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PubMed1991

Substitution of primary care and specialist care: a regional analysis in Denmark.

A debate is going on in health care systems with capitation payment for general practitioner services about the disincentives of the system, leading to a low level of interventions by GPs and a high level of referrals. Increasing the fee-for-service element in the remuneration of GPs is seen as the remedy. A mixed system of fee for service and capitation exists in Denmark. The fee for service part generates administrative data on the number of services. These data have been analysed at province level to find out whether or not a greater number of services by GPs in a province coincides with a lower level of hospital and specialist care. It proves that in provinces with a greater number of services by GPs the number of ambulatory hospital visits is smaller.

Capitation Fee↗
PubMed1992

List size, composition of practice and general practitioners' workload in The Netherlands.

Workload of general practitioners plays an important role in discussions about list size and remuneration in health care systems with fixed patient lists and capitation payments, such as in the Netherlands and in the United Kingdom. Against the background of the fairness of differences in income level between GPs the question is posed to what extent differences in list size reflect differences in workload and to what extent differences in patient characteristics influence workload. Both list size and practice composition relate to the demand led character of general practice. Data collected in the National Study of Morbidity and Interventions in General Practice are used. Central to this study is a three month recording of all contacts of 161 general practitioners (and their locums, assistant GPs and trainees) in the Netherlands. For each practice a patient register has been made to relate contacts to the practice population. The participating GPs kept a detailed diary covering 24 hr a day during one week. As indicators of workload several contact rates, hours worked in practice per week (in direct patient care and in other activities) and average length of office consultations are used. Demand related characteristics have the strongest relation to the number of hours worked by GPs, particularly the number of hours spent in patient-related activities. Rates of contacts, with the exception of the office contact rate, are not related to list size, but mainly to practice composition. The average length of consultations is negatively related to list size and some characteristics of the practice population.

Capitation Fee↗
PubMed1993

Women's work and infant care in the Philippines.

Using data from a survey of 3000 Filipino infants and mothers, we analyze the implications of having more than one preschooler on several work outcomes, as well as the effect of availability of substitute care givers. The work outcomes of interest are those thought to be least compatible with infant care: work outside the home, wage work remunerated on a time basis, and long working hours. Our findings suggest that having multiple preschoolers only makes a difference for mothers whose household income is below the median: it increases their likelihood of working outside the home. Grandmothers and paid helpers consistently increase the likelihood of the various work outcomes and increase hours worked. Our findings suggest that urban residence, an indicator of work opportunity structure, increases the likelihood of wage-time work and is associated with longer working hours.

Adult↗
PubMed1994

Forming and reforming the market for third-party purchasing of health care: a German perspective.

Germany is known for its comprehensive health care coverage by sickness funds and private health insurers and its successful cost containment policy. The stabilization of health care expenditures as a percentage of GNP was enforced by five cost containment laws since 1977. The last one became effective in 1993 and the next ones are planned for 1996 and 2000. The 1993 law has initiated drastic changes of the system. Office based physicians will be paid by a mixture of capitation, fee-for-service and fees for combined service packages. The hospital financing will be transformed from the current per diem remuneration to a payment system where per diems are combined with payments based on diagnostic related groups and patient management categories. Up till now many restrictions exist for insurees to switch sickness funds. These limitations were removed by the 1993 law. To allow unbiased competition between sickness funds, a risk compensation pool, some kind of statutory reinsurance, will transfer financial resources from sickness funds with good risk structure to those with many bad risks. In many respects health policy has imposed what health economists have recommended for a long time. However, there is some doubt whether increased competition will really increase efficiency of providing medical care because it takes place in a highly regulated market.

Cost Control↗
PubMed1995

Three years' experience after national introduction of teaching programs for type II diabetic patients in Germany: how to train general practitioners.

Beginning in July 1991, office-based physicians in Germany were remunerated for providing a structured treatment and teaching program to non-insulin-treated type II diabetic patients. The treatment and teaching program is based upon the respective recommendations of the German Diabetes Association. This article describes the structure of the program and the courses for general practitioners and their nurses. The prospective studies proving the beneficial effects of the program are summarized.

Adult↗
PubMed2005

Perceptions and attitudes of Canadian orthodontists regarding digital and electronic technology.

INTRODUCTION: To plan for future acceptance and implementation of computer-related technology, it is necessary to understand orthodontists' current perceptions and attitudes toward emerging technologies. METHODS: An anonymous, self-administered, mail-out survey of Canadian orthodontists was conducted. The response rate was 45.6% (304/667). RESULTS: Most orthodontists indicated that computer technology could improve current practice efficiency and quality of patient care. Only 15% reported that digital models are quite or very useful; 73.6%, 69.1%, 55%, and 37.4% agreed or strongly agreed with using digital and electronic technology to consult with other dental specialists, other orthodontists, general dentists, and the public, respectively. Cost of the technology was reported as a significant or insurmountable obstacle by 54% of the respondents. Interprovincial legislation, unclear consultation remuneration guidelines, and lack of comfort with the technology were not perceived as significant obstacles. Only 36% reported security or privacy issues as a significant or insurmountable obstacle. CONCLUSIONS: Canadian orthodontists seem to view digital and electronic technology as useful and capable of improving their offices' efficiency and production. Although they are sensitive to some potential obstacles, they are willing to overcome these and incorporate the technology into their practices.

Attitude of Health Personnel↗
PubMed2006

Understanding African-American participation in a behavioral intervention: results from focus groups.

Heart failure (HF) is an increasingly prevalent condition contributing to significant morbidity and mortality among African-Americans. The Heart Failure Adherence and Retention Trial (HART) is the largest NHLBI funded behavioral clinical trial of patients with HF (R01 HL65547). The HART trial has recruited approximately 40% minority participants, with 33% being African-American. The purpose of this qualitative study is to conduct an in-depth examination of the subjective experience of African-American participants in the intervention arm of the HART. Five focus groups were conducted with a total of 25 participants. The mean age of those attending was 55 years, with a range between 39 and 82 years, 52% of the participants were female, and 92% were African-American. Participants gained overall general medical knowledge about HF and how HF influenced their own lives. Participants appeared not only to understand the self-management skills that were taught; but also how to apply them. They also demonstrated understanding of the connection between lifestyle and HF. Factors that may promote retention include mutual support, the opportunity to engage in meaningful social activity, and feeling cared for. Factors that may limit retention include anxiety and denial about HF and logistical and emotional barriers to attending groups. Factors with unclear effects on retention include remuneration, ethnicity of the group leader, and the role of religious or spiritual content in meetings. While a number of perceived benefits exist to group participation, there are significant and logistical barriers to retention. Ongoing attention to cultural sensitivity is a likely factor in successful retention of study participants.

Adult↗
PubMed2006

[Poisons for reproduction in work environment].

This article describes the lawful bases of the reprotoxic risk management in work environment, and sets out the recommendations of the French Société de Médecine du Travail (occupational medicine) for the medical supervision of pregnant wage-earners exposed to toxic substances as far as foetal development is concerned. We start with the description of the lawful bases, clarifying the various types of classification of toxic substances for reproduction, the particular regulation applying to reprotoxic categories 1 and 2, particularly with regard to the labelling of these products, the prohibition of availability to the general public, the principles of prevention and the guarantees of remuneration of the pregnant women exposed to this risk. Then, we present the recommendations worked out by the Société Française de Médecine du Travail, with regard to the medical supervision of pregnant wage-earners. They include: evaluation of the risk on the work place, evaluation of exposure, be it external or internal, presentation of methods of calculation of values guides and of recommendations transmitted to occupational doctors, before and during the pregnancy of their patients. To conclude, it is important to remain rigorous with this reprotoxic risk, by referring to the lawful bases at our disposal and supporting the scientific bases following epidemiologic studies. Adequate information must be given to women but also men pf procreation age. In spite of a well-defined lawful framework, watchfulness is required with the new products put on the market and the new scientific data.

Female↗
PubMed2005

Case-mix payment in Japanese medical care.

The Japanese medical care system, highly rated internationally, has recently experienced a crisis that has placed a burden on all of its citizens, providers, and payers, due to the expansion of medical expenditures in rapidly aging society with the stagnant economy. To address this, in April 2003, Japan implemented a case-mix payment system, instead of conventional fee-for-service payment, based on an original case classification with 2552 groups (Diagnosis Procedure Combination: DPC), with inpatients from 82 special functioning hospitals. This system contains two parts: per diem prospective payment for hospital's fee with a three-level step down according to average length of stay for each diagnosis group, which is adjusted to secure the previous year's remuneration in each hospital; fee-for-service payment for doctor's fee based on national fee schedule. The payment system reduced average length of stay, but did not change inpatient expenditures and increased outpatient expenditures. The in-hospital mortality rate, although un-adjusted, did not changed, but the readmission rate increased mainly through an increase in planned, not accidental, readmissions. For the expansion of this system, ongoing program refinement, reflecting the results of data analysis, is indispensable.

Diagnosis-Related Groups↗
PubMed2004

The role and accountability of senior health care support workers in intensive care units.

BACKGROUND: Nurses have always looked to support their activities through the presence of unregistered co-workers. In the later part of the 20th century this workforce has evolved from a predominance of students to increasing use of variously prepared second level nurses, nursing assistants and Health Care Support Workers. METHOD: The study evaluated the development of 'advanced' support workers for intensive care settings, examining the views of the multi-disciplinary team, the support workers, and making observations of the work undertaken. Ethical approval was gained via a multi-centre committee. Individual interviews, focus groups and fieldwork provided rich qualitative data. It is this, and the views of support workers themselves on which we focus in this report. RESULTS: Senior support workers have a potentially important, but as yet insufficiently clear role to play. Key tasks such as taking arterial blood gas symbolise their rite of passage into the role. Expectations vary by locality and by person and there is great concern over accountability for work done. Delegation of work depends as much on experience as training and individuals are reluctant to delegate to staff they have not personally assessed and come to know as 'competent'. CONCLUSION: These workers should have clear and adequately remunerated career pathways open to them, in particular into nursing and allied health disciplines, and should probably be licensed to practice.

Clinical Competence↗
PubMed2006

Special needs of adolescent and young women in accessing reproductive health: promoting partnerships between young people and health care providers.

This article considers the unique challenges and opportunities that health care providers (HCPs) face when they address the sexual and reproductive health and rights of young women accessing services. Some of the difficulties that HCPs encounter in their work are highlighted, including poor remuneration, the impact of their personal biases and the effect of an under-equipped working environment. The financial, logistical and emotional challenges young people face in accessing services are also described, as well as some small changes that could promote fruitful partnerships between HCPs and their young clientele. Also considered is how international documents concerning reproductive health can be utilized as advocacy tools to ensure that, when governments speak of making young people's needs a priority, resources are also made a priority-so that reproductive health can become a reality for all young people.

Adolescent↗
PubMed2004

An optimal contract approach to hospital financing.

Existing models of hospital financing advocate mixed schemes which include both lump-sum and cost-based payments. The doctor is generally the unique decision maker, which is unrealistic in a hospital setting where both managers and doctors are involved. This paper develops a model in which managers and doctors are responsible for different decisions within the hospital. In this model, public authorities who provide the financing, hospital managers who allocate resources within the hospital, and doctors who assign patients to either a low-tech or a high-tech therapy have information of increasing quality on the casemix of patients. The public authorities sign with hospital managers contracts specifying some lump-sum financing and some size of a high-tech equipment. In turn, managers, who know the broad mix of patients in the hospital, sign with hospital doctors contracts that specify the non-medical resources allocated to this facility as well as some remuneration. Doctors, who know each patient's illness severity, select the patients to be treated by the high-tech facility, and receive from public authorities some fee-for-service payment that is differentiated according to the low- or high-tech treatment used for curing their patients. What emerges is a two-stage agency problem in which contracts are designed to elicit information in the most efficient way.

Contract Services↗
PubMed2005

Physician reimbursement and technology adoption.

This study analyses the incentives of health care providers to adopt new technologies in a world with ex-post moral hazard. It is shown that in a second best efficient world with respect to insurance coverage, a linear remuneration scheme implements the adoption of second best efficient technologies only in special cases. Under a (third best) standard coinsurance contract, the adequate reimbursement rule is characterised depending on the characteristics of the technology and on patients' demand elasticities with respect to monetary and non-monetary costs. A shift from fee-for-service to capitation is likely to display undesirable incentives for very severe illnesses by inducing a reduction in the technically feasible level of healing or an increase in non-monetary costs of treatment.

Attitude to Computers↗
PubMed2005

The treadmill effect in a fixed budget system.

We examine the interaction in the market for physician services when the total budget for reimbursement is fixed. Physicians obtain points for the services they render. At the end of the period the budget is divided by the sum of all points submitted, which determines the price per point. We show that this retrospective payment system involves -- compared to a fee-for-service remuneration system -- a severe coordination problem, which potentially leads to the "treadmill effect". We argue that when market entry is possible, a budget can be efficiency enhancing, if in addition a price floor is used.

Budgets↗
PubMed2006

Selection of treatment under prospective payment systems in the hospital sector.

A model of contracting for hospital treatments is presented. For a given diagnosis of the patient, two treatments are available: a high-intensity (surgical) treatment and a low-intensity (medical) treatment. A purchaser (the National Health Service, public or private insurer) offers a contract to the provider (the hospital) to maximise the patients' benefit net of costs. We show that if the average severity of the patient is private information known only by the provider, the hospital has an incentive to over-provide the surgical treatment to the low-severity patients. The optimal contract with asymmetric information is such that hospitals that provide a higher share of surgical treatments receive a higher price for the surgical treatment and a lower price for the medical treatment. This situation differs from current remuneration systems in which the price for each type of treatment is uniform. A related result is that with asymmetric information the optimal contract involves a higher transfer than with symmetric information.

Algorithms↗
PubMed2006

Evaluation of a visit preparation intervention implemented in two rural, underserved counties of Northern California.

OBJECTIVE: Evaluate satisfaction with visit preparation at three rural resource center sites. METHODS: The resource centers sent eight employees and two volunteers for training at UCSF in Consultation Planning (CP). CP is a service to help patients make a list of questions before seeing their doctors. Researchers used multivariate ordered logistic regression analysis to investigate the variation in satisfaction among 99 CP Clients served by the resource centers in 2003. RESULTS: Sixty-seven CP Clients who completed surveys were highly satisfied (mean=8.67, standard deviation (S.D.)=1.85, range=5-10). Variation in satisfaction was associated only with whether or not the CP Provider was a breast cancer survivor serving a breast patient (p=0.005). Satisfaction was not associated with CP Client demographics; type of upcoming medical visit; or CP Provider age, remuneration status, nursing background, and volume of CP Clients. CONCLUSION: Community-based resource centers have implemented CP to the satisfaction of their clients. Further research should expand the delivery of CP to more underserved members of the community and evaluate its acceptability and impact. There may be a therapeutic alliance formed when survivors provide CP to newly diagnosed patients. PRACTICE IMPLICATIONS: CP should be considered by patient support programs wishing to expand their client services to include visit preparation.

Adult↗
PubMed2005

DHEAS and POMS measures identify cocaine dependence treatment outcome.

UNLABELLED: Early attrition is a significant problem in the treatment of cocaine dependence, but it is unclear why some patients succeed in treatment while others relapse or drop out of treatment without a demonstrated relapse. The goal of this study was to determine whether baseline levels of select hormones, including the adrenal hormone and excitatory neurosteroid dehydroepiandrosterone sulfate (DHEAS), would distinguish between treatment outcome groups. Based on the literature, completion of 90 days of treatment was established as a key outcome variable. METHODS: Quantitative urine levels of the cocaine metabolite benzoylecgonine (BE) and other substance of abuse analytes, plasma levels of DHEAS, DHEA, cortisol, and prolactin, and the profile of mood states (POMS) were serially measured in 38 male cocaine-dependent (DSM-IV) patients and in 28 controls of similar gender and age over a six month study. Exclusion criteria for the patients and controls included Axis I mood, anxiety or psychotic disorders. The patients could not manifest substance dependence except to cocaine. The patients and controls received remuneration for urine and blood collection. Blood samples for hormone levels were obtained between 8 and 10 a.m. on days 1, 14 and 21 of a 21-day inpatient treatment program and throughout 6 months of outpatient study visits at 45-day intervals. RESULTS: Attrition from treatment and study appointments occurred predominately at the junction between inpatient and outpatient programs. Forty percent of patients made the transition to outpatient treatment and remained abstinent and in treatment for a median of 103 days (ABST). Forty-two percent of patients dropped out of treatment during the inpatient stay or never returned after completing the inpatient program (DO) and 18% had a documented relapse either during, or within the first week after, the inpatient stay (REL). POMS total scores were elevated at treatment entry for both the ABST and DO groups. Plasma DHEAS levels in the DO patients were decreased compared to controls and increased in the ABST patients. POMS total scores for the REL patients at baseline were at control levels. Baseline cortisol levels were not statistically different between the outcome groups, though they were elevated for all cocaine patient groups. When treatment outcome was collapsed into whether patients completed (ABST) or did not complete 90 days of treatment (90N), ABST plasma DHEAS and cortisol were significantly elevated compared to the 90N patients and controls across the first 3 weeks of cocaine withdrawal. CONCLUSIONS: At treatment entry, each of the three patient outcome groups was identified by levels of circulating DHEAS and distressed mood. In the ABST patients, distressed mood during withdrawal may have been mitigated through antidepressant-like actions of enhanced endogenous DHEAS activity, thus contributing to improved abstinence and treatment retention. Patients, such as the DO group, with high levels of distressed mood at treatment entry and low DHEAS levels may benefit from adjunctive pharmacotherapy that targets DHEAS and POMS measures. Patients, such as the REL group, who lack distressed mood at treatment entry, may require intense application of motivational approaches plus residential treatment.

Adult↗
PubMed2004

The effect of hospital bed reduction on the use of beds: a comparative study of 10 European countries.

In Europe, the reduction of acute care hospital beds has been one of the measures implemented to restrict hospital expenditure. The aim of this study is to gain insight into the effect bed reductions have on the use of the remaining beds within different healthcare systems. We concentrated on two healthcare system elements: hospital financing system (per diem and global budget systems) and physician remuneration system (fee-for-service and salary systems). We also controlled for technological development and demand for healthcare. We used data from the OECD health data files of 10 North-Western European countries on hospital bed supply and use. The hospital bed indicators used were occupancy rate, average length of stay and admission rate. The data were analysed with multilevel analysis. We found some indication that the different financial incentives of hospital financing systems do indeed influence hospital bed use in the case of reductions in acute care hospital bed supply in different ways. However, we found significant effects only for the hospital bed use indicators "occupancy rate" and "admission rate". For physician financing systems, no significant effects were found.

Bed Occupancy↗