OBJECTIVE: To investigate the effects on general practitioners' activities of a change in their remuneration from a capitation based system to a mixed fee per item and capitation based system. DESIGN: Follow up study with data collected from contact sheets completed by general practitioners in one period before (March 1987) a change in their remuneration system and two periods after (March 1988, November 1988), with a control group of general practitioners with a mixed fee per item and capitation based system throughout. SETTING: General practices in Copenhagen city (index group) and Copenhagen county (control group). SUBJECTS: 265 General practitioners in Copenhagen city, of whom 100 were selected randomly from the 130 who agreed to participate (10 exclusions) and 326 general practitioners in Copenhagen county. MAIN OUTCOME MEASURES: Number of consultations (face to face and by telephone) and renewals of prescriptions, diagnostic and curative services, and specialist and hospital referrals per 1000 enlisted patients in one week. RESULTS: Of the 75 general practitioners who completed all three sheets, four were excluded for incomplete data. Total contact rates per 1000 patients listed rose significantly compared with the rates before the change index in the city (100.0 before the change v 111.7 (95% confidence interval 106.4 to 117.4 after the change) and over the same time in the control group (100.0 v 106.0), but within a year these rates fell (to 104.2(99.1 to 109.6) and 104.0 respectively). There was an increase in consultations by telephone initially but not thereafter. Rates of examinations and treatments that attracted specific additional remuneration after the change rose significantly compared with those before (diagnostic services, 138.1 (118.7 to 160.5) and 159.5 (137.8 to 184.7) and curative services 194.6 (152.2 to 248.9) and 194.8(152.3 to 249.2) for second and third data collections respectively) and with the control group (diagnostic services 105.3, 107.6 and curative services 106.0, 115.0) whereas referral rates to secondary care fell (specialist referrals 90.1 (80.7 to 100.6) and 77.0 (68.6 to 86.4) and hospital referrals 87.4 (71.1 to 107.5) and 68.4 (54.7 to 85.4] in doctors in the city. CONCLUSIONS: Introducing a partial fee for service system seemed to stimulate the provision of services by general practitioners, resulting in reduced referral rates. The concept of a "target income" which doctors aim at, rather than maximising their income seemed to play a part in adjustment to changing the system of remuneration.

Capitation Fee↗

PubMed1990

What every doctor should know about economics. Part 2. The benefits of economic appraisal.

In this article we have discussed a number of aspects of economic appraisal. Economic evaluation considers both costs and benefits. Cost-benefit analysis requires the evaluation of health in dollar terms but allows the comparison of health programmes with other programmes or the evaluation of one project alone. Because of the problems that are associated with placing a monetary value on life and health, cost-benefit analysis has not been used in the health field as extensively as has cost-effectiveness analysis. Cost-effectiveness analysis is used to compare alternative programmes with the same health goal. The importance of quality as well as length of life as health outcomes has led to the development of cost-utility analysis. Finally, a good economic evaluation of health care requires the collaboration of clinicians and health economists.

Cost-Benefit Analysis↗

PubMed1990

What every doctor should know about economics. Part 1. The benefits of costing.

Explore the source record for details and available documents.

Australia↗

PubMed1989

[Economics as an attitude--health economics and nursing in Europe].

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Cost Control↗

PubMed1989

[Nurses should be more inquisitive about economics].

Explore the source record for details and available documents.

Cost Control↗

PubMed1989

The demand for effectiveness, efficiency and equity of health care.

Effectiveness, efficiency and equity in health care are discussed in this article against the background of concerns that 'cost containment' may lead to reductions in quality of care. It is suggested that effectiveness is best seen from the patient's point of view and that it relates to more than simply improved health status. Efficiency and equity are better viewed from a societal stance. The paper discusses the role of the medical profession in effectiveness, efficiency and equity and argues that the role of medical doctors needs to be constrained.

Cost Control↗

PubMed1989

QALYs: are they enough? A health economist's perspective.

John Rawles's criticism of QALYs are seen as being both imprecise and largely unhelpful. This paper accepts that there are problems in both QALYs themselves and in the current decision-making processes with which they seek to help. The QALY pliers tend to play down the former and the QALY knockers the latter. It is suggested that theories (regret theory and prospect theory) other than expected utility theory, which is normally seen as the basis for QALYs, may provide better approaches to measuring health service outputs. Thus equity, information and decision-making per se are not handled as well in the expected utility QALYs as they could be. Developing better QALYs, with qualifications, is the goal.

Decision Making↗

PubMed1989