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PubMed2000

Economic impact of increased clinical intervention rates in community pharmacy. A randomised trial of the effect of education and a professional allowance.

OBJECTIVE: To determine the economic impact of an interventional programme aimed to increase the rate of clinical interventions undertaken in community pharmacy. STUDY DESIGN AND PERSPECTIVE: A randomised controlled trial of 4 parallel groups of pharmacies, conducted from a government perspective. Economic evaluations were based on savings/costs attributable to healthcare costs avoided, healthcare costs incurred by the pharmacists' actions, change in medication costs, pharmacy time and telephone calls made by the pharmacist. The study was conducted during November and December 1996 and costings were based on 1997 figures. INTERVENTIONS: A professional fee-for-service [10 Australian dollars ($A; $A1 = 6.50 US dollars) per intervention] and education (an intensive 1-week course or advanced education) were implemented in an attempt to increase clinical interventions by the pharmacists. Group A pharmacies (n = 10) served as a control group and received neither education nor remuneration; group B received education and professional remuneration (n = 9); group C had received prior continued education and now received advanced education and professional remuneration (n = 11); and group D received professional remuneration with no education. MAIN OUTCOME MEASURES AND RESULTS: The proactive clinical interventions in group C saved a mean of $A85.35 per 1000 prescriptions [95% confidence interval (CI)-$A157.11 to $A24.95). This was 4 times greater than savings generated by pharmacies in group B (mean savings of $A25.65 per 1000 prescriptions) and 6 times greater than control pharmacies. A sensitivity analysis which extrapolated results to Australian prescription figures showed that the control group was capable of generating savings in the order of $A2.4 million per year while pharmacists in group C would save the healthcare system $A15 million per year. CONCLUSIONS: These results provide the first economic estimates for the provision of clinical interventions in Australian community pharmacies. It is believed that they illustrate the value of pharmaceutical services to the healthcare system and to the Australian community in terms of both quality of care and savings.

Australia↗
PubMed2005

Models for financing dental services. A review.

The aim of this review article is to give a brief description of the most important models for financing dental services, and then to describe the effects that the different models can have on patients' and dentists' behaviour. The advantages and disadvantages of the different models will be discussed. The first section focuses on the relationship between insured people and insurance providers. The justifications for a private insurance scheme and a public insurance scheme for dental treatment are discussed. A purely private insurance market for dental services will fail. This is because the benefits of a private dental insurance scheme are few in relation to the costs of having insurance, and because of the problem of adverse selection. There are also problems with public insurance schemes, for example, high transaction costs for collection of taxes and problems with cost containment as a result of moral hazard. The second section focuses on the relationship between the dentist and the patient, more specifically on how different remuneration schemes influence dentists' behaviour. The advantages and disadvantages of three types of remuneration scheme are discussed: fixed salary, per capita remuneration and pure fee-for-item remuneration. One important conclusion is that per capita payments secure effectiveness, while fee-for-item payments secure quality. With per capita payments there is a potential for patient-selection and undertreatment, while cost containment is a problem with fee-for-item payments. In order to counteract the adverse side-effects of each financing system, focus should be placed on the individual dentist in relation to ethics, norms and quality control.

Cost Control↗
PubMed1994

An analysis of the costs and benefits of two strategies to decrease length of stay in children's psychiatric hospitals.

OBJECTIVE: We analyze the costs and benefits of two strategies-intensive home-based services and increased remuneration for providers of community-based placements--to decrease excessive length of stay in a children's psychiatric hospital. DATA SOURCES AND STUDY SETTING: Clinical, demographic, and financial data were collected retrospectively on all children discharged during 1987 through 1989 from the state children's psychiatric hospital that serves Wayne County, Michigan. Characteristics of the discharged children were similar to those reported in other studies of intensive home-based services. STUDY DESIGN: A sample of 22 children was used for a simulation analysis. Excessive length of stay was defined as the duration of hospitalization after readiness for discharge and associated planning were indicated in the record. For the simulated analysis of the intensive home-based program, costs included estimated charges for the program and charges for the children hospitalized due to failure of the intervention. For analysis of the increased remuneration strategy, costs included charges for the out-of-home placement and charges for hospitalization. For both strategies benefits were defined as averted hospitalization charges. DATA COLLECTION/EXTRACTION METHODS: Charts of the discharged children were reviewed and 21 clinical, demographic, and financial variables were extracted. PRINCIPAL FINDINGS: Analysis of costs and benefits of intensive home-based services produced a favorable cost-benefit ratio of .47. Analysis of the strategy to increase remuneration for providers of community-based placements resulted in a cost-benefit ratio of 1, indicating no financial savings. CONCLUSIONS: Intensive home-based services represent an efficient strategy to decrease excessive length of stay for children in psychiatric hospitals by averting hospitalization altogether. Although increased remuneration to providers of community-based placements in order to increase the supply of placements as a means to hasten discharge from the hospital has a neutral cost-benefit ratio, the opportunity to provide care in the "least restrictive" environment argues in its favor as well.

Child↗
PubMed1997

A pre-discharge project--does GP willingness equal involvement?

OBJECTIVE: To compare GPs' willingness to participate in a GP pre-discharge project as measured by a survey, with actual participation rates. To identify the characteristics of GPs likely to make a pre-discharge visit to frail, aged inpatients admitted under the care of a geriatrician. METHOD PRE-IMPLEMENTATION GP SURVEY: Survey of a random sample of 100 GPs from the Central Sydney area using a standardised questionnaire. PRE-DISCHARGE VISIT PROJECT: Information on actual participation rates and GPs who declined to make a pre-discharge visit was obtained from an audit of Division of General Practice records. Information on Patient characteristics was obtained from patient interviews and medical records. The survey was conducted at the Balmain Hospital and Concord Repatriation and General Hospitals located within the Central Sydney Area Health Service. The subjects were GPs practising in central Sydney and patients admitted under the care of a geriatrician at Balmain and Concord Hospitals. RESULTS: Twenty-nine per cent of GPs reported that they were willing to undertake visits without remuneration and 71% reported they were willing to make a pre-discharge visit if remunerated. Fifty-three per cent of GPs actually complied with a request to make a remunerated pre-discharge visit. This was 18% less than the rate determined by the survey. GPs were less likely to make a visit if they were solo practitioners and not members of the Division. Patients who were more dependent, as measured by total Barthel's score, and those from nursing homes were less likely to receive a visit. CONCLUSION: GP surveys may overestimate participation rates in Division projects. In reality, it appears difficult for GPs to accommodate pre-discharge visits in a general practice routine and the offered remunerations may not be adequate compensation for time lost when undertaking a pre-discharge visit. Lastly, some GPs may not see a benefit in visiting more dependent patients.

Aged↗
PubMed2003

Financial incentives and the supply of laboratory tests.

This study examined how the number of laboratory tests taken by a sample of Norwegian contract physicians is influenced by their private economy outside of the practice and by changes in remuneration. The data are drawn from 40,000 consultations carried out by 44 contract physicians in 1991-1994. Two factors which led to changes in the level of physicians' income are considered: changes in remuneration for consultations and laboratory tests and changes in interest rates on loans and bank deposits. The effect which changes in interest rates have on physicians' disposable income was calculated using information about their financial assets and debts obtained from tax assessments. The main finding was that changes in private economy and changes in remuneration have no or only a small effect on the number of laboratory tests taken. Our results suggest that fee regulation can be an effective means of controlling physicians' income and therefore government expenditure on primary physician services.

Journal Article↗
PubMed2004

Emergency room coverage: an evolving crisis.

Historically, a newly graduated plastic surgeon in the United States could build a practice from his or her emergency room coverage. The historical cliche was for the surgeon to be affable, able, and available, and from that basis one's practice would grow. Emergency room exposure was an avenue for starting a practice, developing recognition, and, after that, building a referral pattern. Recently, the cross-shifting influence of management care, rising malpractice insurance costs, and risk ratio are changing this cliche to a crisis. An evaluation of a 2 1/2-year exposure to emergency room coverage has revealed a completely different profile. A total of 300 patient visits resulting in 69 surgical operations were evaluated for insurance and remuneration history. The findings indicated a significant remuneration dilemma for emergency room coverage. Interestingly, a remuneration problem exists in a market different from what one would expect. In this study, a sample from a suburban hospital, rather than an inner-city university hospital, is the greater problem.

Cost Control↗
PubMed2006

Workforce issues in nursing in Queensland: 2001 and 2004.

AIM AND OBJECTIVES: The aim of the study was to identify the factors having an impact upon nursing work and to use the results to inform strategic planning of the Queensland Nurses Union. BACKGROUND: In 2001 and 2004, a study was undertaken to gather data on the level of satisfaction of nurses with their working life. This paper reports the 2004 results on workload, skill mix, remuneration and morale. Where applicable, the results are compared with 2001 data. METHODS: A questionnaire was mailed to 3000 Assistants-in-Nursing, Enrolled and Registered Nurses in October 2004. All participants were members of the Queensland Nurses Union. The results are reported in three sectors - public, private and aged care. A total of 1349 nurses responded to the survey, a response rate of 45%. RESULTS: Nurses in the 2004 study believed: their workload was heavy; their skills and experience poorly rewarded; work stress was high; morale was perceived to be poor and, similar to 2001, deteriorating; the skill mix was often inadequate; and the majority of nurses were unable to complete their work in the time available. Nursing morale was found to be associated with autonomy, workplace equipment, workplace safety, teamwork, work stress, the physical demand of nursing work, workload, rewards for skills and experience, career prospects, status of nursing and remuneration. CONCLUSIONS: Overall the findings of the study are consistent with those determined by the 2001 survey. RELEVANCE TO CLINICAL PRACTICE: The findings of this study indicate the importance of factors such as workplace autonomy, teamwork, the levels of workplace stress, workload and remuneration on nursing morale. The data also indicate that workplace safety and workplace morale are linked. These findings provide information for policy makers and nurse managers on areas that need to be addressed to retain nurses within aged care, acute hospital and community nursing.

Adult↗
PubMed1986

Effects of workload and analysis time on the cost of out-of-hours investigations.

In the UK, under present Whitley Council Regulations for payment for out-of-hours pathology services, there is a complex relationship between the number of requests received, the time taken to analyse each request, and the number of calls for which payment may be claimed for work done. At a fixed average analysis time, the rate of increase of remuneration slows down as workload increases until at higher workloads remuneration falls. The introduction of methods with a shorter average analysis time to improve the clinical service increases remuneration disproportionately. We suggest that a fixed sessional payment would be a better way of funding the service.

Clinical Laboratory Techniques↗
PubMed2006

A cross sectional survey of urban Canadian family physicians' provision of minor office procedures.

BACKGROUND: A discordance exists between the proportion of Canadian family physicians that we expect should be able to perform minor office procedures and the actual provision of care. This pattern has not been extensively studied. The objective of this study was to determine the current patterns and obstacles relating to the provision of four minor office procedures by GP/FPs in a small city in Ontario, Canada. An additional goal was to determine the impact of the remuneration method on the provision of such services. METHODS: A survey was mailed to all GP/FPs practising in Kingston, Ontario. The main outcomes measured in the study were work setting and remuneration method, current procedural practices with respect to four procedures, reasons for not performing procedures, current skill levels, and desire to upgrade. RESULTS: Surveys were mailed to all 108 GP/FPs in the City of Kingston. Completed surveys were collected for 82 percent (89/108) and 10 were excluded leaving 79 eligible participants. The percentages of GP/FPs who reported performing the procedure were as follows: dermatological excision (63.3%), endometrial biopsy (35.4%), shoulder injection (31.6%), and knee injection (43.0%). The majority of GP/FPs who would not do the procedure themselves would refer to a specialist colleague rather than to another GP/FP. The top reason cited for not performing a specific procedure was "lack of up to date skills" followed by "lack of time". The latter was the only statistically significant difference reported between GP/FPs working in Family Health Networks and GP/FPs working in fee for service settings (26.7% vs 47.0%, chi2 = 4.191 p = 0.041). CONCLUSION: A large number of Kingston, Ontario GP/FPs refer patients who require one of four minor office-based procedures for specialist consultation. Referral to other GP/FP colleagues appears underutilized. A perceived lack of up to date skills and a lack of time appear to be concerns. GP/FPs working in Family Health Networks were more likely to perform these procedures themselves. Further studies would clarify the role of changes in medical education, the role of continuing education, and the impact of different remuneration models.

Biopsy↗
PubMedDate not supplied

[Payment systems for health care providers in Latin America and OECD countries].

The system used to pay health services providers is one of the most important components of the contractual relationship between persons who receive health services and the individual practitioners and institutions that provide those services. That payment system is also relevant in assessing a health system, including its efficiency and quality. In this article we present a simple analytical framework for various payment systems. We also provide an overview of the payment approaches used in two groups of countries whose experiences we consider representative: 10 nations of the Organization for Economic Cooperation and Development (OECD) and four countries of Latin America. We present a basic model to characterize the different forms of payment based on two dimensions. One of the dimensions is the payment "unit," which is used to measure the amount of health care services provided or promised. The other dimension is the distribution of financial risks between the service provider and the service purchaser. Each payment system has advantages and disadvantages that should be evaluated in relation to the intended objectives. On one extreme of the approaches is fixed remuneration, without any adjustments; it represents the purest prepayment approach. One example of fixed remuneration is capitated payment, in which providers carry all the financial risks coming from the variability in the cost of providing services. On the other extreme is fee-for-service payment, where service providers are not at financial risk; the insurer or other financing institution carries all the risk from variable costs. Neither of the extremes appears to be the best choice, and so the issue becomes one of selecting a remuneration system that falls between those extremes. Therefore, it is necessary to choose, on the one hand, the optimal payment unit according to the objectives of the financing entity and, on the other hand, a risk distribution approach that allocates to the service provider the risks coming from greater or less efficiency in delivering services.

Health Personnel↗
PubMed2001

The effect of income pooling within a call group on rates of obstetric intervention.

BACKGROUND: On July 1, 1997, the call group at a tertiary referral hospital in Ottawa changed its remuneration. The authors tested the hypothesis that change in an obstetric call group's remuneration from individual fee-for-service billing to equal sharing of the pooled group income would result in reduced rates of obstetric intervention. METHODS: Intervention rates were compared for the 12 months before (1678 births) and the 12 months after (1934 births) the change. Data were collected on onset of labour, indication for induction of labour, mode of delivery and neonatal outcome. Statistical analysis was performed with Wilcoxon's signed-rank test. RESULTS: The mean rate of elective induction of labour was 38.6% in the year before the change and 33.3% in the year after the change (p = 0.01). There were small but statistically significant increases in the mean duration of labour and mean length of the second stage (p = 0.03). INTERPRETATION: Billing policy may affect clinical decisions. Our findings add weight to the literature showing increased intervention rates with fee-for-service remuneration.

Decision Making↗
PubMed2002

Chief executives. Off limits.

Trust remuneration committees are paying chief executives above the limits recommended in Department of Health guidance. In doing so they are ignoring the government's stated policy of fair pay for all in the NHS and their duty of accountability. Excessive awards made by a remuneration committee can be subject to judicial review and overturned. The health secretary should review the workings of trust remuneration committees and ensure that their decisions are transparent to the public.

Administrative Personnel↗
PubMed2004

[What is anaesthesiology worth in the German DRGs?--First experience with German DRGs].

This overview reports on first experience with German DRGs version 1.0 from 2003, with special regard to relevant procedures and diagnoses of anaesthesiology. Basically, the G-DRGs are a translation of the AR-DRGs 4.1. Only the 2004 version represents a first "real" German DRG system. Particularly anaesthesiological measures for procedures which are normally performed without narcosis can lead to essentially relevant remuneration. In intensive care medicine, the hours of artificial ventilation must be recorded exactly. In the 2004 version of the G-DRGs, intensive medical performances are mainly differentiated regarding the time of ventilation, which leads to better payment than under version 1.0. In intensive care medicine, additional remuneration is only intended for dialyses and other organ-supporting procedures. Pain therapy is insufficiently documented in the G-DRGs. Although new codes of pain treatment are included in the G-DRGs, they do not lead to relevant remuneration. Diagnoses and procedures coded by the anaesthetist should be registered in the clinic information system without delay. Only non-anaesthesia-associated diagnoses, i.e. additional diagnoses resulting from the preanaesthetic check-up of the patient in the preanaesthetic department, should be checked by non-anaesthesiological physicians. The correct documentation and transfer of ASA classifications is necessary for additional charges in external quality management and to avoid financial sanctions. In our experience, regarding operated patients, anaesthetists can contribute a lot to enquiries by health insurance companies, e.g. whether the payment code for an in- or an out-patient should be used. Departments of anaesthesia should appoint an anaesthetist as DRG representative to supervise anaesthesiological coding and DRG-relevant procedures.

Anesthesiology↗
PubMed2004

Structural problems in the German hospital system.

The German health care system has been based on the Hospital Financing Act, which the German government introduced in 1972. According to that, the federal states plan hospitals and make investments. The health insurance funds finance the operating costs. But now the Hospital Financing Act is obsolete, because both the health insurance funds and the federal states are in financial trouble and try to avoid the costs, which are nevertheless rising. In order to freeze costs, the legislators have introduced a new remuneration system, called DRGs (Diagnosis Related Groups), which will be mandatory from 2007 onwards. In this system, the treatment provided will be coded and remunerated on the basis of the primary diagnosis. Periods of hospitalisation and different remuneration systems will no longer be relevant. Transparency and quality will thus be promoted, and the upshot will be more competition among the hospitals. Hospitals that cannot meet quality standards will lose patients and will ultimately have to close. Other participants in the health care system, such as, for example, nursing staff, physicians, pharmacies, rehabilitaion centres and patients, will also be concerned in many ways. The consequences of the DRGs for the health care system, its future development and possible alternatives are discussed in this article.

Cost Control↗
PubMed2005

[Practice in private professional corporations].

Since 1992, doctors may exert through a private professional corporation. The Decree no 94-680 of 3rd of August 1994 details the new regulation. For physicians used to the liberal scene, one of the greatest innovation is the payment mode. It is basically divided in two parts: the work remuneration as wages or management allowance, and capital remuneration as dividends. This last possibility offering important savings on social contribution, social contribution being calculated only on the work remuneration part. Taxation being in this case a taxation of the company and of the physician on his incomes and dividends. It is a precious instrument to take part in a regrouping and to integrate new associates. Nevertheless it still is an individual's choice and before getting engaged, consequences of the choices selected have to be appreciated with a qualified professional.

Decision Making↗
PubMed1989

A trial of a capitation system of payment for the treatment of children in the General Dental Service. Final report. Dental Health Services Research Unit, University of Manchester. September, 1989.

A 3-year clinical trial comparing capitation and fee-for-service remuneration systems for general dental practitioners for the treatment of children has been successfully completed. Capitation dentists restored carious teeth at a later stage in the disease process than fee-for-service controls, and carried out more preventive treatment and advice. However, the disease experience of their patients was little different from that of patients treated under fee-for-service. Capitation dentists saw their patients less frequently and took fewer radiographs than their fee-for-service colleagues. The prevalence of both fissue sealants and arrested caries was low in both groups, as was the prevalence of teeth extracted as a result of caries. Levels of oral cleanliness were similar under both systems. Private treatment was rarely prescribed for children, but was more prevalent for patients of fee-for-service dentists. The profession felt that capitation offered greater clinical freedom and more financial stability to dentists, but a greater temptation to under-prescribe treatment. The profession lacked commitment to capitation as a method of remuneration for the treatment of children in the General Dental Service. Fee-for-service dentists appeared to be more innovative, expressed a greater allegiance to their patients and felt a greater temptation to over-prescribe than capitation dentists. The parents had a high opinion of the service for children, irrespective of the remuneration system, and the children found the service very acceptable. Parents had a stronger allegiance to the fee-for-service than the capitation dentists. The study revealed several short-comings in the capitation model tested, but solutions to all of these became apparent. A capitation agreement of more than 12 months would simplify administration and reduce costs, as would a reduction in the number of forms. The need to notify parents when a dentist was replaced in a practice created considerable difficulties and increased expense. The treatment of trauma and extractions for orthodontic purposes should have been items excluded from the capitation fee. The need for information on dentists' activity in capitation was accepted but should be kept simple and relevant. Monitoring quality of care under capitation can be carried out from the routine data collected for administrative purposes. Capitation does not appear to increase participation. Costs of administering capitation are little different from those for fee-for-service. More resources were spent per dentist and per patient under capitation than fee-for-service. In the clinical trial fee-for-service was more cost-effective than capitation.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1998

[Diabetology in the German medical system in 1998].

In 1990, instruction of diabetic patients was not recognised by health insurance providers in Germany, and a practitioner received no remuneration for training patients. Moreover, no physicians specialised in diabetology were recognised by health insurance providers. Specialised diabetology was performed exclusively in hospitals. Physicians conducting their practice in offices and interested in caring for diabetic patients were in a rather difficult situation. In 1991, remuneration was provided for the first time in Germany for therapeutic training of Type 2 (non-insulin-dependent) diabetic patients. Health insurance providers paid physicians DM 60 per patient for 4 class sessions. Since 1993, physicians in the Brandenburg region have been receiving DM 250 per patient for 5 class sessions (thus DM 1,000 for a group of 4 patients) to provide therapeutic training for Type 2 diabetic patients on conventional insulin therapy. This programme has been assessed in two reported studies: one showing that this ambulatory programme is as efficient as training in a hospital and the other evaluating the setting up the Brandenburg programme. However, the number of patients receiving training in medical offices has remained inadequate (around 250,000 patients in total). In 1997/98, in order to improve this situation, a health insurance group, the VdAK/AEV (representing nearly half of the insured persons in Germany), raised fees for physicians from DM 60 to 200 per patient for the training of diabetic patients. Moreover, a book for patients (the "passport for diabetic persons" provided by the German Association of Diabetology) is distributed to patients during the training courses and reimbursed by the insurers. Within a few years in nearly all regions of Germany, diabetologists practising in medical offices have succeeded in obtaining special contracts for performance of ambulatory diabetology. This development began in East Germany but has now spread to most regions of West Germany. In 1998, an annual examination for diabetic patients was established for preventive purposes. Thus, remuneration is related to precise disease documentation (feet, nephropathy, retinopathy). This model is currently being evaluated in Wolfsburg for all diabetic patients covered by the insurers of Volkswagen AG. The first results expected in 1999 will be useful in extending this preventive examination to other regions of Germany.

Diabetes Mellitus↗
PubMed2005

Does more choice reduce waiting times?

This paper develops a model of the supply of elective treatments within a duopolistic market structure where patients can be referred to the hospital with the lowest waiting times. We investigate the effect of a higher degree of substitutability among the two hospitals on equilibrium supply, waiting time and the size of the waiting list. The degree of substitutability is interpreted as the degree of choice or the extent to which patients can switch from one hospital to the other. We show that the greater the degree of substitutability among hospitals, the lower is the supply and the higher the waiting time. The effect on waiting list size is ambiguous. This result holds either when the hospital is remunerated with a fixed budget or with activity-based funding. However, the reduction in supply and the increase in waiting time generated by higher substitutability are higher when hospitals are remunerated with fixed budgets. The main implication of the model is that, under certain assumptions, policies aimed at increasing provider choice may fail to reduce waiting times.

Choice Behavior↗