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PubMed2001

The effects of different kinds of user fee on prescribing costs in rural Nepal.

OBJECTIVES: (1) To estimate the cost of irrational prescribing, and (2) to compare the effect of three different kinds of user fee on prescribing costs, in rural Nepal. METHODS: A controlled before-after study was conducted in 33 government primary health care facilities in rural eastern Nepal during 1992-95. A fee per prescription (covering all drugs in whatever amounts) was regarded as the control against which two types of fee per drug item (covering a full course of treatment for each item) were compared. The average total cost to the patient for two drug items was the same in all fee systems. Total cost, expected cost (according to standard treatment guidelines) and wastage costs (total minus expected cost) per prescription were calculated from an average of 400 prescribing episodes per facility per year. The proportion of prescriptions conforming to standard treatment guidelines was calculated from 30 prescriptions per facility per year. RESULTS: 20-52% of total drug costs were due to inappropriate drug prescription. A fee per drug item, as compared with a fee per prescription, was associated with (1) significantly fewer drug items prescribed per patient, (2) significantly lower drug costs per prescription, (3) significantly lower wastage due to inappropriate drug prescription, and (4) a significantly greater proportion of prescriptions conforming to standard treatment guidelines. Average drug cost per prescription (which was 24-33 Nepali rupees [NRs] across districts and time) was 5.7 NRs (95% confidence interval 1.0 to 10.4) and 9.3 NRs (95% confidence interval 4.8 to 13.8) less with the two different item fees, respectively, than with the fee per prescription. CONCLUSION: The economic consequences of irrational prescribing are severe, particularly in association with charging a fee per prescription. Item fees in the public sector reduce irrational prescribing and associated costs.

Drug Costs↗
PubMed1999

The effect of increased plastic surgeon supply on fees for aesthetic surgery: an economic analysis.

The size of the plastic surgery workforce has important effects on the financial environment of the specialty. Economic theory predicts that increasing the area supply of surgeons performing aesthetic surgery will result in lower fees for their services. This study tested that theory in the actual aesthetic surgery marketplace. The study examined the ratio of plastic surgeons to the general population of several states. It then traced the aesthetic surgery fees resulting from different densities of area plastic surgeons. This information was economically analyzed to project the fee effects of possible future changes in the number of practicing plastic surgeons. For the states of New York, California, and Texas, there is a proportional decrease in fees as the density of plastic surgeons increases. For example, New York has 34 percent more plastic surgeons proportionally than Texas, and its fees are 30 percent lower in real dollars. Economic analysis can project the fee effects of changing the supply of surgeons performing aesthetic surgery. The analysis reveals that a 30 percent national increase in the supply of plastic surgeons would lower fees by approximately 32 percent. Similarly, if the number of plastic surgeons increases by 50 percent, fees will decrease by approximately 53 percent. However, these fee effects can be mitigated by expanding the demand for aesthetic surgery. In conclusion, the size of the plastic surgery workforce has profound effects on the fees paid for aesthetic surgery, and the magnitude of these effects can be understood, predicted, and optimized using the tools of economics.

Fees, Medical↗
PubMed1999

PROFILE: Levying of Ecoenvironmental Compensation Fees in China: An Analysis and Proposals.

/ The levying of ecoenvironmental compensation fees on China's resource exploitation and construction activities, which can cause ecological damage, has been proposed as one effective means to help better manage China's present ecological and environmental problems. Such a fee, however, has not been adopted on a national scale, although small-scale experiments are underway. Using the experience of developed countries as a guide, a policy reform to institute ecoenvironmental compensation fees would require wide-ranging studies and analyses. These would have to include both theoretical and practical investigations on subjects including, but not limited to, methods for setting fees, managing their implementation, and the full range of their impacts (environmental, economic, and social). This article identifies guidelines for the principles and objectives to cover the proposed levy as well as proposals for fee collection and the subsequent these levies.In addition to estimating the total amount of the ecoenvironmental levies, the article analyzes the fee's quantitative effects on the government's major price indexes. Assuming fee collection started in calendar year 1998, total revenues collected by the end of the year 2000 are estimated to range from 6.68 billion Renminbi (RMB, unit of money used in China; 1990's comparative value, the same thereafter), 12.6 billion RMB, to 18.6 billion RMB, depending on the fee rate in question. The revenue collected in this way would, if used to finance environmental reclamation projects, greatly improve important parts of China's endangered environment. Moreover, our calculations indicate that fee collection would likely not lead to significant price fluctuations.KEY WORDS: Ecoenvironmental compensation fee; Levy; Chinahttp://link.springer-ny.com/link/service/journals/00267/bibs/24n3p353.html

Journal Article↗
PubMed2002

Spillover effects of Medicare fee reductions: evidence from ophthalmology.

Relatively little research has examined physicians' supply responses to Medicare fee cuts especially whether fee reductions for specific procedures have "spillover" effects that cause physicians to increase the supply of other services they provide. In this study we investigate whether ophthalmologist changed their provision of non-cataract services to Medicare patients over the time period 1992-1994, when the Medicare Fee Schedule (MFS) resulted in a 17.4% reduction in the average fee paid for a cataract extraction. Following the McGuire-Pauly model of physician behavior (McGuire and Pauly, 1991), we estimated a supply function for non-cataract procedures that included three price variables (own-price, a Medicare cross-price and a private cross-price) and an income effect. The Medicare cross-price and income variables capture spillover effects. Consistent with the model's predictions, we found that the Medicare cross-price is significant and negative, implying that a 10% reduction in the fee for a cataract extraction will cause ophthalmologists to supply about 5% more non-cataract services. Second, the income variable is highly significant, but its impact on the supply of non-cataract services is trivial. The suggests that physicians behave more like profit maximizing firms than target income seekers. We also found that the own-price and the private cross-price variables are highly significant and have the expected positive and negative effects on the volume of non-cataract services respectively. Our results demonstrate the importance of evaluating volume responses to fee changes for the array of services the physician performs, not just the procedure whose fee has been reduced. Focusing only on the procedure whose fee has been cut will yield an incomplete picture of how fee reductions for specific procedures affect physician supply decisions.

Adult↗
PubMed1978

Geographic variation in physicians' fees. Payments to physicians under Medicare and Medicaid.

To study geographic differences in physician fees recognized by the Medicare and Medicaid programs, we analyzed physician reimbursement rates at the national, regional, state, and county levels. The results indicate that nationally, Medicaid specialist fees are 77% of Medicare specialist fees. Meidcare specialist fees in metropolitan areas are 23% higher than those in nonmetropolitan areas, but there are no differences under Medicaid. State Medicare specialist fees varied from 73% to 132% of the national Medicare average, while Medicaid specialist fees ranged from 49% to 179% of the national Medicaid average. State Medicaid fees for specialists ranged from 39% to 100% of Medicare specialist fees. These results indicate that under national health insurance, fees set at national or statewide levels could have notable effects on physician remuneration in some localities.

Fee Schedules↗
PubMed1992

Supply decisions among dentists working within a fixed-fee system of dental care provision.

In Norway fees for dental treatment did not increase at the same rate as prices for other goods and services during the 1980s. The aim of this study was to examine how this decrease in fees in real terms has influenced dentists' work decisions with respect to supply of services. Data on characteristics of the dentist and the dental practice were collected for 1979, 1984, and 1986. The dependent variable was supply of dental services, measured as the number of patient care hours worked per annum. The hourly fee for dental care was equivalent to dentists hourly wage rate. Supply increased as fees decreased. This could be explained either as a response of the patient or the dentist to reduced fees. Although the data did not give conclusive evidence as to which effect was most important, the authors have put forward the view that the main effect was dentists' response to reduced fees. The main argument put in favor of this view is that dentists have an overall knowledge of the effect of a change in fees on their income. The impact of a change in fees is much greater on the provider who supplies the services to many individuals over a long period of time, than on an individual consumer who buys the services once or twice a year. It was concluded that, in the short run, a fixed-fee schedule may not be very effective in limiting costs for dental care.

Adult↗
PubMed1993

Effects of lower surgical fees on the use of physician services under Medicare.

BACKGROUND AND OBJECTIVE: The changes in physician fees that will occur under the resource-based Medicare Fee Schedule (MFS) are similar to those that took place under the Omnibus Budget Reconciliation Act of 1987 (OBRA 87), when Medicare fees for selected "overpriced" procedures and diagnostic tests were reduced. To gain insight regarding the changes in utilization that may occur under the MFS, this study examines the effects of the OBRA 87 fee reductions on the use of physician services by Medicare patients. DATA AND METHODS: The five specialties that were most affected by the OBRA 87 fee reductions were studied: ophthalmology, thoracic surgery, urology, orthopedic surgery, and gastroenterology. Medicare physician claims files for 1987 and 1989 were used to obtain data on utilization and fees. Multivariate regression analysis was used to assess the effect of changes in fees on changes in utilization. RESULTS: The best estimate of the effect of the OBRA 87 fee reductions on overall physician-services utilization, obtained by pooling the five study specialties, was that every 1% decrease in fees led to a 0.09% decrease in the volume and complexity of services (95% confidence interval, 0.49% decrease to 0.31% increase). This result was not sensitive to minor changes in the covariates included in the regression model. CONCLUSION: To calculate payment levels during the transition to the MFS, the Health Care Financing Administration assumed that physicians whose Medicare revenue declines under the MFS will increase service volume and complexity enough to make up one half of the lost revenue. The findings of this study suggest that the Health Care Financing Administration's assumption was, at best, extreme.

Diagnostic Services↗
PubMed1996

[Patient classification systems and nursing fees].

This is the fourth year of five-year research plan sponsored by the National Science Council. The purpose of this study was to use VGH-T Factor Patient Classification Systems to calculate the following nursing Fees: (1) by using time study for each nursing activity, (2) by experts' opinion for ideal nursing activity time and ideal nursing charge to calculate nursing Fees, (3) by using different insurance payments and National Health Insurance payments to compare nursing Fees for four types of patients. The investigation period started on March 14, 1995, and ended on June 30, 1995. Patient Classification Tool was used in four general surgical units. There were 1,028 patients' data for patients' needs used. Reliability and validity were based on inter-rater reliability and experts' opinion. The results showed: (1) based on nursing time, the nursing Fees for Types 1, 2, 3, 4 were NT$314, 649, 895 and 1214; (2) according to experts' opinion, the nursing Fees for Types 1, 2, 3, 4 were NT$377, 786, 1076 and 1463; (3) according to labor insurance payments, the nursing Fees for Types 1, 2, 3, 4 were NT$351, 767, 1235 and 1780; (4) according to National Health Insurance payments, the Fees for the four types were NT$378, 915, 1390 and 1960. There were significant differences between the four types of patients. There were significant differences between the different calculations of nursing Fees. The results help not only in patient classification, but also help insurance companies with reference to payment for nursing fees.

Economics, Nursing↗
PubMed2004

The impact of the introduction of user fees at a district hospital in Cambodia.

Proponents of user fees in the health sector in poor countries cite a number of often interrelated rationales, relating inter alia to cost recovery, improved equity and greater efficiency. Opponents argue that dramatic and sustained decreases in service utilization follow the introduction of user fees, highlighting evidence that user fees reduce service utilization when they fail to result in improved quality of care and/or when services are priced higher than those charged by private health care providers. Utilization of public health services in Cambodia is low. Supply-side factors are significant determinants of such low public sector utilization, including low official salaries of service providers (forcing many to seek additional income in the private sector), and operations budgets which are erratic and often insufficient to cover running costs of service delivery outlets. The Cambodia Ministry of Health (MOH) encourages user fee schemes at operational district level. By allowing revenue to be retained at the health facility level, the MOH aims to improve health care delivery--and consequently service utilization--through increased salaries to health facility staff and increases in operations budgets. This case study of the introduction of user fees at a district referral hospital in Kirivong Operational District in Cambodia, using the findings from empirical research, examines the impact of user fees on health-careseeking behaviour, ability to pay and consultation prices at private practitioners. The research showed that consultation fees charged by private providers increased in tandem with price increases introduced at the referral hospital. It further demonstrates--for the first time that we are aware of from the available literature--that the introduction and subsequent increase in user fees created a 'medical poverty trap', which has significant health and livelihood impact (including untreated morbidity and long-term impoverishment). Addressing the medical poverty trap will require two interventions to be implemented immediately: regulation of the private sector, and reimbursing health facilities for services provided to patients who are exempted from paying user fees because of poverty. A third, longer-term initiative is also suggested: the establishment of a social health insurance mechanism.

Adolescent↗
PubMed2005

Pharmacists' participation in an inhaled respiratory medication program: reimbursement of professional fees.

BACKGROUND: An intervention (termed Initiative) was initiated to facilitate converting beneficiaries of a public drug insurance program in the province of Nova Scotia from respiratory nebulization medications to inhalers. Community pharmacists provided patient education and billed professional fees for conversions or optimizing inhaled respiratory medication technique. OBJECTIVE: To determine community pharmacists' self-reported participation rate and identify facilitators and barriers to billing for professional fees. METHODS: A survey was developed and mailed to Nova Scotia pharmacists. Information on demographics, work environment, professional experience, financial aspects, billing experiences, and the billing process was collected. Quantitative and qualitative data were evaluated using bivariate and multivariate analyses, and a thematic process, respectively. RESULTS: Two hundred ninety-seven pharmacists responded. Self-reported billing rates for fees were 34% (switching delivery devices), 58% (optimizing AeroChamber use), and 37% (follow-up when replacing Aerochambers). Awareness of fees and the perception of consistent claim reimbursement were associated with billing for each fee (p < 0.05). Predisposing billing factors included awareness of fees, identifying situations requiring education, owner/manager position, male gender, perception that billing for education for optimizing technique is a minimum standard of practice, and prescription volume. Themes identified as barriers included inefficient billing process, inadequate fees, and lack of Initiative awareness. CONCLUSIONS: Predisposing factors were the most important facilitators of community pharmacists' participation in this program, while a cumbersome and time-consuming billing process was the primary barrier. Further research should determine the impact of the professional fee on patient health outcomes.

Administration, Inhalation↗
PubMedDate not supplied

Trends in Medicaid physician fees, 1993-1998.

This study uses data on Medicaid physician fees in 1993 and 1998 to document variation in fees across the country, describe changes in these fees, and contrast how they changed relative to those in Medicare. The results show that 1998 Medicaid fees varied widely. Medicaid fees grew 4.6 percent between 1993 and 1998, lagging behind the general rate of inflation. This growth was greater for primary care services than for other services studied. Relative to Medicare physician fees, Medicaid fees fell by 14.3 percent between 1993 and 1998. Medicaid's low fees and slow growth rates suggest that potential access problems among Medicaid enrollees remain a policy issue that should be monitored.

Data Interpretation, Statistical↗
PubMed1993

Physician fee levels: Medicare versus Canada.

Adjusted for differences in purchasing power and practice expenses, Canadian physician fees are, on average, 59 percent of Medicare fees. The general perception that Medicare fees are low is the result of comparison with U.S. private fees, not to the much lower Canadian fees. In the context of the current U.S. health care system, lowering Medicare fees to Canadian levels could jeopardize access to care by Medicare beneficiaries. However, if all payers used the same fee schedule, fees that differed substantially from those currently used by private insurers might be viable.

Canada↗
PubMed1999

Association of managed care market share and health expenditures for fee-for-service Medicare patients.

CONTEXT: Managed care has the potential to transform fundamentally the structure and functioning of the entire health care system, including the care provided to patients who are not enrolled in managed care plans. OBJECTIVE: To determine whether increasing health maintenance organization (HMO) market share is associated with decreased expenditures for the care of patients covered by Medicare's traditional fee-for-service plan, a group cared for well outside the boundaries of managed care. DESIGN AND SETTING: Data from the Health Care Financing Administration were used to compare expenditures for the care of Medicare fee-for-service beneficiaries for 802 market areas, representing the entire United States, for 1990 to 1994. These data were matched with data on system-wide (Medicare and non-Medicare) HMO market share in these areas. PATIENTS: All fee-for-service Medicare beneficiaries (1990-1994) except for those with end-stage renal disease. MAIN OUTCOME MEASURE: Average fee-for-service expenditure per fee-for-service Medicare beneficiary by market area. RESULTS: In a regression model, increases in system-wide HMO market share were associated with declines in both Part A and Part B fee-for-service expenditures per Medicare beneficiary (P<.001). Increases from 10% market share to 20% market share were associated with 2.0% decreases in Part A fee-for-service expenditures and 1.5% decreases in Part B fee-for-service expenditures. CONCLUSIONS: Managed care can have widespread effects on the health care system. Health care for individuals who are not covered by managed care organizations can be influenced by the presence of managed care. Lower expenditures in areas with high HMO market shares may indicate that traditional Medicare beneficiaries in areas with high market shares received fewer or less intensive services than traditional Medicare beneficiaries in other areas.

Fee-for-Service Plans↗
PubMed1993

Ensuring access to health care with the introduction of user fees: a Kenyan example.

Many developing countries are considering or in the process of implementing user fees for government health care services. These fees have the benefit of generating much needed revenue and discouraging unnecessary utilization, but have the potential negative effect of excluding low income individuals from necessary medical care. In 1989, the Ministry of Health of the Government of Kenya briefly implemented user fees for government facilities which included a system for waiving fees for low income patients. This paper examines how that system might have worked in theory and how it worked in practice. Survey data from three districts in Kenya are used to estimate the percentage of health center outpatient fees that may need to be waived to avoid undue burden on low income households. The percentage of outpatient fee exemptions range from 11 to 34% depending on the district and the criterion used to determine ability to pay. This paper then assesses the extent to which ability to pay can be determined by readily obtainable information on patients' socio-economic characteristics. It is shown that these characteristics do predict ability to pay, but not with the degree of accuracy necessary to use as the sole criteria for granting exemptions. Thus, although the evidence from Kenya indicates that the level of outpatient fees could be paid by the majority of the population without undue burden, a minority would require fee exemptions. The main obstacle to implementing a system of exemptions is the inability to easily identify those unable to pay.

Fees, Medical↗
PubMed1995

Resource utilization in treatment of acute myocardial infarction: staff-model health maintenance organization versus fee-for-service hospitals. The MITI Investigators. Myocardial Infarction Triage and Intervention.

OBJECTIVES: This study sought to compare the use of invasive procedures and length of stay for patients admitted with acute myocardial infarction to health maintenance organization (HMO) and fee-for-service hospitals. BACKGROUND: The HMOs have reduced costs compared with fee-for-service systems by reducing discretionary admissions and decreasing hospital length of stay. It has not been established whether staff-model HMO hospitals also reduce the rate of procedure utilization. METHODS: Using data from a retrospective cohort, we performed univariate and multivariate comparisons of the use of cardiac procedures, length of stay and hospital mortality in 998 patients admitted to two staff-model HMO hospitals and 7,036 patients admitted to 13 fee-for-service hospitals between January 1988 and December 1992. RESULTS: The odds of undergoing coronary angiography were 1.5 times as great for patients admitted to fee-for-service hospitals than for those admitted to HMO hospitals (odds ratio 1.5, 95% confidence interval [CI] 1.3 to 1.9). Similarly, the odds of undergoing coronary revascularization were two times greater in fee-for-service hospitals (odds ratio 2.0, 95% CI 1.6 to 2.5). However, higher utilization was strongly associated with the greater availability of on-site cardiac catheterization facilities in fee-for-service hospitals. The length of hospital stay, by contrast, was approximately 1 day shorter in the fee-for-service cohort (7.3 vs. 8.0 days, p < 0.05). CONCLUSIONS: Physicians in staff-model HMO hospitals use fewer invasive procedures and longer lengths of stay to treat patients with acute myocardial infarction than physicians in fee-for-service hospitals. This finding, however, appears to be associated with the lack of on-site catheterization facilities at HMO hospitals.

Aged↗
PubMed1997

The lessons of user fee experience in Africa.

This paper reviews the experience of implementing user fees in Africa. It describes the two main approaches to implementing user fees that have been applied in African countries, the standard and the Bamako Initiative models, and their common objectives. It summarizes the evidence concerning the impact of fees on equity, efficiency and system sustainability (as opposed to financial sustainability), and the key bottlenecks to their effective implementation. On the basis of this evidence it then draws out three main sets of lessons, focusing on: where and when to implement fees; how to enhance the impact of fees on their objectives; and how to strengthen the process of implementation. If introduced by themselves, fees are unlikely to achieve equity, efficiency or sustainability objectives. They should, therefore, be seen as only one element in a broader health care financing package that should include some form of risk-sharing. This financing package is important in limiting the potential equity dangers clearly associated with fees. There is a greater potential role for fees within hospitals rather than primary facilities. Achievement of equity, efficiency and, in particular, sustainability will also require the implementation of complementary interventions to develop the skills, systems and mechanisms of accountability critical to ensure effective implementation. Finally, the process of policy development and implementation is itself an important influence over effective implementation.

Africa↗
PubMedDate not supplied

Influence of emergency room fee on acute stroke presentation in a public hospital in Hong Kong.

A new system of emergency room fee-for-service was recently introduced at public hospitals in Hong Kong. A prospective observational study was undertaken to investigate the effects of the emergency room consultation fee system on presentation delay of acute stroke patients and evaluation of timing of patient presentation with acute stroke. We reviewed 2 specified periods (2-month interval each) before and after the consultation fee system at a public hospital. Primary outcome measures were time from onset of stroke symptoms to arrival at hospital, and predictors of such a time delay. A total of 173 subjects were recruited before institution of the consultation fee system, and 189 after inception of the new system. The mean age was 71 years. The median delay between symptom onset and arrival at hospital was 9 h. Acute ischemic stroke accounted for 91% of the stroke diagnoses. The median baseline NIHSS score measured 6. The median delay for patients before the emergency room consultation fee system was 9.7 h, compared with 8.4 h after introduction of the consultation fee (p = 0.66). At presentation, patients admitted during the consultation fee system were significantly more likely to be unconscious and be in a worse functional premorbid state. We found no difference in the frequency of general practitioner contact between the 2 study periods. Overall, univariate analyses showed that patient age, baseline NIHSS score, consciousness level upon arrival at the emergency department and premorbid ambulatory status were significant factors associated with the timing of presentation after acute stroke. A multivariate linear regression model demonstrated two independent factors: patient age younger than 70 years was independently related to presentation delay, whereas severity of stroke as indicated by unconsciousness upon arrival was associated with shorter delay. While we demonstrated no delays in acute stroke presentation accrued from enactment of the emergency room fee, physicians should endeavor to further explore strategies of reducing the late presentation of acute stroke.

Acute Disease↗
PubMed2004

What are entrepreneurial dietitians charging? The Consulting Dietitians Network National Fee Survey.

To respond to a need to develop a national fee guideline, the Consulting Dietitians Network conducted a membership fee survey. A questionnaire requesting fee information for various nutrition consulting services was distributed to members as an insert with the Consulting Dietitians Network quarterly newsletter and by electronic mail. The response rate was 38.4% (98 respondents) and most respondents (74.5%) had urban practices. The most frequently charged fees (mode) for individual counselling ($75/hour), industry and commercial firm consultations ($150/hour), group facilitation ($150/hour), and media consultations ($150/article) were highest in the region of Ontario, Quebec, and the Atlantic provinces. The most frequently charged fees (mode) for home visits ($100/hour), writing for newspapers ($250/hour), and menu reviews ($60/hour) were highest in the region of Saskatchewan and Manitoba. The minimum and maximum fees were significantly different for the three regions (Ontario, Quebec, and the Atlantic provinces; Manitoba and Saskatchewan; and Alberta, British Columbia, and Yukon Territory) studied for initial client consultations, industry and commercial firm consultations, and menu reviews (p<0.05). For home visits, teaching in an institution, seminar presentations, group facilitation, media consultations, and writing media articles, the differences in the minimum and maximum fees charged were highly significant (p<0.001). Entrepreneurial dietitians may use these data as a reference to establish and negotiate consultation fees.

Canada↗