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PubMed2004

[Inpatient treatment costs of skin diseases. Diagnosis-based cost calculation in a university dermatology clinic].

BACKGROUND AND OBJECTIVE: With the advent of the DRG system, German hospitals are being forced to improve cost transparency and to uncover inefficient structures. METHODS: Diagnosis-based costs were calculated in the Department of Dermatology in the University Hospital of Freiburg for ten samples, each containing 20 cases. By using in-patient files, cost and productivity information for the fiscal year 2000 was attributed to each single case in a bottom-up-approach. The resulting total costs per case were contrasted to their remuneration under the DRG system. RESULTS: Average case costs were determined between EUR 1,339.83 and EUR 5,714.73. With 19.3% to 28.4% of total costs, nursing costs were the biggest single cost factor. Prolonging the length of stay incurred average extra costs of EUR 144.26 to EUR 199.98 per case and day. The correlation of case costs and their corresponding DRG cost weights was modest with r=0,48. There was considerable cost variance within individual DRGs. CONCLUSIONS: The diagnosis-related cost calculation reveals striking cost differences relating to specific diagnoses. This method is more suitable for cost calculations in the hospital than more general approaches.

Academic Medical Centers↗
PubMed2006

Patient and provider perceptions of care for diabetes: results of the cross-national DAWN Study.

AIMS/HYPOTHESIS: We assessed country-level and individual-level patterns in patient and provider perceptions of diabetes care. METHODS: The study used a cross-sectional design with face-to-face or telephone interviews of diabetic patients and healthcare providers in 13 countries from Asia, Australia, Europe and North America. Participants were randomly selected adults with type 1 or type 2 diabetes (n=5,104), and randomly selected diabetes-care providers, including primary-care physicians (n=2,070), diabetes specialist physicians (n=635) and nurses (n=1,122). Multivariate analysis was used to examine the relationships between outcomes and both country and respondent characteristics, and the interaction between these two factors. RESULTS: Providers rated chronic-care systems and remuneration for chronic care as mediocre. Patients reported that ease of access to care was high, but not without financial barriers. Patients reported moderate levels of collaboration among providers, and providers indicated that several specialist disciplines were not readily available to them. Patients reported high levels of collaboration with providers in their own care. Provider endorsement of primary prevention strategies for type 2 diabetes was high. Patients with fewer socio-economic resources and more diabetes complications had lower access (and/or higher barriers) to care and lower quality of patient-provider collaboration. Countries differed significantly for all outcomes, and the relationships between respondent characteristics and outcomes varied by country. CONCLUSIONS/INTERPRETATION: There is much need for improvement in applying the chronic-care model to the treatment and prevention of diabetes in all of the countries studied. Each country must develop its own priorities for improving diabetes care and comparison with other countries can help identify strengths as well as weaknesses.

Adolescent↗
PubMed2005

Is there a gender difference on the association between informal work and common mental disorders?

Economic activity in Brazilian women has been increasing in recent years, particularly in the form of under- and self-employment, which allows more flexibility in the work schedule and facilitates part-time work, a crucial issue for women reconciling family duties and the need for a remunerated occupation. This paper investigates the gender difference in the association between employment status and common mental disorders (CMD). A cross-sectional survey of a random sample of private households included 683 adults aged 15 years and over living in Olinda, Brazil. The self-reporting questionnaire (SRQ-20) was used to estimate the prevalence of CMD. The association between unemployment and CMD for men (OR=1.77, 95% CI 0.8-3.9) was in the same direction as that found for women (OR=2.66, 95% CI 1.1-6.3), but not significant. In contrast to this, while women working in the informal sector were more likely to be a case of CMD than formal workers (OR=3.02, 95% CI 1.3-7.2), no difference was found for informally working men (OR=1.08, 95% CI 0.5-2.4). The estimated OR for female informal workers was out of the 95% confidence intervals of the corresponding OR estimated for males, and the test for interaction was statistically significant (p=0.04). From a policy perspective, the value of encouraging people to take informal work depends both on how quickly individuals can be moved out of unemployment into informal work compared to other destinations, and how well individuals fare once in informal work. The results of the present study suggest that working outside the protection of employment legislation and with limited opportunity for skill use may be a risk for women's mental health.

Adolescent↗
PubMed2003

Anti-kickback laws and safe harbor protections: brief review for surgeons.

The objective of this review is to provide surgeons basic knowledge regarding the Anti-kickback Statute (AKBS) and safe harbors available for legitimate business activities. The rising costs associated with fraudulent activities have led Congress to demand accountability, fiscal responsibility, and reduction of error rates. To deter and prosecute fraud and abuse, the government currently has available an array of civil and criminal remedies, supported by a number of statutes, investigated by multiple agencies and enforced by the Department of Justice. One such statute is the AKBS. This law makes it a crime to exchange any remuneration for patient referrals. Congress has also issued 23 "safe harbors", which are activities that are protected from prosecution and allow physicians to participate, invest, recruit, joint venture, and refer patients under certain conditions. It is necessary for surgeons to have some knowledge of the AKBS, as well as the various safe harbors provided by the legislature, for lawful business relationships.

Fraud↗
PubMed2003

The efficiency of treatment strategies of general practitioners. A Malmquist index approach.

It is widely recognized that general practitioners (GPs) play a key role in determining the use of resources for ambulatory care. In addition to the GPs' working hours, these resources consist of the work of specialists and that of hospital physicians treating the GPs' referrals and the cost of medication and other measures induced by the GP. Different systems of remuneration differ in their power to lead to efficient service provision. This contribution provides empirical evidence on the efficiency of service provision by Austrian GPs. The analysis is based on data for some 600 GPs. The data comprise sufficient information to assess the GPs' efficiency with regard to the way they manage their cases. Data Envelopment Analysis, a nonparametric technique, is used to estimate the production frontier. The results suggest that almost one-half of the GPs in the sample have a relative efficiency of 0.8 or less. A Malmquist decomposition of the productivity change reveals a decline in productivity. This is due to a pronounced negative shift of the frontier whereas individual efficiency rises against the weaker benchmark of the new frontier.

Journal Article↗
PubMed2005

Defining the "Health Benefit Basket" in nine European countries. Evidence from the European Union Health BASKET Project.

This article identifies and analyses a framework for "health baskets," the taxonomy of benefit catalogues for curative services, and the criteria for the in- or exclusion of benefits in nine EU member states (Denmark, England, France, Germany, Hungary, Italy, The Netherlands, Poland and Spain). Focusing on services of curative care, it is found that the explicitness of benefit catalogues varies largely between the countries. In the absence of explicitly defined benefit catalogues, in- and outpatient remuneration schemes have the character of benefit catalogues. The criteria for the in- or exclusion into benefit catalogues are often not transparent and (cost-)effectiveness is applied only for certain sectors. An EU-wide harmonization of benefit baskets does not seem realistic in the short or medium term as the variation in criteria and the taxonomies of benefit catalogues are large but not insurmountable. There may be scope for a European core basket.

Cost-Benefit Analysis↗
PubMed1994

Why students choose a primary care or nonprimary care career. The Specialty Choice Study Group.

PURPOSE: To analyze the factors influencing students to choose residency training in primary care (internal medicine, family medicine, and pediatrics) or nonprimary care specialties and study the combined effect of reported responses on their choice. MATERIALS AND METHODS: A 12-item questionnaire using a 7-point Likert scale was mailed to the 1,164 graduating seniors from 9 medical schools in 1991. Responses ranged from 1, very negative influence, to 7, very positive influence. Four indicated no influence. The overall response rate was 69%. Univariate analysis of factors associated with specialty choice was done with the Mantel-Haenzsel chi-square test. Odds ratios were calculated for each significant variable without controlling for other variables. Factors found to have univariate significance were then tested for combined significance with logistic regression analysis. The regression was performed on a randomly chosen training sample, and validated on a test sample. RESULTS: Forty-five percent of respondents chose an internship and planned residency training in a primary care specialty. Factors that remained positively associated with choosing a primary care specialty when controlling for other factors were desire to provide comprehensive care, to keep options open, and to undertake ambulatory care. Desire for monetary reward was negatively associated with choice of a primary care specialty. CONCLUSIONS: Positive educational experiences in the ambulatory setting should be enhanced, and disparity in remuneration among disciplines reduced.

Adult↗
PubMed1994

Training of clinical laboratory professionals in Russia.

In Russia, specialized education of clinical laboratory physicians who work in the positions of medical technologists, head of laboratory or one of its divisions is conducted in various forms of postgraduate training, namely internship, primary specialization courses, advanced study courses, graduate clinical studies and postgraduate fellowship. Such education is offered at 14 Departments for Clinical Laboratory Diagnostics, which are located within the Institutes for Advanced Medical Studies or at Faculties for Advanced Medical Studies in Medical Institutes. Until the present, the primary specialization courses and the advanced study courses have been the most prevalent forms of training clinical laboratory professionals. These two types of courses offer formal lectures, seminars as well as practical classes, and the course contents are regulated by a uniform curriculum promulgated by the Ministry of Health. Training in these courses is the necessary prerequisite to obtain degree of advanced qualification as an expert in clinical laboratory diagnostics, which in turn provides access to better remunerated positions.

Accreditation↗
PubMed1991

Sources and consequences of satisfaction and dissatisfaction in nursing: findings from a national sample.

The implications for the current nursing shortage of the job satisfaction and dissatisfaction described by 252 members of the American Nursing Association are discussed. Comparison of sources of dissatisfaction by the frequency with which they were mentioned, the strength of emotion with which they were expressed and their potential to provoke defection from nursing, indicate inadequate working conditions and counter-productive attitudes within employing organizations to be the most serious sources of dissatisfaction. Dissatisfaction with remuneration and benefits rank second to structural problems, by each measure. The relative importance of problems with gender and family roles, colleagues, education, and professional associations, and of respect, recognition, and autonomy issues are also discussed.

Adult↗
PubMed1989

The ecological model and the study of child abuse in Nigeria.

Physical abuse and exploitative child labor are two common forms of child abuse in Nigeria. Exploitative child labor exists in both the formal and informal sectors where children work as hairdressers, beggars' assistants, hawkers, and as factory and agricultural workers under conditions characterized by long hours, hazardous environment, and meager remuneration. Research on the incidence of physical abuse in Nigeria is less systematic, and few empirical studies are available. Physical abuse is primarily the result of corporal punishment which has become excessive. Poverty and the existence of a dependent capitalist economy are often proffered as the primary causes of child abuse. While both explanations have some validity, their unidimensional nature limits their explanatory capacity. These explanations also lead to the belief that very little can be done to improve the quality of children's lives until the social order is restructured. The ecological model proposes that child abuse can best be understood if it is analyzed multidimensionally with emphasis on the individual, family, social environment, and cultural milieau, as well as the dynamic interaction between these levels. This model appears appropriate for the study of child abuse in Nigeria, and its application is advocated as a vehicle for improving the quality of child abuse research.

Child↗
PubMed1987

Incentives for cost-effective physician behavior.

The objective of the National Health Service is to maximise improvements in the health status of patients regardless of their willingness and ability to pay. To achieve this objective it is necessary to identify those procedures which maximise improvements in health or quality adjusted life years (QALYs) and direct scarce resources to those therapies with the best cost-QALY characteristics. Unfortunately in the NHS and elsewhere cost-QALY characteristics are largely unknown and the structure of the health service and its provider remuneration systems are such that objectives are vague, behavior perverse due to the haphazard construction of incentive systems, and health status outcomes often unknown due to the failure to evaluate input-outcome relationships. To reform the NHS, in particular ensure more efficient practice by physicians, existing perverse incentives will have to be replaced by the use of buyer (NHS) power and by budgeting mechanisms which induce economizing behavior. It is not clear which type of incentive mechanism will produce outcomes consistent with NHS goals. To remedy this ignorance experimentation with careful evaluation would seem appropriate.

Cost-Benefit Analysis↗
PubMed1987

Cost containment in a statutory health insurance scheme by substitution of outpatient for inpatient care? The case of the Bavarian Contract.

Among manifold attempts at containing the rapid growth of health care expenditure, one which attracted considerable attention was the 1979 agreement between Bavarian sick-funds and the office-based physicians of Bavaria that, in some ways, reshaped the remuneration scheme for ambulatory medical treatment. This so-called 'Bavarian Contract' tried to approach cost containment by initiating transsectoral substitution processes in favour of outpatient medical care and to the disfavour of, above all, the hospital sector of the health care system. This paper deals with the question whether in Bavaria (between 1979 and 1983/84) the structure of services and prescriptions was modified in a way that indicates the occurrence of substitution processes as intended by the 'Bavarian Contract'; also, whether there is any evidence of cost containment effects brought about the intensifying the ambulatory services of office-based physicians. The study results provide some weak hints at substitution processes in favour of ambulatory services; but there is no evidence that expanding ambulatory medical services may help to contain the growth of health care expenditure.

Algorithms↗
PubMed1985

Subsidizing pharmaceutical prescriptions: the experience of Denmark, Finland, Norway and Sweden.

In 1980, drug consumption per capita was 455 Swedish crowns (SEK) in Sweden, SEK 452 in Denmark, SEK 384 in Finland and SEK 382 in Norway; actual figures for Denmark, Finland and Norway being converted into Swedish crowns using the mean 1980 exchange rates. To what extent can these differences be explained by differences in the drug reimbursement programmes of these four Nordic countries? For instance, is it the greater generosity of the Swedish system--in Sweden, the share of drug reimbursement expenditures to total drug consumption is 57%, as against 33% in Norway, 38% in Finland and 34% in Denmark--that makes drug consumption per capita so much higher in Sweden? If the demand for drugs were elastic and if all other influencing factors, besides the reimbursement system, were the same in all the four Nordic countries, then a definite conclusion would, obviously, be fairly easy to reach. However, a number of factors do differ: for instance, income per capita, physician remuneration schemes (and, hence, maybe, physician behaviour) and consumer charges for inpatient and outpatient care; and other factors such as morbidity and patterns of illness may differ. A complete analysis has to take all these factors into account. Too many factors seem to vary to make the sole use of cross-section data meaningful in this case. Time-series data are available and will be used in future analyses.

Cost Control↗
PubMed1985

The nature, meaning and measurement of health and illness: an economic viewpoint.

Health can be seen as a capital asset, subject to depreciation due both to the passage of time (ageing) and to 'wear and tear'. It is valued for the flow of pain-free time and energy it offers us, and we can increase the quantity and quality of this 'flow' by appropriate care and maintenance, which may take the form of adopting a healthy life style or in seeking health care. The valuation of health (as a capital stock) can then be seen as the valuation of the time profile of the stream of pain-free time and energy we expect to get out of it. This in turn depends on the uses to which this time and energy can be put. Its use in paid work is relatively easily valued but unpaid work (especially work in the home) continues to be a source of difficulty, both in principle and in practice, in the search for appropriate money values. Leisure time is still more difficult, though for those in paid work whose remuneration is sensitive to the work/leisure balance, foregone net earnings at that margin may be used in the marginal value of leisure time. But the appropriateness of any valuation depends on the use to which it is to be put, and it is important to distinguish whether it is to reflect 'individual' or 'group' values, and whether it is for ex post compensation associated with some particular event, or for use in ex ante decision making where it is not known who the particular gainers and losers will be.

Decision Making↗
PubMed1986

Physician-induced demand by Irish GPs.

Approximately one-third of the Irish population receive all medical care services free. GPs (general practitioners) treat both public and private patients, and are remunerated on a fee-for-service basis by the state for public patients, and by the patient, at a higher rate, for private patients. In 1981, the first author conducted a national survey of Irish medical care utilization, asking whether patients' most recent GP visits resulted in a return visit being arranged. This measure of self-referral by GPs is significantly and strongly associated with the ratio of GPs to population, and negatively with the ratio to population of persons eligible for free services, and with area per capita income. All three results are as hypothesized from a theoretical model, and point to significant self-interested physician-induced demand by Irish GPs.

Adolescent↗
PubMed1987

Health outcome and higher medical qualifications: an economic conception and notes on implementation.

A major policy issue in the health sector is the relationship between the outcomes of a medical procedure provided by differently qualified medical personnel, and in which the medical service supplied by the different groups of providers are differently priced. This problem, which exists in health systems which have providers' remuneration based on either fee-for-service or salaries, has not been explicitly considered by economists. Although this question has been indirectly treated in the economic literature on occupational regulation, and directly in the medical literature on quality assessment, both literatures are deficient in different respects. This paper applies the characteristics theory of consumer demand to the problem. A procedure for establishing the nature of the relationship between levels of qualifications and health outcome in an illustrative case of discrete choice is outlined. It is emphasised that the nature of this relationship must be established empirically. It is shown that in this illustrative situation there are four distinct cases that can arise and that under certain circumstances the analysis of the problem can be appropriately conducted in terms of a single dimension of health status. Different prices for the medical service are introduced and the conditions under which a higher price for a service provided by a medical practitioner with higher qualifications can be justified in terms of consumer welfare are considered. The paper concludes with a discussion of some issues associated with an empirical application of the conceptual framework.

Health Services↗
PubMed1989

Primary health care in northwestern Somalia: a case study.

This paper examines the problem of initiating health care programmes in areas where there is no effective infrastructure. The problem is examined using Northwestern Somalia as a case study. The project focussed on the establishment of well-trained and well-supported CHWs at the community level. Many of these communities are (semi-)nomadic. The roles of middle-level management staff, community leaders and committees, CHW remuneration and health effects of the project are discussed.

Community Health Workers↗
PubMed1989

Community-based health care in Kibwezi, Kenya: 10 years in retrospect.

In response to the interest of the Kenya government in community-based health care, the Kibwezi Rural Health Scheme was developed by the African Medical and Research Foundation (AMREF) in a semi-arid district in eastern Kenya. Based on a community co-operative philosophy and focussing on health promotion and prevention, the scheme includes the following: a health centre with a 15-bed in-patient unit including four maternity beds, out-patient services, and a 15-bed nutrition rehabilitation unit; a cadre of volunteer community health workers, trained by AMREF, who form the backbone of the project; maternal child health/family planning and nutrition services including an applied nutrition programme, a water project; and a mobile health unit. Designed as a replicable model health programme, the intention was that services would be gradually taken over by the Ministry of Health of Kenya. Much has been learned in the development of the project which should be meaningful to others considering similar endeavours. One of the first lessons learned was that the time taken to sensitize the community to community-based health care is critical to the success of the project and may need to be as long as 1-2 years. Another was that gaining the support of the community for the community health workers (CHW) requires a considerable effort on the part of project staff, but seems to be the only viable solution to the remuneration and recognition of the CHW's work. It also became apparent that preventive and promotive health services should be integrated structurally and operationally with curative health services to provide the most benefits for the community served. Finally, although there are some differences of opinion, it is felt that with some refinements, the project could be replicated in other parts of Kenya.

Child Health Services↗