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PubMedDate not supplied

Effects of performance-based reimbursement on the professional autonomy and power of physicians and the quality of care.

The key question addressed in this study is whether performance-based reimbursement in health care affects the professional power and autonomy of physicians, and if so, whether this has any consequences for the quality of care. This cohort study examines the period 1994-98 in 11 Swedish county councils. Four hundred and eighteen physicians were studied in Stockholm County Council, which has a performance-based reimbursement system, and in ten councils without such a system. The results show that professional power and autonomy are considered to be very limited in all councils, and that they have decreased during the period studied. Professional autonomy is, however, more limited in Stockholm. The limitations in Stockholm are more related to financial considerations, whereas the limitations in the other councils are more due to guidelines and lists of recommended drugs. Professional autonomy and power were found to be important determinants for quality of care, and the physicians in Stockholm estimated the quality of care lower than their colleagues in the ten other councils. Thus, our study suggests that the performance-based reimbursement system might fail to reach the desired results due to its negative impact on professional power and autonomy.

Adult↗
PubMed2000

The impact of medicare funding on the use of mammography among older women: implications for improving access to screening.

BACKGROUND: In 1991, a policy change extended finan cial coverage for biennial mammography to holders of Medicare part B. The impact of this decision on mammography use was examined by comparing mammography use among Medicare-eligible and ineligible women in the years before (1990) and after (1993) the policy change, using National Health Interview Survey (NHIS) data, controlling for socioeconomic indicators and for having a usual source of medical care. METHODS: The Medicare-eligible group consists of 2,419 women ages 65-69 years and women ages 60-64 years who are Medicare-eligible. The Medicare-ineligible group consists of 1,872 women ages 60-64 years. The analysis used logistic regressions and compared women who had undergone mammography in the prior 2 years and controlled for race, ethnicity, socioeconomic status, insurance status, and usual source of care. RESULTS: Medicare reimbursement of mammography appears to have increased the number of Medicare-eligible women who had had a mammogram in the 2 years prior to the survey. However, the analyses suggested that disparities in mammography use due to access to primary care and socioeconomic status persisted after the change in Medicare coverage. Analyses indicated that having additional insurance was the only significant predictor of having a usual source of care among the Medicare population. CONCLUSIONS: This analysis suggests that simply removing financial barriers to mammography for older women (such as the 1998 elimination of a deductible payment for mammograms provided under Medicare) may have limited effectiveness. The strong relationship between having a usual source of care and mammography suggests that disparities in mammography use may reflect inequalities in access to health care in general.

Aged↗
PubMed1979

[Breast feeding money in Switzerland].

A mailed questionnaire was sent to all sickness-insurances on the subject of breast-feeding premium. 52% of the insurances replied, representing 90% of all insured persons. In 1976 23% of the mothers received the premium, in 1977 27%. This figure increased, as the membership of the insurances decreased. It is therefore thought, that mothers are not properly informed on this subject.

Adult↗
PubMed2002

[Influence of the reimbursement system on medical quality].

BACKGROUND: The relationship between reimbursement for medical care and the quality of medicine is mostly discussed if there are warnings about underuse as a consequence of underpayment. By various examples it can be illustrated that not only a lack of services but also an overuse of medical care may be hazardous and reduce quality in medicine. This relates to the risk, which is part of each medical intervention. PRESENT SITUATION: The introduction of the Diagnosis Related Groups (DRGs) in Germany is at present mostly discussed under the aspect of a possible risk of underuse. On the other hand, there are chances for the quality of medicine as a result from a lean diagnostic and therapy, which will be the consequence of economic changes induced by the DRGs. A guideline-oriented medicine will often avoid unnecessary procedures and thereby improve the quality of medical services. CONCLUSION: Loss of quality and improvement of quality arise in the field of medicine from overuse as well as from underuse. Most important for an optimal quality is a quantitatively appropriate treatment. In general, we observe that medical decisions are more and more oriented on economic frames. It has to be observed during forthcoming years to what extent ethical problems arise by this situation.

Germany↗
PubMed2003

[Remarks on the introduction of the German Diagnosis-Related Groups (DRGs) for the specialty of urology].

In January 2003 a new system to charge inpatient treatment was established in Germany: the G-DRGs. This system is based on the thought that equal medical service causes equal costs all over Germany. Hospitals offering a broad spectrum of diagnostics and therapies and being unable to select their patients according to economical aspects are put at disadvantage: Despite a perfect documentation the G-DRGs reflect their medical service only in an insufficient way. Tools for an optimized coding must be a coding manual created for the specific needs of urologists and an infrastructure that allows a permanent quality control for all persons involved.

Diagnosis-Related Groups↗
PubMed2006

Performance-based funding of supported employment for persons with severe mental illness: vocational rehabilitation and employment staff perspectives.

Vocational rehabilitation (VR) supervisors and counselors (n = 35) as well as supported employment (SE) program managers and employment specialists (n = 26) were enrolled in a 12-month evaluation comparing two models of funding services for persons with severe mental illness: fee-for-service and results-based funding (RBF). Quantitative measures of job satisfaction and preference for funding method were obtained prospectively on a quarterly basis, and SE staff activity logs were collected monthly. Qualitative data were collected using a series of focus groups conducted at the conclusion of the study. Despite recording a substantial increase in semi-annualized VR billing charges when using RBF (45-49%), SE staff expressed less satisfaction with RBF over time. Staff raised concerns about increased financial risks and pressures to achieve job placements under RBF. Vocational rehabilitation staff were consistently more satisfied with RBF, expressing particular satisfaction with perceived effectiveness and the payment authorization process. Both VR and SE staff expressed some reservations about RBF, primarily concerning possible pressures for adverse client selection.

Employment, Supported↗
PubMed1995

You are in charge of cost.

Shifts in medical reimbursement dictate that physicians become knowledgeable about resource consumption. Price drives cost. The patient is now a cost center. Various models of physician-hospital integration are presented. A completely integrated staff in the hospital has the greatest potential for economic efficiency. The best method of cost accounting will include activity-based costs in a format that is understandable for physician education. Hospital cost management involves human resources, ordering practices, length of stay, purchasing, capital requirements, and benchmark targets. As health reform takes shape, physicians should be fully cognizant of cost, understand healthcare issues, and commit to improving the environment in which they practice medicine. The purpose of these activities is to improve the value of healthcare delivery for all patients.

Accounting↗
PubMed1989

Hospital costs, cancer patients, and gynecology diagnostic related groups.

This study of 115 Medicare gynecology patients in five noncancer-designated gynecology diagnostic related groups (DRGs) demonstrated that patients with a diagnosis of a malignancy (N = 52) had significantly higher hospital resource utilization compared to patients without a malignancy (N = 63) in these gynecology DRGs. Cancer patients had higher total hospital costs (P less than 0.001), longer hospital length of stay (P less than 0.01), significant financial losses under DRGs (P less than 0.01), greater percentage of outliers (P less than 0.05), greater severity of illness, and greater mortality (P less than 0.001) compared to noncancer patients in these same gynecology DRGs. These findings raise the question of whether hospitals will be adequately reimbursed by DRGs for many gynecology cancer patients. Disincentives for hospitals to treat gynecology cancer patients under the current DRG reimbursement system may affect both the access to and the quality of care.

Aged↗
PubMed1990

Lag between discovery and production of new vaccines for the developing world.

Communicable diseases represent a considerable burden in terms of suffering and costs. The decision to develop a new vaccine varies with perspectives. The public health perspective is influenced largely by cost-benefit ratios; the community perspective by a strong desire to alleviate suffering and disability from disease and from vaccine side-effects; and that of vaccine producers by demand, technological feasibility of development, and anticipated return on investment. Each of these perspectives is important. However, they often are mutually exclusive. From a humanitarian and epidemiological perspective, the most urgent needs related to communicable diseases are those of the poorest countries; in the industrialised world, with the exception of the vaccine for the acquired immunodeficiency syndrome (AIDS), public health priorities, evaluated in terms of the cost-benefit ratio, often differ from those of the market, which usually selects its priorities according to return on investment. The six vaccines used in the Expanded Programme of Immunisation (EPI) are offered cheaply through a highly efficient bidding system. It would have to be extended, under the same form or differently, to other vaccines, such as those for rabies, hepatitis B, or japanese encephalitis. For vaccines that are being developed, such as conjugated polysaccharide or acellular pertussis vaccines, it is difficult to foresee how these expensive vaccines can be distributed. The situation is even worse for vaccines to be developed specifically for the third world. To make these vaccines available to everyone there must be technology that enables producers to sharply reduce production costs, and a subsidy for research and development and production.

Cost-Benefit Analysis↗
PubMed1995

Prediction of length of stay in an inpatient dual diagnosis unit.

The institution of prospective payment systems, in which flat fees are paid per discharge, raised the concern that hospitals might preferentially admit patients expected to have a short length of stay (LOS). This concern presupposes that intake workers could accurately predict psychiatric hospitalization LOS, but this does not appear to have been empirically demonstrated. Accordingly, we examined the ability of two psychiatrists heading separate treatment teams on an inpatient, dual-diagnosis unit and a program coordinator who worked with both teams to predict LOS for 94 patients consecutively admitted to one or the other of these teams. Predictions were highly consistent across the raters and were significantly correlated with actual LOS (r = 0.25, 0.35, and 0.45 for the three raters). However, we found that the psychiatrists were accurate predictors only for patients for whom they were the attending psychiatrist. The program coordinator, who was involved in the treatment of all patients, was an accurate predictor for the patients of either psychiatrist. We concluded that the relationships found between predicted and actual LOS held true only when the rater also influenced treatment management and discharge. Our results do not support the proposition that specialized intake workers independent of those providing care would be able to predict LOS accurately.

Adult↗
PubMed1990

A simple objective method for determining a percent standard in mixed reimbursement systems.

In a mixed system for hospital rate setting, reimbursement is set at the weighted average of provider-specific and standard unit costs. With one or more explanatory variables, forward and reverse regression is used to motivate the simple but objective choice of one minus the squared correlation coefficient as the proportion standard. Special treatment is given to nuisance variables that help explain cost but not reasonable cost. Efron's bootstrap provides confidence intervals for the proportion standard. This regression approach is contrasted with the conventional use of the coefficient of variation, and with economic models for the optimal proportion.

Costs and Cost Analysis↗
PubMed1992

Technological diffusion in primary health care.

The paper contains a theoretical and empirical analysis of the driving forces behind the diffusion of dry chemical laboratory equipment in Norwegian primary health care. The empirical analysis is embedded in a theoretical model of a dynamic investment problem focusing on heterogeneity in the potential adopters' profit functions. The empirical analysis indicates that most adopters are too late in adopting the new technology. A logit analysis of the diffusion process lends some support to the notion that profit function heterogeneity influences the diffusion process. An offspin of the empirical analysis is information on the reimbursement system, indicating that this system does not promote efficient resource allocation in the sector.

Autoanalysis↗
PubMed1986

Hospital financing in Belgium: recent changes and future options.

A new mode of financing hospital operating costs has been gradually introduced in Belgium since 1982. It is a 'prospective pricing' system. Each hospital is assigned a budget envelope at the beginning of the fiscal year. This budget is calculated on a per diem basis. A portion of the budget is variable in function of the number of patient days. The annual budget of each hospital is determined by comparing its performance with the one of a reference group of similar hospitals. Since the introduction of the new mode of financing the financial situation of the Belgian hospitals has improved markedly. Moreover, the hospital expenditures of the health insurance scheme are under control: in 1984 and 1985 these expenditures increased at a lower rate than inflation. The continued increase of other medical expenditures, however, indicates that the principles of this new financing system should be extended to the medico-technical departments.

Belgium↗