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PubMed1978

Federal legislation and agency actions concerning self-care dialysis.

Since the passage of the renal disease provisions of the Social Security Law, the percentage of patients in the United States utilizing self-care treatment has declined from 40% to about 15%. The background and provisions of the Rostenkowski Bill, H.R. 8423, are summarized. Primary aims of the bill are to remove disincentives for use of self-dialysis, remove certain disincentives to transplatation, and to provide for peer review and goal setting for network use of various treatment modalities. Studies of the Health Standards and Quality Bureau, and activities of the Veterans Administration and the Artificial Kidney - Program of the National Institute of Arthritis, Metabolism, and Digestive Diseases relevant to self-care dialysis are briefly summarized.

Hemodialysis, Home↗
PubMedDate not supplied

Risk-rated health insurance programs: a review of designs and important issues.

PURPOSE OF THE REVIEW. The purpose of this review is to assist those who work in the field of health promotion when considering the implementation of an individually risk-rated health insurance plan. It does so by introducing the reader to the concept of individually risk-rating health insurance; uncritically reviewing selected risk-rated health insurance plans; and exploring several issues related to plan implementation, administration, and appropriateness. SEARCH METHODS USED. The review is based on the authors' awareness of the literature in the fields of preventive medicine, health promotion, and employee benefits. The six individually risk-rated health insurance programs that are reviewed were chosen because they demonstrate how aspects of the National Association of Insurance Commissioners' Model have been implemented using various combinations of administrative procedures, verification strategies, and types of economic incentives or disincentives. This review is not intended to be a comprehensive review of the literature. SUMMARY OF IMPORTANT FINDINGS. Individually risk-rated health insurance programs have been established using a variety of administrative procedures, verification strategies, and types of economic incentives or disincentives. The frequency with which these programs are being established is increasing. As the number of risk-rated programs grows, it will be increasingly important to address the many issues that implementing such plans generate: How should lifestyle behaviors be verified? Will healthy lifestyles save money? Can employees fully control their risk factors? Is risk-rating socially responsible? MAJOR CONCLUSIONS. As risk-rating becomes more widespread, there will be a continuing need to address the business, medical, ethical, and legal issues these programs create and to refine them accordingly. The health promotion community has both an opportunity and obligation to see to it that individually risk-rated health insurance programs are implemented in a socially acceptable manner and that the outcomes they generate are cost-beneficial.

Employee Incentive Plans↗
PubMed1988

Perceived autonomy and job satisfaction in occupational therapists.

Perceived autonomy, overall job satisfaction, and specific work incentives and disincentives were surveyed in 249 occupational therapists. Respondents rated autonomy and job satisfaction moderately high. They perceived achievement, interpersonal relationships with co-workers, and the nature of the work itself as incentives. The lack of organizational support for training, opportunity for advancement, and working conditions were seen as job disincentives. Results also showed that perceived autonomy was positively related to overall job satisfaction and to each job satisfaction factor.

Adult↗
PubMed1999

[Little communication between company doctors and private physicians with respect to hindrances to return to work after prolonged absence from work because of low back pain].

OBJECTIVE: To determine occurrence and reasons of contact between company doctors and treating physicians with respect to patients absent with low back pain for three months. DESIGN: Prospective cohort study. METHOD: A cohort of employees who were absent for 3 months with back pain were selected according to defined criteria. A questionnaire about medical status and communication with treating physicians was sent to their company doctors. RESULTS: The company doctors of 300 of 467 employees participated. In 19% of the employees the company doctor contacted the curative sector (56 contacts had taken place, 14 were planned). The contact consisted almost always of exchange of information and less frequently of co-operation towards a mutual policy. In almost 50% of the cases the company doctors regarded the clinical waiting period, length of treatment and opinion of the curative sector as disincentives to return to work. Psychosocial factors such as psychological problems, work-related motivation, private problems and a conflict between employer and employee all were mentioned less frequently. Although contacts were slightly more frequent when psychosocial factors, treatment or opinion of the curative sector inhibited return to work, only disincentives such as work-related motivation, motivation to return to work and the waiting period were significantly associated with the contact frequency. CONCLUSION: The communication rate between company doctors and the curative sector in employees long absent with back pain is low. Communication consists of exchange of information rather than co-operation towards a mutual policy. Although according to many company doctors the curative sector plays an inhibitive role in return to work, they do not communicate accordingly.

Absenteeism↗
PubMed1999

Social Security, retirement incentives, and retirement behavior: an international perspective.

Escalating rates of early retirement are imposing fiscal pressure on retirement systems around the world. In some developed countries, the labor-force participation rates of men ages 60-64 have fallen by 75 percent over the last three decades. One explanation for this striking decline is social security program provisions which create disincentives to continued labor-force participation by older workers. There are substantial differences among developed nations in the labor-force participation of older workers. While two-thirds of 60-year-old American males are working, only one-quarter of men that age are working in Belgium. Over the entire 55-65 age range, 63 percent of American males are working, compared with only 40 percent of French males and 33 percent of Belgians males. There is strong evidence that the early retirement provisions of social security systems in developed countries determine the modal age of retirement. There is a strong relationship between early retirement ages and labor-force withdrawal rates; for example, in France, 60 percent of those working at the early entitlement age of 60 leave the labor force at that age. The core of this analysis is the construction of "implicit tax/subsidy rates" on additional work at older ages through each nation's social security system. These rates measure the change in a worker's retirement wealth entitlement from delaying retirement for one year, relative to the amount that would have been earned over that year. The U.S. Social Security system has an actuarial adjustment for delayed benefits claiming and other features that avoid financial incentives to leave the labor force at age 62 for a married worker, there is a slight disincentive to work for single workers and high wage earners. However, at ages 65 and older there is a stronger incentive to leave the labor force, with implicit tax rates on work of 19 percent for married workers and 33 percent for single workers. By comparison, other nations do not have actuarially fair adjustments, and as a result impose substantial taxes on additional work at older ages. In several countries, implicit tax rates on work at older ages approach or exceed 100 percent. This is because by delaying retirement, workers forgo benefits which often replace close to their full wage, in addition to having to pay the high payroll taxes required to finance generous social security benefits. There is a striking correlation across nations between high implicit tax rates on additional work and low labor-force participation rates among older workers. This suggests that social security program incentives are an important determinant of retirement. These findings have important policy implications for reforming social security programs in the United States and abroad. Policymakers must consider how program reforms will affect incentives for continued work at older ages.

Actuarial Analysis↗
PubMed2000

[Drug use: a life choice or health threat].

The term "enjoyment" is used to denote a pleasurable, utility-creating activity or an act of consumption, which, however, may often be accompanied by subsequent risks, health-care costs or reduction in the quality of life. If viewed from the vantage point of health policy, we may quote several examples of consumer behaviour of this type, ranging first and foremost from the consumption of alcohol and nicotine to the use of "hard" drugs. But certain sports activities or sexual behaviour that may prove damaging to other persons must also be mentioned in this context. All these forms of consumption often lead to direct or indirect consequences to health and thereby result in increased health spending amounting to several thousand million DM. The decline in quality of life resulting from the above-mentioned forms of behaviour could be avoided through health promotion and prevention or, at the very least, through measures of rehabilitation, above all, information, counselling, and education, which represent medium- or long-term measures to that effect. Financial incentives or disincentives, for example, via an increase in co-payment in case of illness caused by risky behaviour, have not been as effective as had been expected by many proponents. Product-specific levies, risk-related payments and other financial incentives and disincentives are generally also not as effective as desired. Health policy measures aimed at influencing behaviour via financial measures are particularly ineffective in case of persons addicted to particular types of consumables, especially to drugs: Information, counselling and education represent non-financial forms of influencing and guiding behaviour with a greater scope for success.

Behavior, Addictive↗
PubMed1992

Blurred edges to population policies.

Fertility is now below replacement level in most European countries, especially the industrialized ones. In the last 20 years, several countries have developed or improved pronatalist programs containing incentives that are designed to motivate couples to have a 2nd and especially a 3rd child, to maintain a stable population. The WHO Sexuality and Family Planning Unit called a short consultation on this subject last October. What actually constitutes a pronatalist population program and the connections between public policies and private reproductive behavior were not very clear. Nor is it easy to assess the longer--term demographic effects of pronatalist policies or what influences their effectiveness. The outcome usually reflects the country's history, cultural and religious traditions, changes in lifestyle, and the value given to the family and children. Incentives are defined as monetary or nonmonetary inducements to voluntary reproductive behavior that conforms to specified population policies. They may be small or large, in cash or kind, parity-specific or income-linked, immediate or developed, one-time or incremental, or any combination of these. Disincentives are negative sanctions that are either incurred or thought likely as a result of violating the policy. But both incentives and disincentives are difficult to define. Pronatalist policies designed to encourage early marriage and larger families, thereby raising the future total fertility rate should not be confused with traditional social welfare policies designed simply to ease the burden of childbearing. Some policies have both demographic and social welfare aims. Strong pronatalist policies may be linked with restrictions on contraceptive availability and legal abortion. Moreover, other public policies affecting social security, education, employment, housing, regional planning and the emancipation of women may unintentionally influence demographic behavior. Population policies are the product of politics. Often written in ambiguous language and intended to affect society as a whole, they still depend for their outcome on microlevel changes in a couple's perceptions of the costs and benefits of having children. In theory, they can be carried out in many ways but in practice such policies are severely limited by administrative, political, technological, economic, and ethical constraints. One difficulty is that governments is rarely enunciate precise goals. Their approach may range from noninterference in private reproductive behavior to total coercion using controls ranging from traditional cultural influences to imposition of fertility regulations. In some countries, fertility rates have increased briefly (in terms of period rates) following introduction of pronatalist policies. However, it is not clear how the rates were influenced, particularly in the case of parities 1, 2, and 3. A forthcoming report will describe experiences in Bulgaria, France, Germany, Sweden, and Norway.

Developed Countries↗
PubMed1999

A survey of factors affecting the recruitment and retention of Medical Laboratory Scientific Officers in Pathology.

OBJECTIVE: To survey the perceptions and attitudes of Medical Laboratory Scientific Officer (MLSO) staff in Pathology to explain difficulties in recruitment and retention and inform attempts to solve the difficulties. DESIGN: Questionnaire to a defined group of MLSOs. SETTING: The Laboratory Medicine Directorate, Aberdeen Royal Infirmary. SUBJECTS: MLSO1 and MLSO2 staff currently or recently working in Pathology (histopathology) in Aberdeen. RESULTS: The survey return rate was 100%. Opportunities for career development in Pathology are poor, this being the worst feature of working in Pathology. Remuneration is poor and is a disincentive to remaining in the speciality. MLSOs feel undervalued in relation to other health care workers. Many have concerns about laboratory organisation, but find a sociable and supportive environment that provides job satisfaction. Staff seek work in other laboratories because of opportunities for promotion, learning new skills and increased pay, although pay in specialities other that Pathology is greater only because of shift working in these disciplines. There is a need to increase public awareness of MLSOs' central role in providing and maintaining excellence in Pathology services. CONCLUSION: MLSO staff have concerns about their career structure and salary scales. The responsibility of MSLOs in Pathology for quality assurance and managing MLAs is not recognised. These factors form a disincentive to working in Pathology laboratories and threaten our ability to staff the service and to maintain the turnover and quality of Pathology services. These issues require to be addressed nationally and rapidly to prevent the continuing decline in MLSO numbers. Matters of local organisation might be addressed by trusts and departments, but recognition of the need to resource changes would require reflection in budgets.

Career Mobility↗
PubMed2003

What rehabilitation counselors should know to assist Social Security beneficiaries in becoming employed.

The 1999 Ticket to Work and Work Incentive Improvement Act (TTWWIIA) has opened new employment opportunities for vocational rehabilitation professionals. The legislation minimized longstanding disincentives in the return to work efforts of beneficiaries collecting Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI). Although some of these key disincentives have been eliminated, rehabilitation counselors working with this population will find some interesting new challenges posed by this population. This article will outline the Social Security Administration's SSI/SSDI programs and process for applying; characteristics of beneficiaries; and information regarding the psychological and physiological aspects of beneficiaries with psychiatric disabilities and musculoskeletal disorders.

Counseling↗
PubMed1992

Clinicians who provide abortions: the thinning ranks.

Access to abortion services in the United States has become increasingly limited because of a decrease in rural hospital providers and a growing shortage of clinicians willing to offer this service. As of 1988, 83% of United States counties had no identified provider. The deficit in numbers of clinicians stems from the current imbalance between incentives and disincentives. The single most powerful incentive appears to be altruism. On the other hand, disincentives include poor pay, frequent harassment, low prestige, suboptimal working conditions, and tedium. In 1990 a symposium on abortion provision was held, sponsored by the National Abortion Federation and ACOG. Among the remedies suggested by the attendees were increasing the integration of abortion training into the mainstream of residency education, improving the pay and work environments for clinicians, and where feasible expanding the capacity of physician providers by using midlevel practitioners working under physician supervision.

Abortion, Induced↗
PubMed1992

Physician participation in a randomized clinical trial for ocular melanoma.

One substudy of the Collaborative Ocular Melanoma Study (COMS) is a randomized trial examining surgery versus radiation therapy for ocular melanoma. To understand the perspective of the physician investigators, a survey of the 101 COMS physicians from 29 major institutions in the United States and Canada was completed before randomization of the first patient. A 95% response rate was obtained, and follow-up interviews were conducted with 87% of the physicians. The study found that (1) COMS physicians identified significant differences between incentives and disincentives to participate in any trial compared with participating in COMS, (2) COMS physicians could be differentiated and had a stronger clinical rather than research orientation, and (3) COMS physicians exhibited a high intention to recruit an identifiable subset of eligible patients. These data suggest that continued support of individual investigators and a close examination of incentives and disincentives to physician participation would be useful in enhancing accrual in this study. A follow-up of this group is planned throughout the anticipated ten-year duration of patient recruitment of this COMS trial.

Adult↗
PubMed1993

Do older Medicare patients cost hospitals more? Evidence from an academic medical center.

BACKGROUND: It is uncertain, under prospective payment, if hospitals face financial disincentives to treat older Medicare patients. Therefore, we studied associations between age and hospital charges and length of stay for Medicare patients and the impact on hospital reimbursement of Medicare's decision in October 1987 to eliminate older age (> or = 70 years) as a criterion for stratifying diagnosis-related groups (DRGs). METHODS: The 23,179 medical and surgical admissions to one academic medical center in 1985 through 1989 who were aged 65 years or more were studied using a retrospective cohort design. Clinical and financial data were obtained from hospital databases; charges and length of stay for each patient were adjusted for DRG weight, the measure used to determine reimbursement. Admission severity of illness was measured for 11,060 patients using the Nursing Severity Index, a previously validated method. RESULTS: Compared with patients aged 65 to 69 years, DRG-adjusted charges were 1%, 5%, 5%, and 6% higher and DRG-adjusted length of stay was 4%, 11%, 16%, and 18% greater for patients aged 70 to 74 years, 75 to 79 years, 80 to 84 years and 85 years or more, respectively. In multivariate analyses, these estimates were similar, even after controlling for sex, race, socioeconomic status, and other variables associated with charges and length of stay. However, further controlling for severity of illness revealed that nearly all of the differences in charges and a large proportion of the differences in length of stay in older patients could be explained by their higher severity of illness. In separate stratified analyses, the association with age was stronger and more consistent in patients admitted after October 1987 and in medical patients. CONCLUSIONS: These findings suggest that currently hospitals may face financial disincentives to care for older Medicare patients and that the equitability of DRG-based hospital payments, with respect to age, may have been adversely affected by Medicare's decision to eliminate older age (> or = 70 years) as a criterion for classifying DRGs. The inclusion of patient age in prospective payment formulas may make hospital reimbursement more equitable.

Academic Medical Centers↗
PubMed1976

Staffing crisis in preclinical medicine.

The proportions of medical graduates on the staffs of the preclinical departments of Australian medical schools have declined dramatically in recent years. It is now extremely difficult to attract medically qualified applicants to positions in these departments. The present proportions of medically qualified staff now fall short of the levels regarded as "educationally desirable" by Australian preclinical departmental chairmen, at a time when the curricula of most of our medical schools are being reformed so as to include more medically relevant courses in the preclinical disciplines. The cause of the problem is that there are serious disincentives, of both salary and career prospects, to the choice of a career in preclinical medicine. Methods of removing these disincentives are discussed in this paper.

Anatomy↗
PubMedDate not supplied

Costs, payments, and incentives in family planning programs: a review for developing countries.

Anxieties about financing health and family planning programs have grown in recent years, leading to discussions of cost-recovery measures that would raise charges to the consumer. Yet some governments wish to lower cost to encourage contraceptive use, and a few use incentives and disincentives. Data from numerous developing countries are presented on contraceptive cost topics: charges for contraceptive supplies and services, in both public and private sectors, and conversely, payments made to clients and providers to offset costs and to increase contraceptive use. The data show great diversity, and much inconsistency within countries, indicating that the structures of charges, payments, and incentives in many programs could be improved. Ethical considerations are discussed, and guidelines are suggested for developing effective financial policies.

Contraception↗
PubMed1977

A component analysis of recent fertility decline in singapore.

To aid in achieving demographic goals, since 1968 the government of Singapore has passed a series of laws designed to limit family size. Policies were instituted in 1968 to discourage couples from having more than three children; policies introduced in 1973 discouraged having more than two. Trends in fertility rates and in the numbers of abortions and sterilizations in recent years are consistent with the intent of these social policies. Decline in third and subsequent births was the most important factor in fertility decline after 1972, and the numbers of abortions and sterilizations undergone by higher parity women have increased substantially sin"e 1970. Although other factors have affected fertility in Singapore, the data suggest that the disincentives have played a role in continued fertility decline in recent years.

Abortion, Legal↗
PubMed1998

Looking locally at China's one-child policy.

Of all the reforms and policies set in motion in the early 1980s in China, the one-child policy has been called the most far-reaching in its implications for China's population and economic development. Almost two decades later, little is known about what the policy looks like across local neighborhoods and villages. To sketch a more general picture of the one-child policy, this article presents panel data from three waves of the China Health and Nutrition Survey (1989, 1991, and 1993) collected in 167 communities in eight provinces. Local policy, including policy strength and policy incentives and disincentives, is detailed separately for urban and rural areas. These data confirm that no single one-child policy exists; policy varied considerably from place to place and within individual communities during the 1989-93 period.

China↗
PubMed1988

Financial risk and hospital cost for elderly patients. Age- and non-age-stratified medical diagnosis related groups.

The purpose of this study was to analyze hospital resource consumption for Medicare patients in non-age- and age-stratified medical diagnosis related groups (DRGs). This study of patients in 74 non-age-stratified DRGs (N = 3643) and 113 age-stratified DRGs (N = 2898) demonstrated that older medical patients (usually greater than or equal to 75 to 80 years of age) had (on average) higher total hospital costs, a longer hospital length of stay, more diagnoses per patient, a greater percentage of outliers, and a higher mortality compared with younger patients in these same DRGs. These findings raise the question of the equity of DRG payment vis-à-vis older Medicare patients in both non-age- and age-stratified medical DRGs. Financial disincentives to treat older medical patients may limit both their access and quality of care in the future.

Aged↗
PubMed1989

Age, resource consumption, and outcome for medical patients at an academic medical center.

At the national level debate is growing about the effects of the diagnosis related group (DRG) hospital payment system on patient access and quality of care. Recent changes to the DRG system have dropped any stratification by age and have delayed any other major change to improve payment equity. We characterized hospital resource consumption and outcome by age for all medical admissions (N = 31,838) to a large academic medical center (January 1, 1985, through December 31, 1987) using the DRG format. Mean hospital cost per patient, hospital length of stay, percentage of outliers, and mortality increased with age. The mean DRG case-mix index and the number of diagnostic codes per patient also rose with age. The DRG payment for all patients would have produced an aggregate profit of $34,426,951 ($1081 profit per patient); however, patients aged 71 years or older generated loses (the highest with patients aged 85 years or older--a $2177 loss per patient). As the financial position of American hospitals continues to deteriorate, these data suggest that the current DRG payment scheme may be inequitable for the medical patient aged 71 years or older, thus providing financial disincentives to treat the elderly medical patient and perhaps limiting their access and quality of care in the future.

Academic Medical Centers↗