goals. Some programs make payments directly to the recipient’s student loan servicer to reduce the balance owed (loan repayment), while others may provide the option of an income stipend or bonus for eligible recipients who meet specified employment and other criteria. This guide provides information on many of the federal and state loan repayment and incentive programs currently available.

Infirmier en psychiatrie de liaison : développement de la supervision en milieu somatique [Liaison psychiatry nurse: The development of supervision in somatic medicine].

BACKGROUND: Over the years, somatic care has become increasingly specialized. Furthermore, a rising number of patients requiring somatic care also present with a psychiatric comorbidity. As a consequence, the time and resources needed to care for these patients can interfere with the course of somatic treatment and influence the patient-caregiver relationship. In the light of these observations, the Liaison Psychiatry Unit at the University Hospital in Lausanne (CHUV) has educated its nursing staff in order to strengthen its action within the general care hospital. What has been developed is a reflexive approach through supervision of somatic staff, in order to improve the efficiency of liaison psychiatry interventions with the caregivers in charge of patients. The kind of supervision we have developed is the result of a real partnership with somatic staff. Besides, in order to better understand the complexity of interactions between the two systems involved, the patient's and the caregivers', we use several theoretical references in an integrative manner. PSYCHOANALYTICAL REFERENCE: The psychoanalytical model allows us to better understand the dynamics between the supervisor and the supervised group in order to contain and give meaning to the affects arising in the supervision space. "Containing function" and "transitional phenomena" refer to the experience in which emotions can find a space where they can be taken in and processed in a secure and supportive manner. These concepts, along with that of the "psychic envelope", were initially developed to explain the psychological development of the baby in its early interactions with its mother or its surrogate. In the field of supervision, they allow us to be aware of these complex phenomena and the diverse qualities to which a supervisor needs to resort, such as attention, support and incentive, in order to offer a secure environment. SYSTEMIC REFERENCE: A new perspective of the patient's complexity is revealed by the group's dynamics. The supervisor's attention is mainly focused on the work of affects. However, these are often buried under a defensive shell, serving as a temporary protection, which prevents the caregiver from recognizing his or her own emotions, thereby enhancing the difficulties in the relationship with the patient. Whenever the work of putting emotions into words fail, we use "sculpting", a technique derived from the systemic model. Through the use of this type of analogical language, affects can emerge without constraint or feelings of danger. Through "playing" in that "transitional space", new exchanges appear between group members and allow new behaviors to be conceived. In practice, we ask the supervisee who is presenting a complex situation, to design a spatial representation of his or her understanding of the situation, through the display of characters significant to the situation: the patient, somatic staff members, relatives of the patient, etc. In silence, the supervisee shapes the characters into postures and arranges them in the room. Each sculpted character is identified, named, and positioned, with his or her gaze being set in a specific direction. Finally the sculptor shapes him or herself in his or her own role. When the sculpture is complete and after a few moments of fixation, we ask participants to express themselves about their experience. By means of this physical representation, participants to the sculpture discover perceptions and feelings that were unknown up to then. Hence from this analogical representation a reflection and hypotheses of understanding can arise and be developed within the group. CONCLUSION: Through the use of the concepts of "containing function" and "transitional space" we position ourselves in the scope of the encounter and the dialog. Through the use of the systemic technique of "sculpting" we promote the process of understanding, rather than that of explaining, which would place us in the position of experts. The experience of these encounters has shown us that what we need to focus on is indeed what happens in this transitional space in terms of dynamics and process. The encounter and the sharing of competencies both allow a new understanding of the situation at hand, which has, of course, to be verified in the reality of the patient-caregiver relationship. It is often a source of adjustment for interpersonal skills to recover its containing function in order to enable caregiver to better respond to the patient's needs.

08005-002 Silver Lake Watershed Final Report

Silver Lake is located in an 18,053-acre watershed. The watershed is intensively farmed with almost all of the wetlands being previously drained or degraded over the last 50 years. Silver Lake is listed on the State of Iowa’s impaired water bodies list due to sediment and high nutrient level. Silver Lake is also known be in the bottom 25 percentile of Iowa’s lakes due Secchi disk readings and Chlorophyll a level. Farming in the watershed is the principle concern and cause for many of the problems occurring in Silver Lake currently with 78% of the watershed being intensively farmed. There are two major drainage ditches that have been used to drain the major wetlands and sloughs that, at one time, filtered the water and slowed it down before it reached Silver Lake. With these two major drainage ditches, water is able to reach the lake much faster and unfiltered than it once did historically. The loss of 255 restorable wetland basins to row crop production has caused serious problems in Silver Lake. These wetland basins once slowed and filtered water as it moved through the watershed. With their loss over the last 50 years that traditional drainage no longer occurs. We propose to create a Wetland Reserve Program incentive project to make WRP a more attractive option to landowners within the watershed. The incentive will be based on the amount of sediment delivery reduction to the lake, therefore paying a greater payment for a greater benefit to the lake. The expected result of this project is the restoration of over 250 acres of wetland basins with an associated 650 acres of upland buffers. The benefit for these wetlands and buffers would be reduced sediment, reduced nutrients, and slowed waters to the lake.

05007-003 Hewitt Creek Watershed Final Report

The goal of this project is to help residents of the Hewitt Creek watershed identify themselves as a watershed community and use cost-effective approaches to control non-point source nutrient and sediment contaminants according to collective science-based environmental goals. The project will tap the low-cost, high-return human resources of local knowledge and resident leadership for economical and sustainable solutions. A watershed council will implement an incentive program to engage their watershed community in locally-acceptable practices and performance (outcome) measures for environmental stewardship that have reasonable cost and are linked with accountable crop and livestock management decisions. The Iowa and Dubuque County Farm Bureau have supported one year of management practice incentives. The performance incentive program will take this effort to the next level, to focus on outcomes.

05028-010 Urban Watershed of Dickinson Cty Lakes Final Report

The Dickinson SWCD is applying for $486,800 over three years from the Watershed Improvement Fund to enhance water quality in Dickinson County through an impairment-based, locally directed watershed improvement project dealing specifically with storm water runoff. The LID Project will provide a cost share incentive and technical expertise to individual and business owners in specially targeted districts who are willing to implement low impact development techniques such as rain gardens, bioswales, pervious paving to reduce storm water runoff from their properties. Goals for the project include: 1) Defining and prioritizing urban watersheds in the Iowa Great Lakes region for implementation of Low Impact Development Practices; 2) Providing technical expertise in the form of a graduate assistant/project manager to design and oversee construction; 3) Continuing public education of such practices and their local existence through project kiosk, brochures, County Naturalist programs, local cable television shows, tours and other interactions of the Clean Water Alliance with its 50 partners in the area concerned about water quality; and 4) Completing 125 separate projects over a three year period.

05037-014 Elk River Watershed Final Report

The Watershed Improvement Review Board (WIRB) Grant will be used to enhance an on-going water quality project in Elk River Watershed. A targeted, locally controlled project has been active in the watershed since 2001. Current funding is being received primarily from the EPA-319 program, administrated by IDNR and the Watershed Protection Fund (WSPF) administrated by IDALS-DSC. Substantial funding is also obtained from the yearly county allocation of the Environmental Quality Incentive Program (EQIP) administrated by the USDA-NRCS. The overall objective of the Elk River Water Quality Project is to improve and restore the water quality in this water body by keying in on the potential sources of the identified impairments, and forging a working partnership between the local residents and the conservation agencies and organizations involved in the project. The major potential sources of the known surface water quality problems were identified during the assessment process and pointed to feedlot runoff and sediment delivery from within priority sub-watersheds. WIRB Funds will be used to cost share the application of Best Management Practices, thus reducing the projects dependency on federal funds. Funds will also be used to overcome a project’s limiting factor associated with insufficient technical assistance.

Current cardiovascular risk management patterns with special focus on lipid lowering in daily practice in Switzerland.

Background: There may be a considerable gap between LDL cholesterol (LDL-C) and blood pressure (BP) goal values recommended by the guidelines and results achieved in daily practice. Design Prospective cross-sectional survey of cardiovascular disease risk profiles and management with focus on lipid lowering and BP lowering in clinical practice. Methods: In phase 1, the cardiovascular risk of patients with known lipid profile visiting their general practitioner was anonymously assessed in accordance to the PROCAM-score. In phase 2, high-risk patients who did not achieve LDL-C goal less than 2.6 mmol/l in phase 1 could be further documented. Results: Six hundred thirty-five general practitioners collected the data of 23 892 patients with known lipid profile. Forty percent were high-risk patients (diabetes mellitus or coronary heart disease or PROCAM-score >20%), compared with 27% estimated by the physicians. Goal attainment rate was almost double for BP than for LDL-C in high-risk patients (62 vs. 37%). Both goals were attained by 25%. LDL-C values in phase 1 and 2 were available for 3097 high-risk patients not at LDL-C goal in phase 1; 32% of patients achieved LDL-C goal of less than 2.6 mmol/l after a mean of 17 weeks. The most successful strategies for LDL-C reduction were implemented in only 22% of the high-risk patients. Conclusion: Although patients at high cardiovascular risk were treated more intensively than low or medium risk patients, the majority remained insufficiently controlled, which is an incentive for intensified medical education. Adequate implementation of Swiss and International guidelines would expectedly contribute to improved achievement of LDL-C and BP goal values in daily practice.

Does a mandatory telemedicine call prior to visiting a physician reduce costs or simply attract good risks?

This paper aims to estimate empirically the efficiency of a Swiss telemedicine service introduced in 2003. We used claims' data gathered by a major Swiss health insurer, over a period of 6 years and involving 160 000 insured adults. In Switzerland, health insurance is mandatory, but everyone has the option of choosing between a managed care plan and a fee-for-service plan. This paper focuses on a conventional fee-for-service plan including a mandatory access to a telemedicine service; the insured are obliged to phone this medical call centre before visiting a physician. This type of plan generates much lower average health expenditures than a conventional insurance plan. Reasons for this may include selection, incentive effects or efficiency. In our sample, about 90% of the difference in health expenditure can be explained by selection and incentive effects. The remaining 10% of savings due to the efficiency of the telemedicine service amount to about SFr 150 per year per insured, of which approximately 60% is saved by the insurer and 40% by the insured. Although the efficiency effect is greater than the cost of the plan, the big winners are the insured who not only save monetary and non-monetary costs but also benefit from reduced premiums. Copyright © 2010 John Wiley & Sons, Ltd.

Meanings and perceptions of patient-centeredness in social work, nursing and medicine: A comparative study.

Answering patients' evolving, more complex needs has been recognized as a main incentive for the development of interprofessional care. Thus, it is not surprising that patient-centered practice (PCP) has been adopted as a major outcome for interprofessional education. Nevertheless, little research has focused on how PCP is perceived across the professions. This study aimed to address this issue by adopting a phenomenological approach and interviewing three groups of professionals: social workers (n = 10), nurses (n = 10) and physicians (n = 8). All the participants worked in the same department (the General Internal Medicine department of a university affiliated hospital). Although the participants agreed on a core meaning of PCP as identifying, understanding and answering patients' needs, they used many dimensions to define PCP. Overall, the participants expressed value for PCP as a philosophy of care, but there was the sense of a hierarchy of patient-centeredness across the professions, in which both social work and nursing regarded themselves as more patient-centered than others. On their side, physicians seemed inclined to accept their lower position in this hierarchy. Gieryn's concept of boundary work is employed to help illuminate the nature of PCP within an interprofessional context.

A methodology to estimate the potential to move inpatient to one day surgery.

BACKGROUND: The proportion of surgery performed as a day case varies greatly between countries. Low rates suggest a large growth potential in many countries. Measuring the potential development of one day surgery should be grounded on a comprehensive list of eligible procedures, based on a priori criteria, independent of local practices. We propose an algorithmic method, using only routinely available hospital data to identify surgical hospitalizations that could have been performed as one day treatment. METHODS: Moving inpatient surgery to one day surgery was considered feasible if at least one surgical intervention was eligible for one day surgery and if none of the following criteria were present: intervention or affection requiring an inpatient stay, patient transferred or died, and length of stay greater than four days. The eligibility of a procedure to be treated as a day case was mainly established on three a priori criteria: surgical access (endoscopic or not), the invasiveness of the procedure and the size of the operated organ. Few overrides of these criteria occurred when procedures were associated with risk of immediate complications, slow physiological recovery or pain treatment requiring hospital infrastructure. The algorithm was applied to a random sample of one million inpatient US stays and more than 600 thousand Swiss inpatient stays, in the year 2002. RESULTS: The validity of our method was demonstrated by the few discrepancies between the a priori criteria based list of eligible procedures, and a state list used for reimbursement purposes, the low proportion of hospitalizations eligible for one day care found in the US sample (4.9 versus 19.4% in the Swiss sample), and the distribution of the elective procedures found eligible in Swiss hospitals, well supported by the literature. There were large variations of the proportion of candidates for one day surgery among elective surgical hospitalizations between Swiss hospitals (3 to 45.3%). CONCLUSION: The proposed approach allows the monitoring of the proportion of inpatient stay candidates for one day surgery. It could be used for infrastructure planning, resources negotiation and the surveillance of appropriate resource utilization.

Regulation of Electricity Transmission and Distribution in Russia

The regulation of electricity transmission and distribution business is an essential issue for any electricity market; it is widely introduced in developed electricity markets of Great Britain, Scandinavian countries and United States of America and other. Those markets which were liberalized recently also need well planned regulation model to be chosen and implemented. In open electricity markets the sectors of electricity distribution and transmission remain monopolies, so called "natural monopolies", as introducing the competition into these sectors in most cases appears to be inefficient. Thatis why regulation becomes very important as its main tasks are: to set reasonable tariffs for customers, to ensure non-discriminating process of electricity transmission and distribution, at the same time to provide distribution companies with incentives to operate efficiently and the owners of the companies with reasonable profits as well; the problem of power quality should be solved at the same time. It should be mentioned also, that there is no incentive scheme which will be suitable for any conditions, that is why it is essential to study differentregulation models in order to form the best one for concrete situation. The aim of this Master's Thesis is to give an overview over theregulation of electricity transmission and distribution in Russia. First, the general information about theory of regulation of natural monopolies will be described; the situation in Russian network business and the importance of regulation process for it will be discussed next. Then there is a detailed description ofexisting regulatory system and the process of tariff calculation with an example. And finally, in the work there is a brief analysis of problems of present scheme of regulation, an attempt to predict the following development of regulationin Russia and the perspectives and risks connected to regulation which could face the companies that try to enter Russian electricity market (such as FORTUM OY).

Johtajiin kohdistuvat paineet ja vaatimukset

Tutkimuksen tarkoituksena oli kertoa johtajien kokemista paineista ja vaatimuksista. Tutkimuksessa käytiin läpi johtajien nykytilaan vaikuttavia tekijöitä, heidän kokemiaan paineita, ylitöitä sekä paineiden vaikutuksia. Lisäksi tehtiin selkoa kannusteista, jotka motivoivat johtajia töihinsä. Tutkimus oli luonteeltaan kvalitatiivinen ja sen pääasiallinen aineisto koostui kuudesta syvällisestä suomalaisten miesjohtajien teemahaastattelusta. Tutkimuksen tulokset tukivat monilta osin aikaisempaa tutkimusta. Johtajat kokivat kovaa painetta niin sijoittajaomistajien, kuin myös asiakkaiden suunnalta. Myös perheen ja vaativan työn yhteensovittamisessa oli monella johtajalla ollut ongelmia - muun muassa ylipitkien työviikkojen takia. Erilaisista kannusteista merkittävimmiksi tekijäksi nousi työn mielenkiintoisuus ja haastavuus. Vaikka johtajan työ antaa paljon, se myös vaatii tekijältään samalla mitalla.