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PubMed1996

Health care utilization and outcomes among persons with rheumatoid arthritis in fee-for-service and prepaid group practice settings.

OBJECTIVE: To compare health care utilization and outcomes over an 11-year period among persons with rheumatoid arthritis (RA) in fee-for-service and prepaid group practice settings. DESIGN: Cohort of persons with RA followed up for as long as 11 years. The principal measures were obtained from an annual structured telephone interview conducted by a trained survey worker. SETTING: Persons with RA presenting to a random sample of community rheumatologists in northern California. PATIENTS: Patients were enrolled in 2 cycles: in 1982 and 1983 and in 1989. Study rheumatologists listed all persons meeting criteria for RA presenting to their offices over a 1-month period. Of the 1062 so listed, we enrolled 1025, or 96.5%. Of the 1025 persons with RA, 227 (22.2%) reported receiving care in prepaid group practice settings. MAIN OUTCOME MEASURES: As of the end of 1994, 5295 person-years of observation were available for the analysis of the annual level of the utilization and outcome measures; 341 persons had been followed up for all 11 years of the study. The main utilization outcomes measured included office visits, outpatient surgeries, hospital admissions, and painful joints. RESULTS: The persons with RA in fee-for-service and prepaid group practice settings did not differ in the quantity of health care used in any 1 year for either RA or non-RA reasons. Among those followed up for all 11 years, the persons in fee-for-service and prepaid group practice settings did not differ in the cumulative quantity of health care used over the entire period of study. The 2 groups did not differ on any outcome measure on either an annual or long-term basis. The results of mortality analyses were inconsistent: using Kaplan-Meier estimates, the persons with RA in prepaid group practice settings survived significantly longer (P<.05 by long-rank test); using Cox proportional hazards methods, the proportion dying each year did not differ signficantly. CONCLUSIONS: We could find no evidence that persons with RA in fee-for-service and prepaid group practice settings received different quantities of health care or experienced different outcomes on either an annual or long-term basis.

Adult↗
PubMed1997

[The impact of postal invitations and user fee on influenza vaccination among the elderly. A randomized controlled trial in general practice].

Influenza epidemics are accompanied by considerable excess morbidity and mortality especially among the elderly and the chronically ill. In the influenza season 1995 a controlled, randomized trial was carried out to examine the impact of postal invitations and user fee on influenza vaccination rates. Five hundred and eighty-five patients aged 65 years or older participated. They were all recognized by their general practitioner (GP) to be in the risk group to whom influenza vaccination is recommended. One third were invited to free influenza vaccination. Another third received postal invitations to influenza vaccination paying the usual fee ($40-$60 US). The last third served as a control group, being vaccinated on their own request and paying the usual fee. In the control group 25% (19-31%, 95% confidence interval) of the patients were vaccinated, compared to 49% (42-56%) in the group which received a postal reminder and paid the usual fee, and 72% (65-78%) in the group invited to be vaccinated free of charge.

Aged↗
PubMed1998

Fee code creep among general practitioners and family physicians in Ontario: why does the ratio of intermediate to minor assessments keep climbing?

BACKGROUND: "Fee code creep" is the increasing tendency of primary care physicians in Ontario to bill for more intermediate than minor assessments over time. The authors examine the extent and nature of fee code creep and describe physician characteristics associated with the changes. METHODS: A cross-sectional and longitudinal analysis of Ontario Health Insurance Plan billing and physician characteristic data was conducted for fee-for-service general practitioners and family physicians (GP/FPs) in Ontario. The ratio of intermediate to minor assessments (I-M ratio) was determined for the period 1978-79 to 1994-95, and the relation of various physician characteristics to high ratios was tested with bivariate and multivariate analysis. RESULTS: The I-M ratio rose 10-fold, from 0.3 in 1978-79 to 2.9 in 1994-95. Although the I-M ratio was higher for older patients and young children, changes in population age profile over time did not account for any of the increase. The median ratio varied widely among groups of physicians: urban physicians had higher ratios than rural ones (3.9 v. 3.0, p < 0.05), and recent graduates had higher ratios than physicians 60 years of age or older (5.1 v. 2.9, p < 0.05). The I-M ratio was inversely related to number of visits; physicians billing for fewer than 5000 visits had a median ratio of 4.2, whereas those billing for 20,000 visits or more had a median ratio of 1.6. INTERPRETATION: Fee code creep has contributed to expenditure growth in Ontario. This phenomenon was related to both an increase in I-M ratio over time among physicians practising throughout the study period and an influx of new physicians billing at a higher ratio. Creep was not the result of aging of the population.

Adult↗
PubMed1998

Longterm health outcomes of patients with rheumatoid arthritis treated in managed care and fee-for-service practice settings.

OBJECTIVE: To compare health care utilization and longterm health outcomes among patients with rheumatoid arthritis (RA) treated in managed care and fee-for-service practice settings. METHODS: We compared levels of health care utilization, treatments, and health outcomes between 57 patients with RA treated predominantly in managed care settings and 125 patients with RA treated predominantly in fee-for-service practice settings. These patients were participants in a community based cohort study of health outcomes in RA, and had been followed prospectively for up to 13 years (mean followup 10.3 yrs). Information on physician visits, hospitalizations, diagnostic testing, treatments, and 3 measures of health status (global arthritis status, pain, functional disability measures of the Health Assessment Questionnaire) was collected using biannual mailed questionnaires. RESULTS: All measures of health care utilization were similar between the managed care and fee-for-service groups, as was the use of the major types of arthritis treatments. Average global arthritis status scores, pain scores, and functional disability scores were closely comparable in the 2 groups. Over time, global arthritis status scores and disability scores worsened in both groups, but the rates of worsening did not differ between groups. CONCLUSION: In this cohort, longterm health outcomes, as well as treatments and health care utilization, were similar among persons with RA who were treated in managed care and fee-for-service practice settings.

Adult↗
PubMedDate not supplied

Effects of different remuneration methods on general medical practice: a comparison of capitation and fee-for-service payment.

There are severe methodological problems to be overcome in comparing the effects of different payment methods on general medical practice, not least because there are many factors which affect the pattern of service delivery. Also, the reliability and comparability of data may be poor. This article emphasises that the effects of capitation and fee-for-service payment methods on general medical practice should be carefully compared with factual information, especially numerical data. In so doing, it is shown that there are supporting data for the contention that a fee-for-service system encourages more consultations, more diagnostic tests, higher drug use, higher surgical rates and higher costs than a capitation system. On the other hand, a capitation system may lead doctors to hastier and less courteous care than a fee-for-service system. The geographical distribution of general practitioners (GPs) may be more even, and continuity of care may be better maintained, under a capitation system; but there may be excessive referrals from GPs to specialists under this system of payment. There is no evidence for the contention that a capitation system encourages preventive medicine, but the financial coverage for preventive procedures does encourage such procedures.

Capitation Fee↗
PubMed2002

Interjudge and intrajudge reliabilities in fiberoptic endoscopic evaluation of swallowing (fees) using the penetration-aspiration scale: a replication study.

This study used Fiberoptic Endoscopic Evaluation of Swallowing (FEES(R)) to assess the reliability of the Penetration-Aspiration Scale (PAS) using 79 swallows and four judges in a replication of a study using videofluoroscopy (VFSS). The swallows were diagnosed using FEES, which allowed for comparison between the two techniques. The findings indicated that all categories of the PAS achieved adequate reliability, both on intrajudge and interjudge assessments. Reliabilities, with the exception of Scale Score 7, were higher in this study than in the original study by Rosenbek and associates. Data analysis indicated that judges were more highly consistent on second ratings compared with their original ratings, indicating a learning curve on the PAS. In addition, findings suggested that the FEES was more reliable on assessing penetration than VFSS, but that VFSS was more reliable on the assessment of the various severities of aspiration. The two techniques were equally effective in discriminating between penetration and aspiration. This study found that FEES was just as reliable as VFSS when using the PAS.

Deglutition Disorders↗
PubMed2005

Fiberoptic endoscopic evaluation of swallowing (FEES) with and without blue-dyed food.

The purpose of this prospective study was to determine if fiberoptic endoscopic evaluation of swallowing (FEES) maintains high intra- and interrater reliability in detecting pharyngeal dysphagia and aspiration without the addition of FD&C Blue No. 1 to food. Twenty consecutive adults referred for a swallow evaluation participated. Nine subjects received blue-dyed food and 11 subjects received regular nondyed food, i.e., yellow pudding and white skim milk. Four variables were rated: (1) the stage transition characterized by depth of bolus flow to at least the vallecula prior to the pharyngeal swallow; (2) evidence of bolus retention in the vallecula or pyriform sinuses after the pharyngeal swallow; (3) laryngeal penetration defined as material in the laryngeal vestibule but not passing below the level of the true vocal folds either before or after the pharyngeal swallow; and (4) tracheal aspiration defined as material below the level of the true vocal folds either before or after the pharyngeal swallow. Three speech-language pathologists experienced in interpreting FEES results independently and blindly reviewed the digitized videotape three times. Intrarater agreements for the four variables with blue-dyed and non-blue-dyed food trials were 100% and monochrome trials ranged from 95% to 100%. Average kappa values for interrater reliability ranged from moderate to excellent agreement (0.61-1.00) for all viewing conditions. Kappa values for blue-dyed trials versus monochrome trials were 0.83 and for non-blue-dyed trials versus monochrome trials were 0.88, indicative of excellent reliability under both viewing conditions. FEES maintains both high intra- and interrater reliability in detecting the critical features of pharyngeal dysphagia and aspiration using either blue-dyed or non-blue-dyed foods. The endoscopist, therefore, can be assured of reliable FEES results using regular, non-dyed food trials.

Adult↗
PubMed2000

Impact of implementation of an embryo storage fee on embryo disposal activity.

OBJECTIVE: To examine the impact of implementation of a new fee for continued storage of cryopreserved embryos on the rate of requests for disposal of embryos. DESIGN: Retrospective cohort study. SETTING: A university-based assisted reproduction program. PATIENT(S): All patients with cryopreserved embryos. INTERVENTION(S): Implementation of a semiannual embryo storage fee of $100 to cover administrative and laboratory costs. MAIN OUTCOME MEASURE(S): The number of embryo disposal requests before and after implementation of the embryo storage fee was compared in relation to the activity of the cryopreserved embryo program as measured by number of frozen embryo transfers. RESULT(S): Annual requests for embryo disposal from 1992 through 1997 ranged from zero to three, which represented 0-5% of the annual frozen embryo program activity. In contrast, a significantly higher number of disposal requests (10, representing 18% of program activity) were received in 1998. CONCLUSION(S): Fees for storage of cryopreserved embryos seem to influence patients' decisions about disposal of cryopreserved embryos.

Choice Behavior↗
PubMed1999

Physician response to a change in Medicaid fees.

This study examines the effects of a change in Medicaid fees on the volume of physician services provided to beneficiaries. The data set includes price and volume at the procedure-level for Medicaid physician services in Texas in 1991, 1993, and 1995. The empirical analysis compares the volume of services provided to Medicaid participants before and after a 1992 change in reimbursement method. The results indicate that, over the period 1991 to 1993, the change in Texas Medicaid physician fees did not have a statistically significant effect on the volume of services provided. When measured over a longer period of time (1991-1995), however, volume increased significantly when price decreased, but, when price increased, there was no significant effect on volume. The results thus provide empirical support for the behavioural offset assumption underlying the switch to Medicare's Resource-Based Relative Value Scale (RBRVS) method of physician payment. A key policy implication is that reduced fees did not lead to a lower volume of physician services provided to Medicaid patients at least over the period of analysis. However, the new Medicaid fee schedule did not have the desired effect of controlling Medicaid expenditures on physician services.

Attitude of Health Personnel↗
PubMed2001

Medicare fees and small area variations in breast-conserving surgery among elderly women.

This study used data from Medicare files, the American Hospital Association's Annual Survey of Hospitals, and the 1990 census to investigate whether Medicare fees for breast-conserving surgery (BCS) and mastectomy (MST) affected the rate of BCS across 799 3-digit ZIP code areas in 1994. The full model, which was based on the conceptual framework of the supply of and demand for different treatments, explained 51 percent of the variation in BCS rates. Medicare fees were statistically significant and had the hypothesized effects: a 10 percent higher BCS fee was associated with a 7 to 10 percent higher BCS rate, while a 10 percent higher MST fee was associated with a 2 to 3 percent lower proportion receiving BCS. Other significant economic variables were proximity to a radiation therapy hospital, a teaching hospital or a cancer center, and the percentage of elderly women with incomes below the poverty rate, which were negatively related to the BCS rate. Variations in age, race, and metropolitan populations had small or insignificant effects. The single most important was the percentage of cases with one or more comorbidities.

Aged↗
PubMedDate not supplied

A proposal for financing postmarketing drug safety studies by augmenting FDA user fees.

I propose to raise funds for postapproval studies of long-term drug safety by augmenting the existing "user-fee" system. Fees would be raised by an amount deemed optimal for revenue collection, and the U.S. Food and Drug Administration (FDA) would direct the incremental funds to a combination of randomized controlled trials, epidemiological studies, and postmarketing surveillance. User-fee augmentation is an achievable, incremental reform that would subsidize information that is now undersupplied in the U.S. health care system; spread the burden of funding postmarketing safety studies among pharmaceutical sponsors; and help restore public, scientific, and professional confidence in the FDA and its user-fee system.

Drug Industry↗
PubMed1999

Effects of changing Medicaid fees on physician participation and enrollee access.

This paper assesses the effects of Medicaid fee changes on physician participation, enrollee access, and shifts in the site of ambulatory care using several natural experiments in Maine and Michigan. We use Medicaid claims and enrollment data to measure these outcomes. The reimbursement changes included substantial percentage changes in fees, however the value of the Medicaid fee improvements relative to the private market eroded very rapidly in the months following the interventions. Although the fee increases did not improve the outcome measures, they might have prevented conditions from worsening.

Health Care Costs↗
PubMed2001

[Cost analysis of procedural fee for percutaneous transluminal coronary angioplasty at six Japanese hospitals].

BACKGROUND: Disease-specific cost analysis is rarely performed in Japan, but is essential for reform of the healthcare reimbursement system and assessment of procedural fees. METHODS: The actual cost associated with the procedural fee of the percutaneous transluminal coronary angioplasty (PTCA) procedure was estimated by dividing into four categories: labor, disposable materials, expenses, and equipment costs. The special cost associated with PTCA devices such as angioplasty balloon and stent was responsible for the majority of PTCA-related hospitalization costs, but was not included in our survey. The six institutions that participated in the survey belong to the national, Red Cross, and Saiseikai organizations. Time study for labor was omitted, and procedural time was predetermined at 3 hours. RESULTS: The labor cost amounted to yen 65,000 to yen 98,000/procedure. To calculate the cost of disposable materials across all six hospitals, a universal amount of yen 60,000 from a model hospital was used. The expenses ranged from yen 1,000 to yen 39,000, and the expenditure plus capital cost from yen 95,000 to yen 224,000, showing significant differences between the hospitals. The total mean cost was yen 294,000 +/- 55,000, which indicated that every hospital was in deficit. CONCLUSIONS: Compared to Medicare in the United States of America, the procedural fee for Japanese physicians is extremely low, in contrast to the bloated special cost for devices, which causes significant pricing gaps between Japan and USA. The differences in total cost among the hospitals were mainly derived from the cost for angiographic equipment. Our survey did not include any private hospitals, but the PTCA-related procedural fee is less than the actual cost under the current health insurance reimbursement scheme at all hospitals.

Angioplasty, Balloon, Coronary↗
PubMed2001

Rehabilitation fees, length of stay and efficiency for hospitalized stroke patients: a preliminary study based on function-related groups.

The purpose of this study was to examine the relationships between severity of disability and factors such as rehabilitation fees, length of stay and efficiency for hospitalized stroke patients. One hundred and seven first-time stroke patients were studied consecutively for this study. They were recruited from a rehabilitation ward in a university medical center during 1997. Functional ability was evaluated using the Functional Independence Measure (FIM) instrument on admission and discharge. Stroke patients who presented with similar degrees of disability were put together using the admission FIM score (FIM Function-Related Groups, FIM-FRGs) for further analysis. Twenty-eight (26.2%) patients examined were categorized as severely disabled (scored 18-36), 48 (44.8%) moderately disabled (scored 37-72) and 31 (29.0%) mildly disabled (scored 73-126). The average expense on rehabilitation fees, for the average rehabilitation length of stay (LOSR) of 34.7 +/- 16.7 days, was NT$ 27,645 +/- 13,812. The FIM score improved from 56.8 +/- 24.2 on admission to 76.6 +/- 26.2 at discharge, with a rehabilitation efficiency index (EIR) of 0.7 +/- 0.7. Further analysis indicated that there were significant differences among the three disability groups on rehabilitation fees and LOSR while EIR was unaffected. The findings of this study suggest that FIM-FRGs can differentiate different rehabilitation needs in terms of rehabilitation fees and LOSR; therefore, a prospective case payment system based on FIM-FRGs is suggested for stroke rehabilitation reimbursement scheme in the future.

Adult↗
PubMed1989

A comparison of length of stay and costs for health maintenance organization and fee-for-service patients.

Enrollees of health maintenance organizations (HMOs) are less frequently hospitalized than are patients cared for by fee-for-service physicians. To determine if care provided to HMO and fee-for-service patient is different once they are hospitalized, we compared length of stay, total costs, and severity of illness for 617 HMO and fee-for-service patients hospitalized during the period 1983 through 1985 at a major teaching hospital. Severity was gauged in the following two ways: the Severity of Illness Index developed by Horn, and ratings by two physicians who were given all records from the first day of each patient's hospitalization. Length of stay was shorter and total costs were less for HMO patients in 7 of 11 diagnosis related groups. Using regression analysis to adjust for age, sex, emergency ward admission, diagnosis related group, and severity, we found that overall length of stay was 14% shorter for HMO patients than for fee-for-service patients (6.2 vs 5.3 days, P less than .01), whereas total costs were only 4% less ($4251 vs $4090, P greater than .2). These findings indicate that while patterns of utilization may vary by diagnosis related groups, HMO patients had shorter lengths of stay but comparable overall costs. Whether shorter lengths of stay represent greater efficiency, substitution of outpatient for inpatient care, or diminution in the quality of care is not clear.

Boston↗
PubMed1999

Competition and supplier-induced demand in a health care system with fixed fees.

The present paper examines whether supplier-induced demand exists for primary physician services in Norway. The research design is adapted to the institutional setting of Norwegian primary physician services, where there is a fixed fee schedule. More than 50% of primary care physicians receive a payment for treatment from the National Insurance Administration on a fee-for-item basis. The results showed that increased competition, measured as a high physician:population ratio, led to a decline in the number of consultations per contract physician. However, the contract physicians in high physician density areas did not compensate for the lack of patients by providing more items of treatment in order to maintain their income. Contract physicians' revenue from items of treatment per consultation were unaffected both by physician density and by the number of consultations per contract physician. These results are further corroborated by data that showed that contract physicians' gross revenue and profits were declining functions of physician density. This paper argues that, from an efficiency point of view, a deregulated health care market with fixed fees may operate well.

Economic Competition↗
PubMed1984

The cost of health care and health insurance in Australia: some problems associated with the fee-for-service system.

This paper reviews the health care system and the supporting health insurance framework in Australia. The importance of the health insurance mechanism is stressed in relation to the maintenance and growth of private fee-for-service medicine. The Medical Benefits Schedule, which is the negotiated basis for medical fees under insurance, is examined for the logic implicit in the fee structure. The high rewards for procedural medicine relative to consulting are suggested as part of the basis of the rapid growth in hospital admissions. It is also argued that the refund schedule has helped to determine the nature of the medical specialist manpower pool. Other problems associated with the complex nature of the refund schedule, such as fraud and wasteful over-servicing, are identified and discussed. It is asserted that the health insurance system and refund schedule are partly determining the nature of medical service provision and inducing inequities in the financing and delivery of medical care in Australia.

Australia↗
PubMed1995

Global fees for managed care in ambulatory surgery.

Managed care, especially health maintenance organizations (HMOs), has expanded rapidly in the United States, with nearly 52,300,000 enrollees. HMOs seek to provide health services in an efficient setting at the most reasonable price. To facilitate this objective, HMOs are shifting the financial risk from payors to the providers. Historically, ambulatory surgery was viewed as a significant cost savings compared with inpatient surgery, eliminating or reducing costly nursing care, boarding charges, medications, and therapies. As the incidence of ambulatory surgery utilization increased from approximately 20% of all surgery performed in the United States in 1982, to nearly 60% in 1993, consuming larger quantities of scarce health dollars, the emphasis shifted to reducing the charges for ambulatory surgery. Initial efforts to contain costs involved utilization management and discounted fee-for-service reimbursement methodologies. When this proved ineffective, a fixed fee per procedure was employed. Recently, full-risk capitation reimbursement has been applied to transfer financial risk and incentive to the provider to mitigate increasing health care costs. Surplus capacity and the consolidation of many covered lives or enrollees with fewer institutional payors (e.g., Blue Cross Blue Shield or Prudential) has made this transformation possible. The combination of these events has provided the HMOs with great leverage. The payors have more choices of providers than ever before, and they seek a safe ambulatory surgery environment at a low charge. In some areas of the country, facility and professional fees are being bundled to differentiate their product and attract more volume. Subcapitation of anesthesia services is being implemented or discussed in regions with very high HMO market penetration. This paper reviews the concept of bundling of services involving anesthesia in ambulatory surgery. It also seeks to provide a process that will assist anesthesiologists to achieve appropriate capitation reimbursement rates from HMOs.

Ambulatory Surgical Procedures↗