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PubMed1995

Evaluating the effects of GP remuneration: problems and prospects.

General practice reform is occurring in a number of countries. Little is known, however, of the effects of remunerating general practitioners on the costs and outcomes of care. Valuable lessons can be learned for the scope and design of future research, however, from the existing literature on the effects of general practioner (GP) remuneration. The objectives of this paper are to highlight some of the problems and pitfalls that should be avoided in any further research on the effects of GP remuneration and to identify the main issues for future research. Eighteen studies of the effects of GP remuneration have been reviewed, with a focus on the methods used. Eight studies addressed the effect of changes in the level of remuneration, three evaluated the effect of special payments and bonuses and seven assessed the effects of different remuneration systems. Although there are often practical constraints on the choice of study design, crude 'before and after' analyses and the use of aggregate data should be avoided in favour of prospective evaluations using consultation-based data. The studies reviewed did not evaluate the effects of remuneration on patient welfare and were characterised by the omission of major confounding variables and an inability to generalise to other settings. These issues present a considerable challenge to researchers, GPs and policy makers.

Australia↗

PubMed1993

Remuneration of GP services: time for more explicit objectives? A review of the systems in five industrialised countries.

The paper examines the nature and use of GP remuneration systems as instruments of health policy in five different countries--Australia, Canada, Denmark, Norway and the UK. Since doctors are not naturally efficient, they need to be encouraged to adopt efficient practices. The paper indicates that while there are great differences in the nature and level of remuneration across the five countries, there is little evidence that policy-makers in these countries have given adequate thought to how to use remuneration to influence the activities of GPs. In all five countries except the UK the objectives of GP services are somewhat vague and largely non-operational. The designs of the remuneration systems seem directed more towards deciding doctors' income levels and controlling public expenditure than towards meeting health care objectives. The remuneration for similar services varies widely across the five study countries. There is a need to clarify what the objectives of general practice are and thereafter to experiment more with GP remuneration systems to determine how best to get doctors to meet these objectives efficiently.

Australia↗

PubMed2002

General dental practitioners' beliefs on the perceived effects of and their preferences for remuneration mechanisms.

OBJECTIVE: To identify GDPs preferences for differing remuneration mechanisms and their beliefs on the effect of the mechanisms in care provision. DESIGN: Postal questionnaire survey of 300 GDPs holding an NHS contract with a London Health Authority. RESULTS: GDPs perceive that remuneration mechanisms are important in determining the provision of care but not overall disease levels. There were differences in the preferred remuneration mechanisms when working under the NHS compared with the non-NHS sector. When providing care under the NHS, either the current remuneration system or a salaried plus bonus would be the preferred choice, while for non-NHS care a fee-per-item mechanism is preferred. Fee-per-item arrangement was the preferred choice of younger general practitioners compared with older practitioners. Females showed a greater preference for a salaried with bonus arrangement compared with males. CONCLUSIONS: If policy makers are to use remuneration mechanisms to influence the provision of care effectively, the beliefs that care providers hold about various mechanisms are important to understand how they would respond to changes in the system.

Adult↗

PubMed1985

Rational remuneration.

Physicians face the end of a phase of unrealistic and unprecedented prosperity fostered by unrestrained third-party remuneration policies. The cost of that phase, along with inflation and the use of expensive technology, has created an economic crisis. I urge my colleagues to take the initiative to address this crisis with other affected groups in the private sector by working to develop guidelines to restrain abuses, promote cost effectiveness, simplify administration, and increase fairness in the remuneration system. Remuneration scales should reflect variations among specialties in terms of skill, stress, and time involved, but should avoid unmeasurable and unverifiable differences within each category of service. Slowness and ineptitude should no longer be rewarded under the guise of "complexity." In the long run, standardized fees will be fair and will simplify the payment process greatly. Reasonable remuneration for agency-subsidized services can be derived in several ways, and once the median remuneration for various services has been established in each specialty, existing relative-value scales can be applied for other cases in that specialty. These measures would effect substantial savings in health care costs without incurring bureaucratic interference or impairing the quality of service. Moreover, they would allow distribution deficiencies to be remedied by permitting a response to market forces--i.e., higher payments would be made in underserved areas.

Economic Competition↗

PubMed2000

[Detection of anti-HIV-1/2 and HIV nucleic acid in population of non-remunerated blood donors in Shenzhen].

OBJECTIVE: To study the prevalent status of HIV-1 in population of non-remunerated blood donors in Shenzhen. METHODS: 46,095 non-remunerated blood donors were tested for anti-HIV-1/2 by ELISA. The donors of anti-HIV positive were further detected for HIV DNA from peripheral blood mononuclear cells (PMBCs) by nested-PCR and HIV RNA from plasma by RT-PCR. The partial genome of env of 2 blood donors were sequenced. RESULTS: The anti-HIV-1 was tested positive in 7 of 46 095 voluntary blood donors and the positive rate was 0.015%. In these 7 non-remunerated blood donors of anti-HIV-1 positive,7 were positive for HIV DNA in PMBCs and 5 positive for HIV RNA in plasma. The sequence analysis showed that 2 donors were infected by HIV-1 subtype E strains. CONCLUSIONS: There exists HIV-1 subtype E infection in population of non-remunerated blood donors in Shenzhen. It is essential to detect and monitor strictly the population of non-remunerated blood donors.

Adolescent↗

PubMed1996

A critical review of the remuneration systems for pharmacists.

This paper provides a critical review of different systems of remunerations of pharmacists which exist in various countries: the percentage mark-up, the graduated mark-up, the capitation system, the fee for service system and mixed system. In these different systems, we refer to the various ways the provisions of pharmaceutical services are paid and reimbursed rather than how persons who physically deliver the services are paid. Therefore, the differences among various types of remuneration may not impact directly the level of responsibility and motivations of the various employees or owners in contact with the patient. The dispensing service remains the essential service of the pharmacist in all systems. However, according to the types of remuneration, the revenue of the pharmacist can be more or less linked to the volume and the price of drugs. Capitation systems, professional allowance and fees in particular can be used to shift the objective of the pharmacist towards increased professionalism. In each system, policy makers, when they can negotiate with the whole national profession, can use the remuneration system to achieve public policy objectives such as cost containment, better drug use, or provisions of large packages of services. This paper discusses to what extent each system can contribute to such objectives. In order to achieve public policy objectives, it may be time to shift the valuation of pharmaceutical services towards more safe and effective therapy instead of safe and effective drugs.

Canada↗

PubMedDate not supplied

Iron stores in remunerated blood donors as evaluated by plasma ferritin levels.

This study was undertaken to investigate body iron stores in so-called remunerated blood donors as well as to evaluate the sensitivity of hemoglobin determination in detecting iron deficiency in two populations of blood donors. The authors studied 522 male donors who were divided into three groups: Group I, first-time volunteer donors with hemoglobin levels greater than or equal to 13 g per dl; Group II, remunerated donors with hemoglobin levels greater than or equal to 13 g per dl; and Group III, remunerated donors rejected because their hemoglobin levels were less than 13 g per dl. Iron stores were evaluated with an enzyme-linked immunosorbent assay for plasma ferritin. In Group I, 4.5 percent were iron-deficient with a mean ferritin value of 55.3 ng per ml; in Group II, 59.7 percent were iron deficient with a mean ferritin level of 17.4 ng per ml, and in Group III, 82.5 percent were iron-deficient and the mean ferritin level was 8.4 ng per ml. The last values represent the highest percentage of iron deficiency and the lowest mean ferritin value thus far reported. In Group I, hemoglobin determination had a sensitivity of 95 percent in detecting iron deficiency, but in Group II had only 40 percent sensitivity. These results indicate that a more accurate and reliable test, such as a plasma or serum ferritin determination, may be necessary to detect iron deficiency in blood donors when they donate more than five times per year, particularly those who are remunerated.

Blood Donors↗

PubMed1990

Changing remuneration systems: effects on activity in general practice.

OBJECTIVE: To investigate the effects on general practitioners' activities of a change in their remuneration from a capitation based system to a mixed fee per item and capitation based system. DESIGN: Follow up study with data collected from contact sheets completed by general practitioners in one period before (March 1987) a change in their remuneration system and two periods after (March 1988, November 1988), with a control group of general practitioners with a mixed fee per item and capitation based system throughout. SETTING: General practices in Copenhagen city (index group) and Copenhagen county (control group). SUBJECTS: 265 General practitioners in Copenhagen city, of whom 100 were selected randomly from the 130 who agreed to participate (10 exclusions) and 326 general practitioners in Copenhagen county. MAIN OUTCOME MEASURES: Number of consultations (face to face and by telephone) and renewals of prescriptions, diagnostic and curative services, and specialist and hospital referrals per 1000 enlisted patients in one week. RESULTS: Of the 75 general practitioners who completed all three sheets, four were excluded for incomplete data. Total contact rates per 1000 patients listed rose significantly compared with the rates before the change index in the city (100.0 before the change v 111.7 (95% confidence interval 106.4 to 117.4 after the change) and over the same time in the control group (100.0 v 106.0), but within a year these rates fell (to 104.2(99.1 to 109.6) and 104.0 respectively). There was an increase in consultations by telephone initially but not thereafter. Rates of examinations and treatments that attracted specific additional remuneration after the change rose significantly compared with those before (diagnostic services, 138.1 (118.7 to 160.5) and 159.5 (137.8 to 184.7) and curative services 194.6 (152.2 to 248.9) and 194.8(152.3 to 249.2) for second and third data collections respectively) and with the control group (diagnostic services 105.3, 107.6 and curative services 106.0, 115.0) whereas referral rates to secondary care fell (specialist referrals 90.1 (80.7 to 100.6) and 77.0 (68.6 to 86.4) and hospital referrals 87.4 (71.1 to 107.5) and 68.4 (54.7 to 85.4] in doctors in the city. CONCLUSIONS: Introducing a partial fee for service system seemed to stimulate the provision of services by general practitioners, resulting in reduced referral rates. The concept of a "target income" which doctors aim at, rather than maximising their income seemed to play a part in adjustment to changing the system of remuneration.

Capitation Fee↗

PubMed1993

Workload and sources of remuneration for radiologists at a tertiary-care teaching hospital in Ontario.

Detailed information about workload and sources of remuneration for radiologists at a large tertiary-care teaching hospital was reviewed for the calendar year 1991 as part of an assessment of medical professional resources. Radiologists at this facility worked an average of about 50 hours per week. When the intensity of the cases was taken into consideration, there was only a small variation among individual radiologists in terms of workload and income earned for the group. Ninety-three percent of the radiologists' remuneration came as payment for clinical patient care. The radiologists were poorly remunerated for the time they spent teaching, conducting research and performing administrative duties, but this low level of remuneration was partially compensated by the activity of senior residents, who did some work without supervision.

Hospital Bed Capacity, 500 and over↗

PubMed1993

The general practitioner's use of time: is it influenced by the remuneration system?

The practice pattern of 116 general practitioners in 60 rural municipalities in Northern Norway was studied with respect to length of consultation, the weekly number of consultations and the proportion of return visits. The average length of consultation was 14 mins, and only slightly lower for fee-for-service (FFS) doctors (13.7) than for salaried ones (14.8). The weekly average number of surgery consultations was higher for FFS doctors than for the salaried (63 vs 49), but the weekly number of hours spent consulting and the proportion of return visits were about the same. Further, the characteristics of the health care system (doctor density and doctor turnover) were associated with variations in the doctors' use of time. The most consistent effects, even if weak, were the age and sex of the patients. The strongest effects on the length of consultation were referrals and various medical procedures. This suggests that in this instance the medical condition at hand would appear to have a greater influence on the doctors' use of time than either the remuneration system or other characteristics of the health care system. Although the association between the doctors' use of time and the type of remuneration was weak, the study indicates that the type of remuneration does matter. Consequently, financial incentives can be used to influence the practice pattern of GPs.

Adult↗

PubMed2003

Remuneration for blood donation and attitudes towards blood donation and receipt in Leeds.

In a survey of attitudes towards remuneration for blood donation in Leeds, the following questions were completed by 489 adults (N), of whom 89 were regular donors, 105 were lapsed donors and 295 had never donated: 'If you needed blood, would you be content if the donor had been paid: yes/no'. 'If I were paid enough I would be less/equally/more likely to donate blood '. The majority (67.7%) of potential recipients would be content if the donor had been paid. The prospect of remuneration made 16.4% of respondents more likely and 14.5% less likely to donate. As the difference is less than 2% of N, offering remuneration may not lead to a significant increase in the number of donations. A statistical comparison (chi2 = 45, d.f. = 2, P << 0.001) showed associations between the responses 'more likely to donate if paid' and 'content to receive blood from a paid donor', and between the responses 'less likely to donate if paid' and 'not content to receive blood from a paid donor'. Age distributions are presented for the donor status categories and the responses to the main questions. Of 129 people who stated a minimum, nonzero payment that would persuade them to donate, 103 (80%) suggested pound sterling 10 or less.

Adolescent↗

PubMed1998

[Remuneration and productivity: the case of the Minas Gerais Hospital Foundation, Brazil, 1992-1995].

This article presents an analysis of the Minas Gerais State Hospital Foundation immediately after the introduction in its health services units in early 1993 of a new system of rewards for good performance and productivity, as a complement to salaried remuneration. Analysis was based on a cross-sectional study of changes in indicators of production and productivity in the Foundation during the 1992-1995 period. Data were obtained from hospitalization authorization forms, payment authorization guides, and bulletins from the Human Resource Administration. The strategy of conditional remuneration and incentives was adopted not only to step up production and productivity, but also to increase the employees' commitment to the institution. Analysis of the selected indicators appears to confirm other study results in that remuneration based on results (conditional incentives) leads to a positive change in the production level of services and productivity, even if it does not last for the long term. Study results also support the notion that such alternatives may be deliberately used as part of a more general strategy of organizational development and not only as an isolated element for concrete improvements in productivity.

Awards and Prizes↗

PubMed1991

General practitioners' attitudes to a recent change in their remuneration system.

The study examines the attitudes of general practitioners in Copenhagen to a recent change in their remuneration system from capitation to a mixed capitation and fee-for-service system. The study was based on two questionnaires, one before and one 18 months after the change, distributed to a primarily self-selected sample of 100 general practioners in Copenhagen City. The questionnaires provided information about certain basic characteristics of the respondents, attitudes to the new remuneration system as compared with the former, and possible changes in attitudes towards professional competence and responsibilities in secondary versus primary care. The majority of the respondents did not feel any changes under the new remuneration system in terms of diagnostic and curative possibilities and their relations to colleagues and patients. Attitudes to secondary versus primary care responsibilities also changed little. The majority felt that there had been an increase in their total work load, but also an improved economic situation in their practice. 21% felt that there was more competition with colleagues and 30% that doctor-patient relationships had suffered as a result of the introduction of a fee-for-service.

Adult↗

PubMed1986

Joint ventures and illegal remuneration: the pressure is growing.

As the healthcare industry becomes more involved in joint venture activity, it must become more concerned with the possibility of illegal remuneration. Illegal remuneration, or the soliciting, receiving, offering, or paying of remuneration in return for the referral of patients or generation of business, is treated very seriously by HHS and the courts. Therefore, joint ventures must be constructed to avoid the danger areas as much as possible, or at least, minimize the risk.

Commerce↗

PubMed1993

Doctor and patient characteristics as modifiers of the effect of a changing remuneration system in general practice.

The objectives of the study was to investigate the effects on general practitioners' activities of a change in their remuneration system from a capitation-based system to a mixed fee-per-item and capitation-based system. It was our hypothesis that the effect of the change in remuneration varied between subgroups of doctors and patients as a result of the modifying effect of the doctors' age, sex, practice facilities, assistance, side jobs, and size of practice as well as patients' age, sex, and diagnostic group. The study was carried out as a follow-up with data collected from contact sheets completed by general practitioners in one period before a change in remuneration and two periods after. These data were supplemented by a questionnaire on doctors' characteristics as well as by health insurance data on population characteristics. The general increases in diagnostic and curative activities and reductions in referrals by general practitioners as a result of the change were found to be quite similar across subgroups of doctors and patients. While, total contact rates changed little, the sex of doctors showed a modifying effect: male doctors tended to increase their contact rates compared to female doctors. This tendency was most prominent among female patients with non-infectious diseases.

Age Factors↗

PubMed2004

Recruitment of voluntary non-remunerated apheresis donors: the second five years' experience in Shenzhen.

The voluntary non-remunerated blood donation campaign in Shenzhen, China, was launched in 1993 and the smooth change from paid donors to unpaid took only a decade. In the first half the volunteer donation system and a sufficient blood supply was promoted and this paved the way for further development in the second half during which the non-remunerated donation system became substantial and integral due to recruitment for plateletapheresis and peripheral stem cells donation as well as whole blood donations. Ninety percent of the donors registered for plateletapheresis do donate and none of the twenty-three non-related donors with matched HLA genotypes broke their promise to donate their peripheral stem cells.

Altruism↗

PubMed1996

The remuneration of dentists in a special project of the Israeli Defence Forces.

The behavior of health care professionals is known to be influenced, in part, by their method of remuneration and the financial incentives they face. Describes how the Medical Corps of the Israel Defence Forces (IDF) went about choosing a reimbursement method to increase incentives for dentists and decrease waiting time for the public. Based on q questionnaire sent to all 23 dentists working in a unique IDF civilian dental clinic, and on other information which was available on the productivity and income of these dentists, a new method of remuneration was suggested and accepted, by which a combined method of fee-for-service and salary will be introduced. The base hourly pay and per crown fee were set on levels which provide for a larger compensation range and increase the incentive for improved productivity levels. This suggested method will be investigated further and re-evaluated one year after its implementation.

Attitude of Health Personnel↗

PubMed1993

Effect of the remuneration system on the general practitioner's choice between surgery consultations and home visits.

OBJECTIVE: To assess the influence of the remuneration system, municipality, doctor, and patient characteristics on general practitioners' choices between surgery and home visits. DESIGN: Prospective registration of patient contacts during one week for 116 general practitioners (GPs). SETTING: General practice in rural areas of northern Norway. MAIN OUTCOME MEASURE: Type of GP visit (surgery v home visit). RESULTS: The estimated home visit rate was 0.14 per person per year. About 7% (range 0-39%) of consultations were home visits. Using multilevel analysis it was found that doctors paid on a "fee for service" basis tended to choose home visits more often than salaried doctors (adjusted odds ratio 1.90, 99% confidence interval 0.98, 3.69), but this was statistically significant for "scheduled" visits only (adjusted OR 4.50, 99% CI 1.67, 12.08). Patients who were older, male, and who were living in areas well served by doctors were more likely to receive home visits. CONCLUSION: In the choice between home visits and surgery consultations, doctors seem to be influenced by the nature of the remuneration when the patient's problem is not acute. Although home visiting is a function of tradition, culture, and organisational characteristics, the study indicates that financial incentives may be used to change behaviour and encourage home visiting.

Acute Disease↗