Running Health Care as a Business. During the 1990s the effects of managed care, reductions in Medicaid and Medicare reimbursements, state budgetary problems, university budg­etary limitations, and cutbacks in research funding all came to a head, putting tremendous financial pressure on health­care institutions. Institutions seeking ways to cut costs and remain competitive formed alliances, merged (16), and inves­tigated the out-sourcing of support services including clinical engineering. These economic pressures often resulted in re­duction of full-time employees (FTE) throughout the health­care institution, including within clinical engineering depart­ments, necessitating reexamination of clinical engineering core services. Outsourcing provided further opportunity for third-party ISO to expand. The importance of running health care, including clinical engineering as a business, became the new paradigm (17).

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