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PubMed2005

Maximizing reimbursement from trauma response fees (UB-92: 68X) - lessons learned from a hospital comparison.

BACKGROUND: The trauma response fee (UB-92:68x) recently has been approved, to be used by hospitals to cover expenses resulting from continuous trauma team availability. These charges may be made by designated trauma centers for all defined trauma patients when notification has been received before arrival (eligible pt). This study compares two trauma centers' performance in collecting this fee help define methodologies that can enhance reimbursement. METHODS: Our trauma system uses two hospitals (A and B) that are designated as the Level I trauma center for the region on alternate years. This allows hospital performance comparisons with relatively consistent patient demographics, injury severity, and payer mix. Data were collected for a one-year period beginning on January 1, 2003 and included charges, collections, and payer source for the trauma response fee. This time frame allowed the comparison of two six-month sequential periods at each trauma center. RESULTS: Out of a total of 871 trauma patients, 625 were eligible for the trauma response fee (72%): hospital A = 65% and hospital B = 77%. Total trauma response fee charges for both centers were 1,111,882 dollars with collections of 319,684 dollars (28.8%). The following payer sources contributed to the collections: Indemnity insurance (77.4%), Managed Care (22.1%), Medicare (0.3%), and Medicaid (0.2%). No collections were obtained from any self-pay patient. Eligible patients were charged a trauma response fee much less frequently in Hospital A than B (29.35% versus 95.2%) but revenue / charge ratios were equivalent at both hospitals (0.32 versus 0.28). These differences resulted in markedly enhanced revenue for each eligible patient in Hospital B compared with A (735 dollars versus 174 dollars) CONCLUSIONS: Enhanced collection by hospital B was a result of a higher charge, compulsive billing of all eligible patients, and emphasis on pre-admission designation of trauma patients. Effective billing and collection process related to trauma response fees results in substantial additional revenue for the trauma center without additional expense.

Academic Medical Centers↗
PubMed2001

"Voluntary" user fees in Buenos Aires hospitals: innovation or imposition?

Voluntary user fees in hospitals in Buenos Aires, which operate outside official controls, have not featured in other studies of health care in Argentina. After providing a historical overview of different hospital funding sources, the authors focus on the activity of cooperadoras--the organizations responsible for levying voluntary fees. Using detailed data from two case-study hospitals and more general financial sources, they assess the importance of these fees, identifying sharp variations between different hospitals, serious problems of under-reporting, and potential abuses. The authors also examine the means by which fees are levied and the degree of coercion involved. Voluntary fees are not a particularly successful funding strategy: the income they generate is variable; they are almost entirely unregulated; and they sometimes conflict with other, more legitimate funding sources. Most importantly, their voluntaristic aspect is largely notional: most patients are heavily pressured to make payments. The main motivation for continuing with voluntary fees is to avoid the political fallout that would probably result from introduction of a formal user fees policy.

Argentina↗
PubMed2004

Factors affecting fee setting for private treatment in general dental practice.

OBJECTIVES: To examine how pricing policies were contrived in general dental practice in terms of fee-for-item and hourly rate and how these were affected by specialist status and the level of private care provided in a practice. DESIGN: A postal questionnaire. SUBJECTS: Members of the British Society for General Dental Surgery working in dental practice. RESULTS: Out of 160 eligible members, responses were received from 124 members (78%). Fifty-seven respondents claimed to specialise in one or more fields of dentistry. The majority of respondents consulted fellow colleagues or partners for advice on fee setting. A minority took external advice. The charging method varied according to the item of treatment with fee-for-item used predominantly for items such as a new patient examination, and hourly rate used more for items such as a direct composite restoration. Seventy-one respondents stated that their practice was 80-100% private treatment and these practitioners were significantly more likely to charge by hourly rate than fee-for-item for many items of treatment. Specialist status did not have any effect on charging method. The most important factors related to the setting of fees-for-item or hourly rate were clinical time spent, practice overheads and laboratory costs. CONCLUSIONS: This project has taken the views of a large group of experienced general dental practitioners, many of whom work purely in the private sector. The most important factors affecting fee setting were clinical time, practice overheads and laboratory costs. The method of charging was most affected by the proportion of private treatment provided by the practice.

Dental Care↗
PubMed2000

Physicians' responses to Medicare fee schedule reductions.

BACKGROUND: Relatively little empirical research has addressed physicians' responses to fee changes under the Medicare Fee Schedule. OBJECTIVES: We analyzed Medicare claims data for ophthalmologists and orthopedic surgeons for the years 1991 through 1994 to evaluate the relative importance of profit-maximizing and target-income theories in determining physicians' supply responses to specific Medicare fee reductions. RESEARCH DESIGN: This study was designed to estimate the impact of fee reductions for cataract extractions and major joint repair/replacement procedures through pooled cross-section time series data. RESULTS: The supply function for cataract extractions has both strong own-price and cross-price effects, as well as a highly significant negative income effect. Yet, the magnitude of the income effect is small; thus, the substitution effect dominates the income effect. Similarly, in the supply functions for joint procedures, the own price has the expected positive sign, implying that as the fee declines, orthopedic surgeons will perform fewer joint surgeries. However, the cross-price variable has the correct sign only if treated as exogenous, and the variables measuring the income effect have the wrong sign, although their magnitude is small. CONCLUSIONS: These results suggest that the Medicare Fee Schedule does have the potential to influence physicians' supply decisions, but these effects may vary by specialty and service.

Adult↗
PubMed1987

Seeking the just price: constructing relative value scales and fee schedules.

Many conceptual issues underlie the current policy debate over how to reform the fee-for-service method of paying physicians, including the development of a relative value scale for physicians' services and the relationship between a relative value scale and a fee schedule. We consider the relationship between fees and costs and the criteria for judging whether a fee is appropriate or right and then propose a two-step process for constructing a relative value scale. A fee schedule based on a relative value scale is the most practical way to reform the current fee-for-service system and makes the most sense from both clinical and economic viewpoints.

Costs and Cost Analysis↗
PubMed1989

User fees for health care in developing countries: a case study of Bangladesh.

In designing country health care programs to achieve the goals of the Alma Alta declaration of 'Health for All', developing countries have been confronted with the problem of increased health care needs and decreased available resources. Health economists have proferred several possible solutions to this fiscal shortfall, including cost-recovery measures through the imposition of user fees for curative services at government health facilities. Health care providers have been noticeably absent from discussions of the many possible implications of these fees; consequently, resultant programs and policies may be economically sound but may fail to place a sufficient emphasis on features designed to maintain and improve the health of the population. In the present paper we examine the possible impact of user fees on the health of individuals residing in Bangladesh, one potential candidate country for user fees. We note evidence that the existing government health care system appears already to be providing care to two of the most medically vulnerable groups in Bangladesh, the poor and women, and provide evidence that such fees may seriously interfere with maintaining this patient profile. We discuss the significant public health role that curative care provides for the individuals, their families and the wider community. We suggest that additional questions should be asked by health care providers, anthropologists and economists prior to institution of user fees in the government system and that such measures should first be introduced in an experimental format with a rigorous and comprehensive impact evaluation.

Bangladesh↗
PubMed1993

User fees plus quality equals improved access to health care: results of a field experiment in Cameroon.

Since the Bamako Initiative was launched in 1988, many African countries have embarked on comprehensive primary health care programs relying, at least partially, on revenues generated through user fees to revitalize health care delivery systems. Although these programs contain two critical components, user fees and improved quality, policy debates have tended to focus on the former and disregarded the latter. The purpose of this study is to provide a net assessment of these two components by testing how user fees and improved quality affect health facility utilization among the overall population and specifically among the poorest people. A "pretest-posttest controlled" experiment was conducted in five public health facilities in the Adamaoua province of Cameroon. Three health centers which were to introduce a user fee and quality improvement (i.e. reliable drug supply) policy were selected as "treatment" centers and two comparable facilities not yet phased into this policy were selected as "controls". Two rounds of household surveys were conducted (each to 800 households in 25 villages surrounding the five study sites) to measure the percentage of ill people seeking care at the health center before and after the implementation of the policy. The experiment was tightly controlled by conducting monthly observations at each study site. Results indicate that the probability of using the health center increased significantly for people in the "treatment" areas compared to those in the "control" areas. Travel and time costs involved in seeking alternative sources of care are high; when good quality drugs became available at the local health center, the fee charged for care and treatment represented an effective reduction in the price of care and thus utilization rose. Moreover, contrary to previous studies which have found that the poorest quintile is most hurt by user fees, this study found that probability of the poorest quintile seeking care increases at a rate proportionately greater than the rest of the population. Since the poor are most responsive to price changes, they appear to be benefitting from local availability of drugs more than others.

Age Factors↗
PubMed1994

Prospects for reform of hospital fees in sub-Saharan Africa: a case study of Niamey National Hospital in Niger.

Hospital finance in developing countries has attracted increasing attention in recent years as economists and health planners have examined whether financial reforms will make public hospitals more financially autonomous and consequently reduce (or limit the increase in) their share of government health budgets. This paper presents estimates of the effects of some reforms of hospital user fees on total hospital revenue and on the amount of fees paid by patients in various payor categories. The reforms include special fees for non-referred patients and changes in exemptions for some categories of patients and types of care. The estimates show that doubling fees for non-referred patients increases revenue more than charging them prices equal to operating costs, because current fees are not uniformly less than operating costs. Eliminating exemptions can be as important as changing fees. For example, eliminating exemptions for surgery and inpatient diagnostic exams increases the percentage of operating costs recovered by the same amount as doubling prices for non-referred patients in estimates with an elasticity of demand equal to zero.

Fees, Medical↗
PubMed1993

Fee-for-benefit: a strategy to improve the quality of health care and control costs through reimbursement incentives.

OBJECTIVES: The purpose of this study was to determine whether reimbursement in direct proportion to expected therapeutic benefit is capable of improving the utilization and cost of health care. BACKGROUND: The benefit associated with a particular medical or surgical treatment varies widely from patient to patient. Nevertheless, payment to the provider of the treatment is essentially invariant under the current fee-for-service system. Under an alternative fee-for-benefit strategy, empiric data are used to construct a multivariate model to predict the expected benefit to an individual patient from a particular health care service on the basis of conventional clinical descriptors. The payers and the providers of the service then openly negotiate an explicit economic relation between expected benefit and monetary payment such that payment is directly proportional to benefit. METHODS: Computer simulations were performed to determine the potential impact of this fee-for-benefit strategy with respect to medical versus surgical treatment of coronary artery disease. RESULTS: Compared with conventional fee-for-service, fee-for-benefit resulted in a 12% improvement in patient benefit (quality-adjusted survival), a 22% reduction in provider payments and a 55% increase in cost/benefit (the ratio of benefit to payment). CONCLUSIONS: The incentives embodied in a fee-for-benefit strategy can be an effective mechanism for encouraging more appropriate health care utilization while simultaneously controlling health care costs.

Actuarial Analysis↗
PubMed2002

Gender dimensions of user fees: implications for women's utilization of health care.

This paper looks at the implications of user fees for women's utilization of health care services, based on selected studies in Africa. Lack of access to resources and inequitable decision-making power mean that when poor women face out-of-pocket costs such as user fees when seeking health care, the cost of care may become out of reach. Even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions. If user fees and other out-of-pocket costs are to be retained in resource-poor settings, there is a need to demonstrate how they can be successfully and equitably implemented. The lack of hard evidence on the impact of user fees on women's health outcomes and reproductive health service utilization reminds us of the urgent need to examine how women cope with health care costs and what trade-offs they make in order to pay for health care. Such studies need to collect gender-disaggregated data in relation to women's health service utilization and in relation to the range of reproductive health services, taking into account not only out-of-pocket fees charged by public health providers but also by private and traditional providers.

Africa↗
PubMed1986

The use of ambulatory testing in prepaid and fee-for-service group practices. Relation to perceived profitability.

To examine the influence of method of payment on ambulatory testing by internists, we compared the rate at which patients with uncomplicated hypertension were tested by 10 doctors practicing in large fee-for-service groups with that by 17 doctors in large prepaid groups. We examined the use of individual tests and asked the doctors in the fee-for-service groups what they believed about the profitability and costs of tests. After correcting for the patient's age, sex, duration of disease, and severity of disease as measured by pretreatment blood pressure, and for the doctor's year of medical school graduation, we found that 50 percent more electrocardiograms were obtained among patients in fee-for-service practices (0.69 per patient per year vs. 0.45, P = 0.006), and 40 percent more chest radiographs (0.49 vs. 0.35, P = 0.11). Fee-for-service doctors believed that both tests were associated with high profit and costs. These results suggest that the use of certain high-profit, high-cost tests is higher in large fee-for-service groups than in large prepaid groups. Although the generalizability of conclusions based on this limited study must be considered tentative, the findings suggest that it may be appropriate to consider changing the payments for tests as part of a more general reform of the fee schedules.

Ambulatory Care↗
PubMed1986

Health outcomes for a chronic disease in prepaid group practice and fee for service settings. The case of rheumatoid arthritis.

The authors compare health care use and outcomes of a panel of persons with rheumatoid arthritis receiving health care in prepaid group practice and fee-for-service settings. In 1982, they randomly sampled one half of all 114 board-certified or eligible rheumatologists in Northern California. Those who participated provided the names of all patients with rheumatoid arthritis presenting during a 1-month period; 812 of these patients (97% of those listed) were interviewed. In 1984, 745 of them (92% of the baseline cohort) were interviewed; 569 receive care in fee-for-service settings and 176 in prepaid group practice. As in the baseline survey year, the prepaid patients received similar amounts and kinds of health care as their fee-for-service counterparts. The prepaid and fee-for-service patients achieved similar outcomes, as measured by symptoms of illness, functional status, and work disability. The fee-for-service patients reported poorer overall health status. The authors conclude, after 2 years of follow-up study, that patients in prepaid group practice receive similar medical care inputs and achieve outcomes at least as good as those in fee-for-service.

Analysis of Variance↗
PubMed1999

The effect of increased consumer demand on fees for aesthetic surgery: an economic analysis.

Economic theory dictates that changes in consumer demand have predictable effects on prices. Demographics represents an important component of demand for aesthetic surgery. Between the years of 1997 and 2010, the U.S. population is projected to increase by 12 percent. The population increase will be skewed such that those groups undergoing the most aesthetic surgery will see the largest increase. Accounting for the age-specific frequencies of aesthetic surgery and the population increase yields an estimate that the overall market for aesthetic surgery will increase by 19 percent. Barring unforeseen changes in general economic conditions or consumer tastes, demand should increase by an analogous amount. An economic demonstration shows the effects of increasing demand for aesthetic surgery on its fees. Between the years of 1992 and 1997, there was an increase in demand for breast augmentation as fears of associated autoimmune disorders subsided. Similarly, there was increased male acceptance of aesthetic surgery. The number of breast augmentations and procedures to treat male pattern baldness, plastic surgeons, and fees for the procedures were tracked. During the study period, the supply of surgeons and consumer demand increased for both of these procedures. Volume of breast augmentation increased by 275 percent, whereas real fees remained stable. Volume of treatment for male pattern baldness increased by 107 percent, and the fees increased by 29 percent. Ordinarily, an increase in supply leads to a decrease in prices. This did not occur during the study period. Economic analysis demonstrates that the increased supply of surgeons performing breast augmentation was offset by increased consumer demand for the procedure. For this reason, fees were not lowered. Similarly, increased demand for treatment of male pattern baldness more than offset the increased supply of surgeons performing it. The result was higher fees. Emphasis should be placed on using these economic relationships to expand the demand for aesthetic surgery.

Fees, Medical↗
PubMed1989

Mammographic screening in southern California: 2 1/2-year longitudinal survey of fees.

The American Cancer Society sponsored a community-wide low-cost mammographic screening project in March 1986. One of the major goals was to effect a decrease in mammographic screening fees. To evaluate the effectiveness of the project, a telephone survey of 58 facilities was conducted six times over 2 1/2 years, beginning January 1986 and at 6-month intervals thereafter. The number of facilities offering lower fees for screening than for consultative mammography increased from two with a mean fee of $50.00 in January 1986 to 16 with a mean fee of $68.71 in July 1988. The trend for differentiating screening and consultative examination fees occurred at both hospital- and office-based practices, but fees were significantly lower in the office-based practices. There was also a statistically significant increase in the number of facilities accepting self-referred patients between January 1986 (15.5% of facilities) and July 1988 (34.5%). At the time of the last survey, 60% of office-based practices were accepting self-referred patients.

California↗
PubMed1988

Making sense of referral fee statutes.

State and federal prohibitions of referral fees have long plagued the health care sector because their broadly worded provisions threaten established and socially valuable business arrangements. Congress has recently instructed the Department of Health and Human Services to issue regulations that clarify the scope of the most threatening of these prohibitions, the Medicare and Medicaid felony referral fee statute. This article examines three possible analytical models for imposing a limiting construction on referral fee statutes by testing the models against three beneficial practices that the statute jeopardizes: physician recruitment, fee discounting, and efficiency bonuses. The article recommends primary reliance on an earned/unearned analysis that detects a prohibited referral fee by asking whether the fee is fully earned by legitimate, nonreferral services.

Fees, Medical↗
PubMedDate not supplied

Changes in medicaid physician fees, 1998-2003: implications for physician participation.

After slow growth during much of the 1990s, Medicaid physician fees increased, on average, by 27.4 percent between 1998 and 2003. Primary care fees grew the most. States with the lowest relative fees in 1998 increased their fees the most, but almost no states changed their position relative to other states or Medicare. Physicians in states with the lowest Medicaid fees were less willing to accept most or all new Medicaid patients in both 1998 and 2003. However, large fee increases were associated with primary care physicians' greater willingness to accept new Medicaid patients.

Fees and Charges↗
PubMed1992

Impact of consumer fees on drug utilisation.

A review of research on consumer fees for drugs and drug utilisation suggests that the demand for drugs tends to be quite insensitive to consumer fees. Although higher consumer fees are associated with slightly reduced rates of drug utilisation, use of most other medical services is not meaningfully affected and health status has not been shown to be adversely affected. The larger impact of consumer fees demonstrated in the published literature is to shift drug costs from third parties to consumers. Since much of the literature is limited to insurance programmes with quite small consumer fees, the generalisability of results may be limited. Ability-to-pay and health needs may also be important considerations in the relationship between use and fees for particular drugs.

Aged↗
PubMed1990

Medicare fee schedule in place.

The Omnibus Budget Reconciliation Act of 1989 (OBRA '89) eliminates Medicare's "reasonable charge" method of reimbursing physicians, replacing it with a fee schedule based on a relative value scale. The new payment system's major goals are to decrease Medicare's long-term spending growth rate for physician services and to divide Medicare physician payments more equitably. The two major components of the fee schedule are a relative value scale and a conversion factor. With adjustments to accommodate geographical variations in practice costs, Medicare will pay the lower of (1) a physician's actual charge for service or (2) the fee schedule amount. The nucleus of the fee schedule will be a resource-based relative value scale (RBRVS), which is intended to reflect the costs efficient physicians are expected to incur when providing a service. OBRA '89 directs the Health and Human Services (HHS) secretary to review the RBRVS at least once every five years. The conversion factor, which the HHS secretary may calculate separately for all physician specialties combined or for groups of specialties, will initially be based on 1991 aggregate Medicare spending. Thereafter a formula will be used to update the fee schedule each year. Another feature of OBRA '89 will be a cap on fees charged by physicians who do not participate in Medicare. Because a number of tasks remain to be completed before RBRVS can be implemented, OBRA '89 provisions may be delayed. There is even a remote possibility that the new payment system may not be implemented.

Fee Schedules↗