The effect of the shift from HMO to PPO plans on the prevalence of hospital bad debt in the insured population: A case study in two Houston-area hospitals

In spite of the dramatic increase and general concern with U.S. hospital bad debt expense (AMNews, January 12, 2004; Philadelphia Business Journal, April 30, 2004; WSJ, July 23, 2004), there appears to be little available analysis of the precise sources and causes of its growth. This is particularly true in terms of the potential contribution of insured patients to bad debt expense in light of the recent shift in managed care from health maintenance organization (HMO) plans to preferred provider organization (PPO) plans (Kaiser Annual Survey Report, 2003). This study examines and attempts to explain the recent dramatic growth in bad debt expense by focusing on and analyzing data from two Houston-area hospital providers within one healthcare system. In contrast to prior studies in which self-pay was found to be the primary source of hospital bad debt expense (Saywell, R. M., et al., 1989; Zollinger, T. W., 1991; Weissman, Joel S., et al., 1999), this study hypothesizes that the growing hospital bad debt expense is mainly due to the shifting trend away from HMOs to PPOs as a conscious decision by employers to share costs with employees. Compared to HMO plans, the structure of PPOs includes higher co-pays, coinsurance, and deductibles for the patient-pay portion of medical bills, creating the potential for an increase in bad debt for hospital providers (from a case study). This bad debt expense has a greater impact in the community hospital than in the Texas Medical Center hospital. ^

A model for use by local public health departments to evaluate pandemic influenza plans

The events of the 1990's and early 2000's demonstrated the need for effective planning and response to natural and man-made disasters. One of those potential natural disasters is pandemic flu. Once defined, the CDC stated that program, or plan, effectiveness is improved through the process of program evaluation. (Centers for Disease Control and Prevention, 1999) Program evaluation should be accomplished not only periodically, but in the course of routine administration of the program. (Centers for Disease Control and Prevention, 1999) Accomplishing this task for a "rare, but significant event" is challenging. (Herbold, John R., PhD., 2008) To address this challenge, the RAND Corporation (under contract to the CDC) developed the "Facilitated Look-Backs" approach that was tested and validated at the state level. (Aledort et al., 2006).^ Nevertheless, no comprehensive and generally applicable pandemic influenza program evaluation tool or model is readily found for use at the local public health department level. This project developed such a model based on the "Facilitated Look-Backs" approach developed by RAND Corporation. (Aledort et al., 2006) Modifications to the RAND model included stakeholder additions, inclusion of all six CDC program evaluation steps, and suggestions for incorporating pandemic flu response plans in seasonal flu management implementation. Feedback on the model was then obtained from three LPHD's—one rural, one suburban, and one urban. These recommendations were incorporated into the final model. Feedback from the sites also supported the assumption that this model promotes the effective and efficient evaluation of both pandemic flu and seasonal flu response by reducing redundant evaluations of pandemic flu plans, seasonal flu plans, and funding requirement accountability. Site feedback also demonstrated that the model is comprehensive and flexible, so it can be adapted and applied to different LPHD needs and settings. It also stimulates evaluation of the major issues associated with pandemic flu planning. ^ The next phase in evaluating this model should be to apply it in a program evaluation of one or more LPHD's seasonal flu response that incorporates pandemic flu response plans.^

Goals, plans, and behavior changes: A relevant part of the post-treatment cancer experience

Background. Colorectal cancer (CRC) survivors have to manage treatment side effects, psychosocial issues, and co-morbidities, as well as modify their lifestyles to decrease risk of recurrence and prolong life. Identifying survivors’ goals and key factors that influence their goals will highlight the issues cancer survivors face post-treatment and the resources needed to help them engage in health-promoting behaviors.^ Objectives and methods. This dissertation examines the health-related goals of post-treatment CRC survivors using two studies: (1) a qualitative study to identify and describe the health goals of CRC survivors during the transition from active treatment to post-treatment survivorship and follow-up care; and (2) a cross-sectional survey to identify CRC survivors’ goals, and key factors that influence their goals.^ Results. (1) The 41 qualitative interviews indicated participants’ health-related goals were to be healthy, get back to normal, and not have a cancer recurrence. Most of the CRC survivors reported they maintained healthy behaviors, made healthy behavior changes, or had goals to change their behavior. Respondents were empowered to improve their health by maintaining follow-up care and regular health screenings, and many were managing treatment side effects in an effort to improve functional abilities. (2) The cross-sectional study found that CRC survivors’ most prevalent goals were related to healthy behaviors (i.e., eat a healthy diet and engage in physical activity), and cancer care or disease management (i.e., keep up with health screenings and monitor symptoms). Goals that survivors identified as important were similar to goals they perceived were important to their providers (i.e., goals related to cancer care, disease management). Certain goals were statistically associated with age, barriers to achieving goals, social support and health-related quality of life.^ Conclusions. CRC survivors have health-promoting goals post-treatment and are interested in making health behavior changes. Goals ranged from cancer care/surveillance and disease management to healthy lifestyle modifications. Patients may need help resolving or managing treatment side effects or co-morbidities prior to implementing health promoting behaviors. Healthcare providers’ recommendations may be a powerful resource to encourage survivors to engage in health-promoting behaviors. Self-management and goal setting support could be an appropriate strategy to assist patients with achieving their post-treatment health goals.^

"I understood what she meant when she said '21st century medicine'": A qualitative analysis of patient responses for plans for colorectal cancer screening following a recommendation from their physician

Although physician recommendation has been significantly associated with colorectal cancer screening (CRCS), it still does not motivate all patients to get CRCS. Although improved physician recommendation for CRCS has been shown to increase patient CRCS screening, questions remain about what elements of that discussion may lead to screening. The objective of this study is to describe patients' perceptions and interpretations about their physician's recommendation for CRCS during their annual wellness exam. A subset of patients (n=51) participating in a supplement study of a behavioral intervention trial designed to increase CRCS completed a follow-up, open-ended interview two to four weeks after their annual wellness visit. Using qualitative methods, transcripts of these interviews were analyzed. Findings suggest that most patients would follow their physician's recommendation for CRCS despite not engaging in much discussion. Patients may refrain from CRCS discussion because of a commitment to CRCS, awareness of screening guidelines, and trust in physician's honesty and beneficence. Yet many patients left their wellness exams with questions, refraining because of future plans to consult with their physicians, perceived time constraints or a lack of a patient-physician relationship. If patients are leaving their wellness exams with unanswered questions, interventions should prepare physicians for patient reticence, teaching physicians how to assure patients that CRCS is a primary care activity where all questions and concerns, including cost and scheduling, may be resolved.^

Chemical composition and isotopic ratios of basic lavas from Iceland and the surrounding ocean floor

Major and trace dement data are used to establish the nature and extent of spatial and temporal chemical variations in basalts erupted in the Iceland region of the North Atlantic Ocean. The ocean floor samples are those recovered by legs 38 and 49 of the Deep Sea Drilling Project. Within each of the active zones on Iceland there are small scale variations in the light rare earth elements and ratios such as K/Y: several central complexes and their associated fissure swarms erupt basalts with values of K/Y distinct from those erupted at adjacent centres; also basalts showing a wide range of immobile trace element ratios occur together within single vertical sections and ocean floor drill holes. Although such variations can be explained in terms of the magmatic processes operating on Iceland they make extrapolations from single basalt samples to mantle sources underlying the outcrop of the sample highly tenuous. 87Sr/86Sr ratios measured for 25 of the samples indicate a total range from 0.7028 in a tholeiite from the Reykjanes Ridge to 0.7034 in an alkali basalt from Iceland and are consistent with other published ratios from the region. A positive correlation between 87Sr/86Sr and Ce/Yb ratios indicates the existence of systematic isotopic and elemental variations in the mantle source region. An approximately fivefold variation in Ce/Yb ratio observed in basalts with the same 87Sr/86Sr ratio implies that different degrees and types of partial melting have been involved in magma genesis from a single mantle composition. 87Sr/86Sr ratios above 0.7028, Th/U ratios close to 4 and La/Ta ratios close to 10 distinguish most basalts erupted in this part of the North Atlantic Ocean from normal mid-ocean ridge basalt (N-type MORB) - although N-type MORB has been erupted at extinct spreading axes just to the north and northeast of Iceland as well as the presently active Iceland-Jan Mayen Ridge. Comparisons with the hygromagmatophile element and radiogenic isotope ratios of MORB and the estimated primordial mantle indicate that the mantle sources producing Iceland basalts have undergone previous depletion followed by more recent enrichment events. A veined mantle source region is proposed in preference to the mantle plume model to explain the chemical variations.

Comparisons of z values between fine-grained titanomagnetites within interstitial glass and large-grained titanomaghemtes in older ocean-floor basalts

Transmission electron microscopy observations and rock magnetic measurements reveal that alteration of fine- and large-grained iron-titanium oxides can occur at different rates. Fine-grained titanomagnetite occurs as a crystallization product within interstitial glass that originated as an immiscible liquid within a fully differentiated melt; in several samples with ages to 32 Ma it displays very little or no oxidation (z = ca. 0). In contrast, samples with ages of 10 Ma or older are observed to also contain highly oxidized (z >/= 0.66) large-grained titanomaghemite. These large grains, having originated by direct crystallization from melt, are associated with pore space. Such pore space can serve as a conduit for fluids that promote alteration, whereas fine grains may have been "armored" against alteration by the glass matrix in which they are embedded. Apparently, alteration of oceanic crust is a heterogeneous process on a microscopic scale. The existence of pristine, fine-grained titanomagnetite in the interstitial glass of older ocean-floor basalts that have undergone significant alteration implies that such glassy material is capable of carrying original thermal remanent magnetization and may be suitable for paleointensity determinations.

Chemical composition of ocean-floor basalts and separated magnetites DSDP Legs 37, 45 and 46

Titanomagnetites separated from 15 different rock samples (including ocean-floor basalts from DSDP Legs 37, 45 and 46) were analyzed together with whole-rock samples by instrumental neutron-activation analysis for Sc, Cr, Co, Zn, Hf, Ta, Th and the REE La, Ce, Nd, Sm, Eu, Gd, Tb, Dy, Tm, Yb and Lu. In titanomagnetities from ocean-floor basalts and some other rocks, REE are enriched with respect to the whole-rock composition by factors of between 1.5 and 3 for light REE and between 1.0 and 1.9 for heavy REE; that is, REE with larger ionic radii are preferentially incorporated into the magnetite lattice. Three magnetite samples are REE depleted. Their whole-rock samples contain P in appreciable amounts, so apatite, an important REE-accumulating mineral, could have captured REE to some extent. All titanomagnetites show a marked negative Eu anomaly, this is most probably caused by discrimination of Eu(2+) from the magnetite lattice. Co, Zn, Hf and Ta are significantly enriched in magnetites. The distribution behaviour of Sc and Cr is masked chiefly by the crystallization of clinopyroxene and therefore is not easy to estimate. Ulvöspinel contents of about 70% for the titanomagnetites from ocean-floor basalts were estimated from qualitative microprobe analysis. Ulvöspinel contents of all other samples varied in a wide range from 20% to about 90%. No correlation could be observed between this and the REE contents of the magnetites. Ilmenite exsolution lamellae could only be observed in titanomagnetites from a doleritic basalt from Leg 45.