PubMed · 4907708
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A Donabedian. 1970-04-01. Patient care evaluation.. https://pubmed.ncbi.nlm.nih.gov/4907708/
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OBJECTIVE: To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the NHS reforms in April 1991. DESIGN: Prospective collection of data on general practitioners' referrals to specialist outpatient clinics between June 1990 and January 1994 and detailed comparisons of three phases--October 1990 to March 1991 (phase 1), October 1991 to March 1992 (phase 2), and October 1993 to January 1994 (phase 3). SETTING: 10 first wave fundholding practices and six non-fundholding practices in the Oxford region. SUBJECTS: Patients referred to consultant out-patient clinics. RESULTS: NHS referral rates increased in fundholding practices in phase 2 and phase 3 of the study by 8.1/1000 patients a year (95% confidence interval 5.7 to 10.5), an increase of 7.5% from phase 1 (107.3/1000) to phase 3 (115.4/1000). Non-fundholders' rates increased significantly, by 25.3/1000 patients (22.5-28.1), an increase of 26.6% from phase 1 (95.0/1000) to phase 3 (120.3/1000). The fundholders' referral rates to private clinics decreased by 8.8%, whereas those from non-fundholding practices increased by 12.2%. The proportion of referrals going outside district boundaries did not change significantly. Three of the four practices entering the third and fourth wave of fundholding increased their referral rates significantly in the year before becoming fundholders. CONCLUSIONS: No evidence existed that budgetary pressures caused first wave fundholders to reduce referral rates, although the method of budget allocation may have encouraged general practitioners to inflate their referral rates in the preparatory year. Despite investment in new practice based facilities, no evidence yet exists that fundholding encourages a shift away from specialist care.
In 1991, the costs for manic-depressive illness, which has a lifetime prevalence of 1.3% among adult Americans, totaled $45 billion. Costs were broken down into their direct and indirect components. Direct costs totaling $7 billion consist of expenditures for inpatient and outpatient care, which are treatment related, as well as nontreatment-related expenditures such as those for the criminal justice system used by individuals with manic-depressive illness. Indirect costs, which were $38 billion, include the lost productivity of both wage-earners ($17 billion) and homemakers ($3 billion), individuals who are in institutions ($3 billion) or who have committed suicide ($8 billion), and caregivers who take care of manic-depressive family members ($6 billion). The method for determining each expenditure is provided, and the implications of these staggering costs are discussed. These calculations rely heavily on methods and data bases that were developed for the accompanying paper on the costs of schizophrenia.
The effectiveness of treatment for depression is not in doubt, and common humanity would indicate that it should be provided to those that need it. However, in this paper I argue that the existence of effective treatment should not be regarded as a sufficient condition for the extension of insurance cover. This is because insurance coverage cannot guarantee that treatment is delivered effectively, nor that it is given to the right people; neither does it lend itself to the maximization of cost-effectiveness. Payment systems must take account of these considerations.