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PubMed2004

Steps forward, backward, and sideways: Canada's bill on exporting generic pharmaceuticals.

In May 2004 Canada's Parliament passed Bill C-9, amending the Patent Act to provide for the compulsory licensing of patented pharmaceutical products. The bill allows generic manufacturers to make cheaper, generic versions of patented products and export them to countries that do not have sufficient capacity to produce their own. Canada thus became the first country to pass legislation implementing a World Trade Organization (WTO) Decision that relaxed WTO rules on pharmaceutical patents. Civil society organizations campaigned to enhance the bill before it passed, and succeeded in obtaining significant improvements. However, the final bill is marred by flaws that mean it falls short of being a "model" that should simply be replicated elsewhere. This article is the second in a series tracing the evolution of Canada's legislation. It reviews the developments leading up to the adoption of Bill C-9 in its final form, and analyzes its positive and negative aspects. Hopefully, other advocates can learn from this experience and other countries can avoid replicating the negative aspects as they implement the WTO Decision.

Canada↗

PubMed2005

Seeing red: Americans driven into debt by medical bills. Results from a National Survey.

New analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey reveals that an estimated 77 million Americans age 19 and older--nearly two of five (37%) adults--have difficulty paying medical bills, have accrued medical debt, or both. Working-age adults incur significantly higher rates of medical bill and debt problems than adults 65 and older, with rates highest among the uninsured. Even working-age adults who are continually insured have problems paying their medical bills and have medical debt. Unpaid medical bills and medical debt can limit access to health care: two-thirds of people with a medical bill or debt problem went without needed care because of cost--nearly three times the rate of those without these financial problems.

Accounts Payable and Receivable↗

PubMed1989

Correlates of certification in family medicine in the billing patterns of Ontario general practitioners.

There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.

Canada↗

PubMed1982

Variable billing for services: new fiscal direction for nursing.

The advantages of variable billing for nursing care that: It identifies revenue nursing cost centers. It facilitates systematic control of revenue and expenses, improving budget planning and management. It generates a tremendous amount of data that can be used in administrative planning and decision making. It is more equitable than past billing practices for the patient, the third-party payer, and the hospital, making it a public relations asset. The disadvantages of variable billing are that: Charges at one hospital are not easily compared with those at another. The mix of patients at varying classification levels has a significant effect on revenue, thus increasing the possibility of lower revenue. More accountability and in some cases more work is required of nursing administrators. In this article, the practical application of variable billing in acute care settings has been discussed. It is hoped that the information provided here will stimulate nursing administrators to assess the feasibility of implementing varible billing for nursing services as a fiscal practice in their own institutions.

Arizona↗

PubMed1993

Diving metabolism and thermoregulation in common and thick-billed murres.

The diving and thermoregulatory metabolic rates of two species of diving seabird, common (Uria aalge) and thick-billed murres (U. lomvia), were studied in the laboratory. Post-absorptive resting metabolic rates were similar in both species, averaging 7.8 W.kg-1, and were not different in air or water (15-20 degrees C). These values were 1.5-2 times higher than values predicted from published allometric equations. Feeding led to increases of 36 and 49%, diving caused increases of 82 and 140%, and preening led to increases of 107 and 196% above measured resting metabolic rates in common and thick-billed murres, respectively. Metabolic rates of both species increased linearly with decreasing water temperature; lower critical temperature was 15 degrees C in common murres and 16 degrees C in thick-billed murres. Conductance (assuming a constant body temperature) did not change with decreasing temperature, and was calculated at 3.59 W.m-2 x degrees C-1 and 4.68 W.m-2 x degrees C-1 in common and thick-billed murres, respectively. Murres spend a considerable amount of time in cold water which poses a significant thermal challenge to these relatively small seabirds. If thermal conductance does not change with decreasing water temperature, murres most likely rely upon increasing metabolism to maintain body temperature. The birds probably employ activities such as preening, diving, or food-induced thermogenesis to meet this challenge.

Animals↗

PubMed1980

Impact of the rural health clinics services bill: a projection.

A survey of directors of midlevel practitioner training programs was conducted to analyze the projected impact of the Rural Health Clinics Services Bill (PL95-210). Sixty-eight percent of the directors responded. The majority of the respondents agreed that the bill would have a positive impact on accessibility and continuity of care and would increase the number of practitioners in rural areas. The directors of nurse practitioner programs disagreed with the directors of physician assistant programs over the issue of physician supervision and midlevel practitioner responsibility for care. Almost half of the respondents believed that the legislated method of reimbursement was not optimal, and 58% felt that financial abuses of the bill may occur. The legal implications of the bill and its impact on cost of care are discussed.

Attitude of Health Personnel↗

PubMed2003

Itemized bill: novel method to audit the process of laparoscopic cholecystectomy.

One of the recurring obstacles to the successful completion of a medical audit cycle is the unavailability of accurate and complete information. This is particularly evident in the review of clinical processes, where the hand-written medical record is the source of information. We have attempted to bypass this information deficit by using information recorded primarily for financial transactions, using the itemized bill. The study was conducted in two parts. Initially information recorded as an itemized bill for the in-hospital process of laparoscopic cholecystectomies over a one-year period was analyzed. Areas for change in practice were identified, and recommendations were developed. These recommendations were presented to a multidisciplinary group consisting of consultants, residents, and nursing staff involved in caring for these patients. A clinical pathway was developed and implemented from these recommendations. One year after introduction, a review of the clinical pathway was undertaken using the same methodology. The in-hospital process consisted of 23 charge categories according to the itemized bill. Of these, 8 accounted for 95% of the total charge. The surgeon's fee and the anesthesiologist's fee accounted for 34% of the total; medical/surgical supplies, 20%; operating theater time, 17%; pharmacy, 7%; radiology, 5%; laboratory, 7%; and ward, 4%. Areas were identified in the latter 6 categories for change. Review of practice 1 year after implementation of the changes showed that a large number of recommendations were in place. We describe a new method for auditing the processes of medical care, using the itemized bill to adapt and use information primarily recorded for financial purposes.

Cholecystectomy, Laparoscopic↗

PubMed2006

An Intranet-based system for inpatient billing in an academic medical center.

Academic physicians face great economic challenges. There is therefore a growing need to increase the efficiency of academic practice. One potential target for improving the "business" of medicine is inpatient billing. Currently many academic centers use "yellow" cards for inpatient billing. This is an inefficient system for capturing patient charges. We describe an Intranet-based system for inpatient billing that improves physician "productivity," reduces billing lag time, and increases the collection rate and total revenues.

Academic Medical Centers↗

PubMed2001

[Distinctive morphofunctional features of the bill and hyoid apparatus of turacos (Aves, Musophagidae): relations with frugivory].

The present study points to morpho-anatomical features that allow vegetarian but mainly frugivorous turacos to fill at best their specific feeding requirements. Mechanisms are analysed which the bird can use to detach a fruit and avoid it rolls out of the bill. It is also examined how vegetable items can be processed particularly when they have to be cut, and what can facilitate their ingestion particularly when they are fruits that have to be swallowed entirely and are large and/or have dry or fibrous skin or flesh. The skeletal and muscular anatomy of the bill and hyoid apparatus is described in details and illustrated. The particularly short and stout bill coupled with a relatively simple system of aponevroses of the adductors reflects a trade-off between two important jaw functional requirements: huge efforts for clamping, and a wide opening for plucking, processing and swallowing relatively large fruit. The clearly oblique orientation of the modified outer adductor seems an adaptation to the detachment of fruits. The os uncinatum, particularly developed in this bird family, is interpreted as maintaining transversal stability, particularly when jaws act as a pair of scissors. Most food items being processed near the base of the bill, mechanisms have been developed which contribute to overcome the risk of breakage at the level of the prokinetic hinge because of a vertically oriented force there.

Animals↗

PubMed2003

[Adaptations of the hoatzin (Opisthocomus hoazin) to leaf-eating. Morphological characteristics and functional features of its bill and hyoid apparatus].

The hoatzin remains one of the most enigmatic birds. A morphofunctional analysis of its bill and hyoid apparatus throws new light on its feeding adaptation as well as on its systematic relationships. Bony and muscular skull, rhamphotheca, palate, and hyoid apparatus were described in details. Though keeping into the general organisation pattern found among Neognathae (except Galliformes), bill and hyoid apparatus of the hoatzin displays a series of species-specific features, some unique among birds. This species appears particularly well adapted to tear of leaves and process them inside the bill before ingestion. Because of very important anatomical and thence functional differences in bill and hyoid structure, any close relationship between the hoatzin and Galliformes cannot be envisioned. Such a hypothesis would implicate a counter-selective evolutionary reversion.

Adaptation, Biological↗

PubMedDate not supplied

Nutrition counseling in the physician's office: how do I bill for advising my patient?

In addition to diagnosing and treating illnesses, physicians often provide nutrition counseling services. Billing and obtaining appropriate reimbursement for these services present a unique challenge. This article utilizes 4 hypothetical scenarios as a basis for examining common categories of service that involve nutrition counseling. These categories are: routine physicals that include nutrition counseling, nutrition counseling alone, nutrition counseling as a small part of a problem-oriented "evaluation and management" (E/M) service, and nutrition counseling as the bulk of a problem-oriented E/M service. The basics of procedure (CPT) and diagnosis (ICD-9) coding are described, and specific billing instructions for each scenario are provided. Although this article provides an introduction to the topic of billing, healthcare providers and their office staff should inform themselves on general coding and billing practices, as well as local payors' guidelines.

Adult↗

PubMed2002

Capturing tobacco status using an automated billing system: steps toward a tobacco registry.

In 1999, Group Health Cooperative (GHC), a health system with 575,000 enrollees, launched a quality improvement initiative to systematically record patient tobacco-use status and provider intervention using an automated billing system. Performance feedback and senior-level incentives were added to foster compliance with the automated recording. Prior to this period, tobacco-use status was recorded primarily via a paper-based chart system, with billing-system recording averaging only 7.5% of primary care visits. In 2000, tobacco-use status was recorded using the billing system in an average of 82% of visits (p<0.001). Significant increases (p<0.0001) were also observed for the absolute number of visits in which automated entry of tobacco-use status was documented using the billing system, as well as for visits where intervention was documented. In 1998, tobacco use was documented in 22,086 visits, with intervention documentation in 13,235 of these visits. By 2000, tobacco-use documentation increased to 76,180, with intervention documentation in 45,527. This work demonstrates the feasibility of using automated performance feedback and senior-level incentives to increase provider compliance with a new system of tobacco status identification and intervention. Other potential uses of this system, and potential limitations, are discussed.

Adult↗

PubMed1998

Some related aspects of platypus electroreception: temporal integration behaviour, electroreceptive thresholds and directionality of the bill acting as an antenna.

This paper focuses on how the electric field from the prey of the platypus is detected with respect to the questions of threshold determination and how the platypus might localize its prey. A new behaviour in response to electrical stimuli below the thresholds previously reported is presented. The platypus shows a voluntary exploratory behaviour that results from a temporal integration of a number of consecutive stimulus pulses. A theoretical analysis is given, which includes the threshold dependence on the number of receptors and temporal integration of consecutive stimuli pulses, the close relationships between electrical field decay across the bill, electroreceptive thresholds and directionality of the platypus bill acting as an antenna. It is shown that a lobe shape, similar to that which has been measured, can be obtained by combining responses in a specific way from receptors sensing the electric field decay across the bill. Two possible methods for such combinations are discussed and analysed with respect to measurements and observed behaviour of the platypus. A number of factors are described which need to be considered when electroreceptive thresholds are to be determined. It is shown that some information about the distance to the source is theoretically available from the pattern of field decay across the platypus's bill. The paper includes a comparative analysis of radar target tracking and platypus prey localization.

Animals↗

PubMed1997

The potential of using billing data for emergency department injury surveillance.

OBJECTIVE: To determine the availability of and sample statewide ED injury information obtained from hospital billing data for the purpose of demonstrating the feasibility of information acquisition for subsequent data linkage. METHODS: A retrospective, database investigation was conducted to obtain data describing a statewide stratified sample of ED patients. The aim was to collect a computerized billing summary record for each injured ED patient seen at each sampled hospital over a 1-year period. All 215 Pennsylvania acute care hospitals in 1991 were eligible for sample selection. Data collection for the project was conducted in 1993. Participants included directors of hospital medical records and billing departments. RESULTS: Twenty-four hospitals contributed data sets from the original target goal of 31 strata. The final combined data set contained 187,404 records with injury diagnoses from approximately 616,000 ED patient visits, representing a 12% sample of all annual statewide ED visits. Age, sex, date of visit, and primary diagnosis fields were completed from the retrieved data > 99% of the time. More than two-thirds of the sampled records had a social security number, and total charges were recorded > 90% of the time. Other variables such as name and address were contained in < 50% of the records submitted. E-codes were usually not available. CONCLUSIONS: Retrospective compilation of multihospital ED billing data to create a statewide ED data sample-with the potential for injury research and probabilistic database linkage-can be accomplished; there are, however, important limitations.

Data Collection↗

PubMed1988

Receptors in the bill of the platypus.

1. Afferent responses were recorded from filaments of the trigeminal nerve in each of two platypuses (Ornithorhynchus anatinus) anaesthetized with alpha-chloralose. All receptive fields were located along the lateral border of the upper bill. Discrete receptive fields could be identified as belonging to two distinct classes of sensory receptor. 2. The most prominent response was an irregular resting discharge which could be increased or decreased by weak electric pulses. These receptors were insensitive to moderately strong mechanical stimulation, and it was concluded that they were electroreceptors. 3. Each electroreceptor had a single spot of maximum sensitivity on the bill surface. When the stimulating electrode over this spot was the cathode it excited the receptor for the duration of the stimulating pulse, using stimulus strengths as low as 20 mV. When it was the anode, it inhibited the discharge. Cathodal excitation was followed by rebound inhibition and anodal inhibition by rebound excitation. 4. Receptors responded to cathodal steps with an initial high-frequency burst of impulses, followed by a lower maintained rate of discharge. Rapidly changing pulses were similarly effective in exciting receptors, adding support to the claim that platypuses are able to detect moving prey by the electrical activity associated with muscle contraction. 5. The centres of the receptive fields of two electroreceptors were marked by the insertion of fine entomological pins. Histological examination established the presence of a large mucus-secreting gland at the marked spot. The epidermal duct of the gland contained an elaborate myelinated innervation, with morphologically distinct axon terminals that we identify as the electroreceptors. 6. As well as electroreceptors, the skin of the bill contained three kinds of mechanoreceptors: slow-adapting receptors, rapidly adapting, vibration-sensitive receptors and receptors with an intermediate adaptation rate. The slowly adapting receptors were characterized by their low threshold to mechanical stimuli, irregular discharge and significant dynamic sensitivity. Vibration receptors showed maintained responses to sinusoidal vibration of the skin up to 600 Hz. 7. These experiments confirm an earlier report that the platypus bill is an electrodetector organ. The presence of electroreceptors of a unique structure and supplied by the trigeminal nerve indicates that electroreception has evolved independently in monotremes. This in turn emphasizes that monotremes are a highly evolved group which split off from the main mammalian stem a long time ago.

Action Potentials↗

PubMed1996

Nutrition support billing practices: results of a nationwide survey and responses from the Health Care Financing Administration.

In response to numerous changes in reimbursement for physician services, a survey was conducted of physician directors of nutrition support services to obtain information about current physician billing practices and reimbursement for nutrition support. Demographic data were obtained concerning the type of practice and institution, percent of time and income derived from nutrition support, and the source of individual billing practices. Responses to six clinical scenarios provided information about billing practices. The responses were collated, analyzed, and then compared with those of a senior official at the Health Care Financing Administration (HCFA). This report summarizes the results of the survey and the responses from HCFA. It is hoped that this information will be useful to nutrition support practitioners and administrators in understanding various aspects of billing for physician services for nutrition support.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed1990

The impact of the amended Ontario Mental Health Act (Bill 7) on patients discharging themselves from hospital against medical advice (AMA): a preliminary study.

Bill 7, the most recent amendment to the Ontario Mental Health Act was introduced in December 1986. It has resulted in some major changes to the practice of psychiatry, especially in provincial hospitals. We compared patients who had discharged themselves against medical advice (AMA) during the six months before the Bill was enacted, with those who discharged themselves AMA in the 12 months following. Significantly more patients discharged themselves AMA in the post- than the pre-Bill period. The majority of these were potentially treatable, acutely ill individuals with schizophrenia or affective disorder. We argue that Bill 7 has largely failed in its objective to improve the overall "quality of care" to psychiatric patients, at least in the short term.

Commitment of Persons with Psychiatric Disorders↗

PubMed1995

The effects of changes in the law concerning mentally disordered offenders: the Alberta experience with Bill C-30.

OBJECTIVE: Until recently, the Criminal Code of Canada, enacted in 1892, stood stalwart to social, political and technological changes, particularly with respect to the regulations pertaining to the management of the mentally ill offender. This became more definitely so with the enactment of the Canadian Charter of Rights and Freedoms (1984) as many regulations in the Code about mentally ill offenders contravened the mandates contained in the Charter. The Supreme Court of Canada's decision on Regina v. Swain spurred the Federal Government to bring the regulations on the mentally ill offender into line with the Charter. The result was the enactment of Bill C-30 which was intended to dramatically change the way in which forensic psychiatry was practised in Canada. This paper presents the Alberta findings from a multi-site evaluation commissioned by the Federal Department of Justice to judge the effects of Bill C-30 on forensic health care practices. METHODS: Health records data were used to compare utilization patterns from the year prior to the enactment of Bill C-30 with the year following. In addition, qualitative data were obtained from key clinical and legal informants outlining implementation difficulties that they had experienced. RESULTS: Results support the judgement that Bill C-30 has not achieved its desired effects with respect to the length of the remand, and has resulted in an increased burden on hospitals and health care providers. In addition, an unanticipated finding was the increased use of the Mental Health Act which was considered to place forensic patients in a position of double jeopardy.

Adult↗