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PubMed2005

Need for eye care among older adults with diabetes mellitus in fee-for-service and managed Medicare.

OBJECTIVE: To compare rates of need for eye care among Medicare beneficiaries with network-model Medicare+Choice (MC) and fee-for-service (FFS) health insurance. METHODS: Cross-sectional study of a random sample of MC and FFS community-dwelling Medicare beneficiaries with diabetes who are older than 65 years of age in Los Angeles County. Study ophthalmologists masked to the participants' type of health insurance performed standardized dilated eye examinations and indicated the need for ophthalmic care during the next 6 months. To evaluate the association between type of insurance and need for treatment, we constructed logistic regression models adjusted for participant sociodemographic and clinical characteristics. RESULTS: The 311 MC and 107 FFS respondents reported comparable rates of eye care provider visits and preexisting eye diseases. However, on masked clinical examination, MC respondents were more likely to have diabetic retinopathy, visually significant cataract, glaucoma, or suspected glaucoma than FFS participants (68% vs 46%, P<.001). In multivariate analyses, persons enrolled in MC were significantly more likely than FFS participants to require further treatment during the next 6 months (42% vs 24%, P = .01). CONCLUSIONS: Data from standardized study ophthalmic examinations suggest high rates of unrecognized and untreated eye diseases among Medicare beneficiaries enrolled in both FFS and MC and significantly higher rates of need for care among MC participants.

Aged↗
PubMed1999

Stage at diagnosis and treatment patterns among older women with breast cancer: an HMO and fee-for-service comparison.

CONTEXT: Few studies have compared patterns of care in health maintenance organization (HMO) and fee-for-service (FFS) settings. OBJECTIVE: To examine breast cancer stage at diagnosis and, for those at an early stage, treatment patterns for elderly women in HMO and FFS settings. DESIGN: Cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) program linked to Medicare enrollment records. SETTINGS AND PARTICIPANTS: Women aged 65 years or older residing in 11 geographic areas who were newly diagnosed as having breast cancer between 1988 and 1993. MAIN OUTCOME MEASURES: Standardized percentage of cases diagnosed at late stages for HMO vs FFS; standardized percentage of early-stage cases undergoing initial treatment with breast-conserving surgery (BCS); and, among BCS cases, standardized percentage receiving adjuvant radiation therapy. Standardization was achieved through logistic regression, controlling for patient demographics, cancer history, county of residence, year of diagnosis, and educational attainment at the census tract level. Analyses of treatment patterns were controlled for stage at diagnosis and tumor size. RESULTS: The HMO enrollees were less likely to have breast cancer diagnosed at late stages than FFS patients (HMO, 7.6%; FFS, 10.8%; difference, -3.2% [95% confidence interval (CI), -4.2% to -2.2 %]). Among early-stage cases, the percentages undergoing BCS were similar in HMO and FFS settings overall (HMO, 38.4%; FFS, 36.8%; difference, 1.6% [95% CI, 0.0%-3.2%]); percentages varied markedly at the individual plan level. Among women undergoing BCS, HMO enrollees were significantly more likely to receive radiation therapy but, again, results varied by plan (HMO, 69.0%; FFS, 63.7%; difference, 5.3% [95% CI, 2.9%-7.7%]). In general, use of BCS and radiation therapy was substantially higher than that found in an earlier study examining cases diagnosed between 1985 and 1989. CONCLUSIONS: Treatment of early-stage breast cancer in HMOs often differs from local FFS patterns, but not in a consistent way. During the period of our study, elderly HMO enrollees did not appear to have systematic access problems with adjuvant radiation therapy following BCS compared with women in an FFS setting.

Aged↗
PubMed2003

Hospice use among Medicare managed care and fee-for-service patients dying with cancer.

CONTEXT: For most patients aged 65 years or older with cancer, hospice services are uniformly covered by Medicare. Hospice care is believed to improve care for patients at the end of life. However, few patients use hospice and others enroll too late to maximize the benefits of hospice services. OBJECTIVES: Because type of insurance may affect use, we examined whether patients with Medicare managed care insurance enrolled in hospice earlier and had longer hospice stays than patients with Medicare fee-for-service (FFS) insurance. DESIGN AND SETTING: Retrospective analysis of the last year of life using the Linked Medicare-Tumor Registry Database in 1 of 9 Surveillance, Epidemiology, and End Results program coverage areas. PATIENTS: A total of 260 090 Medicare beneficiaries aged 66 years or older diagnosed with first primary lung (n = 62 117), colorectal (n = 57 260), prostate (n = 59 826), female breast (n = 37 609), bladder (n = 19 598), pancreatic (n = 11 378), gastric (n = 9599), or liver (n = 2703) cancer between January 1, 1973, and December 31, 1996, and who died between January 1, 1988, and December 31, 1998. MAIN OUTCOME MEASURES: Time from diagnosis to hospice entry and hospice length of stay for patients enrolled in FFS vs managed care plans after adjusting for patient demographics, tumor registry, year of hospice entry, and type and cancer stage. RESULTS: Of the 260 090 patients, most were men (59%), white (85%), and enrolled in FFS (89.7%). Only 54 937 patients (21.1%) received hospice care before death. Hospice use varied by type of primary cancer ranging from 31.8% of patients with pancreatic cancer to 15.6% with bladder cancer. Managed care patients were more likely to use hospice than FFS patients (32.4% vs 19.8%, P<.001). Among hospice patients, median (interquartile range) length of stay was longer for managed care vs FFS patients (32 days [11-82] vs 25 days [9-66], P<.001). After adjustment, managed care patients had higher rates of hospice enrollment (adjusted hazard ratio [HR], 1.38; 95% CI, 1.35-1.42) and had a longer length of stay (adjusted HR, 0.91; 95% CI, 0.88-0.94) vs FFS patients. Managed care patients were less likely to enroll in hospice within 7 days of their death (18.6% vs 22.6%, P<.001) and somewhat more likely to enroll in hospice more than 180 days before death (7.8% vs 6.1%, P<.001); the results for each of the 8 cancer diagnoses were similar. Hospice enrollment and length of stay among managed care vs FFS patients differed significantly by region. CONCLUSION: Medicare beneficiaries enrolled in managed care had consistently higher rates of hospice use and significantly longer hospice stays than those enrolled in FFS. Although these differences may reflect patient and family preferences, our findings raise the possibility that some managed care plans are more successful at facilitating or encouraging hospice use for patients dying with cancer.

Aged↗
PubMed1992

Quality of care for colorectal cancer in a fee-for-service and health maintenance organization practice.

This study assessed the effectiveness of two types of health plans, offered by the same health care provider, in the diagnosis and treatment of colorectal cancer. Data on 330 cases diagnosed from 1984 through 1989 were abstracted from medical records. Of these, 205 (62%) used fee-for-service (FFS) and 125 (38%) used health maintenance organization (HMO) plans. Overall, there were no differences between FFS and HMO cases for duration of symptoms before diagnosis, training of physician who diagnosed the tumor, anatomic location of the tumor, type of primary treatment, Dukes' stage at final diagnosis, or survival. There were differences between the groups for age, presence of symptoms at diagnosis, time from detection to treatment, and method of detection. Cox regression analysis showed no difference in survival by type of health plan before or after adjusting for age and stage at diagnosis. The findings from this study are consistent with those from studies reporting little or no difference in the process or outcome of care for patients with different types of medical insurance coverage.

Colorectal Neoplasms↗
PubMed1987

Third-party fee for service in children's mental health: limitation and suggestions.

The current third-party fee-for-service mode of reimbursement for mental health services emphasizes individual, pathology-oriented intervention and thus has disadvantages for clients and carriers. This article focuses on the mode's effects on outpatient services for children, youth, and families. It examines the ways in which common payment modes seriously limit services and create an incentive for psychologists to take a narrow, often nonempirical, perspective. Suggestions that allow for multisystem, ecological skill building hinge on building relationships between psychologists and the carriers. Desired results take two forms: modification of contingencies between providers and carriers and modification of contingency between insured and carrier. Examples of each are presented.

Adolescent↗
PubMed2000

Intensity of antianginal therapy in patients referred for coronary angiography: a comparison of fee-for-service and health maintenance organization therapeutic strategies.

BACKGROUND: No formal criteria have been developed to guide medical therapy for angina prior to revascularization, and no comparisons have been made between health maintenance organization (HMO) and fee-for-service (FFS) hospitals with respect to angina treatment. HYPOTHESIS: Using a literature-based measure of medical intensity, we tested the hypothesis that there is no difference in anginal medical therapeutic intensity between HMO and FFS systems. METHODS: For each antianginal drug, we developed a model from which an intensity score between 0 and 100 could be calculated. Average and maximal daily doses of drug were fit to a sigmoid curve such that they represented scores of 50 and 99, respectively. Overall intensity scores were obtained by weighted and unweighted averaging of three scores from nitrates, calcium-channel blockers, and beta blockers. This model was applied to 199 patients undergoing angiography at an FFS and an HMO hospital. RESULTS: HMO patients were taking more classes of antianginal drug (1.9 vs. 1.0, p < 0.001). Overall unweighted (17.7 vs. 11.7, p = 0.02) and weighted (27.3 vs. 16.9, p = 0.003) intensity scores for both HMO and FFS patients were low. HMO intensity scores for the use of beta blockers were greater than FFS scores (19.2 vs. 9.6, p = 0.002). The intensity scores for the use of nitrates and calcium blockers were similar. CONCLUSIONS: Models for the measurement of anginal medical therapy intensity can provide important information regarding medical therapy prior to revascularization. The overall intensity of medical therapy was low in both health care systems. These findings have important implications for patient management, guideline development, and national healthcare policy.

Adrenergic beta-Antagonists↗
PubMed2002

The prevalence of major depression or dysthymia among aged Medicare Fee-for-Service beneficiaries.

RESEARCH OBJECTIVE: Estimates of the prevalence of major depression vary widely. Current estimates range from 2 to 14 % depending upon the definition and procedure for diagnosis. Further, most estimates are for special populations, either living in selected geographic areas or receiving specific types of medical care. A national survey of Medicare Fee-for-Service (FFS) beneficiaries provides an opportunity to assess the current level of major depression or dysthymia among a diverse population of older Americans. STUDY DESIGN: The Health Outcomes Survey (HOS) was administered to a national random sample of 1,000 Medicare FFS beneficiaries. We used the Mental Component Summary (MCS) measure of the SF-36 to estimate the prevalence of major depression or dysthymia. Logistic regression was used to examine associated factors. RESULTS: The response rate was 61.7%. Using an MCS score of 42 or lower, prevalence of major depression or dysthymia was estimated to be 25% for respondents age 65 years and older. Logistic regression analysis revealed that the likelihood of major depression or dysthymia was associated with years of education (Odds Ratio (OR) = 0.87), difficulties performing activities of daily living (OR = 1.72), and Medicaid enrollment (OR = 2.67). CONCLUSIONS: The results revealed that one-quarter of the respondents reported mental health problems consistent with major depression or dysthymia. This is higher than previously reported. Like previous studies, years of education, physical impairment, and poverty are strong predictors of major depression or dysthymia. The high rate of major depression or dysthymia implies there may be considerable unmet need among elderly Medicare FFS beneficiaries for diagnosing and treating mental illness.

Aged↗
PubMed1990

Medicaid maternal and child health care: prepaid plans vs. private fee-for-service.

A randomly selected sample of 98 inner-city new mothers was interviewed with regard to (a) their level of satisfaction with and perceived barriers to pediatric and maternal health care, and (b) the health status of their infants. The mothers were divided according to their Medicaid status: 39 (40%) were enrolled into a Medicaid prepaid plan (PPP) and 59 (60%) were enrolled as regular Medicaid fee-for-service (FFS) patients. Comparison of the two groups showed that infant health status was similar but that PPP mothers reported a higher incidence of untreated infant problems and perceived more barriers to pediatric care. Birth outcomes also were similar for the two groups but FFS mothers and infants were hospitalized for significantly longer periods postpartum. The implications of these findings for the delivery of maternal and child health services to low-income populations through the Medicaid program are discussed.

Adolescent↗
PubMed1982

Risk in a "Fee for Service" Health Care System.

This paper describes an approach for assessing the financial risk inherent in a bid for the development and operation of a Management Information System (MIS) that includes processing of claims associated with a "Fee for Service" Health Care System. The discussion establishes the motivation for a risk assessment, defines the context of the problem, and proposes a risk-analysis procedure. Results attainable with the proposed approach are compared with those of a conventional analysis. The advantages of the proposed approach are addressed in terms of the added effort required.

Computers↗
PubMedDate not supplied

A multi-site study of Medicaid-funded managed care versus fee-for-service plans' effects on mental health service utilization of children with severe emotional disturbance.

Although Medicaid-funded managed care arrangements are commonly used in the delivery of mental health and substance abuse services to low-income children and youth, little is known about the effectiveness of such efforts. This article examines differences in mental health services utilization between children and youth with severe emotional disturbance covered by Medicaid-funded managed care behavioral health plans and those covered by fee-for-service plans. Data are from a federally funded multi-site study. In multivariate analyses controlling for child and caregiver demographic and clinical factors, enrollment in a managed care behavioral health plan was associated with lower inpatient/residential, psychiatric medication, and nontraditional services utilization. No difference was found in outpatient services utilization. Medicaid-funded managed care behavioral health plans appear to reduce use of some types of mental health services, but it is important to address the question of whether low-income children's enrollment in such programs deprives them of needed services.

Adult↗
PubMed1975

The Wisconsin Allergy Society fee and practice survey. A study for professional standard review organizations.

Physicians practicing allegy in the State of Wisconsin were surveyed regarding their fees charged and norms of practice relating to the diagnosis and management of patients with allergic diseases. Over 50% of the physicians surveyed responded and the results were compiled and analyzed. The data obtained provide an over-view of the practice of a medical subspecialty and can thus be used for possible peer evaluation.

Fees, Medical↗
PubMed1992

The effect of per-item fees on the behaviour of general practitioners.

The recent government White Paper 'Working for Patients' emphasised the use of financial incentives as a means of altering the behaviour of general practitioners (GPs) in the U.K. This paper examines the impact of financial incentives on GPs' behaviour with respect to maternity care and cervical cytology. Changes in per-item fees over the period 1966-89 appear to have had little effect on the numbers of treatments; rather service provision was related to patient demand and the availability of GPs. However, target payments for cervical cytology introduced in 1990 appear to have had a major impact.

Fees, Medical↗
PubMed1991

Policy and implementation of user fees in Jamaican public hospitals.

User fees and other forms of copayment for health care are becoming of increasing interest to policymakers in developing countries. As indigenous populations continue to expand in response to current and historically high fertility, and government resources become constrained due to macroeconomic circumstances, publicly provided health care is being squeezed financially. Most developing countries have committed their governments to either providing for all health care or at least ensuring that all citizens have access to health care regardless of ability to pay. This has translated in most contexts into blanket coverage for the entire population financed and generally provided by the government. Recent periods of slow growth, high debt burdens and restricted spending on high recurrent cost sectors, such as health care under International Monetary Fund and other donor agreements have reduced many developing countries' budgets and often the real value of health expenditures. The costs of inputs (personnel, drugs and consumables), however, have not declined and quality or quantity have been necessarily reduced. At the same time, options for financial relief outside the tax system have become of increasing interest to financially constrained governments. User charges are straightforward, easily understood and can in theory be profitable in the short term. From a fairness perspective, they also charge those who actually use the health system. Their major drawback for policymakers is the potential for undermining equity in the health system.

Budgets↗
PubMed1995

Negotiating fees for medical specialists in The Netherlands.

This article presents an analysis of the negotiations on fees for medical specialists in the Netherlands since the introduction of the Law on Health Care Charges (WTG) in 1982. The peculiar position of the medical specialists and the institutional setting of the negotiations have produced a complex decision making process. Negotiations between the government and the health insurers on the one hand and the association of medical specialists on the other hand have been dominated by deep conflicts which were sometimes settled by temporary "peace contracts'. Attention is paid to the policy network, to the participants in the network and their principal goals, to the strategic use of the WTG by each participant and to the political effectiveness of the WTG. The article ends with a short overview of some recent developments and a sketch of three alternative scenarios on the future of the payment for specialist care.

Decision Making↗
PubMed2006

Financing electronic waste recycling Californian households' willingness to pay advanced recycling fees.

The growth of electronic waste (e-waste) is of increasing concern because of its toxic content and low recycling rates. The e-waste recycling infrastructure needs to be developed, yet little is known about people's willingness to fund its expansion. This paper examines this issue based on a 2004 mail survey of California households. Using an ordered logit model, we find that age, income, beliefs about government and business roles, proximity to existing recycling facilities, community density, education, and environmental attitudes are significant factors for explaining people's willingness to pay an advanced recycling fee (ARF) for electronics. Most respondents are willing to support a 1% ARF. Our results suggest that policymakers should target middle-aged and older adults, improve programs in communities with existing recycling centers or in rural communities, and consider public-private partnerships for e-waste recycling programs.

Adolescent↗
PubMed2004

The effect of HMOs on fee-for-service health care expenditures: evidence from Medicare revisited.

This paper implements a new method for calculating the extent of selection in the aged Medicare HMO market. Selection is measured as the difference in average costs between new Medicare HMO enrollees and Medicare fee-for-service stayers with data from 1990 to 1994. Results suggest Medicare HMO enrollees were 1030 US dollars cheaper in their first year of enrollment. The effect is found entirely in Part A (hospital) expenditures, confirming selection is based on inpatient rather than outpatient or preventive care. These results are consistent with previous work.

Aged↗
PubMed2006

An analysis of the length of stay and effectiveness of treatment for hip fracture patients in Japan: evaluation of the 2002 Revision of the Medical Service Fee Schedule.

The length of hospital stay and effectiveness of medical treatment are analyzed using data of patients hospitalized due to hip fractures of four hospitals in Japan. The influence of the Revision of the Medical Service Fee Schedule in April, 2002, is evaluated, and factors which may have affected the length of stay and effectiveness of treatment (walking ability upon departure from the hospital) are also analyzed by a newly developed simultaneous equation model.

Fees and Charges↗
PubMed2005

Fee-for-service or donation? Hungarian perspectives on informal payment for health care.

Informal payments are known to be widespread in the post-communist health care systems of Central and Eastern Europe. However, their role and nature remains contentious with the debate characterized by much polemic. This paper aims to make sense of this debate by reviewing and summarizing the main arguments of the theoretical debate in Hungary. The review examines the possible causes of informal payment, the motivation of the actors involved and the impact of informal payment on system performance, focusing on efficiency and equity. The lines of arguments are summarized in two contrasting hypotheses, which envisage informal payment as either a donation or a fee-for-service. Evidence pertaining to the scale of informal payments and the motivation of patients are reviewed, but found to be inconclusive to verify the hypotheses. Although focused on Hungary, accounts from other countries facing informal payments show similar threads of discussion and dilemmas. These theories should be tested further using evidence from existing studies and new empirical research, since the validity of the gratitude payment concept is a central dilemma of effective policy making in the area. To orient future research, a possible agenda is outlined, which links evidence to be obtained to the defining features of gratitude payments.

Coercion↗