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PubMed2002

Incentives in financing mental health care in Austria.

BACKGROUND: In Austria, financing health care -and even more so mental health care- is characterized by a mix of federal and provincial responsibilities, lack of uniformity in service provision and service providers, and diverse funding arrangements. The division between financing structures for health care and social care makes the situation even more complex. This state of affairs results in various, partly counterproductive and sometimes paradoxical financial incentives and disincentives for the providers, recipients and financiers of mental health services. In several provinces of Austria, recent reform plans in mental health care have focused strongly on establishing community-based and patient-oriented mental health care. One of the main challenges in implementing this new policy is the re-allocation of resources. AIMS OF THE STUDY: The authors hypothesize that the existing structure of mental health care financing, with its incentives and disincentives, constitutes an obstacle to patient-oriented community-based mental health care. Analyzing the characteristics of the overall mental health care financing system in one Austrian province, Lower Austria, will provide a better understanding of actor-relationships and inherent incentives and highlight implications for the process of deinstitutionalization. METHOD: The authors used an analytical framework based on the principal-agent theory, empirical evidence, and information on financial, organizational and legal structures to identify the characteristics of actor-relationships and the position of single actors within the system. RESULTS: The article shows how incentives are linked to existing constellations of actors involved in mental health care financing and identifies significant power relations. As a consequence, incentives and disincentives within the financing system result in hospital- centered and supply-oriented mental health care in Lower Austria. DISCUSSION: The current system of financing mental health care provides an obstacle to the provision of patient-oriented and community-based mental care. This is due to existing constellations and power relations among the actors where, most importantly, patients are the weakest party in the patient-payer-provider triangle. Balancing power relations will be a significant prerequisite for alternative financing systems. IMPLICATIONS FOR HEALTH POLICIES AND FURTHER RESEARCH: If a community and needs-based mental health care system is to be established in Austria, the financing structures have to be changed accordingly. Applying a principal-agent framework is useful for identifying key aspects in mental health care financing in relation to the provision of services. Further research is needed to help develop alternative financing mechanisms that support community-based and patient-oriented mental health care systems.

Austria↗
PubMed1982

Incentives, reproductive behavior, and integrated community development in Asia.

Surveying experience with incentives, disincentives, and integrated community development approaches in selected Asian countries, this overview defines concepts, notes policy trends, and discusses ethical and legal constraints, psychosocial and socioeconomic aspects, and cultural-environmental influences on reproductive behavior. Major emphasis is on experience reported from China, India, Indonesia, Korea, Philippines, Singapore, and Thailand. Findings to date suggest that, to be successful, programs using incentives, disincentives, and integrated community development approaches will have to be formulated as consistent, clearly defined, and well-communicated policies, responsive to development needs and sensitive to local autonomy and values, with dynamic leadership to obtain and nurture continued policy backing.

Asia↗
PubMed2006

Outpatient parenteral antibiotic therapy in Singapore.

Outpatient parenteral antibiotic therapy (OPAT) remains in its infancy in Singapore, with the first patients enrolled 4 years ago. Singapore's three largest hospitals, with over 3000 inpatient beds, now have designated and approved OPAT services. This study reviews the demographic, clinical and cost data of all patients enrolled in 2005 to facilitate benchmarking between services in Singapore and abroad and also to identify common needs for further development. In 2005, 225 OPAT enrollments in 208 different patients resulted in 4050 days of OPAT care. Orthopaedic diagnoses constituted 40% of admissions. Vancomycin was the most frequently used antibiotic (34%). The re-admission rate was 8.9%, but complications of OPAT care were only occasionally implicated. An estimated $207,200 was saved by patients despite there being significant financial disincentives to subsidised patients. OPAT is a safe, cost-efficient system that is becoming increasingly accepted in Singapore by patients, clinicians and management. Our three services have evolved independently into very similar practices. There is potential for further innovation, including outreach and carer-delivered dosing. However, major financial disincentives require review.

Adolescent↗
PubMed2002

Physicians' attitudes towards the computerization of clinical practice in Hong Kong: a population study.

OBJECTIVE: To identify the prevailing attitudes among physicians to use of computers in the clinical setting and specifically those attitudes that may be associated with the adoption of computers in practice. DESIGN: A self-completed, 20-question postal questionnaire sent to 4850 randomly selected physicians. The questionnaire focused on details of the physicians' practice; actual computerization of or intention to computerize clinical and administrative functions; attitudes towards computerization; self-perceived computer ability and knowledge; and demographic information. The attitude statements were grouped under four themes according to a factor analysis. RESULTS: The survey was completed by 897 physicians. Only physicians in 'individual' practices were included in the analysis. This group was further dichotomized into clinical users (those with one or more clinical functions computerized) and non-clinical users. Non-clinical users were older and had fewer specialist qualifications. Although there was strong support for the attitude statements among both groups with regard to the benefit of computerization to patient care, there was much less support for electronic medical records. Non-clinical users were concerned about the potentially negative impact of computerization on the clinical encounter and the perceived high cost of computerization. DISCUSSION: The attitudes among current clinical users and non-users were substantially different. The most important disincentives to computerization were the potential for interference with the patient-physician encounter and the cost of computerizing multiple practice locations. Turning these disincentives into opportunities for change remains the challenge.

Attitude to Computers↗
PubMed1992

Evolution and current status of the Orphan Drug Act.

The 1983 Orphan Drug Act was designed in response to market and regulatory disincentives that limited industrial interest in developing drugs needed by people in the United States with rare diseases and conditions. These disincentives evolved from changes in the pharmaceutical industry and in regulatory testing requirements. In the eight years since the Act and subsequent amendments have been in effect, the law has been associated with the new development and approval of 40 marketed drugs and 12 biologicals to treat rare (orphan) diseases. An additional 281 drugs and 141 biologicals have been entered into development and designated as orphans. Finally, the law has mandated exploration of whether the incentives of the Act are necessary and appropriate for stimulating industrial development of orphan medical drugs and devices. Despite this progress, controversies have arisen over three profitable orphan products that have benefited from the law's provisions. This has created the need for continued assessment of the Act's benefits and costs.

Drug Approval↗
PubMed2000

From clinical recommendations to mandatory practice. The introduction of regulatory practice guidelines in the French healthcare system.

In an effort to control ambulatory care costs, regulatory practice guidelines (références médicales opposables or RMOs) were introduced by law in France in 1993. RMOs are short sentences, negatively formulated ("it is inappropriate to..."), covering medical and surgical topics, diagnosis, and treatment. Since their introduction, physicians who do not comply with RMOs can be fined. The fine is determined by a weighted combination of indices of harm, cost, and the number of violations. The impact of the RMO policy on physician practice has been questioned, but so far few evaluations had been performed. At the end of 1997, only 121 physicians had been fined (0.1% of French private physicians). The difficulty of controlling physicians, the large number of RMOs, and the lack of a relevant information system limit the credibility of this policy. The simultaneous development of a clinical guideline program to improve the quality of care and of a program to control medical practice can lead to a misunderstanding among clinicians and health policy makers. Financial incentives or disincentives could be used to change physician behavior, in addition to other measures such as education and organizational changes, if they are simple, well explained, and do not raise any ethical conflict. But these measures are dependent on the structure and financing of the healthcare system and on the socioeconomic and cultural context. More research is needed to assess the impact of interventions using financial incentives and disincentives on physician behavior.

France↗
PubMedDate not supplied

Disaster coordination and management: summary and action plans.

INTRODUCTION: Disaster is a collective responsibility requiring coordinated response from all parts of society. This theme focused on coordination and management issues in a diverse range of scenarios. METHODS: Details of the methods used are provided in the preceding paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. Although the main points developed in Themes 1 and 4 were different from each other (as reported in the Results section), their implementation was similar. Therefore, the chairs of both groups presided over one workshop that resulted in the generation of a set of Action Plans that then were reported to the collective group of all delegates. RESULTS: The main points developed during the presentations and discussions included: (1) the need for evidence-based assessments and planning, (2) the need for a shift in focus to health-sector readiness, (3) empowerment of survivors, (4) provision of relief for the caregivers, (5) address the incentives and disincentives to attain readiness, (6) engage in joint preparation, response, and training, (7) focus on prevention and mitigation of the damage from events, and (8) improve media relations. There exists a need for institutionalization of processes for learning from experiences obtained from disasters. DISCUSSION: Action plans presented include: (1) creation of an Information and Data Clearinghouse on Disaster Management, (2) identification of incentives and disincentives for readiness and develop strategies and interventions, and (3) act on lessons learned from evidence-based research and practical experience. CONCLUSIONS: There is an urgent need to proactively establish coordination and management procedures in advance of any crisis. A number of important insights for improvement in coordination and management during disasters emerged.

Continuity of Patient Care↗
PubMed2001

Further improvements in laparoscopic donor nephrectomy: decreased pain and accelerated recovery.

Fear of postoperative pain is a disincentive to living donor kidney transplantation. Laparoscopic donor nephrectomy (LDN) was developed in part to dispel this disincentive. The dramatic increase in the number of laparoscopic donor nephrectomies performed at our institution has been in part due to the reduction in postoperative pain as compared to traditional, open donor nephrectomy. We sought to further diminish the pain associated with this surgical technique. The purpose of this study was to compare the efficacy of three different postoperative pain management regimens after LDN. All living kidney donors performed laparoscopically (n=43) between September 1998 and April 2000 were included for analysis. Primary endpoints included postoperative narcotic requirements and length of stay. Narcotic usage was converted to morphine equivalents (ME) for comparison purposes. Patients received one of three pain control regimens (group 1: oral and intravenous narcotics; group II: oral and intravenous narcotics and the On-Q pump delivering a continuous infusion of subfascial bupivicaine 0.5%; and group III: oral and intravenous narcotics and subfascial bupivicaine 0.5% injection). Postoperative intravenous and oral narcotic use as measured in morphine equivalents was significantly less in group III versus groups I and II (group III: 28.7 ME versus group I: 40.2 ME, group II: 44.8 ME; P<0.05). Postoperative length of stay was also shorter for group III (1.8 days) versus group I (2.5 days) and group II (2.9 days). LDN has been shown to be a viable alternative to traditional open donor nephrectomy for living kidney donation. We observed that the use of combined oral and intravenous narcotics alone is associated with greater postoperative narcotic use and increased length of stay compared to either a combined oral and intravenous narcotics plus continuous or single injection subfascial administration of bupivicaine. The progressive modification of our analgesic regimen has resulted in decreased postoperative oral and intravenous narcotic use and a reduction in the length of stay. We recommend subfascial infiltration with bupivicaine to the three laparoscopic sites and the pfannenstiel incision at the conclusion of the procedure to reduce postoperative pain. We believe this improvement in postoperative pain management will continue to make LDN even more appealing to the potential living kidney donor.

Adult↗
PubMed2002

The general public's concerns about clinical risk in live kidney donation.

Difficulty in attracting live kidney donors may be related to fears regarding both the surgical procedure for kidney harvesting and future failure of the remaining kidney. We conducted a cross-sectional study of households in Maryland to identify public disincentives to living related kidney donation. In multivariate analyses, we assessed the independent effects of several factors on willingness to donate a kidney to a sibling. We also assessed thresholds for factors above which persons would not donate a kidney. Of 385 participants, 66% were extremely willing to donate to a sibling. After adjustment, those who considered the length of a hospital stay, out-of-pocket expenses, size and appearance of a scar, the time it takes to get to the transplant center, and the donor risk of developing kidney failure very important had 50-60% less odds of being extremely willing to donate. Median acceptable levels for risk of complications, hospital stay, compensated and uncompensated time from work, time requiring pain medications, and out-of-pocket expenses were greater than levels from clinical evidence regarding both laparoscopic and open nephrectomy. Unrealistic concerns among the general public regarding live donation may serve as potential disincentives to donation. Efforts to educate the public regarding live donation might help assuage fears and attract those who may not otherwise donate.

Adult↗
PubMed2000

Use of rubber dam and irrigant selection in UK general dental practice.

AIM: To evaluate factors which influence rubber dam use and irrigant selection in UK National Health Service (NHS) endodontics. METHODOLOGY: A postal survey was conducted amongst two age cohorts of dentists, representing all of the 1970-73 (older) and 1990-93 (younger) graduates of two northern English dental schools (n = 643). Key and supplementary questions were posed on levels of rubber dam use, irrigant selection, and factors influencing practice in NHS endodontics. After manual checking, validated (dual) entry of responses was made to a flat ASCII data file before analysis with SPSS software. The threshold for statistical significance was set at the 95% probability level. RESULTS: Eighty-five per cent of the valid sample responded to the questionnaire. Regardless of age and qualifying school, less than one-fifth of dentists always or frequently used rubber dam, whilst 60% never used it. Qualifying school had a significant influence on rubber dam use, whilst age had a variable influence. Major disincentives to the use of rubber dam included the perception that patients do not like it, that the NHS fee was inadequate to justify its use, that it took too long to apply, and that dentists had received inadequate training. Frequent users of rubber dam were significantly less likely to cite these disincentives than nonusers. Overall, local anaesthetic solution was the most common endodontic irrigant. Irrigant choice was strongly linked to rubber dam use, and to graduation cohort. Seventy-one per cent of rubber dam users irrigated with sodium hypochlorite, compared with only 38% of nonusers. This pattern was reversed for local anaesthetic irrigation. Younger graduates were significantly more likely to irrigate with local anaesthetic solution than their older counterparts, and the younger graduates of one school showed a highly significant increase in the use of chlorhexidine. CONCLUSIONS: 1) The majority of UK Health Service dentists never use rubber dam isolation in endodontic treatment. 2) Qualifying school has a significant impact on rubber dam use, and irrigant selection. 3) Use of rubber dam has a significant association with irrigant choice in endodontics.

Age Factors↗
PubMed1991

Teaching specialty cancer medicine in rural hospitals: the cancer outreach program as a model.

Cancer doctors and nurses are clustered in the metropolitan areas of Virginia. However, cancer patients are found throughout the state, and cancer mortality time trends are worse in the rural areas. Efforts to recruit cancer physicians and nurses to rural hospitals have been unsuccessful due to the practice characteristics, educational isolation, and economic disincentives. Our rural cancer education program involves the physicians and nurses currently in practice at two rural hospitals. We provide hands-on training in cancer care, continuing education, and intense week-long educational sessions. We have observed changes in physician and nurse practice styles that benefit the cancer patient including effective pain management, enrollment of patients on clinical trials, increased use of adjuvant therapy, and breast conservation. We are providing state-of-the-art cancer care at the rural hospitals in the Cancer Outreach Program. We have improved the educational opportunities and increased utilization of the resources of the academic career center. We can modify the practice characteristics by providing needed clinical programs and enhancing the rural hospital/academic medical center link. We have shown that rural cancer care can be revenue-neutral or positive, and we are seeking creative solutions to the financial disincentives of rural specialty practice. We can assist the rural hospital in the recruitment of oncology specialty nurses and physicians by providing cancer care services, and the patient caseload is available to teach prospective rural subspecialty practitioners at the rural hospitals.

Education, Medical, Continuing↗
PubMedDate not supplied

Community preparedness for HIV vaccine trials in the Democratic Republic of Congo.

This paper reports on an assessment of community preparedness for HIV vaccine trials in the Democratic Republic of Congo. Formative research was conducted in the capital city of Kinshasa during the period October 2003 to March 2004 to answer questions pertinent to planning trials of a preventive HIV vaccine and to identify related issues. Twenty-seven in-depth interviews and two focus groups were held with potential trial participants and community leaders. Data was collected on the subjects of vaccines, HIV/AIDS and sexual behaviour, and an HIV vaccine. The study also sought to identify factors that motivate a person to volunteer for a vaccine trial or which are disincentives to participation, along with preparedness of the larger community for trials. Personal concerns for health and for the impact of the epidemic on families and country were common motivations for participation. The danger of an experimental vaccine and the stigma of a positive HIV antibody test as the result of vaccination are major concerns and disincentives. The health, educational, and local non-governmental sectors are identified as having important roles to play in assuring preparedness for trials, although significant challenges exist to achieving community preparedness.

AIDS Vaccines↗
PubMed1982

Factors influencing decisions to enter careers in clinical investigation.

Factors associated with decisions to enter careers in clinical research were studied based on surveys completed by successful clinical investigators. Three aspects of career decision-making were explored: the timing of the decision to enter a research career, the relationship between research success and the timing of the decision, and the impact of two disincentives to enter research careers (the payback provisions of the national research service awards and the abolition of the physician draft that decreased the attractiveness of research training as an alternative). Survey results document the importance of medical school experiences in career decisions. Further, the correlation between the time of career decision and research success supports arguments for early research experiences upon which decisions can be made. Disincentives for entering a research career were not seen as barriers that would have prevented the majority of respondents from entering a research career. The results of the study led to a strong recommendation that research opportunities for medical students be enhanced as one mechanism for positively influencing decisions in favor of research careers.

Career Choice↗
PubMedDate not supplied

A method for developing faculty leaders.

The authors explore peer review as a mechanism for developing faculty leaders who can meet the educational challenges posed by public demands for accountability in higher education and an increasingly diverse student body. How educational paradigms influence the design of peer review programs is described. Incentives and disincentives as well as options for counteracting disincentives also are considered. Recommendations include the need to study effects of peer review programs on productivity, professional relationships, and educational outcomes within situational contexts, resources, and constraints.

Education, Nursing, Baccalaureate↗
PubMed2004

The costs of decedents in the Medicare program: implications for payments to Medicare + Choice plans.

OBJECTIVE: To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life-a group that accounts for more than one-quarter of Medicare's annual expenditures. DATA SOURCE: Medicare administrative claims for 1994 and 1995. STUDY DESIGN: We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters. DATA EXTRACTION METHODS: The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors. PRINCIPAL FINDINGS: Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments. CONCLUSIONS: More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries.

Actuarial Analysis↗
PubMed1990

Economic barriers to widespread implementation of model programs for the seriously mentally ill.

Although deinstitutionalization has been linked with an increase in the number of mentally ill people who are homeless or in jails, several demonstration programs started during the past 30 years have shown that community-based services for the seriously mentally ill can be both humane and cost-effective. Four such programs, none of which has been widely implemented or has significantly influenced service delivery systems, are described. The author contends that the chaotic and illogical funding system for mental health services is primarily responsible for failure of the widespread implementation of demonstrably effective programs. The economic disincentives of the present system include lack of coordination of services at the state and local level and federal policies that favor hospitalization, restrict payment for outpatient and rehabilitation services, and discourage mentally ill persons from working. The author suggests that public services for the mentally ill are unlikely to improve significantly until such disincentives are addressed.

Aftercare↗
PubMed1996

The economic life of seriously mentally ill people in the community.

OBJECTIVE: The study examined economic disincentives and incentives to work among people with serious mental illness. METHODS: Fifty people with severe and persistent mental illness who were living in the community were interviewed about the amount and sources of their income and expenses. In addition, a randomly selected group of 100 people with schizophrenia or schizoaffective disorder was interviewed about work, income, and wage requirements. RESULTS: In the first sample, the mean total cash and noncash income of unemployed subjects ($929 a month), which was derived mainly from disability supports and rent subsidies, was only slightly lower than that of subjects with part-time employment ($1,028 a month). The limited difference was largely a consequence of reductions in entitlement income when subjects worked. To overcome these disincentives, most subjects in the second sample felt they needed to earn between $5 and $6 an hour to make working worthwhile. The mean monthly cost of psychiatric treatment for unemployed subjects was $2,083, compared with $910 for those with part-time employment and $292 for those working full time. CONCLUSIONS: The findings emphasize the importance of developing higher-paying jobs for this population and reforming entitlement programs to incorporate work incentives for the mentally disabled population.

Adult↗
PubMed2005

Minimally invasive surgery for live kidney donors: techniques and challenges.

Live kidney donation is assuming an increasingly prominent role in kidney transplantation programs. The traditional operative approach has been through an incision in the upper quadrant of the abdomen or in the loin, with the attendant potential postoperative complications associated with a large surgical wound. These problems may act as disincentives to prospective donors. The introduction of laparoscopic donor surgery in 1995 heralded a new era offering reduced post-operative pain and improved cosmetic result. It is hoped that these benefits may counter some disincentives and thereby increase donation rates. Three minimal-access approaches and their advantages and disadvantages are described: classical laparoscopic, hand-assisted laparoscopic, and retroperitoneoscopic surgery. Published reports indicate extensive experience with the first 2 of these approaches and less experience with the latter. All 3 approaches present technical, physiological, and anatomical challenges in the context of retrieving an organ that is fit for transplantation. For minimal-access surgery to be accepted as the procedure of choice for live kidney donors, it must be demonstrated that morbidity is not transferred from donor to recipient when these techniques are used. Some concerns about these procedures are addressed. High-level evidence in the form of randomized controlled trials is generally lacking, but experiences of surgeons and patients suggest that, with appropriate modifications, these techniques are safe for both donors and allografts and also benefit donors' recovery.

Clinical Competence↗