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PubMed1994

Alternative volume performance standards for Medicare physicians' services.

The Omnibus Budget Reconciliation Act of 1989 (OBRA89) established volume performance standards (VPSs) as a key element in Medicare physician reform. This policy requires making choices along three dimensions: the risk pool, the scope and nature of the standard, and the application of the standard. VPSs have most effectively controlled expenditures and changed physician behavior when they use states as the risk pool, are composed entirely of Medicare Part B services, and establish per capita utilization targets. The institution of separate standards for voluntarily formed physician groups would pose substantial administrative challenges and has the potential to effect adverse outcomes. Instead, Congress should continue to encourage prepaid plans for the purpose of lowering health care use. Under current law, VPSs will be used to adjust future price increases. Congress may not wish to emulate the example of countries that have imposed expenditure ceilings to control costs unless the current method of using VPSs proves unsuccessful.

Canada↗
PubMed1997

Aligning incentives using risk-sharing arrangements.

Most managed care arrangements do not properly align provider and HMO incentives and thus unintentionally promote conflicting care management patterns. But appropriate risk-sharing arrangements encourage HMOs and providers to agree on the best methods to achieve member satisfaction; high-quality, cost-effective care; and healthy profits. Quality- and cost-based risk-sharing arrangements withhold a certain portion of providers' payments for placement in a risk pool fund. Providers are penalized financially for poor quality and unsatisfactory cost performance; providers are financially rewarded with risk pool funds for the cost-efficient delivery of high-quality health care. Percent-of-premium or capitation risk-sharing arrangements divide member premiums among the parties to the risk-sharing arrangement based on how much financial risk each party is willing to assume for providing care. The risk of controlling variations in cost is assumed by providers, thus minimizing HMOs' financial exposure. Inpatient case rate risk-sharing arrangements pay providers a flat rate for uncomplicated cases. Such arrangements can improve the relationship between HMOs and providers by giving providers primary control over case management and benefits HMOs by reducing their utilization review activities.

Capitation Fee↗
PubMed1999

Using contact capitation to align payment incentives among specialists.

Contact capitation is a means of paying specialists based on the number of patients managed rather than on the number of services provided or procedures performed. Payments to physicians are disbursed from budgets, or risk pools, which are established by specialty and product line (e.g., commercial coverage, Medicare). Each specialist is credited with managing a patient for a specified time period (usually 12 months) following the patient's initial visit. To ensure payments are equitable to all physicians, regardless of specialty or subspecialty, the system may be adjusted by using different contact weights for certain diagnoses or procedures, creating subpools for selected subspecialties and/or procedures, establishing separate capitation rates for different age segments, and setting aside certain specialties as fee-for-service carve-outs. Contact capitation has advantages over traditional specialist capitation of removing physicians' financial incentives to overutilize and allowing for a broad physician specialty panel. Challenges to implementing contact capitation include getting physicians to alter habitual practice patterns and managing the system's administrative complexity.

Capitation Fee↗
PubMed2001

The effect of income pooling within a call group on rates of obstetric intervention.

BACKGROUND: On July 1, 1997, the call group at a tertiary referral hospital in Ottawa changed its remuneration. The authors tested the hypothesis that change in an obstetric call group's remuneration from individual fee-for-service billing to equal sharing of the pooled group income would result in reduced rates of obstetric intervention. METHODS: Intervention rates were compared for the 12 months before (1678 births) and the 12 months after (1934 births) the change. Data were collected on onset of labour, indication for induction of labour, mode of delivery and neonatal outcome. Statistical analysis was performed with Wilcoxon's signed-rank test. RESULTS: The mean rate of elective induction of labour was 38.6% in the year before the change and 33.3% in the year after the change (p = 0.01). There were small but statistically significant increases in the mean duration of labour and mean length of the second stage (p = 0.03). INTERPRETATION: Billing policy may affect clinical decisions. Our findings add weight to the literature showing increased intervention rates with fee-for-service remuneration.

Decision Making↗
PubMed2002

The burden of out-of-pocket payments for health care in Tbilisi, Republic of Georgia.

CONTEXT: In the 1990s, the Republic of Georgia instituted health care reforms to convert the centralized, state-operated health care system inherited from the Soviet Union to a decentralized, market-driven system of health care delivery. Under the new system, 87% of health care expenditures are financed through out-of-pocket payments at the point of service. OBJECTIVE: To describe the effects of health care reforms on access to care and health care financing among ill residents of Tbilisi, Georgia. DESIGN, SETTING, AND PARTICIPANTS: A probability-proportionate-to-size cluster survey conducted in 1999 of 248 households containing 306 household members who had been ill in the past 6 months in Tbilisi, Georgia. MAIN OUTCOME MEASURES: Reported health care utilization, out-of-pocket expenditures, and financing practices. RESULTS: Of sick household members, 51% used official health care services at hospitals and clinics; 49% did not use official services and sought advice from relatives or friends, used traditional medicines, or did nothing. Those with serious illness were more likely to seek care through official services (82%) than those with nonserious illness (27%). Ninety-three percent of respondents said costs were the major deterrent to obtaining health care. Ten percent of ill household members reported that they were unable to obtain health care because of high costs; 16% reported being unable to afford all the medications necessary to treat their illness. Sixty-one percent of ill household members used savings to pay for health care expenditures and 19% of those able to obtain care had to use strategies such as borrowing money or selling personal items to pay for health care. Total out-of-pocket health care expenditures (53%) were paid for by borrowing money or selling personal items. A significant portion of households with ill members (87%) reported an interest in purchasing health care insurance. CONCLUSIONS: Economic disruption and health care reforms have led to access problems and out-of-pocket financing strategies that include reliance on personal savings, selling personal items, and borrowing money. Future reforms should consider an appropriate system for health care insurance risk pooling for the population of Tbilisi, Georgia.

Cluster Analysis↗
PubMed2002

Social risk management options for medical care in Indonesia.

This paper investigates the extent to which price subsidies for medical care are a suitable instrument to reduce household's exposure to catastrophic financial risks associated with ill-health in Indonesia. Using the 1995 SUSENAS household survey, the observed distribution of user fees and health expenditures is used to derive a distribution of 'needed' medical expenditures. The trade-off between the tax burden and effectiveness in reducing the exposure to catastrophic risk is analyzed for two existing price regimes along with a number of hypothetical regimes. We find that the existing regimes significantly reduce the exposure to catastrophic shocks but do not eliminate them. Simulations suggest that further reductions could be achieved if a larger proportion of government subsidies were directed to inpatient care. Subsidizing outpatient treatment is a cost effective policy to reduce exposure to catastrophic risks only for the very poor.

Adult↗
PubMed2002

Private sector unlikely to follow Medicare lead in providing health plan disenrollment comparisons.

BACKGROUND: There have been substantial efforts to improve the measurement and reporting of comparative quality information. A three-stage effort to develop comparative voluntary disenrollment measures for private health insurance plans is described. The literature on disenrollment and how key groups might use disenrollment information is reviewed; the development of a comparative survey of disenrollment is described; reasons employers, purchasing coalitions, and plans were ultimately unwilling or unable to sponsor the survey are delineated; and implications of these findings are discussed. DATA AND METHODS: Methods used to develop the survey included review of existing literature on disenrollment, review of extant disenrollee surveys, cognitive testing, and expert review of the survey. Informal and formal interviews were conducted to assess the feasibility of different sponsors. RESULTS: A disenrollment survey instrument that covered areas of common interest to consumers, purchasers, and plans could be developed, but sponsors to test the collection and reporting of these data could not be recruited. This was due to four interrelated factors: technical challenges in developing appropriate samples, wide variation in resources and capabilities of purchasers and plans, the perception that the costs of the survey outweighed the benefits of comparative information on disenrollment to the different sponsors, and the absence of strong demand from purchasers, regulators, or consumers to motivate plans to collect or report comparative information on disenrollment. IMPLICATIONS: Several major barriers must be overcome before disenrollment information can become a component of comparative health care quality measures for the privately insured.

Benchmarking↗
PubMed2003

Genetic information and testing in insurance and employment: technical, social and ethical issues.

The present paper examines the professional and scientific views on the social, ethical and legal issues that impact on genetic information and testing in insurance and employment in Europe. For this purpose, many aspects have been considered, such as the concerns of medical geneticists, of the insurers and employers, of the public, as well as the regulatory frameworks and unresolved issues. The method used was primarily the review of the technical, social, economical and ethical aspects of advances in genetics and the concerns of parties who are involved, that is, the insurers, the employers and the public. The existing guidelines and legislation on this topic were also reported. Then, the method was to examine the issues debated by these parties in Europe, as well as by 47 experts from 14 European countries invited to an international workshop organized by the European Society of Human Genetics Public and Professional Policy Committee in Manchester, UK, 25-27 February 2000. The result of this was that the most important issues raised by genetic information and testing in insurance and employment in Europe include a need for clear definitions of terms used in genetics, declaring the grounds on which genetic information is or is not used, and promoting confidence between the public and the insurance industry. There is currently very little use of genetic information in relation to employment, but the situation should be kept under review.

Employment↗
PubMed2000

China in transition: the new health insurance scheme for the urban employed.

China has been very successful in achieving good health at a low cost, mostly through national programs for health promotion and illness prevention. However, increased prosperity in recent years has led to higher expectations for therapeutic care, and the change to a socialist market economy has created new risks and opportunities for both financing and care provision. After several years of experimentation, China committed itself in 1996 to a major reform program which includes implementation of a new method of financing of care for the urban employed population. It comprises a mix of government-operated compulsory basic insurance, individual health savings accounts, and optional private health insurance. This paper outlines the new Scheme, and notes some tactical and strategic issues. I conclude that the Chinese government is correctly choosing to balance new and old ideas, but that there are many challenges to be faced including integration of the new Scheme with the rest of the health care system.

China↗
PubMedDate not supplied

Hampshire HealthConnect. A local effort increases access to health care for the uninsured.

In the absence of universal coverage, there is a need to develop solutions at a local and state level to the dramatic rise in the uninsured. This article summarizes a local countywide effort to address this issue in a rural area. Key ingredients for success include both hospital leadership (they have significant resources at their disposal), extensive community involvement (to maintain momentum for the program), and local physician leadership (physicians are, in essence, forgoing income in return for a formalization of who is eligible for the free care program).

Community Participation↗
PubMed1997

Countervailing agency: a strategy of principaled regulation under managed competition.

Despite the failure of recent attempts to reform health care, strategies of managed competition remain the dominant prescription for government oversight of managed care. A number of assumptions and prescriptions in the conventional managed competition model are challenged. More specifically, externalities in the costs and benefits associated with health care and asymmetric information between providers and patients make it unlikely that a managed care system designed to be responsive to consumers will, in practice, produce socially desirable outcomes. An alternative approach for the regulation of managed care more explicitly protects the role of health care professionals as agents for their patients while defining the appropriate role of managed care as the agent for broader societal interests. This strategy of "countervailing agency-" acknowledges that oversight of managed care inevitably involves value-laden choices. It is based on institutional arrangements and regulatory strategies that are intended to balance competing interests and values.

Capitation Fee↗
PubMed2000

Purchasing cooperatives for small employers: performance and prospects.

Health insurance purchasing cooperatives were established in the early to mid-1990s for the purpose of making health insurance more affordable and accessible for small employers. Extensive interviews at six cooperatives reveal that while some cooperatives enrolled large numbers of small employers, most have won only small market shares and a number have struggled for survival, not always successfully. They have allowed small employers to offer individual employees choice of health plans, but none has been able to sustain lower prices than are available in the conventional market. Among the important impediments to their success are limited support from health plans and conflicts over the role of insurance agents.

Group Purchasing↗