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PubMed2004

Commissioning. Meet the new power in primary care.

Practices and PCTs will need to negotiate a variety of options when implementing practice-led commissioning. Available options include how much power is devolved to practices, what services they will be commissioning and the incentives on offer. Practices must be regulated by PCTs. Their decisions should also be made in line with the broad strategic aims of their PCTs.

Contract Services↗
PubMedDate not supplied

Influence of a financial incentive on cognitive services: CARE project design/implementation.

OBJECTIVE: To describe the design and methods of the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project, a demonstration project in which community pharmacies were paid for cognitive services (CS) provided to Medicaid patients, its evaluation objectives, and the extent to which implementation objectives were achieved. DESIGN: Prospective randomized trial. Community pharmacies were allocated to a documentation-and-payment group, documentation-only group, and "silent" control group. CS were reported using a problem-intervention-result classification system embedded within a pseudo-National Drug Code format. Management strategies included use of area coordinators. SETTING: Pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding staff-model health maintenance organization pharmacies and pharmacies predominantly serving long-term-care residents. PARTICIPANTS: 200 community pharmacies (110 treatment; 90 control), with another 100 randomly selected pharmacies as a silent control group. INTERVENTIONS: A modest monthly stipend. The treatment group billed Medicaid for each documented CS associated with a drug therapy-related problem. All participants received training in documentation methods. A unique coding scheme allowed documentation of CS within the constraints of the Medicaid program. Data edit checks and feedback were used to ensure data quality and completeness. Area coordinators were used to facilitate training, compliance with study procedures, and participation. MAIN OUTCOME MEASURES: Participation rates, documentation rates, coding scheme revision, data quality and completeness rates, and effectiveness of area coordinators. RESULTS: Pharmacists documented more than 20,240 CS records. Approximately 89% of records passed edit checks, and 94% did so after modification. Nearly 83% could be linked to a paid drug or CS claim. The coding system was sufficient, with minor modifications, to account for all interventions documented. Area coordinators did not function as expected. CONCLUSION: A system for documentation and payment of pharmacists' CS to Medicaid recipients was implemented successfully and relatively easily in community pharmacies.

Double-Blind Method↗
PubMed2003

Financial incentives, competition and a two tier service: lessons from the UK National Health Service internal market.

The experience of General medical practitioner (GP) fundholding is analysed for evidence of the response by family doctors to financial incentives. An analysis of consultant outreach, the local provision of out-patient services, in Scotland finds little evidence of a response, based on comparing the experience of fundholders with non-fundholders. At least in the case of hospital based services, financial incentives seem to be of secondary importance. Financial incentives for such services depend on consultant compliance which, arguably, was missing when it came to creating a two-tier service which deliberately favoured patients from fundholding practices.

Budgets↗
PubMed1993

Ambulatory care prospective payment: the effect on clinical practice patterns.

Prospective payment for ambulatory surgical services offers the opportunity to achieve a number of operational efficiencies in the health care delivery system by incorporating incentives for both physicians and facilities to reorganize care. The risk associated with this opportunity is the creation of additional bureaucratic infrastructure.

Ambulatory Surgical Procedures↗
PubMedDate not supplied

How disclosing HMO physician incentives affects trust.

Opinions are deeply divided over whether rewarding physicians for lowering costs decreases trust in physicians or insurers. To explore the effects of disclosing physician payment methods in HMOs, members of two similar HMO plans were randomized to intervention and control groups, and the experimental arm was told how the HMO paid their primary care physician. Separate disclosures were developed for each plan, one describing primarily capitation payment, and the other (mixed-incentive plan) describing fee-for-service payment with a bonus that rewards cost savings, satisfaction, and preventive services. The disclosures pointed out more of the positive than the negative features of these incentives. We found that the disclosures doubled the number of subjects with substantial knowledge of the physician incentives and halved the number with no knowledge. Nevertheless, the disclosures had no negative effects on trust of either physicians or insurers. The capitated plan disclosure had a small positive effect on trust of physicians. Disclosing the positive and negative features of incentives and increasing knowledge of these incentives does not, in the short term, reduce trust in physicians or insurers and may have a mild positive impact on physician trust, perhaps as a consequence of displaying candor and increasing understanding of positive features.

Adult↗
PubMed2006

Gain sharing: a good concept getting a bad name?

The introduction of diagnosis-related groups (DRGs) created a clear misalignment between the incentives facing hospitals and those facing physicians. The interest in gain sharing that developed in the 1990s represented an attempt by physicians to extract and hospitals to offer some of the savings being produced by physicians. Advisory bulletins by the Office of Inspector General (Department of Health and Human Services) quickly put a stop to further interest in these strategies. Newer, narrowly defined types of gain sharing have been under consideration. More broadly defined strategies that will be tested under a new Centers for Medicare and Medicaid Services demonstration are more promising.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2005

Managed care organization characteristics and outpatient specialty care use among children with chronic illness.

BACKGROUND: Limited information is available about managed care organization (MCO) characteristics that influence outpatient physician specialist use among children with chronic conditions. OBJECTIVE: To examine the association between MCO characteristics and outpatient physician specialist use among children with chronic conditions who were receiving care in MCOs in which primary care providers (PCPs) served as gatekeepers for referrals and who were publicly insured. DESIGN AND METHODS: A total of 2333 children who had been diagnosed with a chronic condition and had functional limitations, an increased need for or use of health care services beyond what children normally use, and/or dependence on medications or home medical equipment were included in the study. The odds of an outpatient physician specialist visit 1 year after study entry were examined as a function of child health and sociodemographic characteristics, MCO characteristics, the child's prior specialty care use, and provider availability in the MCO service delivery area. RESULTS: Children cared for in MCOs with lower percentages of PCPs paid on a fee-for-service basis (odds ratio: 0.95; 95% confidence interval: 0.92-0.98), with higher percentages of pediatricians in the PCP network (odds ratio: 1.17; 95% confidence interval: 1.07-1.29), and offering financial incentives for meeting quality of care standards (odds ratio: 1.71; 95% confidence interval: 1.28-2.29) had greater odds of outpatient physician specialist visits. Black children had odds of specialty care that were approximately one half those of white children. Children with prior physician specialist use were 52% more likely to have a physician specialist visit in the year after study entry. The children's diagnoses and condition consequences were not related significantly to the odds of a specialty visit. CONCLUSIONS: Specific MCO characteristics were associated with greater specialty care use among a group of low-income children with chronic conditions. Such information should be used to improve the structure of managed care arrangements for these vulnerable children.

Adolescent↗
PubMed1998

Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care.

OBJECTIVES: A randomized controlled trial evaluated the impact of feedback and financial incentives on physician compliance with cancer screening guidelines for women 50 years of age and older in a Medicaid health maintenance organization (HMO). METHODS: Half of 52 primary care sites received the intervention, which included written feedback and a financial bonus. Mammography, breast exam, colorectal screening, and Pap testing compliance rates were evaluated. RESULTS: From 1993 to 1995, screening rates doubled overall (from 24% to 50%), with no significant differences between intervention and control group sites. CONCLUSIONS: Financial incentives and feedback did not improve physician compliance with cancer screening guidelines in a Medicaid HMO.

Aged↗