Determinants of interest rates on tax-exempt hospital bonds

The aim of this paper is to examine the determinants of interest rates on tax-exempt hospital bonds. The results highlight the potential and actual roles of Federal and state policy in the determination of these rates. The shift to a Prospective Payment System under Medicare has subsidized the borrowing costs of some hospitals at the expense of others. The selection of underwriters by negotiation rather than by competitive bidding results in higher interest rates. The Federal tax act of 1986 raised the cost of hospital debt by encouraging bond issues to contain call features.     

Determinants of hospital bad debt: multivariate statistical analysis.

Although the issue of uncompensated care (bad debt plus charity care) has been actively debated in the public arena, there has been little discussion of the bad debt issue alone. This issue is important since issues of bad debt, charity care and uncompensated care are significantly different from each other. Based on 1992 State of Missouri data, the results of our study indicate that more efficient hospitals (measured by occupancy rate), hospitals with more patients covered by prospective payment systems (measured by Medicare discharges), and for-profit hospitals incurred significantly less bad debt cost than other hospitals. However, the difference in bad debt between for-profit hospitals and not-for-profit hospitals is dissipated when using a multivariate statistical model. In addition, this study also reveals that hospitals which provide more charity care have the lowest bad debt costs. Policy implications are also discussed.     

A financial planning model for estimating hospital debt capacity.

A computer-based financial planning model was formulated to measure the impact of a major capital improvement project on the fiscal health of Stanford University Hospital. The model had to be responsive to many variables and easy to use, so as to allow for the testing of numerous alternatives. Special efforts were made to identify the key variables that needed to be presented in the model and to include all known links between capital investment, debt, and hospital operating expenses. Growth in the number of patient days of care was singled out as a major source of uncertainty that would have profound effects on the hospital''s finances. Therefore this variable was subjected to special scrutiny in terms of efforts to gauge expected demographic trends and market forces. In addition, alternative base runs of the model were made under three distinct patient-demand assumptions. Use of the model enabled planners at the Stanford University Hospital (a) to determine that a proposed modernization plan was financially feasible under a reasonable (that is, not unduly optimistic) set of assumptions and (b) to examine the major sources of risk. Other than patient demand, these sources were found to be gross revenues per patient, operating costs, and future limitations on government reimbursement programs. When the likely financial consequences of these risks were estimated, both separately and in combination, it was determined that even if two or more assumptions took a somewhat more negative turn than was expected, the hospital would be able to offset adverse consequences by a relatively minor reduction in operating costs.     

医院债务重组方式和会计处理

广义地讲，所有涉及修改债务条件的事项都应视作债务重组，包括债务人处在持续经营条件下的债务重组，也包括债务人处在清算或改组等非持续经营条件下的债务重组。但我国企业会计准则所规范的债务重组，仅指持续经营条件下的债务重组。     

Estimating prevalence of alcohol abuse and dependence in one general hospital: an approach to reduce sample selection bias.

Prevalence estimates of alcohol abuse or dependence in general hospitals are often limited to single wards, small data collecting periods or insufficient diagnostic procedures. Therefore, the present study aimed to ascertain alcohol abuse or dependence in one general hospital, to compare prevalence data for all the 11 wards and 6 intake months, to establish if screening is sufficient or if a two-step diagnostic procedure is needed, and to determine whether information for an alcohol diagnosis on suspicion is available. A sample of 1309 medical or surgical in-patients were screened by questionnaires or medication for withdrawal, and, if screening-positive, were interviewed with the alcohol section of a standardized psychiatric interview. In screening-negative patients, a diagnosis on suspicion was given if medication to treat withdrawal had been used, or if there was evidence of single criteria of alcohol dependence, somatic disorders from alcohol drinking, raised laboratory parameters on grounds of alcohol drinking or of self-reported high alcohol consumption. Of the medical and surgical in-patients, 20.7 and 16.0% respectively were alcohol abusers or dependents, with a range of prevalence rates of alcohol abuse or dependence among wards of 11.1-32.9% and among intake months between 11.3 and 28.7%. Of the medical department in-patients, 1.9%, and of the surgical in-patients, 2.1%, were screened as false-positive cases. In addition, 5.5% of the medical and 12.0% of the surgical patients were given a diagnosis on suspicion. It is concluded that all general wards and different intake months should be taken into account when estimating prevalence of alcohol abuse or dependence in a general hospital.     

Determinants of hospital utilization in the Netherlands.

Hospital use in the Netherlands is examined in a cross-section analysis of 1969 and 1971 data for 120 service regions. Elasticities of admissions with respect to bed supply and supply of general practitioners are calculated, and the substitutability of first level care (by general practitioners) for hospital care is considered. Substitution effects found indicate that the Dutch government's plan to reduce the ratio of hospital beds to population is feasible.     

Evaluation of selection bias in a cross-sectional survey.

Selection bias is inherent in all occupational cohorts. Selection bias at entry has long been known and is commonly referred to as a "healthy worker effect." Less well appreciated is selection during the life of a cohort resulting from life-style factors (e.g., cigarette smoking); aging with accompanying chronic diseases, economic and demographic circumstances; and diseases that might result from exposures suffered by the cohort being studied, that influence whether individuals remain in a trade. These factors weigh differently at different times. Thus, at any point in time, "surviving" members of a cohort reflect an amalgam of selection factors. When such groups are studied in cross-sectional surveys there can be uncertainty whether clinical, radiological and physiological findings are necessarily representative for the trade or occupation as a whole. We analyzed the results of a large clinical field survey of long-term asbestos insulation workers to investigate whether the non-participants differed substantially from those who were examined. Five thousand three hundred and fifty-five (5,355) men, of an initial cohort of 17,800 established January 1, 1967, had reached 30 or more years from onset of their work by July 1, 1981. All were invited to come for examination. Two thousand and seventy-seven (2,077) came, and 3,278 did not. We questioned a sample of 1,393 non-responders to see why they failed to appear. The answers did not give evidence of significant health-related selection influence. Sickness only infrequently kept them away. We then followed both groups--those examined and those not examined--to the end of 1987 for their mortality experience. There was no great difference. The non-responders had somewhat fewer deaths overall and proportionately fewer of asbestos-associated cancers, such as mesothelioma and lung cancer. The results indicated that, in this cohort, there did not seem to be health-related selection bias that determined whether or not cohort members responded to invitations for examinations.     

Methods of selection of hospital equipment.

With increasingly specialized and sophisticated equipment on the market, our procedures for evaluating possible alternative products must become more scientific and reliable than simply performing cost comparisons and depending on good faith.     

Making waves. IRS zeroes in on bond pools, hospital groups' use of tax-exempt financing

The unused debt of an Ohio hospital association has caught the attention of the Internal Revenue Service, which has been on the lookout for bogus pools that take advantage of tax-exempt financing to generate professional fees. Bondholders have been told that the federal agency is examining the loan pool, and similar scenarios may soon occur in other states.     

Reporting and selection bias in case-control studies of congenital malformations.

Retrospective studies of congenital malformations frequently rely on exposures reported by study subjects. Differential error in exposure reporting by cases and controls, which has alternatively been referred to as "recall bias" and "reporting bias," may result in a biased effect measure. Some authors have attempted to avoid reporting bias by comparing exposures between two malformed groups, rather than between cases and nonmalformed controls. This approach, however, may introduce its own bias, which we call selection bias. Both reporting bias and selection bias are shown to be algebraically equivalent to bias arising from exposure misclassification. The magnitudes of these biases are compared for a range of plausible parametric values. The case-control design is sensitive to both differential reporting and selection bias, and the choice of study design involves balancing these two sources of bias.     

Arthritis and the earnings of men. An analysis incorporating selection bias.

Arthritis is a chronic and crippling disease which affects the work effort and earnings of more than 14 million working-age victims. This paper examines the effects of arthritis on the earnings of men aged 18 to 64. Arthritis has large and significant effects on earnings. Most models incorporating selection bias have examined groups with lower labor force participation rates than prime-age males, but significant selection bias is found here. When selection bias is considered, the estimated absolute effects of arthritis are increased and the percentage of the gap between arthritic and non arthritic males explained by arthritis, as opposed to other factors, increases. This study is unusual in identifying the effects of a single disease on earnings.     

Correcting for selection bias in estimation of within-individual variance

Consider a variable whose expected value distributes among individuals in a population, and which also has an important component of within-individual variance. In a screening study that involves repeated observations only for those individuals whose initial observation exceeds an arbitrary cutoff point, the usual estimator of within-individual variance is biased. Assuming normality and independence, this note gives the derivation of the expected value of the estimator and uses it to obtain an unbiased estimator. The results generalize to the bivariate case that involves selection on only one variable of the pair. A companion paper provides an example with use of blood pressure.     

医院引入负债经营方式的尝试及探讨

长期以来,卫生界对医院是否可进行负债经营有许多争议,但医院的负债行为一直客观地存在于经济活动中。为了多渠道筹措办医资金,参与市场竞争,部分医院在一定条件下向有关部门、银行借款或向其他机构融资来开展经济活动。 在1999年实行的新的《医院财务制度》中,首次系统地将负债的概念引入了医院的财务制度,规定“医院负债是指医院所承担的能以货币计量,需要以资产或劳务偿还的债务”,这一概念的引入,有助于客观、全面地反映医院的理财活动,并有助于规范医院的负债经营活动。 下面通过我们北京胸科医院负债经营运行中正反两方面的经验,结合新的《医院财务制度》,对负债经营的可行性及如何规范负债经营行为进行探讨。     

Meta-analysis and sensitivity analysis for multi-arm trials with selection bias

Multi-arm trials meta-analysis is a methodology used in combining evidence based on a synthesis of different types of comparisons from all possible similar studies and to draw inferences about the effectiveness of multiple compared-treatments. Studies with statistically significant results are potentially more likely to be submitted and selected than studies with non-significant results; this leads to false-positive results. In meta-analysis, combining only the identified selected studies uncritically may lead to an incorrect, usually over-optimistic conclusion. This problem is known asbiselection bias. In this paper, we first define a random-effect meta-analysis model for multi-arm trials by allowing for heterogeneity among studies. This general model is based on a normal approximation for empirical log-odds ratio. We then address the problem of publication bias by using a sensitivity analysis and by defining a selection model to the available data of a meta-analysis. This method allows for different amounts of selection bias and helps to investigate how sensitive the main interest parameter is when compared with the estimates of the standard model. Throughout the paper, we use binary data from Antiplatelet therapy in maintaining vascular patency of patients to illustrate the methods.     

Referral selection bias in the Medicare hospital mortality prediction model: are centers of referral for Medicare beneficiaries necessarily centers of excellence?

OBJECTIVE. Although the Health Care Financing Administration (HCFA) uses Medicare hospital mortality data as a measure of hospital quality of care, concerns have been raised regarding the validity of this concept. A problem that has not been fully evaluated in these data is the potential confounding effect of illness severity factors associated with referral selection and hospital mortality on comparisons of risk-adjusted hospital mortality. We address this issue. DATA SOURCES AND STUDY SETTING. We analyzed the 1988 Medicare hospitalization data file (MEDPAR). We selected data on patients treated at the two Mayo Clinic-associated hospitals in Rochester, Minnesota, and a group of seven other hospitals that treat many patients from large geographic areas. These hospitals have had observed mortality rates substantially lower than those predicted by the HCFA model for the period 1987-1990. STUDY DESIGN. Using the multiple logistic regression model applied by HCFA to the 1988 data, we evaluated the relationship between distance from patient residence to the admitting hospital and risk-adjusted hospital mortality. PRINCIPAL FINDINGS. Among patients admitted to Mayo Rochester-affiliated hospitals, residence outside Olmsted County, Minnesota was independently associated with a 33 percent lower 30-day mortality rate (p < .001) than that associated with residence in Olmsted County. When patients at Mayo hospitals were stratified by residence (Olmsted County versus non-Olmsted County), the observed mortality was similar to that predicted for community patients (9.6 percent versus 10.2 percent, p = .26), whereas hospital mortality for referral patients was substantially lower than predicted (5.0 percent versus 7.5 percent, p = < .001). After incorporation of the HCFA risk adjustment methods, distance from patient residence to the hospitals was also independently associated with mortality among the Mayo Rochester-affiliated hospitals and seven other referral center hospitals. CONCLUSIONS. The HCFA Medicare hospital mortality model should be used with extreme caution to evaluate hospital quality of care for national referral centers because of residual confounding due to severity of illness factors associated with geographic referral that are inadequately captured in the extant prediction model.     

Determinants of delayed initiation of breastfeeding: a community and hospital study from Guinea-Bissau.

A prospective study on the timing of breastfeeding start in Bissau was undertaken in a periurban community (n = 734), and at the Central Hospital (n = 414). Only single, full-term, healthy children born by the vaginal route were included, the purpose being to characterize mothers who delay breastfeeding start for reasons not related to disease. Multivariate failure-time analysis (Cox' regression) was used to relate the child's age at breastfeeding start to a set of independent variables. In the community, those tending to delay breastfeeding start were mothers from the largest ethnic group in the country, mothers who had given birth at times other than the evening hours (6-12 pm) and mothers who had not attended antenatal clinics. At the hospital, delayed initiation was found among young mothers and mothers from one sparsely represented ethnic group. The most important determinant of delayed breastfeeding start was negative cultural ideas about colostrum.