Cidadão e comunidade : que relevância no processo de contratualizaç

RESUMO - Nas últimas décadas, a especialização dos cuidados médicos tem conduzido a uma fragmentação do sistema de prestação, que, associada a uma deficiente coordenação entre serviços, cuidados e prestadores, torna a navegabilidade dos utentes nos sistemas de saúde uma tarefa complexa. Um novo modelo de organização, assente na procura de valor para os cidadãos, deve adoptar uma abordagem sistémica, que tenha subjacente uma coordenação integrada de serviços, numa perspectiva de ciclo de cuidados. Reorientar a prestação de cuidados para a obtenção de resultados e valor em saúde, exige uma reengenharia em torno da estrutura, organização e avaliação1 dos cuidados, requerendo, nomeadamente: i) instrumentos e ferramentas que auxiliem e estruturem este novo modelo; ii) assumpção dos papéis definidos para cada um dos actores do sistema, nomeadamente ao nível da coordenação; iii) encorajamento à adopção de modelos de contratualização, pagamento e competição, que responsabilizem os actores envolvidos não só pela prática que desenvolvem, mas pelos resultados em saúde. Estes mecanismos constituem uma oportunidade para expandir e sustentar abordagens, programas e intervenções integradas. Investir num sistema de pagamento por valor em saúde — P4V — payment for value, traduz uma aposta na relação entre diagnóstico, tratamento, resultados clínicos e custos, enquanto estratégia para assegurar ganhos em qualidade dos cuidados, eficiência dos processos e valor em saúde para o cidadão. Neste contexto, a gestão da doença enquanto modelo direccionado para o reforço da perspectiva e participação activa do cidadão, e avaliação compreensiva de novas formas de organização e gestão do sistema de prestação, constitui um instrumento para informar e sustentar esse processo de reengenharia do sistema. Um modelo que procura assegurar o encontro entre o estado da arte na prestação de cuidados e um nível óptimo, garantindo a qualidade de vida expectável para a pessoa com doença crónica. ----------------- ---------ABSTRACT – In the last decades advanced medical sciences trend to specialized care and fragmented health systems, leaving patients with a challenge on navigating services and care, requiring them to see a sequence of specialists each delivering discrete interventions. To overcome these challenges, every health system must redefine health care delivery to use its resources more efficiently and improve quality of care through an organization of the system as a whole. A system currently organized around value for patients, entails a framework that comprises the entire set of activities needed to address a patient´s medical condition, over the full cycle of care. Value- based care delivery therefore requires an integrated practice, both across services and time, and implies a movement through new structures, organization models, evaluation efforts and payment systems that enables, catalyze and reinforces the extension and sustainability of the steps needed to the change required. A shift from a payment for performance to a payment for value focuses attention on maximizing the overall value of care, and encourages coordination and integration between components of care that extends from screening, diagnoses, all the way through treatment, outcomes and costs, and ensuring an incentive for potentially high value types of care as well as innovation. These leave the actors of the system with the task of best allocating and valuing components of care. Disease management as a model designed to structure patient engagement and involvement in their care, and assure a comprehensive evaluation and monitoring of new organization and care delivery strategies align an opportunity as a source of information and sustainability for the progress of a growing number of likeminded efforts now underway across care delivery for chronic diseases. This framework will allow the fulfillment of the gap between sta

Customer relationship management and central bank payment system services

Tutkimuksen tavoitteena on selvittää, miten kirjallisuudessa kuvattua asiakkuuden hallintaa voitaisiin soveltaa keskuspankin maksuliikepalveluissa. Tarkasteltavana ovat yleiset toimintatavat, sekä asiakkuuden hallintaa tukevat järjestelmät. Tutkimuksen päätavoitteena on Help Desk toiminnan kehittäminen. Tutkimuksessa tarkastellaan asiakkuuden hallinnan eri osa-alueita ottaen huomioon sekä asiakkaan, että palvelun tarjoajan näkökulmat. Asiakkuuden hallinta ymmärretään strategiana, jolla kyetään kuvaamaan kuinka koko organisaatio toimii asiakkaiden kanssa. Asiakkuuden hallinnan ydin on asiakkaan arvontuotantoprosessin ymmärtäminen. Käytettyjä lähdeaineistoja ovat olleet alan kirjallisuus, artikkelit sekä Internet-lähteet. Empirian taustan ovat muodostaneet asiantuntijahaastattelut sekä keskuspankin julkaisut, sisäiset toimintaohjeet ja vakiintuneet käytännöt. Tutkimuksen keskeinen tulos on, että asiakkuudenhallinnan perusajatukset ovat monin tavoin sovellettavissa keskuspankin melko ainutkertaiseen, teknisesti ja viestinnällisesti vaativaan maksuliikepalveluympäristöön, vaikka asiakkaiden lukumäärä onkin pieni. Hyötyjä voidaan saavuttaa jo asiakkuudenhallinnan peruskomponenttien ml. strategianäkökulma tuntemuksella ja melko pieniltäkin näyttävillä toimintatapa-, työnkulku- ja asennemuutoksilla. Asiakkuuden hallintaa tukevan tietoteknologian jonkinasteinen käyttöönotto voi tuoda lisäarvoa, mutta sen kustannukset ja hyödyt on punnittava tämäntyyppisessä ympäristössä tarkoin.

Banks, Lies and Bricks: The Determinants of Home Value Inflation in Spain during the Housing Boom

During the first decade of this century, Spain experienced the most important economic and housing boom in its recent history. This situation led the lending industry to dramatically expand through the mortgage market. The high competition among lenders caused a dramatic lowering of credit standards. During this period, lenders operating in the Spanish mortgage market artificially inflated appraised home values in order to draw larger mortgages. By doing this, lenders gave financially constrained households access to mortgage credit. In this paper, we analyze this phenomenon for this first time. To do so, we resort to a unique dataset of matched mortgage-dwelling-borrower characteristics covering the period 2004–2010. Our data allow us to construct an unbiased measure of property’s over-appraisal, since transaction prices in our data also includes any potential side payment in the transactions. Our findings indicate that i) in Spain, appraised home values were inflated on average by around 30% with respect to transaction prices; ii) creditconstrained households were more likely to be involved in mortgages with inflated house values; and iii) a regional indicator of competition in the lending market suggests that inflated appraisal values were also more likely to appear in more competitive regional mortgage markets. Keywords: Housing demand, appraisal values, house prices, housing bubble, credit constraints, mortgage market. JEL Classification: R21, R31

Usability Centered Implementation of a Web Based Value Added Module

Customer specific functionalities are a challenging part of procurement and invoice automation environments. In Basware Enterprise Purchase to Payment product family the customer specific reports are supported only in a basic level without any seamless interface between all EPP products. Also other customer specific functionalities are not supported as there is no customizable interface between the applications and only the most common features are implemented to the products themselves. In this thesis foundations are created for a new web based value added module where it is possible to create seamless customer specific functionalities throughout the whole EPP product family. The work is implemented in a Proof of Concept type of piloting. The system is created in user centered way where the users are able to explain their requests and determine their needs. The result is an excellent foundation for a module that can be developed further.

The Cycle Times of Working Capital: Financial Value Chain Analysis Method

Interest towards working capital management increased among practitioners and researchers because the financial crisis of 2008 caused the deterioration of the general financial situation. The importance of managing working capital effectively increased dramatically during the financial crisis. On one hand, companies highlighted the importance of working capital management as part of short-term financial management to overcome funding difficulties. On the other hand, in academia, it has been highlighted the need to analyze working capital management from a wider perspective namely from the value chain perspective. Previously, academic articles mostly discussed working capital management from a company-centered perspective. The objective of this thesis was to put working capital management in a wider and more academic perspective and present case studies of the value chains of industries as instrumental in theoretical contributions and practical contributions as complementary to theoretical contributions and conclusions. The principal assumption of this thesis is that selffinancing of value chains can be established through effective working capital management. Thus, the thesis introduces the financial value chain analysis method which is employed in the empirical studies. The effectiveness of working capital management of the value chains is studied through the cycle time of working capital. The financial value chain analysis method employed in this study is designed for considering value chain level phenomena. This method provides a holistic picture of the value chain through financial figures. It extends the value chain analysis to the industry level. Working capital management is studied by the cash conversion cycle that measures the length (days) of time a company has funds tied up in working capital, starting from the payment of purchases to the supplier and ending when remittance of sales is received from the customers. The working capital management practices employed in the automotive, pulp and paper and information and communication technology industries have been studied in this research project. Additionally, the Finnish pharmaceutical industry is studied to obtain a deeper understanding of the working capital management of the value chain. The results indicate that the cycle time of working capital is constant in the value chain context over time. The cash conversion cycle of automotive, pulp and paper, and ICT industries are on average 70, 60 and 40 days, respectively. The difference is mainly a consequence of the different cycle time of inventories. The financial crisis of 2008 affected the working capital management of the industries similarly. Both the cycle time of accounts receivable and accounts payable increased between 2008 and 2009. The results suggest that the companies of the automotive, pulp and paper and ICT value chains were not able to self-finance. Results do not indicate the improvement of value chains position in regard to working capital management either. The findings suggest that companies operating in the Finnish pharmaceutical industry are interested in developing their own working capital management, but collaboration with the value chain partners is not considered interesting. Competition no longer occurs between individual companies, but between value chains. Therefore the financial value chain analysis method introduced in this thesis has the potential to support value chains in improving their competitiveness.

Measuring value in cancer-related health care: A case study in head and neck cancer

In the current climate of escalating health care costs, defining value and accurately measuring it are two critical issues affecting not only the future of cancer care in particular but also the future of health care in general. Specifically, measuring and improving value in cancer-related health care are critical for continued advancements in research, management, and overall delivery of care. However, in oncology, most of this research has focused on value as it relates to insurance industry and payment reform, with little attention paid to value as the output of clinical interventions that encompass integrated clinical teams focusing on the entire cycle of care and measuring objective outcomes that are most relevant to patients. ^ In this study, patient-centered value was defined as health outcomes achieved per dollar spent, and calculated using objective functional outcomes and total care costs. The analytic sample comprised patients diagnosed with three common head and neck cancers—cancer of the larynx, oral cavity, and oropharynx—who were treated in an integrated tertiary care center over an approximately 10-year period. The results of this study provide initial empirical data that can be used to assess and ultimately to help improve the quality and value of head and neck cancer care, and more importantly they can be used by patients and clinicians to make better-informed decisions about care, particularly what therapeutic services and outcomes matter the most to patients.^

Income Distributional Effects of Decoupled Payments Single Payment Scheme in the European Union. Factor Markets Working Paper No. 29, July 2012

This paper analyses the effects of the Single Payment Scheme (SPS) with and without farm structural change, and focuses on how income distributional effects and farm restructuring are impacted by the SPS under: alternative entitlement tradability, cross-compliance and CAP 'greening' requirements, different SPS implementation models, the entitlement stock, market imperfections and institutional regulations. The authors find that the SPS implication details are highly significant, since farmers’ benefits can range from 100% of the SPS value to a negative policy incidence, and farm structural change may also be hindered by the SPS.

Cash or non-cash: that is the question - the story of e-payment for social welfare in Ireland part 2

E-Government in its various forms and extensions, notably T-Government, is often presented as the panacea for resolving such complex social problems as social exclusion, lack of governance transparency, poor value for money and other ailments of modern societies. Yet, E-Government has not been adopted up to predicted levels. Many case studies investigating success factors, maturity models, and the application of acceptance models have been presented over the last 15 years, but a deep understanding of the potential impact and consequences of E-Government is still lacking. This is especially true for those initiatives that involve socio-economic and cultural contexts, which makes their evaluation and the prediction of their impact difficult. This paper reports on an on-going E-Government initiative in Ireland aimed at implementing E-payments for G2C, notably in the social welfare area. Three sets of personal surveys have been carried out to understand the perceived impact of governmental plans of moving from an almost fully cash-based payment system to a fully electronic based solution. Early results indicate that perceived pre-requisites for the planned change may be misleading. The impact on recipients’ lives cannot solely be measured in terms of economic gains: the consequences of such implementation may well reach further than expected.

From Cash to Electronic Payments: Microeconomic, Macroeconomic, and Policy Aspects of Retail Payment Systems

This dissertation explores three aspects of the economics and policy issues surrounding retail payments (low-value frequent payments): the microeconomic aspect, by measuring costs associated with retail payment instruments; the macroeconomic aspect, by quantifying the impact of the use of electronic rather than paper-based payment instruments on consumption and GDP; and the policy aspect, by identifying barriers that keep countries stuck with outdated payment systems, and recommending policy interventions to move forward with payments modernization. Payment system modernization has become a prominent part of the financial sector reform agenda in many advanced and developing countries. Greater use of electronic payments rather than cash and other paper-based instruments would have important economic and social benefits, including lower costs and thereby increased economic efficiency and higher incomes, while broadening access to the financial system, notably for people with moderate and low incomes. The dissertation starts with a general introduction on retail payments. Chapter 1 develops a theoretical model for measuring payments costs, and applies the model to Guyana—an emerging market in the midst of the transition from paper to electronic payments. Using primary survey data from Guyanese consumers, the results of the analysis indicate that annual costs related to the use of cash by consumers reach 2.5 percent of the country’s GDP. Switching to electronic payment instruments would provide savings amounting to 1 percent of GDP per year. Chapter 2 broadens the analysis to calculate the macroeconomic impacts of a move to electronic payments. Using a unique panel dataset of 76 countries across the 17-year span from 1998 to 2014 and a pooled OLS country fixed effects model, Chapter 2 finds that on average, use of debit and credit cards contribute USD 16.2 billion to annual global consumption, and USD 160 billion to overall annual global GDP. Chapter 3 provides an in-depth assessment of the Albanian payment cards and remittances market and recommends a set of incentives and regulations (both carrots and sticks) that would allow the country to modernize its payment system. Finally, the conclusion summarizes the lessons of the dissertation’s research and brings forward issues to be explored by future research in the retail payments area.

Timing and economic value of mergers and acquisitions

Doctor of Philosophy in the Faculty of Business Administration

The Value Of The 2005 International Society Of Urological Pathology (isup) Modified Gleason Grading System As A Predictor Of Biochemical Recurrence After Radical Prostatectomy.

To compare time and risk to biochemical recurrence (BR) after radical prostatectomy of two chronologically different groups of patients using the standard and the modified Gleason system (MGS). Cohort 1 comprised biopsies of 197 patients graded according to the standard Gleason system (SGS) in the period 1997/2004, and cohort 2, 176 biopsies graded according to the modified system in the period 2005/2011. Time to BR was analyzed with the Kaplan-Meier product-limit analysis and prediction of shorter time to recurrence using univariate and multivariate Cox proportional hazards model. Patients in cohort 2 reflected time-related changes: striking increase in clinical stage T1c, systematic use of extended biopsies, and lower percentage of total length of cancer in millimeter in all cores. The MGS used in cohort 2 showed fewer biopsies with Gleason score ≤ 6 and more biopsies of the intermediate Gleason score 7. Time to BR using the Kaplan-Meier curves showed statistical significance using the MGS in cohort 2, but not the SGS in cohort 1. Only the MGS predicted shorter time to BR on univariate analysis and on multivariate analysis was an independent predictor. The results favor that the 2005 International Society of Urological Pathology modified system is a refinement of the Gleason grading and valuable for contemporary clinical practice.

Prognostic Value Of Dna And Mrna E6/e7 Of Human Papillomavirus In The Evolution Of Cervical Intraepithelial Neoplasia Grade 2.

This study aimed at evaluating whether human papillomavirus (HPV) groups and E6/E7 mRNA of HPV 16, 18, 31, 33, and 45 are prognostic of cervical intraepithelial neoplasia (CIN) 2 outcome in women with a cervical smear showing a low-grade squamous intraepithelial lesion (LSIL). This cohort study included women with biopsy-confirmed CIN 2 who were followed up for 12 months, with cervical smear and colposcopy performed every three months. Women with a negative or low-risk HPV status showed 100% CIN 2 regression. The CIN 2 regression rates at the 12-month follow-up were 69.4% for women with alpha-9 HPV versus 91.7% for other HPV species or HPV-negative status (P < 0.05). For women with HPV 16, the CIN 2 regression rate at the 12-month follow-up was 61.4% versus 89.5% for other HPV types or HPV-negative status (P < 0.05). The CIN 2 regression rate was 68.3% for women who tested positive for HPV E6/E7 mRNA versus 82.0% for the negative results, but this difference was not statistically significant. The expectant management for women with biopsy-confirmed CIN 2 and previous cytological tests showing LSIL exhibited a very high rate of spontaneous regression. HPV 16 is associated with a higher CIN 2 progression rate than other HPV infections. HPV E6/E7 mRNA is not a prognostic marker of the CIN 2 clinical outcome, although this analysis cannot be considered conclusive. Given the small sample size, this study could be considered a pilot for future larger studies on the role of predictive markers of CIN 2 evolution.

Predictive Value Of Phase I Trials For Safety In Later Trials And Final Approved Dose: Analysis Of 61 Approved Cancer Drugs.

Phase I trials use a small number of patients to define a maximum tolerated dose (MTD) and the safety of new agents. We compared data from phase I and registration trials to determine whether early trials predicted later safety and final dose. We searched the U.S. Food and Drug Administration (FDA) website for drugs approved in nonpediatric cancers (January 1990-October 2012). The recommended phase II dose (R2PD) and toxicities from phase I were compared with doses and safety in later trials. In 62 of 85 (73%) matched trials, the dose from the later trial was within 20% of the RP2D. In a multivariable analysis, phase I trials of targeted agents were less predictive of the final approved dose (OR, 0.2 for adopting ± 20% of the RP2D for targeted vs. other classes; P = 0.025). Of the 530 clinically relevant toxicities in later trials, 70% (n = 374) were described in phase I. A significant relationship (P = 0.0032) between increasing the number of patients in phase I (up to 60) and the ability to describe future clinically relevant toxicities was observed. Among 28,505 patients in later trials, the death rate that was related to drug was 1.41%. In conclusion, dosing based on phase I trials was associated with a low toxicity-related death rate in later trials. The ability to predict relevant toxicities correlates with the number of patients on the initial phase I trial. The final dose approved was within 20% of the RP2D in 73% of assessed trials.

Value Of Sentinel Lymph Node Biopsy In Papillary Thyroid Cancer: Initial Results Of A Prospective Trial.

The objectives of the study were to evaluate the performance of sentinel lymph node biopsy (SLNB) in detecting occult metastases in papillary thyroid carcinoma (PTC) and to correlate their presence to tumor and patient characteristics. Twenty-three clinically node-negative PTC patients (21 females, mean age 48.4 years) were prospectively enrolled. Patients were submitted to sentinel lymph node (SLN) lymphoscintigraphy prior to total thyroidectomy. Ultrasound-guided peritumoral injections of (99m)Tc-phytate (7.4 MBq) were performed. Cervical single-photon emission computed tomography and computed tomography (SPECT/CT) images were acquired 15 min after radiotracer injection and 2 h prior to surgery. Intra-operatively, SLNs were located with a gamma probe and removed along with non-SLNs located in the same neck compartment. Papillary thyroid carcinoma, SLNs and non-SLNs were submitted to histopathology analysis. Sentinel lymph nodes were located in levels: II in 34.7 % of patients; III in 26 %; IV in 30.4 %; V in 4.3 %; VI in 82.6 % and VII in 4.3 %. Metastases in the SLN were noted in seven patients (30.4 %), in non-SLN in three patients (13.1 %), and in the lateral compartments in 20 % of patients. There were significant associations between lymph node (LN) metastases and the presence of angio-lymphatic invasion (p = 0.04), extra-thyroid extension (p = 0.03) and tumor size (p = 0.003). No correlations were noted among LN metastases and patient age, gender, stimulated thyroglobulin levels, positive surgical margins, aggressive histology and multifocal lesions. Sentinel lymph node biopsy can detect occult metastases in PTC. The risk of a metastatic SLN was associated with extra-thyroid extension, larger tumors and angio-lymphatic invasion. This may help guide future neck dissection, patient surveillance and radioiodine therapy doses.