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PubMed2003

[Proposals for adapting a DRG system in the fields of orthopedics and trauma surgery for 2004].

The introduction of the DRG system in Germany-optional since 1 January 2003 and mandatory for all hospitals as of 1 January 2004-has resulted in great uncertainty, particularly on the part of hospitals, since apprehension prevails that the diagnostic and therapeutic measures practiced in Germany will not be appropriately represented and remunerated by a DRG system. The G-DRG version 1.0 prepared within the framework of substitutive execution is largely identical to the Australian AR-DRG version 4.1. Adjustments that do justice to the realities of German treatment modalities were at most insignificant. It is therefore essential that stock be taken for each medical specialty to determine to what extent treatment procedures commonly followed in Germany are adequately reflected in this G-DRG system or whether adjustments are necessary to make allowances for German realities. To be able to provide qualified statements on the problems involved, scientific analysis of possible problems is necessary utilizing German data. Thus, we undertook an evaluation of how the special fields of orthopedics and accident surgery are represented in the G-DRG system. The resultant data form the basis for evidence of presumable deficits in the representation of orthopedic and accident surgery cases in the G-DRG system. The German Association for Trauma Surgery and the German Association for Orthopedics and Orthopedic Surgery have undertaken a DRG evaluation project together with the Organization of Directors for Accident Surgery (chairperson: Professor Dr. Mischkowsky, Kempten), the Organization of Directors for Orthopedics (chairperson: Professor Dr. Puhl, Ulm), the DRG Working Group of the German Association for Accident Surgery, and the Joint Commission of the Professional Association of German Surgeons and the German Association for Surgery in cooperation with the DRG Research Group of the University Clinic Muenster, the German Hospital Association, and the German Medical Association with the goal of examining the medical and economic homogeneity of the case groups. A total of 12,645 orthopedic and trauma surgery cases were collected from 23 clinics-11 university hospitals and 12 non-university hospitals-and assessed. On the basis of this database and when too few cases were evaluable also based on clinical considerations, 14 adjustment proposals were formulated and submitted on schedule on 31 March 2003 to the Institute for Hospital Remuneration. The results of the DRG evaluation project illustrated the problems involved in representing the exceedingly heterogeneous and complex activities of orthopedic and trauma surgery departments in a flat rate financing system that is not attuned to the realties of German treatment procedures. Version 1.0 of the G-DRG system is not sufficiently differentiated to represent the multifaceted diagnostic and therapeutic services provided by trauma surgery and orthopedic departments in Germany.

Diagnosis-Related Groups↗

PubMed2002

A comparison of actual cost, DRG-based cost, and hospital reimbursement for liver transplant patients.

The financing of health care services in Norway has been changed from a system of global budgeting to a system partly based on Diagnosis-Related Groups (DRG). The government has decided to derive a part of the hospital revenue from DRG-based, per-patient financing. The aim of this study is to determine whether the present remuneration system covers the actual hospital expenses of liver transplant patients, and whether the present method of calculating DRG-costs is adequate for our institution. Our group developed a prospective method of determining the actual cost per patient. We closely observed and collected the data of eight liver transplant patients during their hospital stay. We divided each of the patients' resource requirements into four categories; heavy intensive care, light intensive care, intermediate care, and ordinary care. In addition, we recorded the number of staff involved, the duration of surgery, the major procedures, and the medical- and material costs. The actual cost of each patient was calculated, based on these data. The actual cost was compared with the corresponding hospital remuneration for each patient. Median cost for liver transplantation was NOK 536.785 (range: NOK 295.113-NOK 844.345) (1$=7,5 NOK), while the corresponding hospital refund was NOK 457.785 (range: NOK 436.465-NOK 483.040). The difference is not statistically significant ( P=0.2). The average 100% DRG-based cost of a liver transplantation was NOK 730.321, which is significantly higher than the actual cost ( P=0.02). The hospital's reimbursement for liver transplantation did not differ significantly from the actual registered cost. The computed cost was significantly lower than the DRG-based cost.

Costs and Cost Analysis↗

PubMed2001

[Economic rehabilitation management among patients with chronic low back pain].

BACKGROUND AND STUDY PURPOSE: Back pain causes high costs to society. In Germany, these amount to an estimated total of 5 billion euro of direct costs per year and 13 billion euro of indirect costs, the latter being caused by incapacity to work. The purpose of this study is to develop a concept for economic rehabilitation management. This concept is based on the managed care approach and aims at improving efficiency of care. METHODS: The concept development consists of a theoretical and an empirical part. The method of the theoretical part is based on a systematic literature review on managed care (not included in this article), health systems research and the analysis of economic incentives. For the empirical investigation, long term effects and costs were calculated. For the evaluation of effects, we psychometrically tested and used the EuroQol (EQ-5D) as a measure of health-related quality of life (HRQL). The calculation of costs (both direct and indirect) is based on routine data of payers, a cost diary and the internal cost accounting systems of rehabilitation clinics. We statistically analysed the cost distribution and identified predictors of the management targets (e.g., costs of care) by means of regression analyses. RESULTS: The market-driven managed care approach is based on three tools: (1) a primary care system with case management and gatekeeping, (2) direct influence on providers by utilisation review and setting guidelines, and (3) indirect influence by setting supply-side economic incentives via the remuneration mode. The third managed care tool is most important when managing the rehabilitation of working age patients with chronic low back pain from an economic point of view. This concept consists of three components: (1) a case-based budget for direct costs; this is a prospective remuneration mode for an integrated primary care network including a rehabilitation facility, (2) retrospective bonus payments which are related to savings of indirect costs, and (3) retrospective bonus payments which are related to the effectiveness of rehabilitation, i.e. gains in HRQL. Common features of the three management components are a long-term perspective (e.g., from admission to a rehabilitation clinic until six months after discharge) and risk-adjustment of the three management targets (i.e., direct and indirect costs and gains in HRQL) in order to avoid selection and to limit the financial risk for providers. The EuroQol instrument shows acceptable psychometric properties in the rehabilitation setting for back pain patients. This instrument may yield two kinds of preference-based index values, one reflecting the preferences of the general population and one those of the patient. The Pearson correlation of these two approaches is fair, but there is a systematic difference. Empirical investigation shows that the distribution of both direct and indirect costs is skewed to the right. Statistically relevant predictors of the management targets are incapacity to work and HRQL at admission. CONCLUSIONS: Economic rehabilitation management might help to save money and to improve health outcomes, thus increasing the efficiency of care. The results of our empirical studies show the feasibility of tools for the economic management of rehabilitation. Risk adjustment of the management components is of paramount importance.

Chronic Disease↗

PubMed1999

General practitioners caring for terminally ill patients resident in a hospice.

The goal of this study was to investigate why GPs have little or no involvement in the medical process relating to any of their patients when they are admitted to a palliative care unit (PCU) and what solutions they suggest. The study took the form of a descriptive pilot study based on a short questionnaire. It emerged that GPs felt their involvement was influenced by their job description, by practical factors (time investment, distance between practice and PCU, remuneration, referral) and personal issues (e.g. dealing with dying). It is concluded that GPs need education in palliative/supportive care and approved remuneration as well as knowledge about their task in the PCU.

Attitude of Health Personnel↗

PubMed2006

The reasons of general practitioners for promoting colorectal cancer mass screening in France.

Implementation of colorectal cancer (CRC) mass screening is a public health priority. Obtaining the involvement of general practitioners (GPs) is crucial for ensuring participation by the general public. This study elicited GPs' reasons for promoting CRC screening. The method used was discrete choice modeling. Questionnaires with a set of pairs of hypothetical screening scenarios were sent to 700 GPs. Factors influencing GPs' screening practice were found to be: the effectiveness of the screening program, the proportion of false negatives and false positives, and their remuneration. Hence improving screening test sensitivity and setting up specific remuneration for conducting screening would help to increase GPs' participation in CRC screening in France.

Adult↗

PubMed1994

Education in clinical biochemistry: the Canadian scene.

The Canadian Health Care System is operated governmentally at the provincial level although the costs and benefits are similar in every province. Most physicians are remunerated on the 'charge per service' basis, but laboratory physicians (including medical biochemists) are among the few who are remunerated by salary. The training of medical biochemists is regulated by the Royal College of Physicians and Surgeons of Canada by means of a residency program of 4 years duration, following graduation from medical school and completion of the required internship. The training of clinical biochemists, whose functions overlap many of those attributable to medical biochemists, is regulated by the recently created Canadian Academy of Clinical Biochemistry through a certification process incorporating written and oral examinations approximately 1 year apart. Recognized and accredited training programs for clinical biochemists exist in several medical schools: these courses are of 2 (occasionally 3) years duration and entry to these programs requires a Ph.D. and, preferably, some post-graduate research experience. Details of both medical and clinical biochemistry training programs reveal a difference in emphasis and duration rather than in course content, with medical trainees required to spend at least 1 of their 4 training years in clinical disciplines relevant to the practise of biochemistry.

Biochemistry↗

PubMed1984

Considering the effects of financial incentives and professional ethics on 'appropriate' medical care.

This manuscript presents a model of an 'ethical' physician's allocation of time and income between work and leisure activities for various remuneration types and income levels. The physician is 'ethical' because, ceteris paribus, he prefers to provide that amount of medical care which he believes to be in the patient's best interests. Remuneration systems include fixed, time-based and output-based incomes. Only output-based income provides the physician with incentives which may (if the physician density and medical care price are sufficiently high) generate more-than-'appropriate' care per patient. Fixed and time-based incomes necessarily lead the physician to provide less-than-'appropriate' care.

Ethics, Medical↗

PubMed1993

Dental care in the NHS: reforms with teeth?

Dental services in the UK are currently undergoing a period of major upheaval. This paper examines recent policy initiatives with respect to patient charges, dentists' remuneration, information and patient choice, the supply of dental personnel, and the prevention of dental diseases. It is argued that changes in dentists' remuneration and the greater use of auxiliary personnel are likely to improve efficiency, whereas changes in patient charges are not. Water fluoridation remains the most efficient and equitable means of promoting dental health.

Capitation Fee↗

PubMed1996

Structured treatment and teaching programme for type 2 diabetic patients on conventional insulin treatment: evaluation of reimbursement policy.

The aim of the study was to evaluate the practicability and efficacy of a structured treatment and teaching programme (STTP) for type 2 diabetic outpatients on conventional insulin treatment after introducing remuneration for physicians. Reimbursement policy for the STTP was introduced in the state of Brandenburg, Germany, in July 1993. Between August 1993 and February 1994, 108 physicians and their assistants participated in a postgraduate seminar, which is a prerequisite for remuneration. A standardised interview was performed with 103 physicians and their paramedical personnel. Twenty of the practices who had performed STTP were visited in order to collect data on all the patients who had participated in the programme up to September, 1994. Within the first year already 10% of the target group of physicians participated in the seminars. The seminar and the programme were very well accepted. An improvement of HbA1c levels was observed in patients who had started insulin treatment (n = 35: 9.7 +/- 1.6% of total Hb before, 8.2 +/- 1.3% of total Hb after the programme) and in those who were already being treated with insulin before the STTP (n = 125: 9.6 +/- 2.5% of total Hb before, 8.1 +/- 1.4% of total Hb after the programme). The results of the study demonstrate the efficacy and practicability of an STTP for type 2 diabetic patients on conventional insulin therapy in ambulatory health care.

Diabetes Mellitus, Type 2↗

PubMed1991

The epidemiologist as an expert witness.

Epidemiology is becoming more important in the resolution of torts. As a result, epidemiologists are now much in demand as expert witnesses, a role in which they may contribute much to society. In order to do this, epidemiologists should become familiar with the techniques and the ethics of our adversarial legal system. As an expert witness, the epidemiologist subscribes to an enforceable ethical code. Expert witnesses are subject to many motivations. These include the advocacy of truth and the gaining of professional satisfaction. Other motives, including the wish for financial remuneration, may be less altruistic but are not inherently bad. It is unethical, in the absence of supporting evidence, to suggest that an expert witness has altered his testimony in order to enhance his remuneration.

Epidemiology↗

PubMed2005

Understanding practice change in community pharmacy: a qualitative study in Australia.

BACKGROUND: Much of the research on cognitive pharmaceutical services has focused on understanding or changing community pharmacist behaviour, with few studies focusing on the pharmacy as the unit of analysis or considering the whole profession as an organisation. OBJECTIVES: To investigate practice change and identify facilitators of this process in community pharmacy, with specific focus on the implementation of cognitive pharmaceutical services (CPS) and related programs. METHODS: Thirty-six in-depth, semistructured interviews were conducted with participants from 2 groups, community pharmacies and pharmacy "strategists," in Australia. The interview guide was based on a framework of organizational theory, with 5 subject areas: roles and goals of participants in relation to practice change; experiences with CPS; change strategies used; networks important to the change process; and business impacts of CPS. Interviews were transcribed verbatim and thematically content analyzed, using NVivo software for data management. RESULTS: Five key themes relating to the change process were derived from the interviews: change strategies (process- and behaviorally oriented); social networks (within and beyond the pharmacy); drivers of change (eg, government policy); motivators (eg, professional satisfaction); and facilitators of practice change (remuneration for implementation or service delivery, communication and teamwork, leadership, task delegation, external support or assistance, and reorganization of structure and function). CONCLUSION: The use of an organizational perspective yielded rich data from which an understanding of the practice change process in relation to CPS implementation was gained. Current programs for the implementation and delivery of CPS have not taken into account all of the factors that have the ability to facilitate change in community pharmacy. Not only do future programs need to be underpinned by these elements, but policy makers must include them when planning remuneration and dissemination strategies.

Australia↗

PubMed2001

Results of continual devaluation of cardiothoracic surgical codes by the HCFA between 1984 and 1999.

BACKGROUND: The devaluation of surgical procedural services by Medicare began in 1989 as a result of the federal government's adoption of the Resource Based Relative Value Scale, a method of redistribution of payments to physicians from surgical to primary care services. This method gave to the Health Care Financing Administration (HCFA) effective and complete control of Medicare payments to physicians for the first time. The resultant decrease in the nominal dollar value is well understood, but the effect of changes in inflation frequently is not calculated into the reported loss. METHODS: A method of determining the true extent of this devaluation using the nominal dollar decrease plus the effect of inflation was presented in 1995. RESULTS: Since then, repeated devaluation by the HCFA and other third parties plus continual inflation has further eroded the remuneration for cardiothoracic surgical services. Three different sets of data are used to determine the devaluation of five cardiothoracic operations. One set shows the change between 1988 and 1998; one the change between 1988 and 1999; and one the change between 1984 and 1999. CONCLUSIONS: Depending on the geographic location, it appears that the remuneration for pulmonary procedures between 1988 and 1999 decreased 35% to 60%. Similarly, depending on the years reviewed (between 1984 and 1999) and the geographic location, the fee for cardiac procedures decreased 46% to 69%.

Aortic Valve↗

PubMed1998

Detection of a novel DNA virus (TTV) in blood donors and blood products.

BACKGROUND: A newly discovered DNA virus, transfusion-transmitted virus (TTV), has been implicated as a cause of post-transfusion hepatitis. We investigated the frequency of TTV viraemia in UK blood donors, and the extent to which TTV contaminates blood products such as factor VIII and IX clotting factors. We also investigated the possible aetiological role of TTV in cryptogenic fulminant hepatic failure (FHF). METHODS: We extracted DNA from plasma of blood donors and patients with FHF, and from blood products (factor VIII and IX clotting-factor concentrates, immunoglobulin preparations). We detected TTV by PCR using primers from a conserved region in the TTV genome. FINDINGS: TTV viraemia was detected in 19 (1.9%) of 1000 non-remunerated regular blood donors. Infection occurred more frequently in older donors (mean age 53 years), compared with the age prolife of donors infected with hepatitis C virus and other parenterally-transmitted viruses. TTV contamination was found in ten (56%) of 18 batches of factor VIII and IX concentrate manufactured from such non-remunerated donors, and in seven (44%) of 16 batches of commercially available products. Whereas solvent or detergent treatment had little effect on the detection of TTV in factor VIII and IX by PCR, this virucidal step seemed to inactivate TTV infectivity. TTV infection was detected in four (19%) of 21 patients with FHF; in three cases, infection was detected at the onset of disease and could thus not be excluded from its aetiology. INTERPRETATION: TTV viraemia is frequent in the blood-donor population, and transmission of TTV through transfusion of blood components may have occurred extensively. Clinical assessment of infected donors and recipients of blood and blood products, and assessment of TTV's aetiological role in hepatic and extra-hepatic disease, are urgently needed.

Adult↗

PubMed1997

Do fee descriptors influence treatment choices in general practice? A multilevel discrete choice model.

Before 1990 Australian general practitioners (GPs) were remunerated according to consultation length. This was assumed to encourage GPs to prescribe more, counsel less and provide fewer treatments than were 'appropriate'. In an attempt to change this behaviour, the remuneration system was altered to reflect the content of consultations. This paper analyses, through the use of multilevel modelling, the effect of content-based descriptors on the discrete choice behaviour of GPs while controlling for patient, GP and practice characteristics. GPs who used content-based descriptors were just as likely to prescribe, counsel and treat compared to GPs who used time-based descriptors.

Australia↗

PubMed1998

The psychosocial functioning of nurses in a burn unit.

The aim of the study was to determine what the effect of a stressful work environment is on the psychosocial functioning of burn unit nurses. A standardised scale, the Psychosocial Functioning Inventory, was used to measure psychosocial functioning. In addition, a questionnaire was constructed to identify sources of stress, coping mechanisms and the need for support programmes. Scaling and interpretation of the Psychosocial Functioning Inventory were done by a computer program. A qualitative analysis of data patterns on the questionnaire was done according to modal class. Twenty-one nurses in the burn unit completed the scales. The control group consisted of 18 nurses from the departments of plastic surgery and obstetrics. The psychosocial functioning of burn unit nurses was within optimal levels, except on the stress scale, where they were slightly overactivated. Workload and poor remuneration were the most important stressors. Good relationships amongst the nurses and team support enabled them to cope with the stressors. It is recommended that attention be paid to remuneration of nurses, a better nurse-patient ratio and the promotion of interdisciplinary teamwork.

Adaptation, Psychological↗

PubMed2006

Health systems and access to antiretroviral drugs for HIV in Southern Africa: service delivery and human resources challenges.

Without strengthened health systems, significant access to antiretroviral (ARV) therapy in many developing countries is unlikely to be achieved. This paper reflects on systemic challenges to scaling up ARV access in countries with both massive epidemics and weak health systems. It draws on the authors' experience in southern Africa and the World Health Organization's framework on health system performance. Whilst acknowledging the still significant gap in financing, the paper focuses on the challenges of reorienting service delivery towards chronic disease care and the human resource crisis in health systems. Inadequate supply, poor distribution, low remuneration and accelerated migration of skilled health workers are increasingly regarded as key systems constraints to scaling up of HIV treatment. Problems, however, go beyond the issue of numbers to include productivity and cultures of service delivery. As more countries receive funds for antiretroviral access programmes, strong national stewardship of these programmes becomes increasingly necessary. The paper proposes a set of short- and long-term stewardship tasks, which include resisting the verticalisation of HIV treatment, the evaluation of community health workers and their potential role in HIV treatment access, international action on the brain drain, and greater investment in national human resource functions of planning, production, remuneration and management.

Africa South of the Sahara↗

PubMed2002

A questionnaire: will plateletpheresis donors accept multicomponent donation?

BACKGROUND AND OBJECTIVES: New technological developments make it possible to collect red blood cells (RBC) by apheresis which provides standardised products and has the potential for improved RBC quality. The purpose of this study was to evaluate the donors' opinion about the multicomponent donation procedure. MATERIAL AND METHODS: For evaluating the donors' opinion about this new apheresis technique we compiled a questionnaire. The questionnaire was given to all single needle actual plateletpheresis donors (n = 133) that donated platelets in our Institute during February-March 2001. The questionnaire contained 12 questions related to: (1) general information about previous donations of our donors and (2) donors' opinion about multicomponent donation. After implementation of multicomponent donation in December 2001 the data of the questionnaire were compared with the actual opinions of the donors about the procedure. RESULTS: The mean age of the donors was 38.1 +/- 9.1 years. The median number of previous platelets donations of the interviewed donors was 30. The majority of donors (92.4%) were willing for multicomponent donation. In the same time the majority of donors (74.8%) were willing to donate multicomponents four times per year. The different donation time was not an argument for the donors for the multicomponent donation, while the reduction of incidence of transfusion transmitted diseases was a motivation for them. The decrease of hemoglobin and the side effects caused by possible iron-supplementation therapy were found acceptable from most of our donors. Approximately 74% of the donors thought that the donation of a second component should result in better remuneration whereas 20% of them believed that the remuneration should be unchanged. Seventy-five RBC units were concurrently collected with platelets since December 15th, 2001. Six donors (7.4%) were unwilling to donate an additional RBC unit. CONCLUSION: Acceptance and disacceptance rates were almost equal after the implementation of multicomponent donation and at the time point when the interview was performed. The majority of donors was highly motivated to donate multicomponents, by these means we were able to increase our RBC supply and to improve standardization of our products.

Adult↗

PubMed2000

Autonomy in the medical profession in the United Kingdom--an historical perspective.

This paper reviews the concept of professional autonomy from an historical perspective. It became formalised in the United Kingdom only after a long struggle throughout most of the nineteenth century. In its pure form professional autonomy implies unlimited powers to undertake medical investigations and to prescribe treatment, irrespective of cost. Doctors alone should determine the quality of care and the levels of remuneration to which they should be entitled. In the second half of the twentieth century a steady erosion of professional autonomy occurred in the United Kingdom. The level of remuneration has been restricted for most doctors for nearly fifty years, whilst the costs of health care have steadily reduced the doctor's ability to provide unrestricted care within the health care system. Reorganisation of the National Health Service in 1983 and 1991 has substantially eroded professional autonomy, to the point where research developments, clinical judgement and ethical standards are all now being placed at risk.

Health Care Costs↗