No abstract

This analysis describes hospitals that provide large amounts of uncompensated care and hospitals with sizable teaching programs, using data from the American Hospital Association. Despite current public financial support mechanisms, safety-net hospitals have a lower average total margin and a greater percentage with negative total margins than other groups of hospitals. For graduate medical education, however, the current public financial supports have assisted teaching hospitals with the largest training programs in maintaining their financial viability, although teaching hospitals' average total margins remain below those of nonteaching hospitals.M ANY TYPES OF PROVIDERS and organizations constitute the broad health care safety net that supports the delivery of health care services to a variety of vulnerable populations. However, health services researchers, analysts, and policymakers have focused their attention primarily on the role of the nation's hospitals in forming a safety net of care for those who cannot pay for it and in providing services that may be viewed as public goods, such as medical education, unique or specialized patient care services, and community programs.Many hospitals claim to be part of the safety net. Every year hospitals provide uncompensated care worth billions of dollars, maintain the facilities for educating thousands of physicians and other health professionals, provide the environment for hundreds of scientific and biomedical discoveries, and improve the lives of millions of persons through community services. However, there is substantial variation in the concentration and dispersion of responsibility for indigent care and graduate medical education (GME).As the delivery system transforms into a competitive, price-sensitive structure and constraints are placed on public spending, policymakers are concerned about how well the safety net is holding up and what types of hospitals might fall through holes in the fabric. This analysis identifies and describes the characteristics of hospitals that constiLinda Fishman is associate vice-president,

While patient care has been shifting to the ambulatory setting, the education of health care professionals has remained essentially hospital-based. One factor discouraging the movement of training into community-based ambulatory settings is the lack of understanding of what the costs of such training are and how these costs might be offset. The authors describe a model for ambulatory care training that makes it easier to generalize about to quantify its educational costs. Since ambulatory care training does not exist in a vacuum separate from inpatient education, the model is compatible with the way hospital-based education costs are derived. Thus, the model's elements can be integrated with comparable hospital-based training cost elements in a straightforward way to allow a total-costing approach. The model is built around two major sets of variables affecting cost. The first comprises three types of costs--direct, indirect, and infrastructure--and the second consists of factors related to the training site and factors related to the educational activities of the training. The model is constructed to show the various major ways these two sets of variables can influence training costs. With direct Medicare funding for some ambulatory-setting-based education pending, and with other regulatory and market dynamics already in play, it is important that educators, managers, and policymakers understand how costs, the characteristics of the training, and the characteristics of the setting interact. This model should assist them. Without generalizable cost estimates, realistic reimbursement policies and financial incentives cannot be formulated, either in the broad public policy context or in simple direct negotiations between sites and sponsors.

The vocalizations of six children with severe-profound hearing loss were audio-recorded in two conditions during individual speech-language intervention sessions: (a) auditory amplification alone, and (b) auditory amplification plus the Tactaid II, a two-channel vibrotactile device (Franklin, 1986). Utterances were categorized according to the infraphonological framework described by Oller (1980, 1986) and Oller and Lynch (1992). Vocalizations were categorized in a developmental framework relative to mature speech. Those utterances containing well-formed consonant-vowel syllables were transcribed with broad phonetic transcription and analyzed at both the syllabic and segmental levels. Statistically significant differences were found between the two conditions for vocal volubility (i.e., quantity of vocalizations produced); subjects vocalized more when using both auditory amplification and the Tactaid II together than with auditory amplification alone. Trends in the early vocal development of these children with severe-profound hearing loss are described at the infraphonologic, segmental, and syllabic levels.