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PubMed1999

The effects of fee bundling on dental utilization.

OBJECTIVE: To examine dental utilization following an adjustment to the provincial fee schedule in which preventive maintenance (recall) services were bundled at lower fees. DATA SOURCES/STUDY SETTING: Blue Cross dental insurance claims for claimants associated with four major Ontario employers using a common insurance plan over the period 1987-1990. STUDY DESIGN: This before-and-after design analyzes the dental claims experience over a four-year period for 4,455 individuals 18 years of age and older one year prior to the bundling of services, one year concurrent with the change, and two years after the introduction of bundling. The dependent variable is the annual adjusted payment per user. DATA COLLECTION/EXTRACTION METHODS: The analysis was based on all claims submitted by adult users for services received at recall visits and who reported at least one visit of this type between 1987 and 1990. In these data, 26,177 services were provided by 1,214 dentists and represent 41 percent of all adult service claims submitted over the four years of observation. PRINCIPAL FINDINGS: Real per capita payment for adult recall services decreased by 0.3 percent in the year bundling was implemented (1988), but by the end of the study period such payments had increased 4.8 percent relative to pre-bundling levels. Multiple regression analysis assessed the role of patient and provider variables in the upward trend of per capita payments. The following variables were significant in explaining 37 percent of the variation in utilization over the period of observation: subscriber employment location; ever having received periodontal scaling or ever having received restorative services; regular user; dentist's school of graduation; and interactions involving year, service type, and regular user status. CONCLUSIONS: The volume and intensity of services received by adult patients increased when fee constraints were imposed on dentists. Future efforts to contain dental expenditures through fee schedule design will need to take this into consideration. Issues for future dental services research include provider billing practices, utilization among frequent attenders, and outcomes evaluation particularly with regard to periodontal care and replacement of restorations.

Adolescent↗
PubMed1976

Dentists' fees and inflation. Joint report of the Bureau of Economic Research and Statistics and the Bureau of Public Information.

Dentists' fees, as measured by the Consumer Price Index, increased at about the same rate in the past eight years as average prices in the economy. Between 1967 and 1975, dentists' fees increased 61.9% compared with a 61.2% increase in average prices of all goods and services measured in the index. In the years since 1967, the cost of conducting a dental practice has steadily increased. Dentists' expenses for materials and services increased approximately twice as fast as the increase in dental fees. On the basis of ADA survey data, 1-3 dentists' professional expenses increased 133% and dentists' salary expenses for auxiliaries increased 148% between 1967 and 1975, whereas dentists' fees increased only 62%.

American Dental Association↗
PubMed2001

Effect of removing user fees on attendance for curative and preventive primary health care services in rural South Africa.

User fees are used to recover costs and discourage unnecessary attendance at primary care clinics in many developing countries. In South Africa, user fees for children aged under 6 years and pregnant women were removed in 1994, and in 1997 all user fees at all primary health care clinics were abolished. The intention of these policy changes was to improve access to health services for previously disadvantaged communities. We investigated the impact of these changes on clinic attendance patterns in Hlabisa health district. Average quarterly new registrations and total attendances for preventive services (antenatal care, immunization, growth monitoring) and curative services (treatment of ailments) at a mobile primary health care unit were studied from 1992 to 1998. Regression analysis was undertaken to assess whether trends were statistically significant. There was a sustained increase in new registrations (P = 0.0001) and total attendances (P = 0.0001) for curative services, and a fall in new registrations (P = 0.01) and total attendances for immunization and growth monitoring (P = 0.0002) over the study period. The upturn in demand for curative services started at the time of the first policy change. The decreases in antenatal registrations (P = 0.07) and attendances (P = 0.09) were not statistically significant. The number of new registrations for immunization and growth monitoring increased following the first policy change but declined thereafter. We found no evidence that the second policy change influenced underlying trends. The removal of user fees improved access to curative services but this may have happened at the expense of some preventive services. Governments should remain vigilant about the effects of new health policies in order to ensure that objectives are being met.

Ambulatory Care Facilities↗
PubMed2001

Differences in the structure of CAHPS measures among the medicare fee-for-service, medicare managed care, and privately insured populations.

OBJECTIVE: To confirm in a new population, the Medicare fee-for-service population, the factor structure previously found in two Consumer Assessment of Health Plans Study (CAHPS) field-test surveys with Medicare HMO and adult privately insured populations. DATA SOURCES: Primary data were collected in the fall of 1998. Survey responses from the Medicare Fee-for-Service CAHPS survey field test were compared to results from the Medicare HMO and adult privately insured field-test studies conducted in the fall of 1996. STUDY DESIGN: Respondents for the field-test survey were a random sample of Medicare beneficiaries in five states who had opted for the original Medicare plan (fee-for-service). DATA COLLECTION: Data were collected by a mailed survey with a telephone follow-up survey to those who did not return the mailed survey. PRINCIPAL FINDINGS: A confirmatory factor analysis in two different samples of Medicare fee-for-service beneficiaries provided basic support for a previously reported three-factor structure underlying the CAHPS reports and rating items: (1) quality of provider or staff communications; (2) timely access to quality health care; and (3) quality of plan administration. An exploratory factor analysis revealed a variant three-factor structure. CONCLUSION: Because of differences in the factor structures among the different populations discussed, caution needs to be exercised in any composite development, based on factor analysis or any other basis, by which cross-population comparisons will be made. Comparisons should only be made on composites representing stable structure across all populations concerned.

Consumer Behavior↗
PubMed2001

ADEA annual survey of clinic fees and revenue: 1998-1999 academic year.

The American Dental Education Association's 1998-1999 Survey of Clinic Fees and Revenue obtained data by which to report, by school, clinic revenue information per undergraduate student. Fifty of the fifty-five U.S. dental schools responded to the survey. The median revenue per third-year student was $6,313. It was $11,680 for fourth-year students. Clinic revenue data was also obtained by type of postdoctoral program. The postdoctoral general dentistry programs had the highest per student clinic revenues, at over $59,000 per AEGD student and almost $35,000 per student of GPR programs. Other areas of the survey provided information regarding clinic fees by type of program, levels of uncompensated care by type of program, clinic revenue by source of payment, and dental school fees as a percent of usual and customary private practice fees.

Dental Clinics↗
PubMed2000

Comparison of appendectomy medical expense and clinical outcome between fee for service and prospective payment system.

Since the introduction of national health insurance on March 1st 1995 in Taiwan, another 9 items (including appendectomy) were introduced into the Taiwan/prospective payment system (T/PPS). The modified T/PPS was based on those complicated appendectomy cases with secondary diagnosis or second operation where a total fee over 37,500 New Taiwan (NT) dollars was paid by National Health Insurance Bureau (NHIB) according to the real cost. The T/PPS was implemented in October 1997 due to the continuously increasing financial burden of medical expenses on the NHIB. The purpose of this study is (1) to compare the length of stay (LOS) and total medical expense of appendectomy of fee for service (FFS) and T/PPS and (2) to compare the clinical outcome of wound healing after discharge of the two systems by telephone interview. Our study investigated 100 consecutive appendectomy cases under FFS payment system and 99 consecutive appendectomy cases under T/PPS. We retrospectively analyzed LOS, operation time, and hospital cost of different items through chart review and computer data. Our results revealed that the LOS and operation time of T/PPS were significantly shorter than those of FFS (both p < 0.01). The total hospital cost, fee for room service, treatment, pharmacy, examination and anesthesia in T/PPS were also significantly less than those in FFS (all p < 0.01, except for anesthesia p < 0.05). There existed positive correlation between total hospital cost and LOS, operation time, fee for room service, treatment, pharmacy, examination and anesthesia both for T/PPS and FFS. To evaluate the clinical outcome of appendectomy between T/PPS and FFS, we interviewed 73 T/PPS cases and 73 FFS cases by telephone and chart review. Our results revealed that there were no significant differences in frequencies of having painful incision, clear incision wound on the day of discharge, and removal of stitches at hospital (p all > 0.05). We concluded that compared to FFS, T/PPS can decrease LOS and total hospital cost of appendectomy, and T/PPS's clinical outcome of appendectomy in T/PPS showed no significant difference from that in FFS.

Adult↗
PubMed2002

Medicare program; fee schedule for payment of ambulance services and revisions to the physician certification requirements for coverage of nonemergency ambulance services. Final rule with comment period.

This final rule establishes a fee schedule for the payment of ambulance services under the Medicare program, implementing section 1834(l) of the Social Security Act. As required by that section, the proposed rule on which this final fee schedule for ambulance services is based was the product of a negotiated rulemaking process that was carried out consistent with the Federal Advisory Committee Act and the Negotiated Rulemaking Act of 1990. The fee schedule described in this final rule will replace the current retrospective reasonable cost payment system for providers and the reasonable charge system for suppliers of ambulance services. In addition, this final rule requires that ambulance suppliers accept Medicare assignment; codifies the establishment of new Health Care Common Procedure Coding System (HCPCS) codes to be reported on claims for ambulance services; establishes increased payment under the fee schedule for ambulance services furnished in rural areas based on the location of the beneficiary at the time the beneficiary is placed on board the ambulance; and revises the certification requirements for coverage of nonemergency ambulance services.

Ambulances↗
PubMed2002

Medicare fees for physician services are resource-based.

Beginning January 1, 1992, Medicare has relied on a resource-based relative value scale (RBRVS) to establish physician fees. Medicare pays 80 percent of the lower of the amount a physician bills for the service or the fee schedule amount. The patient is responsible for the remaining 20 percent, as well as the annual Part B deductible of $100, plus any additional amount the physician may be allowed to bill. Rarely is the billed amount below Medicare's fee schedule amount. Adoption of the RBRVS fee schedule severed the link between the amount a physician charged for a service and the amount Medicare paid for it. RBRVS implementation required significant changes in the coding system used to document and bill physician services, particularly medical visits and consultations.

Accounting↗
PubMed1996

Registration and reregistration application fees. Final rule; remanded for further notice and comment.

On October 6, 1992, Congress passed the Departments of Commerce, Justice, and State, the Judiciary, and Related Agencies Appropriations Act of 1993, Pub. L. No. 102-395, 106 Stat. 1828 (1992) (codified at 21 U.S.C. 886a) (Act). In section 886a(3) of this Act, Congress directed that "fees charged by the DEA under its Diversion Control Program (DCP) shall be set at a level that ensures the recovery of the full costs of operating the various aspects of the (diversion control) program." On December 18, 1992, DEA published its proposal to adjust the existing registration fee schedule. 57 FR 60,148. After notice and comment, DEA published a Final Rule on March 22, 1993, setting the new registration fees. 58 FR 15,272. Following publication of the final rule, a complaint was filed by the American Medical Association (AMA) and others in the United States District Court for the District of Columbia. On July 5, 1994, the district court issued its final order granting the government's motion for summary judgment, and thus disposed of all claims with respect to all parties. American Medical Association v. Reno, 857 F. Supp. 80 (D.D.C. 1994). The AMA appealed. On June 27, 1995, the United States Court of Appeals for the District of Columbia Circuit issued its decision holding that DEA's rulemaking was inadequate and that the rule must be remanded, without being vacated, to the DEA for further proceedings in which DEA provides both an opportunity for meaningful notice and comment on, and an explanation of, the components of the diversion control program. 57 F.3d 1129 (D.C. Cir. 1995) On August 29, 1995, the United States Court of Appeals for the District of Columbia Circuit remanded this action to the district court with instructions. On November 22, 1995, the District Court remanded the matter to DEA for proceedings consistent with the opinion of the United States Court of Appeals for the District of Columbia Circuit. This document responds to that requirement and provides a description of the components of the fee-funded diversion control program.

Drug and Narcotic Control↗
PubMed2002

Medicare's ambulance fee schedule dispatched.

Ambulance fees vary with the level of service and length of the beneficiary's trip. New fee schedule is expected to trim Medicare spending. Higher fees have been implemented for rural transports and air ambulance services. Lower fees have been implemented for urban transports. Providers and suppliers must revise chargemasters, policies, and procedures.

Aged↗
PubMed2004

Medicare program; changes to Medicare payment for drugs and physician fee schedule payments for calendar year 2004. Interim final rule with comment period.

This interim final rule implements the provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MPDIMA) of 2003, Pub. L. 108-173, which are applicable in 2004 to Medicare payment for covered drugs and physician fee schedule services. These provisions revise the current payment methodology for Part B covered drugs and biologicals that are not paid on a cost or prospective payment basis; make changes to Medicare payment for furnishing or administering drugs and biologicals; revise the geographic practice cost indices and change the physician fee schedule conversion factor. The 2004 physician fee schedule conversion factor will be $37.3374. The 2004 national anesthesia conversion factor (prior to making adjustment for the geographic practice cost indices) will be $17.4969. The information contained in this final rule related to payment under the physician fee schedule supercedes the information contained in the November 7, 2003, final rule to the extent that the two are inconsistent. All other provisions of the November 7, 2003, final rule are unchanged unless otherwise noted. This rule also extends the "opt-out" provisions of 1802(b)(5)(3) of the Social Security Act to dentists, podiatrists, and optometrists.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2000

Two-year changes in health and functional status among elderly Medicare beneficiaries in HMOs and fee-for-service.

OBJECTIVE: To compare two-year changes in health and functional status among a national sample of elderly Medicare beneficiaries in risk-based HMOs and in fee-for-service. DATA SOURCE: Medicare Current Beneficiary Survey (MCBS) for 1995 to 1998. MCBS is a longitudinal, in-person survey of a nation ally representative sample of the Medicare population. Respondents are asked once a year about health and functional status. STUDY DESIGN: Noninstitutionalized respondents in the fall 1995 and fall 1996 rounds of MCBS for whom follow-up data were available two years later were included. Of the sample, 1,126 members were in HMOs and 3,449 were in fee-for-service at baseline. Ordered logistic regression and binary logistic regression were used to examine the association of HMO membership at baseline with each measure of health or functional status at follow-up, controlling for baseline health and functioning and other variables. PRINCIPAL FINDINGS: No significant differences were found between HMO and fee-for-service respondents with respect to two-year changes in health and functional status, either for the full sample or for subsets of chronically ill respondents. there was little ef f ct on the findings when the analysis was restricted to persons who remained in the same care system (HMO or fee-for-service) between baseline and follow-up. Separate analyses of the 1995-97 and 1996-98 cohorts revealed some in consistencies between the cohorts with respect to patterns of change in health and functioning. CONCLUSION: There was no consistent evidence of an "HMO effect " on the health and functioning of enrollees over a two-year period.

Activities of Daily Living↗
PubMed2006

ADEA survey of clinic fees and revenue: 2003-04 academic year.

The American Dental Education Association's 2003-04 Survey of Clinic Fees and Revenue obtained data by which to report, by school, clinic revenue information per student. Fifty-one of the fifty-four dental schools that had third- and fourth-year students responded to the survey. The median revenue per third-year student was dollar 9,937. It was dollar 13,602 for fourth-year students. Clinic revenue was also obtained for programs of advanced dental education. General Practice Residency programs generated the highest revenue per student at dollar 66,474, followed by programs of Advanced Education in General Dentistry at dollar 63,860. Other areas of the survey provided information regarding clinic fees by type of program, levels of uncompensated care by type of program, clinic revenue by source of payment, and dental school fees as a percent of usual and customary private practice fees.

Data Collection↗
PubMed1990

How the physician fee schedule affects Medicare patients' out-of-pocket spending.

Simulations of the redistributive effects of the new Medicare fee schedule have focused primarily on physicians, but patients may also be affected. Using a national sample of Medicare patients, we studied the fee schedule's potential impact on both components of out-of-pocket spending: copayments and balance bill amounts. While the fee schedule would raise copayments for the average patient, this effect would be more than offset by the balance billing limits (also imposed by Congress). Nevertheless, almost 10% of patients, particularly those who are black or living in rural areas, would experience large increases in their liability. Finally, the fee schedule with balance billing limits also serves as a "catastrophic coverage" program; patients with extraordinarily high medical expenses would enjoy substantial reductions in their out-of-pocket payments.

Aged↗
PubMed1990

The consequences of offering fee-based services in a medical library.

Fee-based services may influence, both subtly and dramatically, the operation of a medical library. Fears that have been raised about the consequences of fee-based services are recalled and applied to the context of medical librarianship. Specifically covered are the effects of fee-based services on service to traditional user groups, collection development, interlibrary cooperation, and management style. The discussion includes references to the program of fee-based services offered by the New York Academy of Medicine Library.

Fees and Charges↗
PubMed1987

A comparison of patient satisfaction among prepaid and fee-for-service patients.

This study compares levels of patient satisfaction (a valid, indirect measurement of quality of care) between prepaid and fee-for-service patients. A chart audit approach was used to determine whether prepaid and fee-for-service patients seen in an academic family health center at the end of the first six months of a new cost-containment program were comparable in terms of demographic characteristics and indirect measures of health and health behavior. Next, using a 26-item patient satisfaction questionnaire, 436 patients from a single group of providers in the same family health center seen six months after the programs began were randomly surveyed. Sociodemographic and health-related characteristics of prepaid and fee-for-service patients were similar for both groups in the chart audit. There was no statistically significant difference between the overall satisfaction levels of prepaid and fee-for-service patients. Individual constructs that comprise general satisfaction were also statistically similar except for an unexpected finding of dissimilar levels of satisfaction with "physician conduct/humaneness" (P less than .05). Assessed from at least one standpoint, cost containment does not seem to affect overall quality of care, but further investigation is needed, especially in the realm of "physician conduct/humaneness."

Adult↗
PubMed1979

Dentists' incomes, fees, practice costs, and the Economic Stabilization Act: 1952 to 1976. Bureau of Economic and Behavioral Research.

Throughout the 20-year period from 1952 to 1972, dentists' net incomes, adjusted for inflation, increased and provided greater monetary rewards to the practice of dentistry. Evidence discloses a close association between the purchasing power of dentists' net incomes and the general level of economic activity (measured by the GNP inconstant dollars). Dentists are not immune to temporary recessions. The period from 1972 to 1974, with the imposed fee guidelines of Nixon's Economic Stabilization Act, was unusual. With effective fee guidelines during the latter two phases coupled with freely fluctuating input prices, dentists were caught in an income squeeze. During 1972 to 1974, the purchasing power of dentists' net incomes fell at a rate of 10.1% per year as the price index of practice costs outpaced dentists' fees. After the Economic Stabilization Act expired in 1974, trends returned to normal. Dentists' net incomes increased at rates consistent with changes in the GNP and dentists' fees increased slightly faster than the "Price Index of Cost of Conducting a Dental Practice."

Costs and Cost Analysis↗
PubMed1993

Effects of the relative fee structure on the use of surgical operations.

OBJECTIVE: The goal is to develop a theoretical and empirical framework for investigating how the demand for an operation may be affected by the fee for the operation (the own-price) and by fees for other services provided by surgeons in the same specialty (the cross-price). The theory suggests an empirical test of whether surgeons create demand for surgery. DATA SOURCES AND STUDY SETTING: The study examines the use of 11 frequently performed surgical operations by elderly Medicare enrollees in a cross-section of 316 U.S. metropolitan areas. Medicare physician claims and enrollment files for 1986 are the principal sources of data. STUDY DESIGN: Using econometric methods, a structural demand equation modified to include the own-price and the cross-price is estimated for each study operation. PRINCIPAL FINDINGS: The theory suggests that the utilization response to changes in fees may differ among operations depending on whether demand creation occurs and on the interplay of distinct own-price and cross-price effects. However, the results of the empirical analyses are inconclusive regarding the most appropriate economic model of surgical utilization. Both neoclassical behavior and demand creation are observed, but technical limitations of the analyses, including the cross-sectional design of the study, preclude definitive inferences. CONCLUSIONS: Despite the lack of definitive empirical results, the study has several implications for future research regarding the effect of changes in fees on surgical utilization. In particular, future studies should consider the roles of distinct own-price and cross-price effects, examine the importance of the supply-demand balance in physician services markets, and assess whether typologies of operations that are based on the strictness of their clinical indications predict the appropriate economic model of utilization.

Aged↗