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PubMed2000

Appropriateness of coronary angiography after myocardial infarction among Medicare beneficiaries. Managed care versus fee for service.

BACKGROUND: Previous studies have documented that cardiac procedures are performed less frequently in patients enrolled in managed-care plans than in those with fee-for-service coverage. However, it is not known whether this difference is due to less frequent use of cardiac procedures when they are indicated or to less frequent use when they are not indicated. METHODS: We compared the use of coronary angiography after acute myocardial infarction among Medicare beneficiaries who had traditional fee-for-service coverage with the use among Medicare beneficiaries enrolled in managed-care plans. The analysis was adjusted for differences in demographic and clinical characteristics of the patients and for characteristics of the hospitals to which they were admitted. We studied more than 50,000 beneficiaries in seven states and evaluated their care according to guidelines proposed by the American College of Cardiology and the American Heart Association (ACC-AHA). RESULTS: Among the 44 percent of patients in both groups who had ACC-AHA class I indications (those for which angiography is useful and effective), more fee-for-service beneficiaries than managed-care enrollees underwent angiography (46 percent vs. 37 percent, P<0.001). The rate of angiography was very low among patients with class I indications who were admitted to hospitals without angiography facilities (31 percent in the fee-for-service group and 15 percent in the managed-care group, P<0.001). Among patients with class III indications (those for which angiography is not effective), the rate of use was low in both groups (approximately 13 percent). CONCLUSIONS: In situations in which angiography is thought to be useful, it is used less often among Medicare beneficiaries enrolled in managed-care plans than among those with fee-for-service coverage. Moreover, rates of use among patients with class I indications are fairly low in both groups, suggesting that there is room for improving the care of elderly patients with myocardial infarction, especially those admitted to hospitals without angiography facilities.

Aged↗
PubMed1997

Breast cancer survival and treatment in health maintenance organization and fee-for-service settings.

BACKGROUND: Enrollment in health maintenance organizations (HMOs) has increased rapidly during the past 10 years, reflecting a growing emphasis on health care cost containment. To determine whether there is a difference in the treatment and outcome for female patients with breast cancer enrolled in HMOs versus a fee-for-service setting, we compared the 10-year survival and initial treatment of patients with breast cancer enrolled in both types of plans. METHODS: With the use of tumor registries covering the greater San Francisco-Oakland and Seattle-Puget Sound areas, respectively, we obtained information on the treatment and outcome for 13,358 female patients with breast cancer, aged 65 years and older, diagnosed between 1985 and 1992. We linked registry information with Medicare data and data from the two large HMOs included in the study. We compared the survival and treatment differences between HMO and fee-for-service care after adjusting for tumor stage, comorbidity, and sociodemographic characteristics. RESULTS: In San Francisco-Oakland, the 10-year adjusted risk ratio for breast cancer deaths among HMO patients compared with fee-for-service patients was 0.71 (95% confidence interval [CI] = 0.59-0.87) and was comparable for all deaths. In Seattle-Puget Sound, the risk ratio for breast cancer deaths was 1.01 (95% CI = 0.77-1.33) but somewhat lower for all deaths. Women enrolled in HMOs were more likely to receive breast-conserving surgery than women in fee-for-service (odds ratio = 1.55 in San Francisco-Oakland; 3.39 in Seattle). HMO enrollees undergoing breast-conserving surgery were also more likely to receive adjuvant radiotherapy (San Francisco-Oakland odds ratio = 2.49; Seattle odds ratio = 4.62). CONCLUSIONS: Long-term survival outcomes in the two prepaid group practice HMOs in this study were at least equal to, and possibly better than, outcomes in the fee-for-service system. In addition, the use of recommended therapy for early stage breast cancer was more frequent in the two HMOs.

Aged↗
PubMed2002

User fees impact access to healthcare for female children in rural Zambia.

The World Bank and International Monetary Fund favor healthcare user fees. User fees offer revenue and may decrease inappropriate care. However, user fees may deter needed care, especially in vulnerable populations. A cross-sectional analysis of healthcare utilization in a large Zambian hospital was conducted for children 3-6 years of age during a 1-month observation period. Diagnoses and treatments were compared using paired t-tests. Chi-squared tests compared outpatient service use. The relative risk of admission was determined for each stratum. Logistic models were developed to evaluate the impact of age, gender, and the age-gender interaction on hospital admissions. Trends suggest female children may be less likely to present for care when user fees are imposed. However, treatment type, treatment number, and number of diagnoses did not differ between genders. The relative risk of admission was highest for males 5-6 years old. Neither age nor gender alone was a significant determinant of hospital admission. However, the age-gender interaction was significant with female admissions least likely when costs were incurred. We conclude that user fees appear to decrease differentially utilization of inpatient care for female children in rural Zambia.

Ambulatory Care↗
PubMed1987

An access-oriented negotiated fee schedule. The Caterpillar experience.

This paper describes the system used by Caterpillar Corporation (CAT) in Peoria, Illinois, to reimburse surgeons. The CAT system assures access for Caterpillar employees and their families to a selection of qualified surgeons, while achieving cost savings through improvements in processing of surgical claims and negotiation of selected fees. CPT-4 codes are recorded for greater accuracy, when indicated, surgical services that have been incorrectly unbundled are rebundled, and the appropriateness of surgical assistant charges is reviewed. A "degree of difficulty" relative value scale (DODRVS) of surgical services is periodically revised as technology changes. The DODRVS multiplied by a regional factor, determined by local market research, establishes the fee that CAT will pay the surgeon. Balance billing is permitted if the patient (1) is informed in advance by the surgeon that the fee will be higher than CAT will pay, and (2) knows that the service can be obtained from other local surgeons who will accept the CAT fee. The goal of the CAT method of surgeon reimbursement is to gain physician support for an access-oriented, market-driven negotiated fee schedule. Compared with a resource-based relative value scale RBRVS) methodology, the CAT system is not formula-driven and depends on physician acceptance.

Fee Schedules↗
PubMed1994

Switches between prepaid and fee-for-service health systems among depressed outpatients: results from the Medical Outcomes Study.

We analyzed switches between prepaid and fee-for-service health care plans among depressed outpatients in the longitudinal part of the Medical Outcomes Study. Patients of mental health specialists in fee-for-service plans had the lowest adjusted rate of plan switching (8.1%), compared to fee-for-service general medical patients (13.5%) and prepaid patients of both types of providers (10.1% to 11.7%). Although there were no substantial differences in initial sickness by payment system among enrolled patients, differing switching rates by provider specialty and payment system indicated biased selection over time. In addition, we found that married, nonwhite, and wealthier individuals were significantly more likely to leave fee-for-service than prepaid care plans. We analyzed whether system switching had an effect on patient satisfaction and outcomes. None of the results were highly significant, but the power of the data to analyze this issue was limited. Nevertheless, it appears that patients switching from prepaid to fee-for-service may be at risk for poorer functioning outcomes, although there was no similar effect on mental health status.

Adult↗
PubMed2002

Does the implementation of responsibility centers, total quality management, and physician fee programs improve hospital efficiency? Evidence from Taiwan hospitals.

OBJECTIVES: This study evaluates whether the implementation of various types of hospital-physician integration strategies, such as the responsibility centers system, total quality management, and physician fee programs, enhance efficiency for Taiwan hospitals. Because hospitals in Taiwan are structurally similar to staff-model HMOs, the study has implications beyond Taiwan. RESEARCH DESIGN: The Data Envelopment Analysis model is applied to measure hospital efficiency. Hospital efficiency refers to the ability to produce more outputs (eg, ambulatory and emergency visits, inpatient days, and inpatient visits) with the same inputs (eg, physicians, nurses, ancillary labor, and hospital beds). The sample consists of 90 general hospitals in Taiwan from 1994 to 1996. In addition, multitobit regression analysis is used to simultaneously estimate the effects of the hospital-physician integration strategies and provide better control for the effect of other factors (eg, size, degree of competition, ownership structure, teaching status, and the change in regulatory regime) that may also affect hospital efficiency. RESULTS: When evaluating the hospital-physician integration strategies individually, hospitals that implemented the responsibility centers system, total quality management, and physician fee programs were more efficient than hospitals that did not. Controlling for other factors using the multitobit model, hospitals that implemented physician fee programs remained significantly more efficient than others. In addition, hospitals that implemented total quality management were more efficient when they had implemented the strategy for at least 2 years. Hospitals that implemented the responsibility centers system were more efficient but only when integrating the system with formal incentive schemes. CONCLUSIONS: Physician fee programs seem to provide the most direct and robust incentives to enhance hospital efficiency under a fee-for-service regime like that in Taiwan. Because of time-lagged effects, hospitals that implemented the total quality management programs were more efficient but only when the programs had been implemented for at least 2 years. The responsibility centers system can also be effective when the system was associated with formal incentive schemes. The results indicate the importance of having both the individual-based and team-based incentives in place. Finally, the hospital-physician integration strategies appear to be effective individually, but the results change significantly when they are evaluated simultaneously, together with other control variables, in the tobit model. This indicates the importance of investigating hospital-physician integration strategies as a portfolio instead of a single tool.

Decision Making, Organizational↗
PubMed2002

Fee-paying systems and service patterns in a Hong Kong dental clinic.

OBJECTIVE: This study aimed to describe and compare patients' consumption of dental services and dentists' productivity in a university campus clinic before and after changing from a time-based to an item-based fee-paying system. METHOD: Data were collected from the University of Hong Kong dental clinic which serves all university students and staff. A time-based fee-paying system had been in use up to February 1999 when it was switched to an item-based system. Computerised records of all patients in two 1-year periods starting from February 1996 and February 1999 were analysed. RESULTS: The percentages of eligible users who attended the University dental clinic were similar in the two study periods (30% in 96/97 vs 29% in 99/00). However, on average, patients consumed more dental service items in a year after the switch in fee-paying system (3.2 vs 4.1). There was also an increase in the mean number of dental service items provided by a dentist per working week after the change in fee-paying system (71.5 vs 99.4). CONCLUSION: On switching from a time-based to an item-based fee-paying system, dentists in the UHS dental clinic became more productive and the consumption of dental services per patient also increased.

Dental Care↗
PubMed1997

Monitoring the impact of the Medicare Fee Schedule on access to care for vulnerable populations.

Implementation of the Medicare Fee Schedule (MFS) introduced concerns about the potential for reduced access to care, especially for vulnerable populations. These analyses show differences in access before and after the MFS that cannot be explained by health status. In particular, those without private or public supplementary insurance, those with low incomes, African Americans, and the oldest old had lower utilization before the MFS. The impact after implementation of the MFS on vulnerable populations was similar, for the most part, to that for other beneficiaries: reduced utilization in areas with fee increases and increased utilization in areas with fee decreases. An exception was that African Americans, those without supplemental insurance, and those with low incomes in areas of fee decrease saw reductions in the use of surgical services relative to their counterparts in areas with no fee change.

Ethnicity↗
PubMed1990

Designing fee schedules by formulae, politics, and negotiations.

Fee-for-service cannot be used successfully by organized health insurance without a fee schedule. America first tried to pay doctors under Medicare by an involved formula system without a fee schedule, but the effort has failed. The United States has now commissioned a research project to design a unique fee schedule that will precisely reflect physicians' effort and practice costs and that will represent the prices produced by a perfectly competitively market. The primary goal is the same as that pursued recently by reformers in all countries: viz., narrow the spread in fees and income between surgical and cognitive fields. There are serious technical limitations on this effort, despite the talent of the research team. An additional difficulty lies in the nature of the subject: paying the doctor involves conflicts of interest between payers and all doctors as well as among the medical specialties, and the conflicts cannot be resolved by any formulae calculated by any single research team. Methodological and political compromises will be necessary, in order to adopt a reform. The new method may be just as politically driven, complicated, and disputed as the old one, despite America's pretenses that it prefers free markets and opposes excessive government.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1994

Rationing or rationalizing children's medical care: comparison of a Medicaid HMO with fee-for-service care.

OBJECTIVES: This paper examines how medical care obtained by children enrolled in a Medicaid health maintenance organization (HMO) differs from that obtained by similar children who receive care from fee-for-service Medicaid providers. METHODS: In a randomized trial, some Medicaid households were assigned to remain in a traditional fee-for-service arrangement and others were randomly selected to join a Medicaid prepaid plan (an HMO). Participating households recorded data on children's health status and use of medical care. RESULTS: The prepaid plan members and the fee-for-service recipients received equivalent numbers of checkup visits, but the children in the prepaid plan made significantly fewer acute care visits. This plan appeared to target its services to children with the greatest health care needs. However, the content of health visits in the two systems did not differ, nor did prepaid and fee-for-service enrollees use the emergency room differently. CONCLUSIONS: It is possible to design a Medicaid HMO that achieves financial savings without reducing services to the most vulnerable patients. However, these findings alone do not provide a basis for widespread policy change in the direction of Medicaid HMOs. Further research is needed to establish whether the children treated in the HMO differed in health outcomes from those treated by fee-for-service care.

Child↗
PubMed1997

User fee policies to promote health service access for the poor: a wolf in sheep's clothing?

An international survey of health service user fee and exemption policies in 26 low- and middle-income countries assessed whether user fee policies were supported by measures that protect the poor. In particular, it explored whether governments were introducing a package of supportive measures to promote service improvements that benefit disadvantaged groups and tackle differential ability to pay through an effective series of exemptions. The results show that many countries lack policies that promote access for disadvantaged groups within user fee systems and quality improvements such as revenue retention at the health care facility and expenditure guidelines for local managers. More significant policy failures were identified for exemptions: 27 percent of countries had no policy to exempt the poor; in contrast, health workers were exempted in 50 percent of countries. Even when an official policy to exempt the poor existed, there were numerous informational, administrative, economic, and political constraints to effective implementation of these exemptions. The authors argue that user fee policy should be developed more cautiously and in a more informed environment. Fees are likely to exacerbate existing inequities in health care financing unless exemptions policy can effectively reach those unable to pay.

Africa↗
PubMed1999

Analysis of the user fee for health care policy in Eritrea.

OBJECTIVES: To assess the macro-context of the user fee policy design and implementation; to critically evaluate the content of the user free policy with respect to its implications for efficiency, equity, quality and utilisation of health care and to scrutinize the implementation of the scheme and identify the successes and problems encountered since the introduction of the user fee policy in 1996. DESIGN: Cross sectional. SETTING: Mekane Hiwot Central Referral Hospital and Semenawi Asmore Health Centre. SUBJECTS: 50 health professionals and support staff; 150 outpatients of which 100 patients were from the hospital and 50 from the health centre and 50 inpatients from the hospital. MAIN OUTCOME MEASURES: Service utilisation. RESULTS: The policy was launched against a conducive macro-economic, political and health sector background. Fees reduced attendance at the tertiary referral hospital and reversed the previous trend of sharply declining use of primary level facilities. However, the fee levels could not give an adequate signal to patients to use the appropriate cost effective levels of care and the referral system. The cost recovery ratio for the system as a whole was found to be one of the highest in sub-Saharan Africa. At some of the lowest levels of the health care system, however, the scheme does not seem viable. Fee waivers were infrequent, and the process of means testing was lengthy, thus adversely affecting equity. CONCLUSIONS: The new policy resulted in a cost recovery ratio. There was some indication of allocative efficiency achievement as a result of the price signals. The policy required some refinement in terms of expanding the exemption categories and revenue retention at the facility level.

Attitude of Health Personnel↗
PubMed2002

[A study on the relationship between the actual situation of nursing activities, in the outpatient section of oral surgery, and medical fees].

In our outpatient oral surgery section, nurses have performed such nursing activities as guidance and consultation for outpatients. The present survey was conducted to clarify the actual situation of nursing activities, and that of claims for medical fees during fiscal year 2000, the year the claim for medical fees was started. At that time, the problems involved were examined to further improve nursing activities for outpatients. The nurses gave guidance on alimentation, oral hygiene, and breast feeding, from the nurse's record which were classified and totalled according to each disease, guidance item, and time required (less than 30 minutes or more than 30 minutes). The total numbers of patients were 172 persons and 357 cases. Major guidance items were alimentary guidance (179 cases), oral hygiene guidance (105 cases), and breast feeding guidance (73 cases). The items claimed for medical fees were two: "Athrocytosis function therapeutics" (9 cases) and "the guidance fee for the treatment of specific dental disease" (32 cases). The problems that discouraged claiming a fee for performed chargeable nursing activities are listed as 1. there are no exclusive guidance rooms, 2. insufficiency in securing staff, 3. the instructions and the requests by dentists have not been made exactly and smoothly. Thus, the problems to be considered hereafter would be 1. review and improvement in the guidance environment to an appropriate level, 2. make regulations for securing necessary staff, 3. construction of a system for exact and smooth instruction and requests, and 4. promotion to enrich the content of guidance and to make the results public.

Ambulatory Surgical Procedures↗
PubMed1991

Comparison of the quality of ambulatory care for fee-for-service and prepaid patients.

OBJECTIVE: To determine whether the quality of care for common ambulatory conditions is adversely affected when physicians are provided with incentives to limit the use of health services. DESIGN: Retrospective cohort study over a 2-year period. SETTING: Four group practices that cared for both fee-for-service patients and prepaid patients within a network model health maintenance organization (HMO). PATIENTS: Equal numbers of prepaid (HMO) and fee-for-service patients were selected by randomly choosing medical records from each group practice: 246 patients with chronic uncomplicated hypertension and 250 women without chronic diseases who received preventive care. MAIN OUTCOME MEASURES: Adequate hypertension control was defined as a mean blood pressure of less than 150/90. Adequate preventive care was defined as the provision of blood pressure screening, colon cancer screening, breast cancer screening, and cervical cancer screening within guidelines recommended by the 1989 U.S. Preventive Services Task Force. Resource use was measured by the annual number of visits and tests. MAIN RESULTS: The adjusted relative odds of HMO patients having controlled hypertension, compared with fee-for-service patients, were 1.82 (95% CI, 1.02 to 3.27). The relative risks of HMO patients receiving preventive care within established guidelines were 1.19 (CI, 0.93 to 1.51) for colon cancer screening, 1.78 (CI, 1.11 to 2.84) for annual breast examinations, 1.75 (CI, 1.08 to 2.84) for biannual mammography, and 1.35 (CI, 1.13 to 1.60) for Papanicolaou smears every 3 years. Prepaid patients had visit rates that were 18% to 22% higher than those of fee-for-service patients. CONCLUSIONS: In the type of network model HMO we studied, the quality and quantity of ambulatory care for HMO patients was equal to or better than that for fee-for-service patients. In this setting, the incentives for physicians to limit resource use may be offset by lack of disincentives for HMO patients to seek care.

Ambulatory Care↗
PubMed1991

Fees for certifying insulin drugs--FDA. Interim rule; opportunity for public comment.

The Food and Drug Administration (FDA) is issuing interim regulations to revise the fee schedule for insulin certification services. Under the revision, FDA will charge a fixed fee for each master lot or batch submitted for certification. The changes in fee schedule reflect a change in agency testing policy for certification and release of batches of insulin. The changes in fees will allow FDA to continue to maintain an adequate insulin certification program as required by the Federal Food, Drug, and Cosmetic Act (the act). The fees are intended to recover the full costs of operation of FDA's insulin certification program, including the unfunded liability of the Civil Service Retirement Fund and appropriate overhead costs of the Public Health Service and Department of Health and Human Services.

Certification↗
PubMed1992

Comparing physician fee schedules in Canada and the United States.

Although Canada and the United States have fundamentally different systems for financing health care, there are many similarities between the two countries in their approaches to physician payment. The similarities have increased recently with the adoption of the Medicare fee schedule. Canadian provinces have been using fee schedules for more than 20 years. This article provides an overview of the fee schedules used by Medicare and the four largest Canadian provinces, highlighting specific similarities and differences. We conclude that, although some differences in service definitions exist, the major areas of contrast relate to what services are paid for and how fees are updated. Updating fees is important because it affects how rapidly expenditures grow.

Canada↗
PubMed1995

Medicare program; physician fee schedule update for calendar year 1996 and physician volume performance standard rates of increase for federal fiscal year 1996--HCFA. Final notice.

This final notice announces the calendar year 1996 updates to the Medicare physician fee schedule and the Federal fiscal year 1996 volume performance standard rates of increase for expenditures for physicians' services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848 (d) and (f), respectively, of the Social Security Act. The fee schedule update for calendar year 1996 is 3.8 percent for surgical services, -2.3 percent for primary care services, and 0.4 percent for other nonsurgical services. While it does not affect payment for any particular service, there was a 0.8 percent increase in the update for all physicians' services for 1996. The physician volume performance standard rates of increase for Federal fiscal year 1996 are -0.5 percent for surgical services, 9.3 percent for primary care services, 0.6 percent for other nonsurgical services, and a weighted average of 1.8 percent for all physicians' services. In our July 26, 1995 proposed rule concerning revisions to payment policies under the Medicare physician fee schedule for calendar year 1996, we proposed using category-specific volume and intensity growth allowances in calculating the default Medicare Volume Performance Standard (MVPS). We received 20 comments on this proposal. Since this proposal is related to the MVPS and this notice deals with MVPS issues, we are responding to those comments in this notice instead of in the final rule for the fee schedule entitled "Medicare Program; Revisions to Payment Policies and Adjustments to the Relative Value Units Under the Physician Fee Schedule for Calendar Year 1996" published elsewhere in this Federal Register issue.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1997

Site registration fee schedule and related matters for facilities transferring or receiving select agents--CDC. Notice.

The Centers for Disease Control and Prevention is announcing its site registration fee schedule for facilities registered under 42 CFR 72.6. This notice includes the total fee for facilities in three categories, small, medium, and large. The fee is broken down into subtotals that illustrate how the agency derived the total fee. In return for the fee, the facility receives a 3 year site registration and is subject to inspection during that time period. Also included in this notice is clarification of the exemption of certain toxins, as well as clarification of biosafety levels for certain viruses in the regulation.

Centers for Disease Control and Prevention, U.S.↗