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PubMed1986

Joint ventures and illegal remuneration: the pressure is growing.

As the healthcare industry becomes more involved in joint venture activity, it must become more concerned with the possibility of illegal remuneration. Illegal remuneration, or the soliciting, receiving, offering, or paying of remuneration in return for the referral of patients or generation of business, is treated very seriously by HHS and the courts. Therefore, joint ventures must be constructed to avoid the danger areas as much as possible, or at least, minimize the risk.

Commerce↗
PubMed1993

Doctor and patient characteristics as modifiers of the effect of a changing remuneration system in general practice.

The objectives of the study was to investigate the effects on general practitioners' activities of a change in their remuneration system from a capitation-based system to a mixed fee-per-item and capitation-based system. It was our hypothesis that the effect of the change in remuneration varied between subgroups of doctors and patients as a result of the modifying effect of the doctors' age, sex, practice facilities, assistance, side jobs, and size of practice as well as patients' age, sex, and diagnostic group. The study was carried out as a follow-up with data collected from contact sheets completed by general practitioners in one period before a change in remuneration and two periods after. These data were supplemented by a questionnaire on doctors' characteristics as well as by health insurance data on population characteristics. The general increases in diagnostic and curative activities and reductions in referrals by general practitioners as a result of the change were found to be quite similar across subgroups of doctors and patients. While, total contact rates changed little, the sex of doctors showed a modifying effect: male doctors tended to increase their contact rates compared to female doctors. This tendency was most prominent among female patients with non-infectious diseases.

Age Factors↗
PubMed2004

Recruitment of voluntary non-remunerated apheresis donors: the second five years' experience in Shenzhen.

The voluntary non-remunerated blood donation campaign in Shenzhen, China, was launched in 1993 and the smooth change from paid donors to unpaid took only a decade. In the first half the volunteer donation system and a sufficient blood supply was promoted and this paved the way for further development in the second half during which the non-remunerated donation system became substantial and integral due to recruitment for plateletapheresis and peripheral stem cells donation as well as whole blood donations. Ninety percent of the donors registered for plateletapheresis do donate and none of the twenty-three non-related donors with matched HLA genotypes broke their promise to donate their peripheral stem cells.

Altruism↗
PubMed2004

[New forms of remuneration and care delivery: their impact on rehabilitation].

Current health policy reform efforts in Germany include introduction of a DRG (Diagnosis Related Group) based funding system in the hospital sector as well as integrated delivery of health care and disease management programs, developments that will directly affect the medical rehabilitation sector. Decreasing lengths of hospital stay induced by the DRG system will inter alia entail a shifting of cases and costs to subsequent sectors. Moreover, hospitals might not least seek compensation for shorter hospital stays by extending their scope to include rehabilitation and long-term care services. Introduction of the DRG system in acute-hospital care has resulted in major changes in respect of early rehabilitation. Existing specialized early rehabilitation facilities providing high-quality care face serious funding problems on account of the newly introduced early rehabilitation DRGs. For hospitals previously not involved in early rehabilitation on the other hand, incentives arise to set up new early rehabilitation structures although the need for these additional capacities obviously is questionable. Introduction of the DRG-based funding system has reinforced the discussion about applying a flat-rate system also in the rehabilitation sector. This form of remuneration however is inappropriate to medical rehabilitation concepts. On the other hand, a remuneration system incorporating cross-institutional per-diem fees and "treatment time" budgets might enable using essential advantages of flat-rate payment without having to expect repercussions for the quality of care. In the context of integrated care and disease management programs the issue at stake for rehabilitation primarily is to be able to contribute its specific competencies appropriately. Also, integrated health care is bound to result in stronger competition among the various health care sectors. If rehabilitation is set to face this competition, further research efforts will urgently have to be made along with ongoing development of clinical practice guidelines.

Budgets↗
PubMed1996

The remuneration of dentists in a special project of the Israeli Defence Forces.

The behavior of health care professionals is known to be influenced, in part, by their method of remuneration and the financial incentives they face. Describes how the Medical Corps of the Israel Defence Forces (IDF) went about choosing a reimbursement method to increase incentives for dentists and decrease waiting time for the public. Based on q questionnaire sent to all 23 dentists working in a unique IDF civilian dental clinic, and on other information which was available on the productivity and income of these dentists, a new method of remuneration was suggested and accepted, by which a combined method of fee-for-service and salary will be introduced. The base hourly pay and per crown fee were set on levels which provide for a larger compensation range and increase the incentive for improved productivity levels. This suggested method will be investigated further and re-evaluated one year after its implementation.

Attitude of Health Personnel↗
PubMed1993

Effect of the remuneration system on the general practitioner's choice between surgery consultations and home visits.

OBJECTIVE: To assess the influence of the remuneration system, municipality, doctor, and patient characteristics on general practitioners' choices between surgery and home visits. DESIGN: Prospective registration of patient contacts during one week for 116 general practitioners (GPs). SETTING: General practice in rural areas of northern Norway. MAIN OUTCOME MEASURE: Type of GP visit (surgery v home visit). RESULTS: The estimated home visit rate was 0.14 per person per year. About 7% (range 0-39%) of consultations were home visits. Using multilevel analysis it was found that doctors paid on a "fee for service" basis tended to choose home visits more often than salaried doctors (adjusted odds ratio 1.90, 99% confidence interval 0.98, 3.69), but this was statistically significant for "scheduled" visits only (adjusted OR 4.50, 99% CI 1.67, 12.08). Patients who were older, male, and who were living in areas well served by doctors were more likely to receive home visits. CONCLUSION: In the choice between home visits and surgery consultations, doctors seem to be influenced by the nature of the remuneration when the patient's problem is not acute. Although home visiting is a function of tradition, culture, and organisational characteristics, the study indicates that financial incentives may be used to change behaviour and encourage home visiting.

Acute Disease↗
PubMed1996

Costs and remuneration for cervical screening in general practice in the west of Scotland.

OBJECTIVES: To investigate associations between costs and remuneration for cervical screening in general practice in relation to skill mix, features of practice structure and deprivation levels in the local area; and, to identify efficient policies for organising cervical screening in general practice. METHOD: Questionnaire survey and interview study in 87 general practices in Greater Glasgow Health Board an area in the west of Scotland which covers a socio-economically varied population. The main outcome measures were remuneration to cost ratios (RCRs) for cervical screening and their natural logarithms (logRCRs). RESULTS: Both the costs of cervical screening and RCRs varied widely between the 87 practices taking part. RCRs ranged from 0.29 to 14.67 (mean 2.64, median 2.18, interquartile range 1.15-2.98). Twenty-one per cent (18) of practices earned less than they spent on the organisation of screening, whilst 9% (8) of practices had PCRs of more than 5:1. RCRs were significantly lower if medical staff were involved in either taking smears or dealing with results. RCRs did not vary by social deprivation score, despite uptake being lower in practices in more deprived areas. This was explained by nurses working in practices in deprived areas being more likely to take smears than nurses working in more affluent areas. Sensitivity analyses were undertaken, altering key time and cost assumptions. As a result, the absolute values of the RCRs changed, although the overall pattern of association did not, with the exception of doctor involvement in processing results which was no longer significant when average general practitioners' income was substituted for locum rates. CONCLUSIONS: Practices in deprived areas may be responding to greater pressure of work by making optimal use of skill mix within the primary health care team. A more graduated incentive payment scheme may more fairly reward practices in deprived areas which are less likely to achieve 80% uptake due to relatively intractable features of practice structure. Assuming that practice nurses provide an equivalent quality of service to that provided by general practitioners, results suggest that doctor-nurse substitution would be cost-effective for general practice based cervical screening. Resource savings (principally doctor's time) could be redeployed to other areas of primary health care.

Clinical Competence↗
PubMed2006

Remunerating primary care physicians: emerging directions and policy options for Canada.

How primary care physicians are remunerated is an important component of healthcare reform debates in Canada. This paper contributes to the policy debate by drawing together the theoretical insights gained from existing economic theory and evidence on how payment schemes affect physicians' behaviour. Several policy implications for the efficient and effective remuneration of physicians emerge from the analysis, as do directions for future research.

Canada↗
PubMed1999

Method of physician remuneration and rates of antibiotic prescription.

BACKGROUND: Rates of antibiotic prescription in Canada far exceed generally accepted rates of bacterial infection, which led the authors to postulate that rates of antibiotic prescription depend to some extent on factors unrelated to medical indication. The associations between antibiotic prescription rates and physician characteristics, in particular, method of remuneration and patient volume, were explored. METHODS: The authors evaluated all 153,047 antibiotic prescriptions generated by 476 Newfoundland general practitioners and paid for by the Newfoundland Drug Plan over the 1-year period ending Aug. 31 1996, and calculated rates of antibiotic prescription. Linear and logistic regression models controlling for several physician characteristics, specifically age, place of education (Canada or elsewhere), location of practice (urban or rural) and proportion of elderly patients seen, were used to analyse rates of antibiotic prescription. RESULTS: Fee-for-service payment (rather than salary) and greater volume of patients were strongly associated with higher antibiotic prescription rates. Fee-for-service physicians were much more likely than their salaried counterparts to prescribe at rates above the median value of 1.51 antibiotic prescriptions per unique patient per year. The association between rate of antibiotic prescription and patient volume (as measured by number of unique patients prescribed to) was evident for all physicians. However, the association was much stronger for fee-for-service physicians. Physicians with higher patient volumes prescribed antibiotics at higher rates. INTERPRETATION: In this study factors other than medical indication, in particular method of physician remuneration and patient volume, played a major role in determining antibiotic prescribing practices.

Adult↗
PubMed2000

A safer plasma supply from remunerated donors--"The Immuno/Community Bio-Resources experiment".

With the goal of increasing the safety of plasma used in the manufacture of therapeutic products, Immuno and its subsidiary Community Bio-Resources (now a division of Baxter Healthcare Corporation), have developed a comprehensive plasma quality programme. This programme includes four main safety initiatives: a plasma centre location/appearance programme, a Qualified Donor programme, an Inventory Hold, and the PCR testing of plasma pools. Many of these initiatives have been adopted in part by the plasma collection and fractionation industry. Using a statistical model that takes into consideration the unique donation characteristics of remunerated plasma donors, combined with 1998 CBR virus reactive rates, an estimated residual likelihood of an undetected donation entering a plasma pool was determined. These estimates, for each million donations, were 0, 1.64, and 4.68 donations for HIV, HBV, and HCV, respectively, and were far below those previously reported for remunerated or volunteer donations. These estimates were confirmed by subsequent PCR testing, which allowed for the additional removal of positive units before manufacture. The low virus load of this plasma supply, combined with increasingly effective virus removal and inactivation procedures, has resulted in the safest ever supply of plasma derivatives.

Biological Products↗
PubMed1993

Collection of source material from remunerated donors.

The collection of plasma for further manufacture into medicinal products and in vitro diagnostic reagents is predominantly accomplished in the USA through the remuneration of donors who participate in plasmapheresis programmes. A well regulated system under the control of the Food and Drug Administration has been in place since the mid-1970s. Requirements of this regulatory system with regard to the need for donor acceptance and frequency of participation criteria, and plasma acceptability standards are reviewed. Information regarding several groups of donors participating in plasmapheresis procedures at various frequency intervals over 10 years is presented. Data on microhaematocrit, body weight, total protein, and individual serum protein distribution have been compiled and statistically analysed; the results of these analyses are included. Given the existence of a comprehensive approach which encompasses donor safety, plasma testing, and effective manufacturing procedures, safe and efficacious plasma derivatives can be produced from plasma drawn from remunerated donors and can be made available in sufficient quantity to meet medical needs in an economic manner.

Biological Products↗
PubMed1996

Family practitioners' intervention against smoking in Germany and the UK: does remuneration affect preventive activity?

The effect of different systems of remuneration on preventive activity of family practitioners (FPs) were studied. Interventions against smoking were compared in FPs' practices in Germany and the UK. Almost 800 consecutively attending patients were included in a cross-sectional survey. Smoking prevalence was remarkably similar among German and British practice attenders. Slightly more than 50% of smokers in both countries remembered an intervention against their smoking by their FP or related staff. Multiple logistic regression analysis also showed that there was no significant difference for remembered interventions between the two countries (adjusted OR 1.15 [95%-Cl 0.6, 2.2]). The structure of interventions employed was similar in both countries. Most British and German ex-smokers denied that their FP had made an important contribution to their giving up smoking. There is evidence that, under capitation, FPs concentrate their activities on patients who are more at risk. Overall, however, the economic structure does not seem to influence the core of preventive behaviour of FPs to any great extent. Smoking cessation efforts in Family Practice need to be improved in both countries.

Cross-Sectional Studies↗
PubMed1998

Family practitioners' remuneration and patterns of care--does social class matter?

The objective of the study is to examine whether medical care patterns and/or outcomes for patients under a prepaid system differ from those under fee-for-service according to social class. An effect of this kind was suggested by the investigators reporting on the RAND Health Insurance Experiment (RAND HIE). We performed a cross-sectional study in family practice in Germany (fee-for-service) and the UK (predominantly capitation i.e. prospective payment). 778 attending patients aged 18 and above were included. Indicators of care, relating mainly to cardiovascular prevention, were collected by patient interview and questionnaire, doctor's questionnaire, analysis of records, and blood pressure (BP) measurement. Multiple linear and logistic regression models with these indicators as dependent variables were calculated to examine possible interactions between social class and system of payment. Social class as a main effect was related to diastolic BP, BP measurement frequency, and the number of non-pharmacological interventions to lower BP. The data on the process and the outcome of primary care from British and German family practice do not show any significant interaction between system of family practitioners' remuneration and patients' social class. We were unable to reproduce the effect postulated by the RAND HIE investigators.

Adolescent↗
PubMed1996

The effect of capitated and fee-for-service remuneration on physician decision making in gynecology.

OBJECTIVE: To evaluate the variations in physician behavior leading to performance of gynecologic surgical procedures related to fee-for-service and capitation reimbursement systems. METHODS: This study compared the physician practice utilization of surgical services for fee-for-service and capitated contract reimbursement systems within a gynecology clinic. Attending gynecologists were reimbursed on a fee-for-service basis for all surgical services performed during a 6-month interval; subsequently, the same physicians were reimbursed on a capitated basis for 6 months and received a fixed payment for the clinical and surgical services provided. RESULTS: Three thousand seven hundred eighty consecutive outpatient gynecology visits were evaluated at the university gynecology clinic during 1994. We found a 15% overall decrease in the number of surgical procedures that were performed during the capitated reimbursement period compared with the fee-for-service time interval. The procedure most responsible for the reduction of surgical services was elective sterilization by laparoscopy, which underwent a statistically significant decrease (P < .01). CONCLUSION: The remuneration system in our review seemed to affect physician decision making for only the most elective procedures, whereas physicians maintained similar practice patterns for more severe conditions. Fee-for-service seems to encourage, whereas capitation seems to discourage, gynecologist from performing elective procedures.

Adult↗
PubMed1989

Scottish dentists' preferences for remuneration and their opinions on the scope of General Dental Service treatment.

A questionnaire was sent to a list of what was considered to be all dentists currently in practice in the General Dental Service (GDS) and Community Dental Service (CDS) in Scotland; 72% responded. The dentists were asked to indicate the general method by which they would prefer to be paid, given a choice of fee for item-of-service, salary or capitation. Opinion was split among the GDS respondents, between fee for item-of-service (34.9%), a salaried system of payment (32.6%), or a service based on differing remuneration systems for the dental care of adults and children (22.5%). Only 22.6% of GDS respondents said they would prefer a capitation system for the treatment of child patients. Most CDS respondents said they preferred to be salaried. Dentists in both services were asked if they felt there was a need to extend the range of treatment items which are currently permitted in the GDS; most felt that there was. About 80% of all respondents felt that there was a need to allow payment for various items of preventive dental care within the GDS. Almost a third of GDS respondents also mentioned various items of restorative dental treatment which they felt should be funded (a concern which fewer CDS respondents (6.7%) mentioned). Few respondents suggested any other additional types of treatment items.

Attitude of Health Personnel↗
PubMed2005

Motivation, recruitment and retention of voluntary non-remunerated blood donors: a survey-based questionnaire study.

BACKGROUND AND OBJECTIVES: The aim of this study was to establish which motivational and socio-demographic factors are important for the development of a long-term commitment as a voluntary, non-remunerated blood donor. STUDY DESIGN AND METHODS: A cross-sectional sample survey of active blood donors in Oslo, Norway, was conducted. Donors filled in a self-administered questionnaire during donation. Data on motivation were analysed using factor analysis. RESULTS: The blood donors' socio-demographic characteristics were found to be similar to those of the population as a whole. The single, most important, recruitment channel was the influence of active blood donors. Five dimensions of blood-donor motivation were identified with factor analysis. These were: altruism and empathy; social reasons (such as the influence of friends and family); strengthening of one's self-esteem; positive experiences associated with donation; and a moral obligation to donate. Support for statements on altruistic motives for donation was strong and similar in long-time and short-time donors. In contrast, short-time donors were more likely to be motivated by factors related to self-esteem than were long-term donors. CONCLUSION: The 'good habit' of continued blood donation seems not to be exclusively linked to a high degree of reported other-regarding ('altruistic') reasons, but also to a combination of motives, including some modestly self-regarding motives.

Altruism↗
PubMed2004

Consultants in nhs scotland: a survey of work commitments, remuneration, job satisfaction and retirement plans.

BACKGROUND AND AIMS: UK consultants have reported working long hours, increased stress and reduced morale. This study set out to elicit consultants' views on flexible working and to gather data on consultants' workloads, remuneration, job satisfaction and retirement plans. As such it is the first comprehensive study of consultants in NHS Scotland. METHODS: The Information and Statistics Division of the Scottish Executive Health Dept provided a list of consultants working in NHS Scotland Focus groups and interviews informed the design of a postal self-completion, questionnaire. RESULTS: The response ratewas 61%. Almost two-thirds (65%) of respondents felt their workloads were unreasonable and unsustainable and 67% were unable to provide their desired standards of patient care. Two-thirds (67%) did not normally take meal breaks, 63% had insufficient time for outside interests, whilst 44% felt their health was being adversely affected Many (84%) believed that some of their work could be delegated to someone less qualified but 79% agreed that there were insufficient staff to make this possible. The average planned retirement age was 60 years, with 23% describing their plans as definite and 70% as quite or very likely. When asked what might induce them to postpone retirement, 50% cited reduced workload/work intensity. CONCLUSIONS: In 2003, a majority of consultants in the UK voted in favour of the new consultant contract. This will improve consultant pay and introduce a standard 40-hour working week, including worked on-call. This should address tow of the main areas of consultant dissatisfaction in NHS Scotland. However, staff shortages will require to be addressed if the contract is to be successfully implemented.

Adult↗
PubMed1985

A cost comparison of alternative remuneration arrangements for visiting orthopaedic surgeons at a major Sydney teaching hospital.

The remuneration of medical practitioners working in public hospitals has emerged as a critical issue during the doctors dispute associated with the Medicare programme in New South Wales. In this paper the authors present the findings of a study, conducted at the Prince Henry/Prince of Wales Hospitals Group, of the costs of replacing the present sessional arrangements for treatment of non-changeable orthopaedic patients with a system of fee-for-service payments. Under certain assumptions, public hospitals could find that fee-for-service becomes a cheaper method of payment for certain surgical procedures.

Australia↗