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PubMed1994

Home health care outcomes under capitated and fee-for-service payment.

In this article, case-mix-adjusted outcomes of home health care are found to be superior for Medicare fee-for-service (FFS) patients relative to Medicare health maintenance organization (HMO) patients. The superior outcomes for FFS patients were accompanied by higher utilization and cost of home health services, suggesting a volume-outcome (or dose-response) relationship that was further substantiated by within-HMO and within-FFS analyses. The findings suggest that greater attention should be paid to both outcome-based quality assurance and managed care practices that may be overly restrictive in terms of the use of home health services.

Capitation Fee↗
PubMed1996

Health status of Medicare enrollees in HMOs and fee-for-service in 1994.

We compared the health status of 863 health maintenance organization (HMO) enrollees with that of 4,576 non-enrollees, controlling for demographics and area of residence, using 1994 data from the Medicare Current Beneficiary Survey (MCBS). HMO respondents were less likely to report fair or poor health, functional impairment, or heart disease. Average predicted costs based on various health-status measures were substantially lower for HMO respondents than for respondents in fee-for-service (FFS) arrangements. The Medicare payment formula for HMOs does not adequately adjust for the better health and consequent lower expected costs of HMO enrollees. The addition of health-status measures would improvement payment accuracy and reduce average HMO payments significantly below current levels.

Activities of Daily Living↗
PubMed1997

Medicare+Choice program; collection of user fees from Medicare+Choice plans and risk-sharing contractors--HCFA. Interim final rule with request for comments.

This interim final rule with a request for comments establishes the methodology that will be employed to assess fees applicable to Medicare risk-sharing contractors for fiscal year (FY) 1998. Under section 4002 of the Balanced Budget Act of 1997, these contractors must contribute their pro rata share of costs relating to beneficiary enrollment, dissemination of information, and certain counseling and assistance programs. The Medicare+Choice regulation to be published in June of 1998 will implement this requirement for Medicare+Choice plans.

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PubMed1989

Selection of prepaid or fee-for-service care by Medicaid families: examining the health-risk hypothesis.

These results indicate that one PHP, relative to the FFS system, experienced favorable selection on the part of Medicaid AFDC eligibles who have voluntarily enrolled in the plan. Moreover, they suggest the value of adding at least one simple health measure to Medicaid AFDC capitation formulae. The results regarding selection should be considered preliminary because they represent only one PHP-FFS comparison. Data from this PPMHC evaluation, as well as those from other ongoing comparative evaluations of Medicaid eligibles in prepaid and fee-for-service care (e.g., Freund et al., 1989), should provide considerably more information than is currently available on these issues, as well as on issues of the relative impact of PHP and FFS care on utilization and outcomes of Medicaid AFDC eligibles.

Capitation Fee↗
PubMed1987

Assessing process of care under capitated and fee-for-service Medicare.

In 1986 more than 770,000 Medicare beneficiaries were enrolled in risk-based health plans that had very little experience in providing medical care to elderly patients. This article addresses one major facet of the National Medicare Competition Evaluation of capitated versus fee-for-service delivery of Medicare benefits, sponsored by the Health Care Financing Administration: the assessment of the quality of the process of care delivered to Medicare enrollees. The rationale, design, and analysis plans for this subpart of the larger evaluation and its interrelationships with the other components of the project are described.

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PubMed1987

HMO physician reimbursement. The case for fee-for-service IPAs.

Individual Practice Association (IPA)-model HMOs use two methods of physician reimbursement: capitation and fee-for-service (FFS). Advantages and disadvantages of these two systems are explored. The author describes the organization of his group's IPA and gives the reasons for its adoption of FFS payment. An inherent problem of this system--minimal incentive for participating physicians to limit provision of medical services--now requires his group to identify the small percentage of its members who engage in overly expensive practice styles. Alternatives are discussed for dealing with those physicians who incur costs that exceed the norm for their specialties. Finally, the author gives basic recommendations for physicians who are interested in organizing their own FFS-model IPA.

Capitation Fee↗
PubMed2000

Health care utilization by old-old long-term care facility residents: how do Medicare fee-for-service and capitation rates compare?

OBJECTIVE: To describe the healthcare utilization of a long-term care population receiving primary and specialty care in a closed system and to compare Medicare fee-for-service (FFS) reimbursement with the amount that would have been paid under capitation for these services. SETTING: A life care community in California composed of two facilities, both having residential care and nursing facility (NF) beds. PARTICIPANTS: Residents (n = 700) living in the community between September 1995 and February 1996. METHODS: Data on Medicare Part A and Part B reimbursements were gathered from billing records for hospitalizations, based on diagnostic related group payments, primary and specialty care visits, various procedures, diagnostic tests, and therapeutic services. These data were compared with what the facility, in collaboration with the providers and an affiliated hospital, would have received under Medicare capitated rates at that time. RESULTS: Annually, residents averaged 16.3 primary care visits, 7.7 specialist visits, and 3453 hospital days per thousand. Nursing facility residents received significantly more primary care than did those in residential care. Total Medicare Part A and B payments per resident per month averaged $558. The monthly capitation rate in effect at the time for this population was substantially higher at $1085, generating an annual "risk pool" of $9.1 million. Care provided in the two facilities varied greatly. Hospitalization rates, clinic-based primary care and specialist visits, and therapy sessions were greater in facility one. Overall expenditures were lower for residents at facility two, where the majority of care was provided by trained geriatricians in collaboration with physician extenders and without sophisticated clinical pathways and utilization controls. CONCLUSIONS: Our data support other studies that suggest that teams of geriatricians and physician extenders can reduce hospitalization rates and overall expenditures. Capitated rates for the frail, geriatric population warrant careful study. These rates must balance fiscal responsibility with the need for adequate, risk-adjusted payments that create incentives for providers to produce high quality as well as cost-effective care.

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PubMed2000

Medicare, fee-for-service subsidies, and market outcomes: a partial description of Australia's health care financing labyrinth.

In Australia, both in-hospital and out-of-hospital services are subsidized via a national, social health insurance scheme, referred to as "Medicare." Revenue for the scheme is raised via general taxation and an earmarked "tax," which is presently 1.5 percent of taxable income. Members are entitled to the subsidized consumption of a broad range of medical practitioner services provided on both an in-hospital and an out-of-hospital basis, in both private and public facilities. Moreover, the range of services subsidized by the Australian scheme is broad, and includes the types of medical care that are available only to those U.S. Medicare patients who have opted for the Supplementary Medical Insurance Program. The purpose of this article is to provide a descriptive account of the Australian Medicare arrangements, particularly those that pertain to private, fee-for-service, medical practice. This article emphasizes the fact that, although the provisions are nationally uniform in application, these arrangements do not give rise to homogeneity of consumer payments and medical practitioner revenue. The article's theme is that, just as the simple terms "Medicare" and "Medicaid" belie the complexity of U.S. social health insurance, the Australian application of the term "Medicare" also describes a health care financing labyrinth.

Ambulatory Care↗
PubMed2005

Survey: capitated groups outperform fee-for-service physicians.

Capitated medical groups continue to earn more per physician and appear to be more productive in terms of relative value units than fee-for-service physicians, according to data from the American Medical Group Association's 2004 Medical Group Compensation & Financial Survey.

Capitation Fee↗
PubMed2006

Analysis of anti-epileptic drugs in fee-for-service Wisconsin Medicaid.

INTRODUCTION: Off-label use of prescription drugs presents issues of patient safety and can significantly increase the overall prescription drug expenditure in providing health care services. As a class, the anti-epileptic drugs are provided for off-label use on a frequent basis. Because of the safety issues and increased cost with such prescribing practices, the Wisconsin Medicaid Drug Utilization Review Board (DUR board) reviewed the use of anti-epileptic agents in the fee-for-service Wisconsin Medicaid population. METHODS: Prescribers with the highest amount paid for drugs in this class, and for which there was no appropriate diagnosis (intervention group), were provided with a list of the patients for whom they prescribed the drug for an off-label clinical condition. A total of 488 prescribers were contacted and informed of the costs and hazards of off-label prescribing. RESULTS: Using a comparison group of patients who were prescribed anti-epileptic agents but who did not reach the amount paid threshold (non-intervention group), the study demonstrated a decrease of 6652 prescriptions in the intervention group and an increase of 4194 in the non-intervention group. In addition, expenditures for the intervention group dropped by dollar 752,232 and the non-intervention group rose by dollar 835,351. It is estimated that the overall financial impact of this intervention was a savings of dollar 2,552,077 over the 5-month period of review.

Anticonvulsants↗
PubMed1990

[What does the established physician expect from the West German health system? Fee reduction and drug control as a consequence of economic assessment. What can be done?].

We have briefly tried to inform about the fact why controls of profitableness have to be carried out, how is their course and by virtue of which standards the unprofitableness is assessed. In form of a randomized summary we will once more specify what the physician by all means should do if the fee is reduced or a drug recourse takes place: 1. The date of receipt is to be written clearly visible on the control rescript, since this is of importance for the grace when legal remedies may be applied. 2. Test the rescript, whether or not the reducing or the recourse seems to be justified or whether you have the impression that the data of your activity and management of your practice have not been fully taken into consideration. In this case you at once object and announce a detailed argument. 3. Test quietly, after the first irritation has subsided, whether the points of view explained in the paragraphs 3 and 4 have been taken into consideration, in particular: a. Is the comparative group right? b. Is the present elevation of the average values suited to justify the reducing measure performed? c. Are all peculiarities of the practice taken into consideration? d. Are the peculiarities of the practice sufficiently exactly quantified? e. Was a possible compensatory less expenditure taken into consideration? 4. Summarize the result of your own inquires, as they are described in item 3, in a relevant argument as short as possible. If you need statistical data, which are not at your disposal, for writing this argument, so request such data from the control department of your health-insurance company. 5. In a drug recourse you control, whether or not you can acknowledge the judgment of the arguments for reducing declared. Otherwise you request from your health insurance company the examination into the adequate prescriptions, in which case you probably have to go into the business premises of your health insurance company, in order to be able to take notes there.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost Control↗
PubMed1989

Considerations in establishing fees for home-care pharmaceutical services.

The activities of home-care pharmacists are highlighted, and factors that should be considered in establishing a reimbursement schedule are described. Pharmacists are important members of the home health-care team. Responsibilities of the pharmacist include assisting in the development of a therapeutic plan, reviewing and monitoring drug therapy, and ensuring that appropriate and correctly prepared medications are available to the patient. The degree of pharmaceutical service depends on the therapy prescribed. The traditional type of third-party reimbursement--cost of drug plus dispensing fee--is often inadequate and can discourage pharmacists from becoming involved in home health care or from providing services of optimal quality. An appropriate reimbursement schedule should take into account the variety of pharmaceutical services provided to home-care patients and should give special consideration to activities, such as discontinuation of unneeded drug therapy, that lower medical costs. Whether pharmacists are able to provide high-quality home health-care services may depend on how adequately they are reimbursed.

Fee Schedules↗
PubMed1986

Family practitioner committee records--a neglected resource. 1. An information service for general practitioners based on claims for fees.

Data held by a London family practitioner committee for the purpose of paying general practitioners' capitation and item of service fees were analysed every quarter for one year to provide an information service for general practices in the area. Each practice received a quarterly printout showing the age structure of its patient population, the numbers of new registrations and removals and data about items of service. These were expressed as rates which could be compared with those of the area as a whole, and with the highest and lowest rates found in individual practices. A survey at the end of the year showed that the service was welcomed and found useful by the practices. A fully computerized family practitioner committee could provide a similar service without great difficulty, and could make it more informative by linking items of service to specific age groups; data about prescribing and use of hospital and district services could also be incorporated when the relevant agencies are fully computerized too.

Capitation Fee↗
PubMed1986

Family physicians and the future of fee-for-service payment plans.

The mechanisms by which health care providers in the United States are reimbursed for their services are undergoing dynamic and rapid changes. Traditional fee-for-service payment schemes as the predominant reimbursement methods are declining and are being supplanted by a plethora of different schemes that incorporate prepayment as the mode of compensation for service. A number of trends over the past decade predict that this transference to prepayment will continue in the future and will have a profound impact on the future practice of family medicine. It is important for family medicine educators and practicing family physicians to understand these market forces and trends so they will be better able to alter their training programs and future practices to meet future needs.

Capitation Fee↗
PubMed1985

Percentage of anaesthetic fee refunded to patients by schedule-using private medical insurers in New Zealand.

Refunds for anaesthetic services payable to patients by schedule-using private medical insurers or agencies have not been realistically adjusted for inflation or growth in incomes. Patients receive a lower actual refund than that usually implied by the insurers. If private anaesthetic fees had increased in line with award weekly wages, the average refund to patients would have been approximately 50% for most of the period 1968-1981.

Anesthesia↗
PubMed1995

Patient-level cost of home health care under capitated and fee-for-service payment.

This article examines costs for a national sample of 1,260 Medicare patients receiving home health care from 38 home health agencies. It uses data from a study that compares home health care provided to Medicare beneficiaries in health maintenance organizations (HMOs) and the traditional fee-for-service (FFS) system. The major findings indicate significantly lower costs, based on fewer home health visits, for HMO patients compared to FFS patients, even after adjustment for case mix and other factors. However, FFS patients also attain better outcomes, suggesting that HMOs may provide too few visits to home health patients. At the same time, the number of visits to FFS patients may be greater than is necessary to achieve the better FFS outcomes.

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PubMed1999

Timeliness and quality of care for elderly patients with acute myocardial infarction under health maintenance organization vs fee-for-service insurance.

BACKGROUND: A commonly voiced concern is that health maintenance organizations (HMOs) may withhold or delay the provision of urgent, essential care, especially for vulnerable patients like the elderly. OBJECTIVE: To compare the quality of emergency care provided in Minnesota to elderly patients with acute myocardial infarction (AMI) who are covered by HMO vs fee-for-service (FFS) insurance. METHODS: We reviewed the medical records of 2304 elderly Medicare patients who were admitted with AMI to 20 urban community hospitals in Minnesota (representing 91% of beds in areas served by HMOs) from October 1992 through July 1993 and from July 1995 through April 1996. MAIN OUTCOME MEASURES: Use of emergency transportation and treatment delay (>6 hours from symptom onset); time to electrocardiogram; use of aspirin, thrombolytics, and beta-blockers among eligible patients; and time from hospital arrival to thrombolytic administration (door-to-needle time). RESULTS: Demographic characteristics, severity of symptoms, and comorbidity characteristics were almost identical among HMO (n = 612) and FFS (n = 1692) patients. A cardiologist was involved as a consultant or the attending physician in the care of 80% of HMO patients and 82% of FFS patients (P = .12). The treatment delay, time to electrocardiogram, use of thrombolytic agents, and door-to-needle times were almost identical. However, 56% of HMO patients and 51% of FFS patients used emergency transportation (P = .02); most of this difference was observed for patients with AMIs that occurred at night (60% vs 52%; P = .02). Health maintenance organization patients were somewhat more likely than FFS patients to receive aspirin therapy (88% vs 83%; P = .03) and beta-blocker therapy (73% vs 62%; P = .04); these differences were partly explained by a significantly larger proportion of younger physicians in HMOs who were more likely to order these drug therapies. All differences were consistent across the 3 largest HMOs (1 staff-group model and 2 network model HMOs). Logistic regression analyses controlling for demographic and clinical variables produced similar results, except that the differences in the use of beta-blockers became insignificant. CONCLUSIONS: No indicators of timeliness and quality of care for elderly patients with AMIs were lower under HMO vs FFS insurance coverage in Minnesota. However, two indicators of quality care were slightly but significantly higher in the HMO setting (use of emergency transportation and aspirin therapy). Further research is needed in other states, in different populations, and for different medical conditions.

Adrenergic beta-Antagonists↗
PubMed2002

Primary care quality in the Medicare Program: comparing the performance of Medicare health maintenance organizations and traditional fee-for-service medicare.

BACKGROUND: Since 1972, Medicare beneficiaries have had the option of enrolling in a Medicare-qualified health maintenance organization (HMO). Little information exists to inform beneficiaries' choices between the traditional fee-for-service (FFS) Medicare program and an HMO. OBJECTIVES: To compare the primary care received by seniors in Medicare HMOs with that of seniors in the traditional FFS Medicare program, and among HMOs, and to examine performance differences associated with HMO model-type and profit status. METHODS: Data were derived from a cross-sectional observational survey of Medicare beneficiaries 65 years or older in the 13 states with mature, substantial Medicare HMO markets. Only beneficiaries continuously enrolled for 12 months or more in traditional FFS Medicare or a qualified Medicare HMO were eligible. Data were obtained using a 5-stage protocol involving mail and telephone (64% response rate). Analyses included respondents who identified a primary physician and had all required data elements (N = 8828). We compared FFS and HMO performance on 11 summary scales measuring 7 defining characteristics of primary care: (1) access, (2) continuity, (3) integration, (4) comprehensiveness, (5) "whole-person" orientation, (6) clinical interaction, and (7) sustained clinician-patient partnership. RESULTS: For 9 of 11 indicators, performance favored traditional FFS Medicare over HMOs (P<.001). Financial access favored HMOs (P<.001). Preventive counseling did not differ by system. Network-model HMOs performed more favorably than staff/group-model HMOs on 9 of 11 indicators (P<.001). Few differences were associated with HMO profit status. CONCLUSIONS: The findings are consistent with previous comparisons of indemnity insurance and network-model and staff/group-model HMOs in elderly and nonelderly populations. The stability of results across time, geography, and populations suggests that the relative strengths and weaknesses of each system are enduring attributes of their care. Medicare enrollees seem to face the perennial cost-quality trade-off: that is, deciding whether the advantages of primary care under traditional FFS Medicare are worth the higher out-of-pocket costs.

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