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PubMedDate not supplied

Cost-containment strategies for centers offering open heart product lines: one conceptual model.

Those hospitals currently offering cardiovascular service lines must look carefully at cost and outcome criteria. Certain considerations, such as the aging population, declining reimbursement rates, more critically ill patients and advances in healthcare technology, may be cause for many hospital administrators to rethink the viability of offering open heart services. The sometimes brutal competition in healthcare threatens the existence of many smaller programs. Some may argue that the corporate culture of healthcare is fast becoming more and more bottom-line oriented. True, the bottom line is important, but at what point is quality affected? The concept of managed care and capitated fees has, in effect, sent third-party payers into a "feeding frenzy" with respect to contract negotiations. This often results in the pitting of one hospital or doctor against another in what could be argued to be a calculated effort to drive down cost. Health-service organizations performing open heart surgery must understand a multitude of political and economic factors in order to provide cost-effective care. At the top of the priority list must be quality of care. Programs which experience low mortality/morbidity rates will be those facilities that consumers and payers choose. In fact, adjusted mortality/morbidity reports are already a reality in some states. Successful heart programs will be those known in the community (and, perhaps more importantly, to payers) as "centers of excellence," which offer customers high-tech and cost-conscious healthcare. Paramount to successful heart programs will be variables such as favorable managed-care contracts, program size, peer review and proactive case management.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Surgical Procedures↗
PubMed1983

State Medicaid contracts--HCFA. Final rules.

These regulations--(1) Make it possible for Medicaid agencies to contract on a risk basis with health maintenance organizations (HMOs) other than those that meet all the requirements for a Federally qualified HMO; (2) Ease requirements that limit the proportion of HMO enrollees that may be persons eligible for Medicare or Medicaid; and (3) Permit States to continue to provide Medicaid (through the benefits provided to the recipient as an HMO enrollee), for a period of up to 6 months from the date of enrollment in a Federally qualified HMO, even if the enrollee loses Medicaid eligibility before the end of that period. These regulations are necessary to implement section 2178 of the Omnibus Budget Reconciliation Act of 1981. They also include changes made as part of regulatory reform. The intent is to encourage and enable Medicaid agencies to make greater use of HMOs and other prepaid health plans (PHPs) to payments for a person not currently eligible. The fluctuations also make it impossible for the HMO to be certain of the amounts it will receive, in capitation fees, for a particular period. Section 2178 of Pub. L. 97-35 amended section 1902(e) of the Act to provide States the option of continuing Medicaid, for a period of up to 6 months from date of enrollment in a Federally qualified HMO, even if the enrollee loses Medicaid eligibility before the end of that period. This will help to resolve the administrative problems for both States and HMOs and facilitate use of HMOs in Medicaid.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1999

Do nursing home residents make greater demands on GPs? A prospective comparative study.

BACKGROUND: The number of people residing in nursing homes has increased. General practitioners (GPs) receive an increased capitation fee for elderly patients in recognition of their higher consultation rate. However, there is no distinction between elderly patients residing in nursing homes and those in the community. AIM: To determine whether nursing home residents receive greater general practice input than people residing in the community. METHOD: Prospective comparative study of all 345 residents of eight nursing homes in Glasgow and a 2:1 age, sex, and GP matched comparison group residing in the community. A comparison of contacts with primary care over three months in terms of frequency, nature, length, and outcome was carried out. RESULTS: Nursing home residents received more total contacts with primary care staff (P < 0.0001) and more face-to-face consultations with GPs (P < 0.0001). They were more likely to be seen as an emergency (P < 0.01) but were no more likely to be referred to hospital, and were less likely to be followed-up by their GP (P < 0.0001). Although individual consultations with nursing home residents were shorter than those with the community group (P < 0.0001), the overall time spent consulting with them was longer (P < 0.001). This equated to an additional 28 minutes of time per patient per annum. Some of this time would have been offset by less time spent travelling, since 61% of nursing home consultations were done during the same visit as other consultations, compared with only 3% of community consultations (P < 0.0001). CONCLUSION: Our study suggests that nursing home residents do require a greater input from general practice than people of the same age and sex who are residing in the community. While consideration may be given to greater financial reimbursement of GPs who provide medical care to nursing home residents, consideration should also be given to restructuring the medical cover for nursing home residents. This would result in a greater scope for proactive and preventive interventions and for consulting with several patients during one visit.

Aged↗
PubMed2004

Family medicine in Croatia: past, present, and forthcoming challenges.

The aim of this paper is to present the effects of the reform of primary care by privatization and direct contracting between general practitioners/family physicians and the Croatian Institute for Health Insurance, as well as to propose possible improvements. Using the data of the Croatian Institute of Public Health, we analyzed the coverage of population and accessibility of service, management of chronic illnesses, home visits, and preventive check-ups in the family medicine service. In 2001, 2,408 (30.8% vocationally trained) doctors worked in the family medicine service, taking care of 3.759,248 (84.7%) registered inhabitants of Croatia. There was an average of 6 office encounters, 0.1 home visits, 0.05 preventive check-ups and 1.4 referrals per patient per year. Within the Project of Health System Reform a working group of primary care experts proposed the following improvements: 1) the family medicine service should be organized in accordance with the fundamental principles of accessibility, continuity, and integrated care; and 2) a multilayered financing model should be used, containing a capitation fee payment, fee for service payment, and specific program payment. Taking into account the European Union recommendation, a project aimed at ensuring the specialization of family medicine for all doctors working in the family medicine service was started in 2003. This study indicates that there is a gap between proclaimed health system improvements and effects of the reform of primary care. In order to achieve evidence-based health policy, concerted action of all participants in the decision-making process is needed.

Croatia↗
PubMed1991

How well do family practitioner committee and general practice records agree? Experience in a semi-rural practice.

General practice notes may be inaccurate for various reasons. A study was carried out in one semi-rural practice to investigate the agreement between records held by the family practitioner committee and those kept in the practice. Details on the practice notes and the family practitioner committee list were compared for 800 patients. The details examined included name, sex, date of birth, address and National Health Service number. While 58% of records agreed, discrepancies occurred in 339 records (42%). The most common discrepancies concerned the patient's address (30.6%), date of birth (9.4%) and NHS number (8.0%). Nearly 5% of the practice notes appeared to be for patients who were no longer on the practice list or dependent on its care. These findings have implications under the new general practitioner contract where screening programmes, target related payments, and increased capitation fees require accurate practice records.

Documentation↗
PubMed1991

A national long-term care program for the United States. A caring vision. The Working Group on Long-term Care Program Design, Physicians for a National Health Program.

The financing and delivery of long-term care (LTC) need substantial reform. Many cannot afford essential services; age restrictions often arbitrarily limit access for the nonelderly, although more than a third of those needing care are under 65 years old; Medicaid, the principal third-party payer for LTC, is biased toward nursing home care and discourages independent living; informal care provided by relatives and friends, the only assistance used by 70% of those needing LTC, is neither supported nor encouraged; and insurance coverage often excludes critically important services that fall outside narrow definitions of medically necessary care. We describe an LTC program designed as an integral component of the national health program advanced by Physicians for a National Health Program. Everyone would be covered for all medically and socially necessary services under a single public plan, federally mandated and funded but administered locally. An LTC payment board in each state would contract directly with providers through a network of local public agencies responsible for eligibility determination and care coordination. Nursing homes, home care agencies, and other institutional providers would be paid a global budget to cover all operating costs and would not bill on a per-patient basis. Alternatively, integrated provider organizations could receive a capitation fee to cover a broad range of LTC and acute care services. Individual practitioners could continue to be paid on a fee-for-service basis or could receive salaries from institutional providers. Support for innovation, training of LTC personnel, and monitoring of the quality of care would be greatly augmented. For-profit providers would be compensated for past investments and phased out. Our program would add between $18 billion and $23.5 billion annually to current spending on LTC. Polls indicate that a majority of Americans want such a program and are willing to pay earmarked taxes to support it.

Aged↗
PubMed1987

[An assessment of the social welfare system in the United Kingdom].

This report describes the British social welfare system with reference to expected future developments in Japanese medical care. In developed countries where the average life expectancy is high, a large percentage of the population is elderly, resulting in high social welfare expenditure. In Britain, the "social welfare state", the average life expectancy is similar to that of other developed countries, while expenditure by the Department of Health and Social Security is considered to be the lowest. For example, expenditure on medical care for an average elderly man is approximately 60% of that in Japan. Some of the reasons are as follows. The family practitioner services are medical services given to patients by doctors of their own choice. The family doctor undertakes the initial diagnosis and management, but may refer the patients for either specialized services or hospital consultation. The general basis for remuneration of the family doctor is a standard capitation fee and an allowance. This system does not lead to over diagnosis or excessive treatment. The numbers of medical consultations performed and prescriptions issued by British doctors is lower than that in Japan. In Japan the number of elderly persons who are incapable of caring for themselves is increasing and poses not only a financial burden, but also a social problem. In the UK, these patients are cared for by social welfare workers (Japanese nurses) or at health centres (unlike Japanese hospitals and homes for the aged) which is less costly than inpatient hospital care. The Government is responsible for the National Health Service.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1994

Teaching parents to look after children's teeth.

Children's toothpastes with fluoride help to prevent decay, but parents should ask their dentist before giving fluoride supplements to children. Overdosage is harmful. Sugars eaten as part of a meal do less harm to teeth than those eaten frequently as snacks. Sugar-free infant drinks and children's confectionery are now on the market and are more "tooth friendly". Look out for the "happy tooth" symbol. Babies can be registered with NHS dentists as soon as the first teeth start to come through, and should be taken regularly to the dentist throughout childhood. Under the NHS scheme, dentists are paid a capitation fee to provide continuing preventive care and treatment for children free of charge.

Adolescent↗
PubMedDate not supplied

Effects of different remuneration methods on general medical practice: a comparison of capitation and fee-for-service payment.

There are severe methodological problems to be overcome in comparing the effects of different payment methods on general medical practice, not least because there are many factors which affect the pattern of service delivery. Also, the reliability and comparability of data may be poor. This article emphasises that the effects of capitation and fee-for-service payment methods on general medical practice should be carefully compared with factual information, especially numerical data. In so doing, it is shown that there are supporting data for the contention that a fee-for-service system encourages more consultations, more diagnostic tests, higher drug use, higher surgical rates and higher costs than a capitation system. On the other hand, a capitation system may lead doctors to hastier and less courteous care than a fee-for-service system. The geographical distribution of general practitioners (GPs) may be more even, and continuity of care may be better maintained, under a capitation system; but there may be excessive referrals from GPs to specialists under this system of payment. There is no evidence for the contention that a capitation system encourages preventive medicine, but the financial coverage for preventive procedures does encourage such procedures.

Capitation Fee↗
PubMed1988

Capitation and fee-for-service dental benefit plans: economic incentives, utilization, and service-mix.

Insurance carriers, corporations, and labor groups are actively developing and marketing dental capitation benefit plans. Incentives to both dentists and patients in these plans differ from those in the traditional fee-for-service system used with conventional benefit plans. This paper describes the likely effects of these incentive differences on utilization and service-mix patterns in both systems. Data for a large (approximately 10,000), homogenous group of subscribers are presented and discussed. Faced with a dual option, at no cost to the employee, 60% of the subscribers chose the fee-for-service plan, and 40% chose the capitation plan. Observed differences in the utilization and mix of services between the two plans cannot be explained solely in terms of dentists' responses. Employee response to altered economic incentives appears to be strong.

Capitation Fee↗
PubMed1997

Prepaid capitation versus fee-for-service reimbursement in a Medicaid population.

Utilization of health resources by 37,444 Medicaid recipients enrolled in a capitated health maintenance organization was compared with that of 227,242 Medicaid recipients enrolled in a traditional fee-for-service system over a 1-year period (1983-1984) in the state of Kentucky. Primary care providers in the capitated program had financial incentives to reduce downstream costs like specialist referral, emergency room use, and hospitalizations. The average number of physician visits was similar for both groups (4.47/year in the capitated program; 5.09/year in the fee-for-service system). However, the average number of prescriptions (1.9 versus 4.9 per year), average number of hospital admissions per recipient (0.11 versus 0.22 per year), and average number of hospital days per 1,000 recipients (461 versus 909 per year) were 5% to 60% lower in the capitated group than in the fee-for-service group. The Citicare capitated program resulted in a dramatic reduction in healthcare resource utilization compared with the concurrent fee-for-service system for statewide Medicaid recipients.

Aid to Families with Dependent Children↗
PubMed1989

Preventive services in a hybrid capitation and fee-for-service setting.

The potential omission of indicated tests for patients enrolled in prepaid health care plans has been raised as a possibility. This study reviewed the charts of 149 adult patients seen for routine physical examinations or checkups in university-based family medicine or internal medicine clinics. Of the patients included, 67 were enrolled in a capitated plan and 82 enrolled in fee-for-service based plans. Results showed that the rates of compliance with preventive services appropriate to patients' age and sex (Papanicolaou smears, breast examination, mammography, and stool examination for occult blood) were not significantly different for capitated and fee-for-service patients.

Adult↗
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.

Aged↗
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↗
PubMed1992

Ambulatory testing for capitation and fee-for-service patients in the same practice setting: relationship to outcomes.

Previous studies of the impact of varying reimbursement incentives on physician behavior have not explored the simultaneous implications for patients' health outcomes. Using a single group of physicians who provided care for hypertensive patients with either capitation (N = 99) or fee-for-service (N = 66) health insurance plans, physicians' test-ordering behavior and patients' subsequent health outcomes were examined. After controlling for patients' age, severity of hypertension, and level of comorbidity, it was found that patients with capitation health insurance had fewer laboratory tests and lower overall charges than the fee-for-service patients, with no clinical or statistically significant differences in 1-year health outcomes, specifically blood pressure control. The study concludes that capitation can result in reduction in charges associated with management of hypertension, without apparent compromise in proximate health outcomes.

Adult↗
PubMed1995

Case mix of home health patients under capitated and fee-for-service payment.

OBJECTIVE: We compare case mix of Medicare home health patients under HMO and FFS payment. STUDY DESIGN: A pseudo-experimental design was employed to study case mix using three types of Medicare-certified home health agencies (HHAs): HMO-owned agencies, pure FFS agencies that admit few Medicare HMO patients (less than 5 percent of admissions are Medicare HMO patients), and mixed (or contractual) agencies that admit at least 15 Medicare FFS patients and 15 Medicare HMO patients per month. SAMPLES OF PROVIDERS AND PATIENTS: Random samples of Medicare-aged patients (> or = 65 years) were selected at admission between June 1989 and November 1991 from the 38 study HHAs. Sample sizes by agency type were: 308 patients from 9 HMO-owned agencies; 529 patients from 15 pure FFS agencies; and 381 HMO patients and 414 FFS patients from 14 contractual agencies. DATA: Primary longitudinal data were prospectively collected at admission for all patients on health status indicators, demographics, admission source, and home environment. MEASURES: The most important case-mix measures were functional and physiologic indicators of health status, including (instrumental) activities of daily living ([I]ADLs). Selected indicators of demographic variables, prior location, living situation, characteristics of informal caregivers, mental/behavioral factors, and resource needs were also used. PRINCIPAL FINDINGS: (a) The case mix of Medicare FFS patients compared with Medicare HMO patients was more intense in terms of impairments in ADLs, IADLs, and various physiologic conditions. Pressure ulcers as well as neurological and orthopedic impairments requiring rehabilitation care were also more prevalent among FFS patients. (b) Relative to HMO patients admitted to contractual agencies, HMO patients admitted to HMO-owned agencies were moderately more dependent in ADLs and IADLs. However, only 62 percent of HMO patients admitted to HMO-owned agencies, in contrast to 77 percent of HMO patients admitted to contractual agencies, had been hospitalized during the 30 days prior to home health admission. (c) In all, the case mix of patients receiving care from HMO-owned agencies is more heterogeneous than the case mix of HMO patients receiving care from contractual agencies. CONCLUSIONS: The case-mix (and selected utilization) findings indicate that HMOs use home health care differently than does the FFS sector. The greater diversity of case mix for HMO-owned agencies and the narrower or less diverse case mix that characterizes HMO patients receiving home care on a contractual basis point to the likelihood of cost differences among the two types of HMO patients and FFS patients, and raise the question of possible outcome differences.

Activities of Daily Living↗
PubMedDate not supplied

From capitation to fee-for-service in cincinnati: a physician group responds to a changing marketplace.

The experience of Group Health Associates, a multispecialty practice physician group in Cincinnati, Ohio, offers an important case study of how payment incentives and market realities can change the way physicians practice medicine. After nearly thirty years as a capitation-based medical group, these physicians recently switched completely to fee-for-service reimbursement-not willingly, but in response to an evolving marketplace. Their new business strategy seeks to create a case for being paid for performance and treating the chronically ill.

Capitation Fee↗