Ancillary Cost Research Articles

Penentuan Tarif Badan Layanan Umum RSUD “X” Berdasarkan PERMENKES Nomor 85 Tahun 2015

<p><em>This study aims to determine the process of calculating rates at RSUD “X" in Indonesia. Periodically, when needed, each hospital always fixes the calculation of service rates charged to patients. Similarly, RSUD “X," which is 2021, will also perform a re-calculation of rates adjusted to current conditions and Permenkes No. 85, 2015 regarding the calculation of rates. The flow rate calculation process is obtained from interviews with consultants who perform rates calculations at RSUD "X" accompanied by supporting data. The research method is descriptive qualitative. There are seven steps adopted by Shepard (1998) to perform rates calculations, starting from the identification of the final product to the final report. There are three cost centers in cost identification: the general cost center, ancillary cost center, and clinical cost center. The clinical cost center is the final product of rates calculation, where the rates is calculated based on unit cost. Costs that arise from general and ancillary are allocated to primarily clinical based on floor area. The report on the results of the rates calculation is in the form of the rates for each action that is part of the clinical. The rates will be stated in the local Regent Regulation. In addition, the final result is a complete report on the flow of calculations and sources of information that are used as a basis for hospital management to evaluate and calculate rates in the future.</em></p>

A NEW FRACTIONAL-ORDER STABILITY ANALYSIS OF SIR MODEL FOR THE TRANSMISSION OF BURULI DISEASE: A BIOMEDICAL APPLICATION

In this paper, a new computing technique is investigated for the cause of Mycobacterium ulcerans (MU) with the help of differential equations through the SIR model. This study is carried out to find the cause between the ulcer and the environment for the spread of Buruli ulcer (BU). Fractional-order SIR model is applied to discuss in detail the BU disease. The construction and development of this given numerical scheme are performed for the SIR epidemiological model concerning the transmission dynamics of BUs. Mathematical modeling of the presented scheme with the help of stability techniques is accomplished. Further, the behavior of the scheme is accessed by the evaluation of the different parameters of interest. The attained numerical results are observed for the illustration of the benefit of introducing a fractional model. Finally, we profound that the presented numerical scheme maintains all required control measuring features of the corresponding dynamical system and decreases the ancillary cost when studied over a long time. With the help of a given novel and unique approach, a significant observation is noted and recommended for other epidemiological fractional-order models. In future, this novel fractal technique will be appertained in chemical and biomedical engineering applications.

Ancillary Cost Implications of Physicians Multisiting and Inter‐Organizational Collaboration During Healthcare Delivery

This study investigates diagnostic testing and pharmacy expenditures, commonly referred to as ancillary costs in the United States acute‐care hospitals. These ancillary costs are charges associated with services provided to support patient treatment, including laboratory, radiology, and pharmacy charges. Despite of investment in inter‐organizational and technological collaboration practices, these costs continue to rise. Our research examines the role of individual healthcare providers, namely multisiting physicians, who practice at more than one hospital, in reducing ancillary cost. We also look at how inter‐organizational collaboration measured by the hospital's affiliation in an accountable care organization (ACO) model affect this relationship. To do this, we assembled a unique data set of 163,617 patients treated by 4411 physicians at 182 hospitals in Florida from 2014 to 2016. Using an econometric estimation approach accounting for endogeneity, we find that patients treated by multisiting physicians experienced, on an average, per‐hospitalization reduction in laboratory and radiology charges of 58.57% and 30.11%, respectively. These savings increase when multisiting physicians have less practice experience. We also find that hospitals participating in ACO model complement the savings achieved through multisiting physicians in the form of even lower pharmacy costs. In post‐hoc analyses, we find such cost reduction comes from reducing the total number of procedures or tests ordered. We also show that the lower treatment charges do not compromise the clinical quality of patients treated by multisiting physicians. Collectively, the findings offer important insights to the healthcare operations management literature on the interaction between individual‐organizational collaboration efforts and patient‐level outcomes.

MPG Illusion and Vehicle Choice: An Empirical Study of the Japanese Household Survey

Previous studies have shown that people understand the future ancillary cost of durable goods such as an automotive vehicle. However, consumers tend to misunderstand the future benefits and costs of these goods. One of the most interesting discussions about consumer cognitive ability for future energy cost is the miles per gallon (MPG) illusion. In this study, we analyze people’s misunderstanding of the relationship between kilometers per liter (KPL) and the actual amount of fuel saved using vehicle owner survey data. We developed some questions to measure how much each person is involved with the MPG (or KPL) illusion. Additionally, our survey includes questions capturing some preferences affecting future fuel costs, such as time. Controlling for the most important respondent characteristics, such as income or gender, our empirical model analyzes the extent of the misunderstanding of how much actual KPL selections of personal auto vehicles are affected. We found that many Japanese consumers tend to misunderstand the relationship between KPL and actual fuel costs. Our results demonstrate that people who misunderstand the relationship tend to choose a higher 4.324 km per liter car than those who understand. This finding implies that the KPL illusion affects the KPL selection of consumers’ cars.

Children really are not little adults: What we can take away from the 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices

Children really are not little adults: What we can take away from the 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices

Methods for estimating the cost of treat-and-release emergency department visits.

To evaluate and compare approaches to estimating the service delivery cost of emergency department (ED) visits from total charge data only. The 2013-2017 Healthcare Cost and Utilization Project's (HCUP) State Emergency Department Databases (SEDD) and the Centers for Medicare and Medicaid Services Healthcare Cost Report Information System (HCRIS) public use files. Compare a baseline approach (requiring cost-center-level charge detail) and four alternative methods (relying on total charges only) for estimating ED visit costs. Estimation errors are calculated after applying each method to a sample of ED visits, treating estimates from the baseline approach as the "true" cost. Performance metrics are calculated at the visit and hospital levels. The charges, revenue center codes, and patient/hospital characteristics were extracted from the SEDD. Detailed costs and charges were extracted from HCRIS public use files. Baseline ("true") ED visit costs increased from $383 to $420 per visit between 2013 and 2017. Three methods performed comparatively well estimating mean cost per visit. The method using an overall cost-to-charge ratio (CCR) for all ancillary cost centers without regression adjustment (ANC-CCR) performed the worst, overestimating "true" costs by $63-$113 per visit. The other three methods, which used CCRs computed from selected cost centers, exhibited much smaller bias, with two of the methods yielding estimates within $2 of the "true" cost in 2017. Compared with ANC-CCR, the other three methods had more compact estimation error distributions. The estimated mean visit costs from all four methods have relatively small statistical variance, with 95% confidence intervals for mean cost in a hospital with 25,000 ED visits ranging between $4 and $7. When cost-center-level charge detail for ED visits is unavailable, alternative methods relying on total ED charges can estimate ED service costs for patient and hospital segments.

Ancillary Cost Implications of Multisiting and Organizational Boundary Spanning during Healthcare

This study investigates the management of diagnostic testing and pharmacy expenditures in U.S. acute-care hospitals. These so-called ancillary costs are charges associated with services provided to support patient treatment, including laboratory, radiology, and pharmacy charges. Previous studies suggest that investing in structural and technological boundary-spanning practices may help reduce the increasing ancillary costs. In this research, we examine the role of individual boundary spanners, namely multisiting physicians who practice at more than one hospital, in reducing ancillary cost. We also look at how organizational boundary spanning abilities measured by the hospital’s affiliation in an accountable care organization (ACO) model affect this relationship. To do this, we assembled a unique data set of 163,617 patients treated by 4,411 physicians at 182 hospitals in Florida from 2014 to 2016. Using an econometric estimation approach accounting for endogeneity, we find that patients treated by multisiting physicians experienced per-hospitalization reductions in laboratory and radiology charges of 49.16% and 32.04%, respectively. These savings increase, moreover, when multisiting physicians have less practice experience. We also find that hospitals participating in ACO model complements the savings achieved through multisiting physicians in the form of even lower pharmacy costs. In our post-hoc analysis, we find the cost reduction that multisiting physicians achieve come through reducing the total number of procedures or tests ordered. We also find that lower treatment charges do not compromise the clinical quality of patients treated by multisiting physicians. Collectively, the findings offer important insights to the healthcare operations management literature on the interaction between individual-organizational boundary-spanning efforts and patient-level outcomes.

From over to optimal irrigation in paddy production: what determines over-irrigation in Bangladesh?

This paper examines the level of optimal irrigation and the determinants of over-irrigation in paddy production since about three-fourth of freshwater withdrawal is used to irrigate paddy plants in Bangladesh. Cobb–Douglas production function reveals that optimal irrigation is 75 × 102 m3 per acre per season. Results show nearly, 39% of water is over-irrigated. It escalates farmer’s irrigation cost by USD 56 per acre and induces additional depletion 60 × 102 million m3 freshwater with substantial welfare loss USD 70–73 million in south-western Bangladesh. Further analyses reveal that farm characteristics, salinity, and irrigational modes determine over-irrigation in the study area. This study suggests that the alternate wetting and drying (AWD) technique helps farmers to reduce irrigation substantially and to reach the optimal level. Welfare effects of the AWD technique are 89–93% reduction in over-irrigation 68–71% reduction in ancillary cost.

Comparative Cost Benefit Analysis of Conventional Farming and Agroecological Farming for Paddy Cultivation in Bachok, Kelantan

In Malaysia, conventional rice farming is the predominant method of rice cultivation with attendant problems like the harmful effects of the utilisation of synthetic pesticides and synthetic fertilisers. Thus, conventional rice farming was compared to the System of Rice Intensification (SRI) method, a variant of agroecological rice farming, in Kampung Klerek, Bachok District, and Kelantan. It must be noted that the agroecological rice farming method is the farmer’s maiden attempt. Agroecological rice farming is a much more environmentally friendly approach. The aim of this paper is to compare conventional rice farming vis-à-vis agroecological rice farming from a financial perspective. Comparative Cost Benefit Analysis has been adopted to determine which the better alternative is. However, the results go beyond financial consideration as conventional rice farming is chemically driven whereas agroecological rice farming is grounded on environmentalism. The results indicated that agroecological rice farming is a better financial alternative with higher revenue and lower cost of production. The higher revenue is due to higher production yield whereas the lower cost of production is due to contributory factors like lower labour cost, lower seed utilisation and ancillary cost, zero cost for synthetic fertilisers and lower fuel and ancillary cost for machinery despite higher organic fertiliser cost. Thus, on a long-term basis, with the effect of the learning and experience curve, the cost of production can be lowered further. Moreover, the higher rice yield, less seed wastage, utilisation of organic fertilisers, organic pesticides and natural pest control methods are in sync with good environmental practices.

Frequency stability improvement in wind‐thermal dominated power grids

With the proliferation of intermittent renewable energy sources, power systems need to withstand an increasing number of disturbances that may affect system frequency. In this paper, we focus on the effects of high penetration level of wind turbine-generators (WTG) on the power system operational planning from the frequency point of view. Specifically, an exact formulation for the minimum frequency calculation is presented to increase accuracy and speed of analyses. Then, the effect of WTG's frequency response on the power system frequency stability is investigated to compute the maximum acceptable generation outage as a function of penetration level. Finally, as an application to power system operational planning, the obtained frequency dynamics of the power system and the wind turbine frequency response are integrated into the unit commitment problem. Simulations are performed on the IEEE 39-bus test system to study the effects of the WTGs on the frequency stability of the system. Results illustrate a more secure and reliable operation of the power system when the wind turbines participate in the frequency regulation task. Moreover, including the frequency response of the wind turbines in the unit commitment problem can reduce the ancillary cost, meanwhile increase the frequency stability of the system.

Wind-integration benefits of controlled plug-in electric vehicle charging

Flexibility in plug-in electric vehicle (PEV) charging can reduce the ancillary cost effects of wind variability and uncertainty on electric power systems. In this paper, we study these benefits of PEV charging, demonstrating that controlled PEV charging can reduce costs associated with wind uncertainty and variability. Interestingly, we show that the system does not require complete control of PEV-charging loads to mitigate the negative cost impacts of wind variability and uncertainty. Rather, PEV owners giving the system a two-hour window of flexibility in which to recharge their vehicles provides much of the benefits that giving full charging control does.

The Cost of Providing District-Level Surgery in Malawi

BackgroundThree district hospitals in Malawi that provide essential surgery, which for many patients can be lifesaving or prevent disability, formed the setting of this costing study.MethodsAll resources used at district hospitals for the delivery of surgery were identified and quantified. The hospital departments were divided into three categories of cost centres—the final cost centre, intermediate and ancillary cost centres. All costs of human resources, buildings, equipment, medical and non-medical supplies and utilities were quantified and allocated to surgery through step-down accounting.ResultsThe total cost of surgery, including post-operative care, ranged from US$ 329,000 per year to more than twice that amount at one of the hospitals. At two hospitals, it represented 16–17% of the total cost of running the hospital. The main cost drivers of surgery were transport and inpatient services, including catering. The cost of a C-section ranged from $ 164 to 638 that of a hernia repair from $ 137 to 598. Evacuations from uterus were cheapest mainly because of the shorter duration of patient stay.ConclusionLow bed occupancy rates and utilisation rates of the operating theatres suggest overcapacity but may also indicate a potential to scale up surgery. This may be achieved by adding surgical staff, although there may be rate-limiting steps, such as demand for surgery in the community or capacity to provide anaesthesia. If a scale-up of surgery cannot be realised, hospital managers may be forced to reduce the number of beds, reorganise wards and/or reallocate staff to achieve better economies of scale.

Clinical and financial implications of emergency department visits for synthetic marijuana

BackgroundMany users believe that synthetic cannabinoids offer a safe and legal means of getting high. However, spikes in emergency department visits have been associated with use of synthetic cannabinoids. The purpose of the current study was to document emergency department visits from three large hospitals in one metropolitan area over a two month period. MethodThis was a retrospective chart review examining 218 patients presenting to three inner city emergency departments between March and April 2014. Data collected included demographic information, information regarding ED diagnosis and treatment, signs and symptoms, ancillary testing, ED disposition, and cost of the medical treatment. ResultsThe majority of patients (75.7%) were discharged after ED workup, but 12.4% were admitted for medical treatment and 11.5% were admitted for psychiatric treatment. Ten patients (4.6%) were admitted to the ICU. Symptoms experienced most frequently include: hypertension, tachycardia, agitation, drowsiness, nausea, and confusion. Cluster analysis revealed four symptom clusters of individuals presenting after using synthetic cannabinoids: 1) confusion, hostility, agitation, 2) nausea, vomiting, abdominal pain, 3) drowsiness, and 4) the absence of these symptoms. ConclusionThis study has three important findings. First, significant ED resources are being used to treat individuals presenting due to effects of synthetic cannabis. Second, synthetic cannabis is not a benign substance. Third, while the hostile and agitated user is generally presented in the media, this study finds significant heterogeneity in presentation. Further research is needed to fully understand the implications of synthetic cannabinoid use.

The use of extracorporeal carbon dioxide removal to avoid intubation in patients failing non-invasive ventilation--a cost analysis.

BackgroundTo evaluate the economic implications of the pre-emptive use of extracorporeal carbon dioxide removal (ECCO2R) to avoid invasive mechanical ventilation (IMV) in patients with hypercapnic ventilatory insufficiency failing non-invasive ventilation (NIV).MethodsRetrospective ancillary cost analysis of data extracted from a recently published multicentre case–control-study (n = 42) on the use of arterio-venous ECCO2R to avoid IMV in patients with acute on chronic ventilatory failure. Cost calculations were based on average daily treatment costs for intensive care unit (ICU) and normal medical wards as well as on the specific costs of the ECCO2R system.ResultsIn the group treated with ECCO2R IMV was avoided in 90 % of cases and mean hospital length of stay (LOS) was shorter than in the matched control group treated with IMV (23.0 vs. 42.0 days). The overall average hospital treatment costs did not differ between the two groups (41.134 vs. 39.366 €, p = 0.8). A subgroup analysis of patients with chronic obstructive pulmonary disease (COPD) revealed significantly lower median ICU length of stay (11.0 vs. 35.0 days), hospital length of stay (17.5 vs. 51.5 days) and treatment costs for the ECCO2R group (19.610 vs. 46.552 €, p = 0.01).ConclusionsAdditional costs for the use of arterio-venous ECCO2R to avoid IMV in patients with acute-on-chronic ventilatory insufficiency failing NIV may be offset by a cost reducing effect of a shorter length of ICU and hospital stay.

Pricing of fluctuations in electricity markets

In an electric power system, demand fluctuations may result in significant ancillary cost to suppliers. Furthermore, in the near future, deep penetration of volatile renewable electricity generation is expected to exacerbate the variability of demand on conventional thermal generating units. We address this issue by explicitly modeling the ancillary cost associated with demand variability. We argue that a time-varying price equal to the suppliers’ instantaneous marginal cost may not achieve social optimality, and that consumer demand fluctuations should be properly priced. We propose a dynamic pricing mechanism that explicitly encourages consumers to adapt their consumption so as to offset the variability of demand on conventional units. Through a dynamic game-theoretic formulation, we show that (under suitable convexity assumptions) the proposed pricing mechanism achieves social optimality asymptotically, as the number of consumers increases to infinity. Numerical results demonstrate that compared with marginal cost pricing, the proposed mechanism creates a stronger incentive for consumers to shift their peak load, and therefore has the potential to reduce the need for long-term investment in peaking plants.

Do Auditors Perceive Real Earnings Management as a Business Risk?

We examine the relationship between real earnings management (REM) and audit fees. While studies have investigated the influence of accrual-based earnings management on audit fees, empirical research is silent on whether REM activities explain audit fees. We report a positive association between both current and prior period REM and audit fees and show that firms with greater incentives to manage earnings drive this relationship. The prior period REM finding indicates that auditors perceive REM as a business risk, whereas the current period effect could reflect either perceived business risk or auditor effort. To provide more insight on the current period effect, we extend our analysis into the banking industry and examine a REM activity (gains trading) that is less likely to require additional audit effort. We again document a positive prior period REM effect but do not find support for the current period effect. Thus, our banking analysis supports the notion that the prior period effect captures increased business risk, and suggests the current period effect in our main analyses is attributable to increased auditor effort. Our study provides evidence that an ancillary cost of REM is higher audit fees.

The Cost of Care for Patients with HIV from the Provider Economic Perspective

Health care costs for HIV infection are often reported from the economic perspective of third party payors and little data exist to show how total costs are distributed across specific health service categories. We used a retrospective cohort design to measure total medical costs for 1 year in a randomly selected sample of 280 patients treated for HIV infection at an urban health care facility. Inpatient and outpatient costs were measured from the economic perspective of the health care provider. Hospital costs included ward, ancillary, and procedure costs. Ambulatory included medications, primary and specialty care, case management, ancillary, and behavioral comorbidity treatment costs. The mean total was $20,114 per patient, of which $6,322 was for inpatient and $13,842 was for ambulatory services. Specific ambulatory costs were: medications, $9,257; primary, specialty and ancillary services, $3,470; and behavioral comorbidity treatment, $1,111. The mean annual outpatient ancillary cost was $841. Over 30% of the total service cost was for building and administrative overhead and approximately 25% of both hospital and clinic costs were for ancillary services. Independent predictors of high cost were CD4 counts, Medicaid eligibility, and behavorial comorbidities. Our outpatient costs were higher, with less variation than previously reported. Increasingly, there has been a shift of HIV care from hospital to ambulatory settings. We postulate that reimbursement rates have not captured the recent flourishing of ambulatory care. If reimbursement is not commensurate with outpatient advances, providers may be paradoxically underreimbursed for improving care.

Daily cost prediction model in neonatal intensive care.

One barrier to economic evaluation alongside neonatal randomized controlled trials is the expense of collecting detailed patient resource information. To reduce this data collection burden, we identified the key resource items that predict daily ancillary costs for extremely low birth weight infants. Participants were 385 infants enrolled in the Trial of Indomethacin Prophylaxis for Preterms in nine tertiary level neonatal intensive care units in Canada. Information on eighty-nine nonpersonnel resource items was abstracted from the hospital chart from admission to tertiary hospital discharge. Unit costs were derived from a provincially standardized cost accounting system. Using stepwise linear regression, models correlating total daily ancillary costs with key resource items were constructed for each of five periods of admission. Models were derived in a randomly split half of the total sample of patient days and validated against the remainder. The 385 infants contributed resource information from 23,354 admission days. The regression model for weeks one to twelve included the covariates surfactant, chest radiograph, red blood cell transfusion, cranial ultrasound, abdominal radiograph, parenteral amino acid infusion, surgery, platelet transfusion, and echocardiogram and explained 91% of the variability in daily nonpersonnel costs (P<.0001). Models for other admission periods similarly included between four and eight covariates, were highly significant (P<.0001) and explained between 76% and 94% of daily ancillary cost variability. The regression equations showed excellent predictive power when applied to the second half of the patient data set. Daily nonpersonnel costs for extremely low birth weight infants are driven by a limited number of key resource variables. The ability to predict total ancillary costs with minimal data collection will facilitate inclusion of economic evaluations in neonatal trials.

Assessing ICU performance using administrative data

PARTICIPANTS: Dr. Deborah Cook, Dr. William Sibbald, Dr. Gordon Rubenfeld, Dr. Derek Angus, and Dr. Sean Keenan. Dr. Michael Breslow: The intensive care unit is probably the highest mortality center in the average hospital and the highest cost center. Even though it accounts for about 10% of beds, it represents about 25% of acute care costs. There has been considerable attention focused on the consequences of the inefficiencies of our critical care units in terms of emergency department diverts and operating room inefficiencies. Solucient, LLC, provides mission critical intelligence to the health care industry by transforming multiple streams of health care data into actionable information and knowledge. Solucient performs the 100 Top Hospitals: Benchmarks for Success studies to achieve 3 goals: 1. To create useful benchmarks for measuring hospital performance nationally. 2. To highlight areas of wide variation in hospital performance in high-risk, high-cost, and highvolume services. 3. To focus attention on and encourage performance improvement by publishing benchmark scores by hospital type and the names of the 100 hospitals that have set the benchmark scores. VISICU, Inc. was approached to advise them on methodology. A major motivation for our participation in the project was the recognition that hospital administrators and the public are largely ignorant of the important role served by our ICUs, and the considerable variability in ICU performance that exists across hospitals. In addition, though administrative interventions in the ICU environment have not generally succeeded, focused clinical interventions have had impressive efficacy, with some programs showing mortality reductions of as large as 50%, and financial savings of up to 25%. In designing the study, we had to balance Solucient’s desire to have a national sample of hospitals across the United States with the reality that many hospitals have too few ICU patients to accurately assess quality of care. We elected to use Medicare data for analysis (as opposed to some of the state databases in which there might be more detail) because detailed databases are not available for most states. Performance was measured in 3 discrete populations of ICU patients: (1) patients admitted with a medical diagnoses, (2) patients admitted after a surgical procedure, and (3) patients that required mechanical ventilation for more than 96 hours (our presumption of the truly critically ill). To create the first 2 groups, we identified the most frequently encountered ICD-9-CM admitting diagnoses for ICU patients and those ICD-9-CM diagnoses that most often had an ICU stay. Although we were interested in identifying diagnoses with the largest number of patients admitted to the ICU, we did not wish to include diagnoses in which only a small subset went to the ICU. The outcome variables examined for the ICU patients of each hospital were hospital mortality, hospital length of stay (LOS), complications, and daily ICU ancillary costs. We used hospital mortality as an outcome variable because we did not have the ability to differentiate who died in the ICU and who died external to the ICU. Medicare data only provides total ancillary costs for the entire hospitalization without differentiation of what is consumed in the ICU and what is consumed outside the ICU. Because nationwide ancillary costs per day in the ICUs are about 3 times the ancillary cost per day on the floor, we estimated daily ICU ancillary costs from the following: the number of ICU days, the number of floor days, and the total ancillary expenditures for the hospitalization, by using a 3:1 cost ratio. We chose cost per day as opposed to total ancillary cost per ICU stay because total ICU ancillary costs primarily reflect ICU LOS, rather than discretionary use of ancillary resources. Complications were only measured in the surgical population based on the work of Lawthers et al, which suggests that complications cannot be accurately determined from administrative data in medical patients.

Energy-efficient lighting in Thai commercial buildings

We explore the opportunities to reduce the electricity required for lighting in prototypical Thai offices, hotels, and shopping centers. Using a whole-building energy analysis approach, we calculate the savings from lighting conservation measures directly, and from associated reductions in cooling load. Ancillary cost savings of air-conditioning energy and capacity comprise a significant 30 to 50% of the total. Lighting technologies considered in this study include electronic ballasts; tri-phosphor, narrow-diameter lamps; specular reflectors; occupancy sensors; lumen maintenance and daylighting controls; and compact fluorescent lamps. From a societal economic perspective, the cost of conserved energy of employing all applicable lighting conservation measures to these buildings is one-quarter or less than the average retail price of electricity for commercial customers, with a payback time of less than one year in hotels and retail buildings and approximately three years in offices. The internal rate of return for installing all lighting measures is 35% in offices, 142% for hotels, and 107% for shopping centers. Several current policy initiatives in Thailand, including a proposed energy standard for commercial buildings, with specific provisions for lighting, and plans by the nation's electric utility to develop two commercial sector conservation programs, should help to spur the adoption of more efficient lighting products. We strongly recommend that the currently high tariffs and taxes (50% and greater) for imported efficient lighting products be reduced.