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PubMed2003

Distribution of orthodontic services and fees in an insured population in Washington.

Previous attempts to quantify the amount and type of orthodontic therapy provided by nonorthodontists in the United States have relied on survey data. Although there are advantages to surveys, such as control over survey recipients and inclusion of specific questions, they also have limitations, such as low response rates, response bias, and recall bias. This study used insurance claims data from a large dental benefits provider in Washington to assess the distribution of orthodontic services and fees among various dental providers. All orthodontic claims allowed by Washington Dental Service in 2001 were retrieved, along with treatment codes, fees, and demographic information for both patients and providers. A total of 102,984 orthodontic claims were included in the study. General dentists submitted 7.0% of these claims, orthodontists submitted 90.9%, and pedodontists submitted 1.9%. Orthodontists submitted higher average fees for space maintainers, first payments, and records. The percentage of orthodontic treatment preformed by general dentists and pedodontists in this claims-based study was substantially less than what has been previously reported in survey-based studies. Additionally, a smaller percentage of general dentists and pedodontists in this study performed comprehensive treatment, compared with previous studies. This study illustrates the value of insurance claims data to assess the provision of orthodontic care.

Analysis of Variance↗
PubMed2000

Financing blood transfusion services in sub-Saharan Africa: a role for user fees?

The provision of a secure and safe blood supply has taken on new importance in sub-Saharan Africa with the onset of the AIDS epidemic. Blood transfusion services capable of providing safe blood are not cheap, however, and there has been some debate on the desirability and sustainability of different financing mechanisms for blood transfusion services. This paper examines patterns of financing blood transfusion in three countries--Côte d'Ivoire, Zimbabwe and Mozambique. It goes on to consider the conceptual options for financing safe blood, and to examine in detail the possible role of user fees for blood transfusion in Africa, developing a simple model of their likely burden to patients based on data from Côte d'Ivoire. The model indicates that, at best, there can only be a limited role for user fees in the financing of safe blood transfusion services, due mainly to the relatively high cost of producing a unit of safe blood. Charging individuals for the blood they receive is likely to be administratively complex and costly, could realistically recover only a fraction of the production costs involved, and is further complicated by the fact that the main recipients of blood transfusion in sub-Saharan Africa are children and pregnant women. If cost-recovery for safe blood is to be attempted, the most viable option appears to be that of charging a collective fee, levied upon all inpatients, not just on those who receive blood. Such a mechanism is not without problems, not least in its failure to offer incentives for more appropriate blood use, and it is still likely to recover only a portion of the costs of producing safe blood. Whether or not cost-recovery is instituted, there will remain an important role for public funding of blood transfusion services, and, by implication, an important role for foreign donor support.

Blood Banks↗
PubMed2005

Do increases in the market share of managed care influence quality of cancer care in the fee-for-service sector?

BACKGROUND: Increases in the market share of managed care in an area are associated with decreases in expenditures in the fee-for-service sector (i.e., a spillover effect). Given concerns that these decreases in expenditures result from reductions in necessary care, we examined associations between increases in managed care market share and changes in the quality of care delivered to cancer patients in the fee-for-service sector. METHODS: We studied a population-based sample of fee-for-service Medicare beneficiaries aged 66 years or older who were diagnosed with breast (N = 41,394) or colorectal (N = 48,027) cancer during 1993-1999. We used fixed effects regression analysis of SEER cancer registry and Medicare claims data to assess whether county-level increases in the market share of managed care over time were associated with the quality of cancer care. All statistical tests were two-sided. RESULTS: Increases in the market share of managed care were not associated with most quality indicators, including receipt of surveillance mammography after diagnosis for patients with breast cancer (P = .83), receipt of radiation after breast-conserving surgery among women who underwent breast-conserving surgery (P = .16), receipt of adjuvant chemotherapy for patients with stage III colorectal cancer (P = .94), or surveillance colonoscopy after treatment for colorectal cancer (P = .39). Increases in the market share of managed care were associated with increased rates of surveillance carcinoembryonic antigen testing for colorectal cancer patients (P = .001). CONCLUSIONS: Increases in managed care market share had limited or no effect on the quality of care for cancer patients. Concerns that increases in managed care would have large negative spillover effects on the quality of cancer care appear to be unfounded; however, the potential for managed care to stimulate improved quality throughout the medical care system have not yet been realized.

Aged↗
PubMed1976

Developing physical therapy fee schedules based on Social Security Amendments of 1972.

Implications of the requirements related to the documentation and justification of the cost of physical therapy services are considered. These implications include 1) the cost components of physical therapy services, 2) the development of fee schedules, and 3) reimbursement requirements of third-party payers. The development of a fee schedule based on a sampling of the prevailing rates in two San Francisco Bay area counties is presented. The relationship between cost accounting, community standards, and the "prevailing rate" as defined by Medicare is documented. Public Law 92-603 and its ramifications for physical therapy fees and salaries are discussed.

California↗
PubMed2001

An incentive plan for professional fee collections at an indigent-care teaching hospital.

The authors describe the implementation and development of an incentive plan to improve professional fee collections at an indigent-care teaching hospital. They theorized that an incentive plan based on relative value unit (RVU) productivity would increase billings and collections of professional fees. Unique RVU targets were set for individual services based on the number of faculty full-time equivalents and average reported productivity for academic physicians by specialty. The incentive plan was based on the level of expected faculty billings, measured in RVUs, for each department. A "base + incentive" model was used, with the base budget being distributed monthly throughout the year, and the incentive held as a "withhold" to be paid at the year's end only if the billing target in RVUs was met. Additionally, a task force worked with physician billing office and the hospital to improve collections. In the first year after implementation of the system was in place, important increases were noted in total RVU productivity (30.5% over the previous year) and in collections (49.5% over the previous year). Sixteen of 23 departments exceeded their incentive targets, and it was possible to make distributions of professional fees to those departments, to be used within the hospital system to enhance clinical services. Moreover, the plan created an overall positive attitude toward billings and documentation of faculty activities. The authors believe that this kind of incentive plan will be increasingly important for academic faculty working in public hospital systems.

Efficiency↗
PubMed1998

A comparison of self-reported utilization of ophthalmic care for diabetes in managed care versus fee-for-service.

PURPOSE: To assess the association between structural factors in the health care delivery system and self-reported utilization of ophthalmic services by patients with diabetes in the Medical Outcomes Study (MOS). METHODS: Self-reported utilization of ophthalmic services within the 6 months preceding enrollment into the MOS among 522 of 567 individuals with diabetes in the MOS longitudinal panel was measured. Use of eye care services was regressed (logistic model) on patient demographics, geographic location, physician specialty, type of practice, and finance plan (prepaid or fee-for-service). RESULTS: None of the variables was significantly associated with a higher or lower likelihood of having used ophthalmic services in the preceding 6 months. Thus, no difference between prepaid or fee-for-service plans or among solo practice, large multispecialty groups, or HMOs were identified. Having seen an internist, family practitioner, or diabetes specialist for diabetes care was not related to use of ophthalmic services. CONCLUSIONS: Despite a presumed greater interest in preventive health, prepaid health plans were no more or less likely than the fee-for-service sector to have patients with diabetes reporting an eye examination within the prior 6 months. Thus, steps to improve the rate of eye examinations of diabetics may need to focus beyond the structural elements of the health care delivery system.

Diabetes Mellitus↗
PubMed2004

Impact of managed care on the treatment, costs, and outcomes of fee-for-service Medicare patients with acute myocardial infarction.

OBJECTIVE: To examine the effects of market-level managed care activity on the treatment, cost, and outcomes of care for Medicare fee-for-service acute myocardial infarction (AMI) patients. DATA SOURCES/STUDY SETTING: Patients from the Cooperative Cardiovascular Project (CCP), a sample of Medicare beneficiaries discharged from nonfederal acute-care hospitals with a primary discharge diagnosis of AMI from January 1994 to February 1996. STUDY DESIGN: We estimated models of patient treatment, costs, and outcomes using ordinary least squares and logistic regression. The independent variables of primary interest were market-area managed care penetration and competition. The models included controls for patient, hospital, and other market area characteristics. DATA COLLECTION/EXTRACTION METHODS: We merged the CCP data with Medicare claims and other data sources. The study sample included CCP patients aged 65 and older who were admitted during 1994 and 1995 with a confirmed AMI to a nonrural hospital. PRINCIPAL FINDINGS: Rates of revascularization and cardiac catheterization for Medicare fee-for-service patients with AMI are lower in high-HMO penetration markets than in low-penetration ones. Patients admitted in high-HMO-competition markets, in contrast, are more likely to receive cardiac catheterization for treatment of their AMI and had higher treatment costs than those admitted in low-competition markets. CONCLUSIONS: The level of managed care activity in the health care market affects the process of care for Medicare fee-for-service AMI patients. Spillovers from managed care activity to patients with other types of insurance are more likely when managed care organizations have greater market power.

Aged↗
PubMedDate not supplied

Survey results of reduced-fee and free-of-charge dental services by the membership of the Federation of Special Care Organizations in Dentistry.

In 1996, a questionnaire was mailed to all members of the Federation of Special Care Organizations in Dentistry (FSCO) in an attempt to learn more about their professional practices. Questions focused primarily on the amount of free and reduced-fee dentistry that the membership provided to the public. The questionnaire asked respondents to identify their field of practice; estimate the amount of time, the number of patients, and the monetary value of the dentistry provided; as well as to classify the types of patients to whom they provided these dental services for free or at reduced fees. Each of the FSCO respondents reported providing an average of $14,820 in free dentistry in 1995. Not surprisingly, the respondents reported treating a significant number of special-needs patients. Members also reported spending 31.0% of their clinical time working at reduced fees and 7.4% of the time working for free. This questionnaire revealed that the Federation of Special Care member respondents are donating a significant amount of dentistry and treating a large segment of special-needs patients.

Aged↗
PubMed1987

Use of outpatient mental health services over time in a health maintenance organization and fee-for-service plans.

The authors compared the use of outpatient mental health services in a health maintenance organization (HMO) and fee-for-service plans over a 5-year period, using data from a randomized controlled trial. In any given year, enrollees in the HMO and a fee-for-service plan with identical benefits were equally likely to visit a mental health specialist. Over several years, the HMO enrollees were about 50% more likely ever to visit a mental health specialist; fee-for-service enrollees were more likely to receive mental health care in more than 1 study year.

Adult↗
PubMed1992

Cost-sharing and the future of fees for service for frail elders in state programs.

Although Congress has rejected the concept of mandatory cost-sharing under the Older Americans Act, many states already use client fee systems under state-funded home and community-based services programs. This research included a survey of actual state experiences and a review of earlier studies. States are compared on issues concerning policy and experience with fee systems, including income verification, fee schedules, termination policies, and costs of administration. Although policy and practice differ markedly across states, certain states are close to operationalizing comprehensive policies in this area. The author concludes that there is a need to conduct additional state-level demonstrations that address policy issues identified in the research. Evaluation research is needed to determine program effectiveness and efficiency, particularly concerning whether cost-sharing increases the amount of services available and ensures a high level of services to minorities.

Aged↗
PubMedDate not supplied

Quality of care of Medicare patients with diabetes in a metropolitan fee-for-service primary care integrated delivery system.

Diabetes care in the United States is suboptimal. Although closed-panel health maintenance organizations (HMOs) and the Department of Veterans Affairs (VA) report performance superior to national norms, fee-for-service performance is uncertain. To address this issue, 3 outcome and 5 process indicators were measured for 2010 Medicare diabetes patients across 22 sites in a large, fee-for-service primary care group practice. American Diabetes Association standards for glycemic control, low-density lipoprotein cholesterol, and blood pressure were met by 53%, 46%, and 19% of patients, respectively. Diabetes Quality Improvement Project/Alliance poor control markers for the same measures were exceeded by 9%, 20%, and 54% of patients. Chart abstraction demonstrated annual eye examination, foot examination, and nephropathy screening rates of 16%, 49%, and 38%, while Medicare claims showed an annual eye examination rate of 63%. Observed processes and outcomes in this fee-for-service setting were superior to reported national performance and similar to the best performance in staff-model HMOs and the VA.

Aged↗
PubMed1995

Who belongs to HMOs: a comparison of fee-for-service versus HMO enrollees.

As employers have turned to managed care to curtail the rising cost of health care benefits, the number of HMO enrollees has proliferated. Between 1984 and 1994, HMO enrollment increased from approximately 15 million to over 49 million individuals. Although research has indicated that HMOs have been effective in limiting medical costs, there is mixed evidence in the literature on how they achieve these savings. This article uses data from the 1987 National Medical Expenditure Survey to examine one hypothesis for these patterns: that HMOs enroll a healthier population than fee-for-service plans. To test this hypothesis we examine HMO and fee-for-service enrollees with respect to socioeconomic variables such as age, race, sex, income, education, health status, and location. Our results indicate that HMOs tend to enroll a younger but not much healthier population than traditional fee-for-service plans, suggesting that self-selection is not a major contributor to HMO cost savings.

Adolescent↗
PubMed2004

[Investigation of cost and medical service fee for pharmaceutical management in home medical care].

Due to the evolvement of the aged society and the steep rise in medical costs, the environment encircling the medical care industry has been changing remarkably. For this reason, it has become both necessary and fundamental for a community pharmacist to participate in home medical care through the pharmaceutical management service. We have studied the associated costs and medical service fees for pharmaceutical management in home medical care. The costs and medical service fees were calculated based on the pharmaceutical management service data collected during the three years from November 1998 to October 2001. As a result, the medical service fees were calculated using the old system which lasted until March 2002. Calculations using this system took into account 550 points per visit, up to two visits per month. Under the new system which started in April 2002, the number of visits taken into account is four times a month, 500 points for the first visit, 300 points from the second through to the forth visit. Then, we simulated a break-even point (BEP). It is clear that it is difficult for any community pharmacy to be specialized in home medical care. In order for the pharmacist to actively participate in home medical care in the future, it is necessary to further improve the system.

Aged↗
PubMed1993

Physician incomes under an all-payer fee schedule.

This DataWatch estimates physicians' net incomes under various scenarios for universal adoption of the Medicare fee schedule. American Medical Association (AMA) data on physicians' gross incomes by payer are adjusted for differences in fees across Medicare, Medicaid, and private payers. Net income (gross income net of practice costs) is shown under several alternatives. Average net incomes would range from roughly $100,000 to $200,000, depending on specialty and the particular assumptions used. General practitioners' incomes would typically rise, and income differences across specialties would be narrowed significantly. The Medicare fee schedule, as intended, would increase incomes of primary care physicians relative to specialists.

Costs and Cost Analysis↗
PubMed1995

Medicaid physician fee levels and children's access to care.

This study examines the effects of physician fees on children's use of preventive and illness-related ambulatory physician services under the Medicaid program. Using data from the 1987 National Medical Expenditure Survey (NMES), we examine the effects of Medicaid fee generosity on physician service use and overall ambulatory physician spending. The results indicate that more generous fees are associated with a greater likelihood of having a doctor's office as a usual source of care and a higher number of preventive visits at office-based sites of care. Having a doctor's office as a usual source of care is associated with lower overall ambulatory physician expenditures.

Child↗
PubMed1981

The effect of a thirty per cent reduction in physician fees on Medicaid surgery rates in Massachusetts.

In this paper, we use an interrupted time series analysis to assess the effect of a 30 per cent reduction in the Medicaid reimbursement fee for physician services on the rate at which eight elective surgical procedures were performed in the Massachusetts Medicaid population. Tonsillectomy/adenoidectomy is the only procedure in which there was a statistically significant decline in the rate of surgery in most areas of the state following the fee cut. There is some evidence of an increase in the rate of disc surgeries/spinal fusions. The rate of other procedures increased in some areas of the state and decreased in other areas in the period after the fee cut.

Adenoidectomy↗
PubMed1991

Geographic variation in relative fees under Medicare.

Little is known about geographic variation in Medicare's relative fee structure. Using 1986 Part B Medicare claims data, ratios among physician fees for surgical procedures belonging to small families of closely related procedures, excluding outliers, were found to vary up to twofold. Under Medicare's current system of physician payment, physicians in different areas face different financial incentives for performing one procedure in preference to possible alternatives. Changes in incentives under a resource-based Medicare fee schedule will be more pervasive than previously recognized.

Economics, Medical↗
PubMed2002

Body MR imaging and CT volume: variations and trends based on an analysis of medicare and fee-for-service health insurance databases.

OBJECTIVE: We examined Medicare and fee-for-service data sets to understand better the utilization of MR imaging for imaging the pelvis, abdomen, and chest relative to its use in imaging for other body parts and to the utilization of CT. MATERIALS AND METHODS: CT and MR imaging procedure volumes for pelvis, abdomen, chest, and total were extracted from the 1993, 1996, and 1999 Health Care Financing Administration Physician/Supplier Procedure Summary Master Files, based on CPT-4 codes. We also analyzed a fee-for-service health insurance database for January 1998 through July 1999 from a single northeastern state, which included provider location (rural, suburban, or urban) and type (teaching or nonteaching site). RESULTS: The greatest 3-year Medicare increase was for abdominal MR imaging, from 1996 to 1999 (101% increase). However, pelvic, abdominal, and chest MR imaging together remained less than 5% of total MR imaging. Abdominal MR imaging increased more than did total MR imaging in all 10 Health Care Financing Administration regions. In the fee-for-service database, the relative procedure volume of abdominal MR imaging varied approximately fivefold from rural to urban provider locations, and approximately double from nonteaching to teaching hospitals. CONCLUSION: Although far more abdominal CT than abdominal MR imaging is performed, the rate of abdominal MR imaging utilization has increased more rapidly since 1993. The relative procedure volume of abdominal MR imaging varied more than fivefold from rural to urban provider locations and double from nonteaching to teaching hospitals.

Abdomen↗