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PubMed2001

Monitoring patient satisfaction with university dental services under two fee-paying systems.

AIMS: The aim of this survey was to study patients' satisfaction with the dental service of a university in Hong Kong under a recently introduced item-based fee-paying system and reasons for non-attendance at the clinic; and to compare results of the present survey with that of a similar survey of the same dental service under a time-based fee-paying system in 1996. METHOD: A modified Dental Satisfaction Questionnaire was distributed to a random sample of students (n=194) in their lecture rooms and they were asked to complete the questionnaire on the spot. The same questionnaire was sent to a random sample of staff and their spouses (n=207) by mail. RESULTS: Dental Satisfaction Index (DSI) scores calculated from the returned questionnaires were 66 for students and 70 for staff and their spouses. Compared to the scores in 1996, there was no significant difference for that of the students (DSI=65 in 1996) but there was a significant improvement in that of the staff and their spouses (DSI=66 in 1996). Moreover, in the present survey, "busy/no time" and "no perceived dental problem" were the major reasons for non-attendance, in contrast to "long waiting time for an appointment" in the 1996 survey, were the major reasons for non-attendance. CONCLUSION: The recent attempts by the University Dental Clinic to shorten patient waiting time and the change in fee-paying system might have improved the patients' satisfaction with the service.

Chi-Square Distribution↗
PubMed2003

Estimating private sector professional fees for VA providers.

OBJECTIVES: To describe new methods used to estimate inpatient and outpatient Medicare-based professional fees for Veterans Health Administration (VA) services. METHODS: National VA utilization files provided estimates of inpatient physician services, whereas local provider and utilization files gave counts of outpatient services by physicians, nurse practitioners, physician assistant, clinical psychologists, and clinical social workers. Services from ambulatory surgery, emergency room, and clinics (eg, dermatology and gastroenterology) were coded by study health information management staff (coders). VA-based billing information was edited against Medicare guidelines. Estimates for VA services without comparable Medicare fees were obtained from other commercial sources. RESULTS: Hypothetical professional fees for VA services were 17% more ($109 million vs. $93 million) than the VA budget for physicians over 1 fiscal year at six sites. Total payments of nearly $21 million were generated for VA inpatient care. In fiscal year 1999, there were 30,209 admissions (of which 4549 were psychiatric) to the study sites; 30,518 discharges; 229,783 inpatient days, including 27,235 in critical care units; and 38,348 surgical days of care. DISCUSSION: Differences between the VA and the private sector maybe overstated because VA salaries of nonphysicians were not included in the VA budgets. Conversely, the extent to which VA professional services were undercounted in VA information systems used in this study may understate the difference. Future research may consider additional data collection approaches or information systems enhancements to enumerate more accurately all provider services that are reimbursable in the private sector.

Budgets↗
PubMed1993

Allocating practice expense under the Medicare fee schedule.

Currently, relative value units for practice expense are determined under the Medicare fee schedule (MFS) using historical physician charges. This seems inconsistent with the goal of a resource-based fee schedule. A specialty resource-based method of determining practice expense payments is presented and simulated here. The method assumes that, for each service, the payment for practice expense should be the same proportion of the total payment as actual physician practice expenses are of total practice revenues. A comparison with the approach developed by the Physician Payment Review Commission (PPRC) shows similar fees, but the specialty-based method proposed here requires no data beyond what is already employed in the MFS.

Computer Simulation↗
PubMed1996

Preferred provider organizations and physician fees.

Preferred provider organizations (PPOs) represent a form of managed care in which providers agree to accept discounted fees in exchange for the expectation that their patient volume will increase or at least be maintained. Managed care plans that rely on discounted fee-for-service (FFS) payments have increased from about 10 plans in 1981 to over 700 plans in 1994. In this study, we document levels of discounts achieved by two large national insurers and discuss how the size of the discount varies by type of service and how the discounted rates relate to Medicare fees. Our results show that, despite achieving large discounts (approximately 10 20 percent) relative to their indemnity plans, the two nationwide PPOs studied here pay at rates substantially above Medicare levels.

Fee-for-Service Plans↗
PubMedDate not supplied

Should fee-for-service group practices develop a prepaid component?

Many fee-for-service group practices are considering the advantages of developing activities using health maintenance organization concepts. In some cases, the decision to become involved with an HMO as an addition to current fee-for-service activities may become essential because of competition with other medical groups who are also considering an HMO alternative. There are a number of different ways or models for fee-for-service groups to become involved with an HMO.

Capitation Fee↗
PubMedDate not supplied

Turn your fee schedule into a valuable management tool.

This article describes a method of performing a fee schedule analysis that will give you some important management information and tools. By using the methodology described in this article to set your fees, you will confirm that your fees are sufficient, assess your cash flow position, determine the approximate value of your accounts receivable, and estimate the collectible amounts of any new services being considered.

Efficiency↗
PubMed1992

Physician responses to fee-for-service and capitation payment.

The ability to achieve reductions in health care costs is determined in part by physician payment mechanisms. This study observes the response to a change in the reimbursement mechanism by a group of physicians who participated in a fee-for-service plan and then formed an IPA using capitation payment for primary care physicians and a reduced fee schedule for specialists. Patient benefits were similar under the two plans. Analyses of data for a group of continuous enrollees show that the change in the physician payment mechanism was associated with a reduction in hospitalizations but increases in length of hospital stay and number of ambulatory visits. These increases may have occurred because capitation for primary care physicians and a reduced fee schedule for specialists led to a greater number of referrals with no incentive in place for reductions in length of stay for specialty admissions.

Ambulatory Care↗
PubMed1994

The effect of user fees on the utilization of family planning services. A clinical study.

A new fee structure was introduced to the Advanced Training and Research in Fertility Management Unit in 1992. The study looked at the effect of the new fees on attendance and the choice of contraceptive methods through an examination of clinical records and a questionnaire survey. There was a decline in attendance of roughly 28 per cent between 1992 and 1993. The decline affected mainly new clients and those who accepted injectables. A reduction in the price of injectables is suggested since the fee for this short-term method is more in line with those charged for long-term and permanent methods.

Family Planning Services↗
PubMed1998

A comparison of capitated and fee-for-service Medicaid reimbursement methods on pregnancy outcomes.

OBJECTIVE: To determine if the payment method influenced the likelihood of selected obstetrical process measures and pregnancy outcome indicators among Medicaid women. DATA SOURCE/STUDY SETTING: Data from the live birth certificates computer file for 1993 from the State of California. The computer files contain information about the demographic characteristics of the mother, her medical conditions prior to delivery, medical problems during labor and delivery, delivery method, newborn and maternal outcomes, and expected principal source of payment for prenatal care and for hospital delivery. STUDY DESIGN: The study sample consisted of singleton live births to women in the California Medi-Cal program residing in one of two counties in which a mixed-model managed care plan was the method of reimbursement or in one of three counties in which fee-for-service was the payment method. The study and control counties were matched in terms of geographic proximity and sociodemographics. PRINCIPAL FINDINGS: Among Medi-Cal women, the likelihood of low birth weight (LBW) was lower in the capitated payment group than in the fee-for-service payment group even when controlling for maternal and newborn characteristics and adequacy of prenatal care. There was no difference in either the adequacy of prenatal care, the cesarean birth rate, or the likelihood of adverse pregnancy outcomes other than LBW between the two payer groups. CONCLUSIONS: Results of this "natural experiment" suggest that enrollment of pregnant Medi-Cal beneficiaries in capitated healthcare services through a primary care case management system in a county-organized health system/health insuring organization can have a beneficial effect on low birth weight and provide care comparable to a fee-for-service system.

Adolescent↗
PubMed1993

Outcomes for adult outpatients with depression under prepaid or fee-for-service financing.

OBJECTIVE: To compare change over time in symptoms of depression and limitations in role and physical functioning of patients receiving prepaid or fee-for-service care within and across clinician specialties. METHOD: Observational study of change in outcomes over 2 years for 617 depressed patients of psychiatrists, psychologists, other therapists, and general medical clinicians in three urban sites in the United States. RESULTS: Psychiatrists treated psychologically sicker patients than other clinicians in all payment types. Among psychiatrists' patients, those initially receiving prepaid care acquired new limitations in role/physical functioning over time, while those receiving fee-for-service care did not. This finding was most striking in independent practice associations but varied by site and organization. Patients of psychiatrists were more likely to use antidepressant medication than were patients of other clinicians, but among psychiatrists' patients, there was a sharp decline over time in the use of such medication in prepaid compared with fee-for-service care. Outcomes did not differ by payment type for depressed patients of other specialty groups, or overall. CONCLUSION: Depressed patients of psychiatrists merit policy interest owing to their high levels of psychological sickness. For these patients, functioning outcomes were poorer in some prepaid organizations. The nonexperimental evidence favors (but cannot prove) an explanation based on care received, such as a reduction in medications, rather than on preexisting sickness differences.

Adult↗
PubMed1982

Do fees help heal?

Fees for mental health services is a subject that is often discussed but seldom researched. Fee information that pertained to 112 adult outpatients who returned a follow-up questionnaire and 147 who did not return it was reviewed in light of several indices of patients' response to clinic services. The study also assessed impact of change in a facility's billing format. Differences in billing format were in terms of amount of charge and whether fees were per session or lump-sum. Nonparametric statistics were applied to determine any relationship that (a) assessment by the clinic, (b) source of payment, (c) assessment to the patient, and (d) payment had with (a) return to clinic, (b) number of sessions, and (c) reports of help and satisfaction. The only association found was between presence of third-party coverage and likelihood that the patient returned. Change in billing format did not bear upon return to the clinic or satisfaction with services rendered, but did influence payment. Finally, some of the findings suggest that payment is associated with a predisposition to honor requests and obligations.

Adult↗
PubMed2000

Managed care and fee discounts in psychiatry: new evidence.

This article describes the extent of managed care and fee discounting in psychiatric practice using data on 970 randomly sampled American Psychiatric Association members from the 1996 National Survey of Psychiatric Practice. Seventy percent of psychiatrists were found to have some patients in managed behavioral health care programs. The survey data illustrate that psychiatrists' involvement in managed care spans primary practice settings and is fairly evenly distributed across regions of the United States. Nationally, psychiatrists discount fees for 35% of their patients, with significant variation by practice type and extent of involvement in managed behavioral health care. The average level of discount is 25% with little variation by practice type or extent of involvement in managed behavioral health care. There is little evidence that psychiatrists with patients in managed care have higher fee levels than psychiatrists with no patients in managed care.

Cost Sharing↗
PubMed2004

Impact of increasing consultation fees on malaria in Africa.

To evaluate the impact of the increase in consultation fees on malaria incidence in children presenting in the outpatient clinic of a privately funded hospital, we measured the impact of two fee increases on the number of pediatric outpatients. A 74% reduction in outpatients and a 78% reduction in malaria cases occurred in a course of four years. No differences were observed in an adjacent public hospital that does not charge consultation fees. This surprisingly strong effect may be the basis for increase in malaria morbidity and mortality, since in the time course of 4 years, an estimated 3000 children did not receive adequate malaria treatment in this region. Furthermore, it may drive parasite resistance, due to inadequate auto-medication.

Child↗
PubMed2006

Spatial equity in facilities providing low- or no-fee screening mammography in Chicago neighborhoods.

Recent research suggests living in an economically disadvantaged neighborhood is associated with decreased likelihood of undergoing mammography and increased risk of late-stage breast cancer diagnosis. Long distances and travel times to facilities offering low- or no-fee mammography may be important barriers to adherence to mammography screening recommendations for women living in economically disadvantaged urban neighborhoods, in which African-Americans are disproportionately represented. The purpose of this study was to examine whether the spatial distribution of facilities providing low- or no-fee screening mammography in Chicago, Illinois, is equitable on the basis of neighborhood socioeconomic and racial characteristics. We found that distance and travel times via automobile and public transportation to facilities generally decrease as neighborhood poverty increases. However, we also found that the strength of the association between neighborhood poverty level and two of the spatial accessibility measures-distance and public transportation travel time-is less strong in African-American neighborhoods. Among neighborhoods with the greatest need for facilities (i.e., neighborhoods with the highest proportions of residents in poverty), African-American neighborhoods have longer travel distances and public transportation travel times than neighborhoods with proportionately fewer African-American residents. Thus, it appears that the spatial accessibility of low- and no-fee mammography services is inequitable in Chicago. In view of persistent social disparities in health such as breast cancer outcomes, these findings suggest it is important for researchers to examine the spatial distribution of health resources by both the socioeconomic and racial characteristics of urban neighborhoods.

Black or African American↗
PubMed1991

Physician response to fee changes with multiple payers.

This paper develops a general model of physician behavior with demand inducement encompassing the two benchmark cases of profit maximization and target-income behavior. It is shown that when income effects are absent, physicians maximize profits, and when income effects are very strong, physicians seek a target income. The model is used to derive own and cross-price expressions for the response of physicians to fee changes in the realistic context of more than one payer under the alternative behavior assumptions of profit maximization and target income behavior. The implications for public and private fee policy, and empirical research on physician response to fees, are discussed.

Choice Behavior↗
PubMed2002

The relation between managed care market share and the treatment of elderly fee-for-service patients with myocardial infarction.

PURPOSE: To determine if greater managed care market share is associated with greater use of recommended therapies for fee-for-service patients with acute myocardial infarction. SUBJECTS AND METHODS: We examined the care of 112,900 fee-for-service Medicare beneficiaries aged > or = 65 years who resided in one of 320 metropolitan statistical areas and who were admitted with an acute myocardial infarction between February 1994 through July 1995. Use of recommended medical treatments and 30-day survival were determined for areas with low (<10%), medium (10% to 30%), and high (>30%) managed care market share. RESULTS: After adjustment for severity of illness, teaching status of the admission hospital, and area characteristics, areas with high levels of managed care had greater use of beta-blockers (relative risk [RR] for greater use = 1.18; 95% confidence interval [CI]: 1.06 to 1.29) and aspirin at discharge (RR = 1.05; 95% CI: 1.02 to 1.07), but less appropriate coronary angiography (RR = 0.93; 95% CI: 0.86 to 1.01) and reperfusion (RR = 0.95; 95% CI: 0.85 to 1.03) when compared with areas with low levels of managed care. CONCLUSIONS: Medicare beneficiaries with fee-for-service insurance who resided in areas with high managed care activity were more likely to have received appropriate treatment with beta-blockers and aspirin, and less likely to have undergone coronary angiography following admission for myocardial infarction. Thus, the effects of managed care may not be limited to managed care enrollees.

Adrenergic beta-Antagonists↗
PubMed2002

The influence of user fees and patient demand on prescribers in rural Nepal.

Irrational prescribing and over-prescription is a world-wide problem. Prescribers often cite patient demand as one of the main reasons why they over-prescribe, but the degree to which this is so is unknown. This article describes a study to test the hypothesis that patient demand causes over-prescription. The study occurred within the context of different kinds of nominal user fee for drugs in Nepal, where it was assumed that charging per drug item would deter patient demand, and hence over-prescription, as compared to charging per prescription. Focus group discussions with patients attending rural health facilities explored patient attitudes towards drugs. Patients and health workers were interviewed to gather quantitative data on (1) patient demand, and (2) health worker views of patient demand and their own prescribing habits, and comparing these with the drugs actually prescribed and dispensed to patients. Patients felt they needed more drugs than they were prescribed or dispensed, but stated that they would be happy to accept advice from prescribers for fewer drugs. In all areas of whatever fee type, there was no association between the number of drug items patients felt they needed pre-consultation and the number of drug items that they actually received as observed postconsultation. However, there was a significant association between the average number of drug items per patient that prescribers stated they usually prescribed and the actual number that were prescribed. It was concluded that patient demand was not affected by different kinds of user fee and did not directly influence prescribing behaviour.

Attitude of Health Personnel↗