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Abiona O, Haywood P, Yu S, Hall J, Fiebig DG, van Gool K. Physician responses to insurance benefit restrictions: The case of ophthalmology. Health Econ 2024; 33:911-928. [PMID: 38251043 DOI: 10.1002/hec.4799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 10/04/2023] [Accepted: 01/01/2024] [Indexed: 01/23/2024]
Abstract
This study examines the impact of social insurance benefit restrictions on physician behaviour, using ophthalmologists as a case study. We examine whether ophthalmologists use their market power to alter their fees and rebates across services to compensate for potential policy-induced income losses. The results show that ophthalmologists substantially reduced their fees and rebates for services directly targeted by the benefit restriction compared to other medical specialists' fees and rebates. There is also some evidence that they increased their fees for services that were not targeted. High-fee charging ophthalmologists exhibited larger fee and rebate responses while the low-fee charging group raise their rebates to match the reference price provided by the policy environment.
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Affiliation(s)
- Olukorede Abiona
- Macquarie University Centre for the Health Economy (MUCHE), Macquarie University Business School (MQBS) and Australian Institute of Health Innovation (AIHI), Macquarie University, Sydney, New South Wales, Australia
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, New South Wales, Australia
| | - Phil Haywood
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, New South Wales, Australia
| | - Serena Yu
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jane Hall
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, New South Wales, Australia
| | - Denzil G Fiebig
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, New South Wales, Australia
- School of Economics, UNSW Business School, University of New South Wales, Sydney, New South Wales, Australia
| | - Kees van Gool
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, New South Wales, Australia
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Beckschulte K, Lederer AK, Storz MA. Long-term trends in international medical electives fees: a database mining study. BMC Med Educ 2024; 24:152. [PMID: 38374078 PMCID: PMC10875856 DOI: 10.1186/s12909-024-05123-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Abroad medical electives are recognized as high-impact practice and considered a necessity to provide global health training. As of recently, the COVID-19 pandemic and its related travel restrictions prohibited most international elective activities. Another important barrier to abroad electives that received comparably little attention is elective and application fees, which - combined - may be as high as $5000 per month, and may prevent students with limited financial resources from applying for an international elective. Elective fees have never been systematically analyzed and trends in teaching and application fees have rarely been subject to dedicated scientific investigations. METHODS Using data from two large elective reports databases, the authors addressed this gap in the literature. The authors analyzed trends in abroad elective fees within the last 15 years in some of the most popular Anglo-American elective destinations among students from Germany, including the United States of America, Australia, New Zealand, the Republic of South Africa, Ireland and the United Kingdom. RESULTS The authors identified n = 726 overseas elective reports that were uploaded between 2006 and 2020, of which n = 438 testimonies met the inclusion criteria. The United Kingdom and Australia were the most popular elective destinations (n = 123 and n = 113, respectively), followed by the Republic of South Africa (n = 104) and the United States of America (n = 44). Elective fees differed substantially-depending on the elective destinations and time point. Median elective fees were highest in the United States of America (€ 1875 for a 4-week elective between 2018-2020), followed by the Republic of South Africa (€ 400) and Australia (€ 378). The data also suggests an increasing trend for elective fees, particularly in the United States. CONCLUSIONS Rising fees warrant consideration and a discussion about the feasibility of reciprocity and the bidirectional flow of students in bidirectional exchange programs.
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Affiliation(s)
- Kai Beckschulte
- Department of Internal Medicine II, Centre for Complementary Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Ann-Kathrin Lederer
- Department of Internal Medicine II, Centre for Complementary Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
- Department of General, Visceral and Transplant Surgery, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Maximilian Andreas Storz
- Department of Internal Medicine II, Centre for Complementary Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
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Li D, Yang J, Li J, Zhao N, Ju W, Guo M. Agent-Based Modeling and Simulation (ABMS)on the influence of adjusting medical service fees on patients' choice of medical treatment. BMC Health Serv Res 2023; 23:928. [PMID: 37649036 PMCID: PMC10468860 DOI: 10.1186/s12913-023-09933-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 08/14/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND We explored the impact of medical service fee adjustments on the choice of medical treatment for hypertensive patients in Beijing. We hope to provide decision-making reference to promote the realization of hierarchical diagnosis and treatment in Beijing. METHODS According to the framework of modeling simulation research and based on the data of residents and medical institutions in Beijing, we designed three models of residents model, disease model and hospital model respectively. We then constructed a state map of patients' selection of medical treatment and adjusted the medical service fee to observe outpatient selection behaviors of hypertensive patients at different levels of hospitals and to find the optimal decision-making plan. RESULTS The simulation results show that the adjustment of medical service fees can affect the proportion of patients seeking medical treatment in primary and tertiary hospitals to a certain extent, but has little effect on the proportion of patients receiving medical treatment in secondary hospitals. CONCLUSIONS Beijing can make adjustments of the current medical service fees by reducing fees in primary hospitals and slightly increasing fees in tertiary hospitals, and in this way could increase the number of patients with hypertension in the primary hospitals.
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Affiliation(s)
- Danhui Li
- Office of Medical Affairs, Shaanxi Provincial People's Hospital, No. 256 Youyi West Road, Beilin District, Xi'an, 710068, Shaanxi, China
| | - Jia Yang
- School of Public Health, Capital Medical University, No. 10 Xitoutiao, You'anmen Wai, Fengtai District, Beijing, 100069, China.
| | - Jin Li
- School of Public Health, Capital Medical University, No. 10 Xitoutiao, You'anmen Wai, Fengtai District, Beijing, 100069, China
| | - Ning Zhao
- School of Public Health, Capital Medical University, No. 10 Xitoutiao, You'anmen Wai, Fengtai District, Beijing, 100069, China
| | - Wensheng Ju
- Beijing Municipal Health Big Data and Policy Research Center, No.277 Zhaodengyu Road, Beijing, 100034, China
| | - Moning Guo
- Beijing Municipal Health Big Data and Policy Research Center, No.277 Zhaodengyu Road, Beijing, 100034, China
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Zimmermann S. Learning from the German experience of user fees. BMJ 2023; 380:603. [PMID: 36940977 DOI: 10.1136/bmj.p603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
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Dickman SL, Himmelstein G, Himmelstein DU, Strandberg K, McGregor A, McCormick D, Woolhandler S. Uncovered Medical Bills after Sexual Assault. N Engl J Med 2022; 387:1043-1044. [PMID: 36103420 DOI: 10.1056/nejmc2207644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Rathi VK, Ross JS, Redberg RF, Dhruva SS. Medical Device User Fee Reauthorization - Back to Basics or Looking Ahead? N Engl J Med 2022; 387:196-199. [PMID: 35675195 DOI: 10.1056/nejmp2204947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Vinay K Rathi
- From the Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston (V.K.R.); the Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (J.S.R.); and the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco (R.F.R., S.S.D.)
| | - Joseph S Ross
- From the Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston (V.K.R.); the Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (J.S.R.); and the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco (R.F.R., S.S.D.)
| | - Rita F Redberg
- From the Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston (V.K.R.); the Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (J.S.R.); and the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco (R.F.R., S.S.D.)
| | - Sanket S Dhruva
- From the Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston (V.K.R.); the Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (J.S.R.); and the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco (R.F.R., S.S.D.)
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Affiliation(s)
- A Jay Holmgren
- School of Medicine, University of California, San Francisco
| | - David Cutler
- Department of Economics, Harvard University, Cambridge, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Rha J, Rathi VK, Naunheim MR, Miller LE, Gadkaree SK, Gray ST. Markup on Services Provided to Medicare Beneficiaries by Otolaryngologists in 2017: Implications for Surprise Billing. Otolaryngol Head Neck Surg 2021; 165:662-666. [PMID: 33620271 DOI: 10.1177/0194599821994826] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The degree of markup between provider charges and Medicare prices reflects the potential balance bill for out-of-network commercially insured patients. Using publicly available Medicare data, we performed a retrospective cross-sectional analysis of markup ratios (MRs; ie, the ratio of submitted charges to Medicare-allowed prices) for services commonly performed by otolaryngologists in 2017. Median MRs were as follows: 2.9 (interquartile range, 2.0-4.3) in facility settings (eg, hospital) and 2.1 (interquartile range, 1.7-2.9) in nonfacility settings (eg, physician office). Among the 10 highest-markup procedures performed by otolaryngologists in facility and nonfacility settings, there was no consistent increase in median MRs between 2012 and 2017 (compound annual growth rates, -4.6% for labyrinthotomy to 24.6% for ultrasound-guided biopsy). Median MRs for these procedures were not consistently lower in states with surprise billing protection laws. These findings may reflect the comparatively low potential to "balance bill" patients for elective otolaryngologic services and the limitations of state-level protections against surprise billing.
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Affiliation(s)
- Jacob Rha
- School of Medicine, Tufts University, Boston, Massachusetts, USA
| | - Vinay K Rathi
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | | | - Lauren E Miller
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | | | - Stacey T Gray
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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Kim HA, Jung SH, Park IY, Kang SH. Hourly wages of physicians within medical fees based on the Korean relative value unit system. Korean J Intern Med 2020; 35:1238-1244. [PMID: 31870135 PMCID: PMC7487311 DOI: 10.3904/kjim.2018.452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/15/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS It is difficult to reach a social agreement on the appropriate level of compensation for professionals. This study was performed to examine the physician fee embedded in the relative value unit (RVU) system in comparison with the Korean hourly minimum wage. METHODS The Health Insurance Service Price and the Korean Classification of Procedural Terminology were used to obtain the hourly wages of physicians for designated health care services. In addition, the physician fee schedule at the United States Centers for Medicare and Medicaid Services and the Organisation for Economic Co-operation and Development (OECD) report on minimal wage were used. Health care service fees were selected based on laboratory, pathology, imaging, and procedure codes as well as examination fees. For calculation of physician labor costs per hour, physician workload × conversion factor was divided by the time involved. To calculate the proportion of physician labor fee in the total fee, the physician workload RVU for each service fee was divided by the total RVU. RESULTS A total of 27 physician fee codes were selected. Compared to the Korean hourly minimum wage in 2015, the average physician wages were greater by 2.80- fold for primary care and by 3.05-fold for tertiary care. The mean proportion of physician labor cost in the total cost was 0.19, which was significantly lower than that of corresponding procedures in the United States RVU (mean, 0.48). CONCLUSION The average Korean physician wages compared to the hourly minimum wage were disproportionately low compared to the USA and other reference OECD countries.
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Affiliation(s)
- Hyun Ah Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
- Correspondence to Hyun Ah Kim, M.D. Division of Rheumatology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang 14068, Korea
Tel: +82-31-380-1826 Fax: +82-31-381-8812 E-mail:
| | - Sung Hoon Jung
- Department of Internal Medicine, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Young Park
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Seong Hun Kang
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
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Chhabra KR, Sheetz KH, Nuliyalu U, Dekhne MS, Ryan AM, Dimick JB. Out-of-Network Bills for Privately Insured Patients Undergoing Elective Surgery With In-Network Primary Surgeons and Facilities. JAMA 2020; 323:538-547. [PMID: 32044941 PMCID: PMC7042888 DOI: 10.1001/jama.2019.21463] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills ("surprise bills") from out-of-network clinicians they did not choose. In elective surgery, this can occur if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians. OBJECTIVE To evaluate out-of-network billing across common elective operations performed with in-network primary surgeons and facilities. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of claims data from a large US commercial insurer, representing 347 356 patients who had undergone 1 of 7 common elective operations (arthroscopic meniscal repair [116 749]; laparoscopic cholecystectomy [82 372]; hysterectomy [67 452]; total knee replacement [42 313]; breast lumpectomy [18 018]; colectomy [14 074]; coronary artery bypass graft surgery [6378]) by an in-network primary surgeon at an in-network facility between January 1, 2012, and September 30, 2017. Follow-up ended November 8, 2017. EXPOSURE Patient, clinician, and insurance factors potentially related to out-of-network bills. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of episodes with out-of-network bills. The secondary outcome was the estimated potential balance bill associated with out-of-network bills from each surgical procedure, calculated as total out-of-network charges less the typical in-network price for the same service. RESULTS Among 347 356 patients (mean age, 48 [SD, 11] years; 66% women) who underwent surgery with in-network primary surgeons and facilities, 20.5% of episodes (95% CI, 19.4%-21.7%) had an out-of-network bill. In these episodes, the mean potential balance bill per episode was $2011 (95% CI, $1866-$2157) when present. Out-of-network bills were associated with surgical assistants in 37% of these episodes; when present, the mean potential balance bill was $3633 (95% CI, $3384-$3883). Out-of-network bills were associated with anesthesiologists in 37% of episodes; when present, the mean potential balance bill was $1219 (95% CI, $1049-$1388). Membership in health insurance exchange plans, compared with nonexchange plans, was associated with a significantly higher risk of out-of-network bills (27% vs 20%, respectively; risk difference, 6% [95% CI, 3.9%-8.9%]; P < .001). Surgical complications were associated with a significantly higher risk of out-of-network bills, compared with episodes with no complications (28% vs 20%, respectively; risk difference, 7% [95% CI, 5.8%-8.8%]; P < .001). Among 83 021 procedures performed at ambulatory surgery centers with in-network primary surgeons, 6.7% (95% CI, 5.8%-7.7%) included an out-of-network facility bill and 17.2% (95% CI, 15.7%-18.8%) included an out-of-network professional bill. CONCLUSIONS AND RELEVANCE In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities with in-network primary surgeons, a substantial proportion of operations were associated with out-of-network bills.
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Affiliation(s)
- Karan R. Chhabra
- National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Kyle H. Sheetz
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, University of Michigan, Ann Arbor
| | - Ushapoorna Nuliyalu
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | | | - Andrew M. Ryan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
- Center for Evaluating Health Reform, University of Michigan, Ann Arbor
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, University of Michigan, Ann Arbor
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Affiliation(s)
- Simon C Mathews
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Abstract
BACKGROUND In Canada, family physicians are permitted to charge patient fees for administrative services that are not covered by the public health insurance program, such as prescription renewals outside of an office visit, and completion of forms and sick notes. The objective of this study was to estimate the proportion of Ontario family physicians who offer various fee structures (i.e., à la carte, annual block fees for all uninsured services rendered or no charge) for uninsured administrative services. METHODS This was a cross-sectional telephone survey conducted from April to July 2019 of a random sample of family physicians licensed to practise in Ontario. We excluded physicians with missing contact information or additional specialties, or whose primary practice was outside of Ontario, with a walk-in clinic, with an emergency department, or with an organization that cared for a specific population (e.g., nursing home) or did not provide care (e.g., insurance company). We categorized the geographic location of practices as large urban centre (population > 100 000), small to medium centre (population 1000-99 999) or rural area. We calculated survey weights to account for nonresponse and to ensure representativeness of the sample by geographic area and payment model. RESULTS Among the 221 physicians who met the inclusion criteria, the telephone was not answered at 42 practices, and the contact information was incorrect for 13, resulting in a sample of 166 physicians (response rate 75.1%). The majority of practices reported that they charged fees for uninsured services: 97 (58.3%, 95% confidence interval [CI] 50.6-65.8) charged à la carte, and 33 (20.3%, 95% CI 14.8-27.3) offered patients the option to pay an annual block fee; 19 (11.4%, 95% CI 7.4-17.3) charged no fees. Fee structures varied by geographic area but not physician payment model. INTERPRETATION The use of à la carte and annual block fees for uninsured administrative services was commonly reported by a sample of Ontario family physicians. Further research is needed to examine the prevalence of patient payment of fees for uninsured services, patient and physician perceptions of fees, and concordance with regulatory guidance.
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Affiliation(s)
- Jamie R Daw
- Department of Health Policy and Management (Daw, Rice), Columbia University Mailman School of Public Health, New York, NY; Department of Family and Community Medicine (Raza), Faculty of Medicine, University of Toronto; Department of Family and Community Medicine (Raza), St. Michael's Hospital, Toronto, Ont.
| | - Kaitlyn E Rice
- Department of Health Policy and Management (Daw, Rice), Columbia University Mailman School of Public Health, New York, NY; Department of Family and Community Medicine (Raza), Faculty of Medicine, University of Toronto; Department of Family and Community Medicine (Raza), St. Michael's Hospital, Toronto, Ont
| | - Danyaal Raza
- Department of Health Policy and Management (Daw, Rice), Columbia University Mailman School of Public Health, New York, NY; Department of Family and Community Medicine (Raza), Faculty of Medicine, University of Toronto; Department of Family and Community Medicine (Raza), St. Michael's Hospital, Toronto, Ont
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Affiliation(s)
- Maja Hempel
- *Institut für Humangenetik Universitätsklinikum Hamburg-Eppendorf, Germany
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Mochizuki Y, Takeuchi C, Osako M, Minatogawa M, Shibata N. [Investigation of transition from pediatric to adult health care for patients with special health-care needs for neurological disease dating from childhood]. Rinsho Shinkeigaku 2019; 59:279-281. [PMID: 31061300 DOI: 10.5692/clinicalneurol.cn-001242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
We investigated the patients followed in our hospital's adult neurology department to evaluate issues during the transition from pediatric to adult health care for patients with special health-care needs for neurological diseases. There has been an increase in the number of transition patients, and they were often recommended for the transition by pediatricians. Many patients had complications such as epilepsy, and there were also patients with an intractable disease. Therefore, patients undergoing this transition need neurologists. The transition requires a long time, and there is a difference in the medical administrative fees between pediatric and adult health care. The Japanese Society of Neurology and related societies need to take measures to improve these health-care transitions.
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Affiliation(s)
- Yoko Mochizuki
- Department of Neurology, Tokyo Metropolitan Kita Medical and Rehabilitation Center for the Disabled
| | - Chisen Takeuchi
- Department of Neurology, Tokyo Metropolitan Kita Medical and Rehabilitation Center for the Disabled
| | - Miho Osako
- Department of Neurology, Tokyo Metropolitan Kita Medical and Rehabilitation Center for the Disabled
| | - Mitsuko Minatogawa
- Department of Neurology, Tokyo Metropolitan Kita Medical and Rehabilitation Center for the Disabled
| | - Naomi Shibata
- Department of Neurology, Tokyo Metropolitan Kita Medical and Rehabilitation Center for the Disabled
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Renggli S, Mayumana I, Mshana C, Mboya D, Kessy F, Tediosi F, Pfeiffer C, Aerts A, Lengeler C. Looking at the bigger picture: how the wider health financing context affects the implementation of the Tanzanian Community Health Funds. Health Policy Plan 2019; 34:12-23. [PMID: 30689879 PMCID: PMC6479827 DOI: 10.1093/heapol/czy091] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2018] [Indexed: 11/14/2022] Open
Abstract
In Tanzania, the health financing system is extremely fragmented with strategies in place to supplement funds provided from the central level. One of these strategies is the Community Health Fund (CHF), a voluntary health insurance scheme for the informal rural sector. As its implementation has been challenging, we investigated different CHF implementation practices and how these practices and the wider health financing context affect CHF implementation and potentially enrolment. Two councils were purposively selected for this study. Routine data relevant for understanding CHF implementation in the wider health financing context were collected at council and public health facility level. Additionally, an economic costing approach was used to estimate CHF administration cost and analyse its financing sources. Our results showed the importance of considering different CHF implementation practices and the wider health financing context when looking at CHF performance. Exemption policies and healthcare-seeking behaviour influenced negatively the maximum potential enrolment rate of the voluntary CHF scheme. Higher revenues from user fees, user fee policies and fund pooling mechanisms might have furthermore set incentives for care providers to prioritize user fees over CHF revenues. Costing results clearly pointed out the lack of financial sustainability of the CHF. The financial analysis however also showed that thanks to significant contributions from other health financing mechanisms to CHF administration, the CHF could be left with more than 70% of its revenues for financing services. To make the CHF work, major improvements in CHF implementation practices would be needed, but given the wider health financing context and healthcare-seeking behaviours, it is questionable whether such improvements are feasible, scalable and value for money. Thus, our results call for a reconsideration of approaches taken to address the challenges in health financing and demonstrate that the CHF cannot be looked at as a stand-alone system.
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Affiliation(s)
- Sabine Renggli
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, Basel, Switzerland
- University of Basel, Petersplatz 1, Basel, Switzerland
| | - Iddy Mayumana
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, Dar es Salaam, Tanzania, and
| | - Christopher Mshana
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, Dar es Salaam, Tanzania, and
| | - Dominick Mboya
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, Dar es Salaam, Tanzania, and
| | - Flora Kessy
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, Dar es Salaam, Tanzania, and
| | - Fabrizio Tediosi
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, Basel, Switzerland
- University of Basel, Petersplatz 1, Basel, Switzerland
| | - Constanze Pfeiffer
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, Basel, Switzerland
- University of Basel, Petersplatz 1, Basel, Switzerland
| | - Ann Aerts
- Novartis Foundation, Basel, Switzerland
| | - Christian Lengeler
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, Basel, Switzerland
- University of Basel, Petersplatz 1, Basel, Switzerland
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Ganle JK, Mahama MS, Maya E, Manu A, Torpey K, Adanu R. Understanding factors influencing home delivery in the context of user-fee abolition in Northern Ghana: Evidence from 2014 DHS. Int J Health Plann Manage 2019; 34:727-743. [PMID: 30657200 DOI: 10.1002/hpm.2731] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 12/19/2018] [Indexed: 11/07/2022] Open
Abstract
User-fee exemption for skilled delivery services has been implemented in Ghana since 2003 as a way to address financial barriers to access. However, many women still deliver at home. Based on data from the 2014 Ghana Demographic and Health Survey, we estimated the prevalence of home delivery and determined the factors contributing to homebirths among a total of 622 women in the Northern region in the context of the user-fee exemption policy in Ghana. Binary and multivariate logistic regression analyses were employed. Results suggest home delivery prevalence of 59% (365/622). Traditional birth attendants attended majority of home deliveries (93.4%). After adjusting for potential confounders, making less than four antenatal care visits (aOR = 2.42; CI = 1.91-6.45; p = 0.001), being a practitioner of traditional African religion (aOR = 16.40; CI = 3.10-25.40; p = 0.000), being a Muslim (aOR 2.10; CI = 1.46-5.30; p = 0.042), not having a health insurance (aOR = 1.85; CI = 1.773-4.72; p = 0.016), living in a male-headed household (aOR = 2.07; CI = 1.02-4.53; p < 0.01), and being unexposed to media (aOR = 3.10; CI = 1.12-5.38; p = 0.021) significantly predicted home delivery. Our results suggest that unless interventions are implemented to address other health system factors like insurance coverage, and socio-cultural and religious beliefs that hinder uptake of skilled care, the full benefits of user-fee exemption may not be realized in Ghana.
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Affiliation(s)
- John Kuumuori Ganle
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana
| | - Musah Salifu Mahama
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana
| | - Ernest Maya
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana
| | - Abubakar Manu
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana
| | - Kwasi Torpey
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana
| | - Richard Adanu
- Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana
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Abstract
Organized medicine long yearned for the demise of Medicare's Sustainable Growth Rate (SGR) formula for updating physician fees. Congress finally obliged in 2015, repealing the SGR as part of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA established value-based metrics for physician payment and financial incentives for doctors to join alternative delivery models like patient-centered medical homes. Throughout the law's initial implementation, the politics of accommodation prevailed, with federal officials crafting final rules that made MACRA more favorable for physicians. However, the era of accommodation could be short-lived. The discretion that the Centers for Medicare and Medicaid Services had during the first two years of implementation is ending. Additionally, euphoria over the SGR's repeal has given way to concerns over the new program's value-based purchasing arrangements and uncertainty over their sustainability. MACRA eliminated the SGR, but not the politics of physician payment.
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Policy on Third-Party Reimbursement of Medical Fees Related to Sedation/General Anesthesia for Delivery of Oral Health Care Services. Pediatr Dent 2018; 40:117-9. [PMID: 32074871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Whaley CM, Brown TT. Firm responses to targeted consumer incentives: Evidence from reference pricing for surgical services. J Health Econ 2018; 61:111-133. [PMID: 30114564 PMCID: PMC10830325 DOI: 10.1016/j.jhealeco.2018.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 06/25/2018] [Accepted: 06/27/2018] [Indexed: 06/08/2023]
Abstract
This paper examines how health care providers respond to a reference pricing insurance program that increases consumer cost sharing when consumers choose high-priced surgical providers. We use geographic variation in the population covered by the program to estimate supply-side responses. We find limited evidence of market segmentation and price reductions for providers with baseline prices above the reference price. Finally, approximately 75% of the reduction in provider prices is in the form of a positive externality that benefits a population not subject to the program.
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Affiliation(s)
- Christopher M Whaley
- RAND Corporation, United States; School of Public Health, University of California, Berkeley, United States.
| | - Timothy T Brown
- School of Public Health, University of California, Berkeley, United States.
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Chan MK, Zeng G. Unintended consequences of supply-side cost control? Evidence from China's new cooperative medical scheme. J Health Econ 2018; 61:27-46. [PMID: 30053710 DOI: 10.1016/j.jhealeco.2018.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 03/31/2018] [Accepted: 06/13/2018] [Indexed: 06/08/2023]
Abstract
We examine the effects of a "per-episode fee limit" that was recently implemented as a cost-control policy in China's health care system. Using hospital administrative data on a rural public health insurance program in China, we find that hospital departments dynamically adjust episode fees in response to the level of stress under fee limits. We also document anomalous cycles in the fees and length of stay of discharged episodes, which are consistent with the dynamically optimizing behavior to comply with the fee limit. We find qualitatively similar results in administrative data from an urban public health insurance program.
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Affiliation(s)
- Marc K Chan
- Faculty of Business and Economics, University of Melbourne, Parkville, VIC 3010, Australia.
| | - Guohua Zeng
- School of Economics and Management, Jiangxi University of Science and Technology, China.
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Frakt AB, Chernew ME. Price Setting for Physician Services-Reply. JAMA 2018; 319:2558-2559. [PMID: 29946719 DOI: 10.1001/jama.2018.4669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Austin B Frakt
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Al Achkar M, Kengeri-Srikantiah S, Yamane BM, Villasmil J, Busha ME, Gebke KB. Billing by residents and attending physicians in family medicine: the effects of the provider, patient, and visit factors. BMC Med Educ 2018; 18:136. [PMID: 29895287 PMCID: PMC5998502 DOI: 10.1186/s12909-018-1246-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 05/31/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Medical billing and coding are critical components of residency programs since they determine the revenues and vitality of residencies. It has been suggested that residents are less likely to bill higher evaluation and management (E/M) codes compared with attending physicians. The purpose of this study is to assess the variation in billing patterns between residents and attending physicians, considering provider, patient, and visit characteristics. METHOD A retrospective cohort study of all established outpatient visits at a family medicine residency clinic over a 5-year period was performed. We employed the logistic regression methodology to identify residents' and attending physicians' variations in coding E/M service levels. We also employed Poisson regression to test the sensitivity of our result. RESULTS Between January 5, 2009 and September 25, 2015, 98,601 visits to 116 residents and 18 attending physicians were reviewed. After adjusting for provider, patient, and visit characteristics, residents billed higher E/M codes less often compared with attending physicians for comparable visits. In comparison with attending physicians, the odds ratios for billing higher E/M codes were 0.58 (p = 0.01), 0.56 (p = 0.01), and 0.63 (p = 0.01) for the third, second, and first years of postgraduate training, respectively. In addition to the main factors of patient age, medical conditions, and number of addressed problems, the gender of the provider was also implicated in the billing variations. CONCLUSION Residents are less likely to bill higher E/M codes than attending physicians are for similar visits. While these variations are known to contribute to lost revenues, further studies are required to explore their effect on patient care in relation to attendings' direct involvement in higher E/M-coded versus their indirect involvement in lower E/M-coded visits.
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Affiliation(s)
- Morhaf Al Achkar
- Department of Family Medicine, University of Washington, 314 NE Thornton Place, Seattle, WA 98125 USA
| | - Seema Kengeri-Srikantiah
- Department of Family Medicine, Indiana University, 1110 W Michigan St #200, Indianapolis, IN 46202 USA
| | - Biniyam M. Yamane
- Department of Economics, Indiana University, 100 S Woodlawn Ave, Bloomington, IN 47405 USA
| | - Jomil Villasmil
- Department of Family Medicine, Indiana University, 1110 W Michigan St #200, Indianapolis, IN 46202 USA
| | - Michael E. Busha
- Western Michigan University Homer Stryker MD School of Medicine, 300 Portage Street, Kalamazoo, MI 49007 USA
| | - Kevin B. Gebke
- Department of Family Medicine, Indiana University, 1110 W Michigan St #200, Indianapolis, IN 46202 USA
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Abstract
OBJECTIVES The organized population-based screening programme for abdominal aortic aneurysm in Stockholm, Sweden, started in 2010. An examination fee was initially charged, but later removed because of a policy change. We examined the effect on screening attendance of removing the fee. METHODS The periods before and after removing the examination fee were compared with regard to screening attendance, overall, by municipality and by district. RESULTS Screening attendance was 79.2% in the period with an examination fee and 79.9% in the period without an examination fee (p = 0.1787), with no significant change in screening attendance between the periods. CONCLUSIONS Although removing examination fees has been shown to have a positive impact on attendance in other screening programmes, we did not find this association in our study.
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Affiliation(s)
- Anneli Linné
- 1 Department of Surgery, Södersjukhuset, Stockholm, Sweden
- 2 Department of Clinical Science and Education, Karolinska Institutet at Södersjukhuset, Stockholm, Sweden
| | - Rebecka Hultgren
- 3 Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
- 4 Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Daniel Öhman
- 5 Regional Cancer Centre Stockholm Gotland, Stockholm, Sweden
| | - Sven Törnberg
- 5 Regional Cancer Centre Stockholm Gotland, Stockholm, Sweden
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Burke LG, Wild RC, Orav EJ, Hsia RY. Are trends in billing for high-intensity emergency care explained by changes in services provided in the emergency department? An observational study among US Medicare beneficiaries. BMJ Open 2018; 8:e019357. [PMID: 29382680 PMCID: PMC5829666 DOI: 10.1136/bmjopen-2017-019357] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE There has been concern that an increase in billing for high-intensity emergency care is due to changes in coding practices facilitated by electronic health records. We sought to characterise the trends in billing for high-intensity emergency care among Medicare beneficiaries and to examine the degree to which trends in high-intensity billing are explained by changes in patient characteristics and services provided in the emergency department (ED). DESIGN, SETTING AND PARTICIPANTS Observational study using traditional Medicare claims to identify ED visits at non-federal acute care hospitals for elderly beneficiaries in 2006, 2009 and 2012. OUTCOMES MEASURES Billing intensity was defined by emergency physician evaluation and management (E&M) codes. We tested for overall trends in high-intensity billing (E&M codes 99285, 99291 and 99292) and in services provided over time using linear regression models, adjusting for patient characteristics. Additionally, we tested for time trends in rates of admission to the hospital and to the intensive care unit (ICU). Next, we classified outpatient visits into 39 diagnosis categories and analysed the change in proportion of high-intensity visits versus the change in number of services. Finally, we quantified the extent to which trends in high-intensity billing are explained by changes in patient demographics and services provided in the ED using multivariable modelling. RESULTS High-intensity visits grew from 45.8% of 671 103 visits in 2006 to 57.8% of 629 010 visits in 2012 (2.0% absolute increase per year; 95% CI 1.97% to 2.03%) as did the mean number of services provided for admitted (1.28 to 1.41; +0.02 increase in procedures per year; 95% CI 0.018 to 0.021) and discharged ED patients (7.1 to 8.6; +0.25 increase in services per year; 95% CI 0.245 to 0.255). There was a reduction in hospital admission rate from 40.1% to 35.9% (-0.68% per year; 95% CI -0.71% to -0.65%; P<0.001), while the ICU rate of admission rose from 11.7% to 12.3% (+0.11% per year; 95% CI 0.09% to 0.12%; P<0.001). When we stratified by diagnosis category, there was a moderate correlation between change in visits billed as high intensity and the change in mean number of services provided per visit (r=0.38; 95% CI 0.07 to 0.63). Trends in patient characteristics and services provided accounted moderately for the trend in practice intensity for outpatient visits (pseudo R2 of 0.47) but very little for inpatient visits (0.051) and visits overall (0.148). CONCLUSIONS Increases in services provided in the ED moderately account for the trends in billing for high-intensity emergency care for outpatient visits.
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Affiliation(s)
- Laura G Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Cambridge, Massachusetts, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, 02115
| | - Robert C Wild
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - E John Orav
- Department of Biostatistics, Harvard T H Chan School of Public Health, Cambridge, Massachusetts, USA
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
- Philip R Lee Institute of Health Policy Studies, University of California San Francisco, San Francisco, California, USA
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Buret L, Duchesnes C, Giet D. [Clinical integration programs for complex situations: Functional support and normative challenge]. Presse Med 2017; 46:1113-1114. [PMID: 28919270 DOI: 10.1016/j.lpm.2017.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 06/14/2017] [Accepted: 08/02/2017] [Indexed: 11/19/2022] Open
Affiliation(s)
- Laetitia Buret
- Université de Liège, faculté de médecine, département de médecine générale, avenue Hippocrate, 13, bâtiment B23, 4000 Liège, Belgique.
| | - Christiane Duchesnes
- Université de Liège, faculté de médecine, département de médecine générale, avenue Hippocrate, 13, bâtiment B23, 4000 Liège, Belgique
| | - Didier Giet
- Université de Liège, faculté de médecine, département de médecine générale, avenue Hippocrate, 13, bâtiment B23, 4000 Liège, Belgique
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Abstract
Japan's universal healthcare system is relatively inexpensive, provides accessible services, and was established nearly 10 years before Canada's. Two aspects of Japan's system are particularly interesting. The first is that there is active competition for patients between a variety of hospital providers, which can be privately or publicly owned. This competition is based on service quality because prices are set centrally. The second feature is that these prices are adjusted biannually by a National Council, the Chuikyo, that includes payers (employers), providers, and third-party experts in public negotiations. This process improves transparency, reduces political stakes, and allows for appropriate fee adjustments. Recent movements in Canada toward more activity-based funding and greater management accountability are developing the capabilities of healthcare executives to embrace these ideas, if introduced in Canada. The increased autonomy afforded to providers will empower their leaders to make strategic decisions to improve the quality and efficiency of healthcare services.
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Affiliation(s)
| | - Ken Kato
- 2 Fujita Health University, Toyoake, Aichi Prefecture, Japan
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Affiliation(s)
- Jay Bhatia
- The Keck School of Medicine, University of Southern California, Los Angeles
| | | | - Michael Hochman
- Gehr Family Center for Implementation Science, Keck School of Medicine, University of Southern California, Los Angeles
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Payette MJ. The Unsustainable Cost of Medicaid: Insights from a Hospital-Based Academic Dermatology Practice. Conn Med 2017; 81:267-269. [PMID: 29738127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate the lost revenue associated with Medicaid patients in a university-based dermatology practice over a one-year period compared to non-Medicaid patients. Specifically, the goal was to investigate the change in revenue if Medicaid visits were associated with a range of copayments. RESULTS The total billed across all encounters for the 2014 -2015 fiscal year was $31017159, of which $3715393 (13.61%) was for Medicaid. 'he total revenue for all encounters was $12267832, of which $420230 (3.55%) was for Medicaid. After adding potential copayments, the reduced financial impact that such fees would have had on our practice for the past fiscal year ranged from $745.85 at $0.05/visit to $149170 at $10/visit. CONCLUSION Adding a small copaymentforMedicaid patients would decrease lost revenue. The degree of financial impact would vary based on the size of the copayment. Broad adoption of such a plan could significantly help hospitals reduce lost revenue.
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Johar M, Mu C, Van Gool K, Wong CY. Bleeding Hearts, Profiteers, or Both: Specialist Physician Fees in an Unregulated Market. Health Econ 2017; 26:528-535. [PMID: 26913491 DOI: 10.1002/hec.3317] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Revised: 10/23/2015] [Accepted: 12/13/2015] [Indexed: 06/05/2023]
Abstract
This study shows that, in an unregulated fee-setting environment, specialist physicians practise price discrimination on the basis of their patients' income status. Our results are consistent with profit maximisation behaviour by specialists. These findings are based on a large population survey that is linked to administrative medical claims records. We find that, for an initial consultation, specialist physicians charge their high-income patients AU$26 more than their low-income patients. While this gap equates to a 19% lower fees for the poorest patients (bottom 25% of the household income distribution), it is unlikely to remove the substantial financial barriers they face in accessing specialist care. There are large variations across specialties, with neurologists exhibiting the largest fee gap between the high-income and low-income patients. Several possible channels for deducing the patient's income are examined. We find that patient characteristics such as age, health concession card status and private health insurance status are all used by specialists as proxies for income status. These characteristics are particularly important to further practise price discrimination among the low-income patients but are less relevant for the high-income patients. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Meliyanni Johar
- Economics Discipline Group, University of Technology Sydney, Sydney, NSW, Australia
| | - Chunzhou Mu
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, NSW, Australia
| | - Kees Van Gool
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, NSW, Australia
| | - Chun Yee Wong
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, NSW, Australia
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Affiliation(s)
- Ge Bai
- Johns Hopkins Carey Business School, Baltimore, Maryland
| | - Gerard F Anderson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Abstract
In the Australian Medicare system, general practitioners (GPs) are paid on a fee-for-service basis. A practitioner can choose to bill the government directly (termed bulk billing) and receive 85% of a regulated fee as full payment. Bulk billed consultations are free to the patient. However, GPs are free to charge above the regulated fee. The patient can then claim a rebate from the government but only the equivalent of 85% of the regulated Medicare fee. Such co-payments for GP consultations cannot be covered by private health insurance. In the ten years following the introduction of Medicare in 1984, the bulk billing rate for GP consultations steadily increased to 84%. Since then the rate has fallen to below 68%. In April 2003 the Minister for Health announced a reform package under the title A Fairer Medicare which aimed, among other things, to increase the availability of bulk billing for some patients. A key feature of the proposal involved changes to the way that GPs are reimbursed. Following political opposition that would have prevented it passing both houses of the federal parliament, a revised version, MedicarePlus, was released in November 2003. This paper describes the factors influencing a GP's choice to bulk bill and examines the two proposals, in this context.
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Kondo S, Kondo Y, Fuse M. [Revision of Medical Fee System for Treatment at Nursing Homes - The Influential Consideration of the Introduction of One-Patient-Per-Visit Method on the Welfare of Elderly Patients at Nursing Homes]. Gan To Kagaku Ryoho 2016; 43:69-70. [PMID: 28028284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The 2014 revision of the medical fee system includes the introduction of a one-patient-per-visit method at nursing homes, which should be followed to avoid a drastic reduction in medical fees. We followed the new method, resulting in much more frequent visits to nursing homes(For example, we visit a facilitythree times per week instead of the previous two times per month). Frequent visits to multiple facilities are time- and effort-consuming on our side as a clinic, but, on the other hand, patients have more opportunities to see a doctor when theyare sick even if theyare not scheduled to do so. In this study, we examined how the new method affects the welfare of elderlypatients at nursing homes.
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Affiliation(s)
- Seiji Kondo
- Medical Corporation Seijyu Kai, Sakura Home Clinic
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Adams EK, Bronstein JM, Florence CS. The Impact of Medicaid Primary Care Case Management on Office-Based Physician Supply in Alabama and Georgia. INQUIRY 2016; 40:269-82. [PMID: 14680259 DOI: 10.5034/inquiryjrnl_40.3.269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The success of the “primary care case management (PCCM)” form of managed care implemented in many state Medicaid programs over the past several years depends in part on the expanded availability of primary care physician sites to substitute for hospital-based outpatient care and to provide a medical home for enrollees. However, the PCCM requirement for physicians to accept assignment of a caseload of patients and to provide all of their primary care likely conflicts with the approach of limited Medicaid participation favored by many Medicaid physician participants. This study examines the early impact of PCCM implementation, in the absence of physician reimbursement level increases, on the patterns of Medicaid participation by physicians in communities in Georgia and Alabama. We find that the implementation of PCCM under these conditions often was associated with reductions in the proportion of physicians participating in Medicaid, reductions in the number of very small Medicaid practices, and declines in Medicaid visit volumes across all participating physicians. We also find evidence of an overall reduction in the number of primary care visits per Medicaid enrollee, but an increase in the proportion of these visits that were for preventive care services associated with initial PCCM implementation.
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Kyanko KA, Busch SH. Patients' success in negotiating out-of-network bills. Am J Manag Care 2016; 22:647-652. [PMID: 28557516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Out-of-network (OON) care is one area where patients might be more likely to challenge their healthcare bills due to the high out-of-pocket costs and unexpected charges related to emergency care or hospital-affiliated providers. We aimed to determine whether, and under what circumstances, patients negotiate with either insurers or providers when services are billed OON and how often patients that do engage in negotiation are successful. STUDY DESIGN Internet-based survey. METHODS We conducted a 2011 Internet survey on OON care on a nationally representative sample of privately insured adults (n = 721). We considered whether patients would be more likely to negotiate OON charges by demographic characteristics and under several scenarios: emergency visits, bills from hospital-affiliated OON providers at in-network hospitals, and balance bills. RESULTS We found patients negotiated 19% of OON bills, were successful in lowering their costs 56% of the time, and were more likely to be successful negotiating with providers compared with insurers (63% vs 37%; P <.01). Men were more likely than women to be successful in lowering their costs (76% vs 50%; P <.05). OON bills for emergencies, providers at in-network hospitals, and with a balance bill were more likely to be negotiated, although bills from providers at in-network hospitals and with balance bills were less likely to be successfully negotiated. CONCLUSIONS Patients had low rates of success in negotiating OON bills for emergency care and for OON providers at in-network hospitals. Policy makers aiming to protect patients under these scenarios should consider policies that allow for an easily accessible, formal, and unbiased mediation process.
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Affiliation(s)
- Kelly A Kyanko
- Department of Population Health, New York University School of Medicine, 550 1st Ave, TRB 6th Fl, Rm 646, New York, NY 10016. E-mail:
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Dormont B, Péron M. Does Health Insurance Encourage the Rise in Medical Prices? A Test on Balance Billing in France. Health Econ 2016; 25:1073-1089. [PMID: 27160420 DOI: 10.1002/hec.3347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 03/02/2016] [Accepted: 03/08/2016] [Indexed: 06/05/2023]
Abstract
We evaluate the causal impact of an improvement in insurance coverage on patients' decisions to consult physicians who charge more than the regulated fee. We use a French panel data set of 43,111 individuals observed from 2010 to 2012. At the beginning of the period, none of them were covered for balance billing; by the end, 3819 had switched to supplementary insurance contracts that cover balance billing. Using instrumental variables to deal with possible non-exogeneity of the decision to switch, we find evidence that better coverage increases demand for specialists who charge high fees, thereby contributing to the rise in medical prices. People whose coverage improves increased their average amount of balance billing per consultation by 32%. However, the impact of the coverage shock depends on the supply of physicians. For people residing in areas where few specialists charge the regulated fee, better coverage increases not only prices but also the number of consultations, a finding that suggests that balance billing might limit access to care. Conversely, in areas where patients have a genuine choice between specialists who balance bill and those who do not, we find no evidence of a response to better coverage. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Brigitte Dormont
- Université Paris-Dauphine, PSL Research University, LEDa, [LEGOS], Paris, 75016, France
| | - Mathilde Péron
- Université Paris-Dauphine, PSL Research University, LEDa, [LEGOS], Paris, 75016, France
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Flink IJ, Ziebe R, Vagaï D, van de Looij F, van 't Riet H, Houweling TA. Targeting the poorest in a performance-based financing programme in northern Cameroon. Health Policy Plan 2016; 31:767-76. [PMID: 26888360 PMCID: PMC4916320 DOI: 10.1093/heapol/czv130] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2015] [Indexed: 11/14/2022] Open
Abstract
Performance-Based Financing (PBF) is a promising approach to improve health system performance in developing countries, but there are concerns that it may inadequately address inequalities in access to care. Incentives for reaching the poor may prove beneficial, but evidence remains limited. We evaluated a system of targeting the poorest of society ('indigents') in a PBF programme in Cameroon, examining (under)coverage, leakage and perceived positive and negative effects. We conducted a documentation review, 59 key informant interviews and 33 focus group discussions with community members (poor and vulnerable people-registered as indigents and those not registered as such). We found that community health workers were able to identify very poor and vulnerable people with a minimal chance of leakage to non-poor people. Nevertheless, the targeting system only reached a tiny proportion (≤1%) of the catchment population, and other poor and vulnerable people were missed. Low a priori set objectives and implementation problems-including a focus on easily identifiable groups (elderly, orphans), unclarity about pre-defined criteria, lack of transport for identification and insufficient motivation of community health workers-are likely to explain the low coverage. Registered indigents perceived improvements in access, quality and promptness of care, and improvements in economic status and less financial worries. However, lack of transport and insufficient knowledge about the targeting benefits, remained barriers for health care use. Negative effects of the system as experienced by indigents included negative reactions (e.g. jealousy) of community members. In conclusion, a system of targeting the poorest of society in PBF programmes may help reduce inequalities in health care use, but only when design and implementation problems leading to substantial under-coverage are addressed. Furthermore, remaining barriers to health care use (e.g. transport) and negative reactions of other community members towards indigents deserve attention.
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Affiliation(s)
- Ilse Je Flink
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands,
| | - Roland Ziebe
- The Higher Institute of the Sahel, the University of Maroua, Maroua, Cameroon and
| | - Djebba Vagaï
- The Higher Institute of the Sahel, the University of Maroua, Maroua, Cameroon and
| | | | | | - Tanja Aj Houweling
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Zimmermann GW. [Treating and billing chronic wounds faster]. MMW Fortschr Med 2016; 158:30. [PMID: 27221401 DOI: 10.1007/s15006-016-8242-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Workneh MH, Bjune GA, Yimer SA. Assessment of health system challenges and opportunities for possible integration of diabetes mellitus and tuberculosis services in South-Eastern Amhara Region, Ethiopia: a qualitative study. BMC Health Serv Res 2016; 16:135. [PMID: 27095028 PMCID: PMC4837556 DOI: 10.1186/s12913-016-1378-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 04/12/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The double burden of tuberculosis (TB) and diabetes mellitus (DM) is a significant public health problem in low and middle income countries. However, despite the known synergy between the two disease conditions, services for TB and DM have separately been provided. The objective of this study was to explore health system challenges and opportunities for possible integration of DM and TB services. METHODS This was a descriptive qualitative study which was conducted in South-Eastern Amhara Region, Ethiopia. Study participants included health workers (HWs), program managers and other stakeholders involved in TB and DM prevention and control activities. Purposive sampling was applied to select respondents. In order to capture diversity of opinions among participants, maximum variation sampling strategy was applied in the recruitment of study subjects. Data were collected by conducting four focus group discussions and 12 in-depth interviews. Collected data were transcribed verbatim and were thematically analyzed using NVivo 10 software program. RESULT A total of 44 (12 in-depth interviews and 32 focus group discussion) participants were included in the study. The study participants identified a number of health system challenges and opportunities affecting the integration of TB-DM services. The main themes identified were: 1. Unavailability of system for continuity of DM care. 2. Inadequate knowledge and skills of health workers. 3. Frequent stockouts of DM supplies. 4. Patient's inability to pay for DM services. 5. Poor DM data management. 6. Less attention given to DM care. 7. Presence of a well-established TB control program up to the community level. 8. High level of interest and readiness among HWs, program managers and leaders at different levels of the health care delivery system. CONCLUSION The study provided insights into potential health systems challenges and opportunities that need to be considered in the integration of TB-DM services. Piloting TB and DM integrated services in selected HFs of the study area is needed to assess feasibility for possible full scale integration of services for the two comorbid conditions.
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Affiliation(s)
- Mahteme Haile Workneh
- />Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- />Amhara Regional State Health Bureau, Bahir-Dar, Ethiopia
| | - Gunnar Aksel Bjune
- />Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Solomon Abebe Yimer
- />Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- />Amhara Regional State Health Bureau, Bahir-Dar, Ethiopia
- />Department of Microbiology, Oslo University Hospital, Oslo, Norway
- />Department of Bacteriology and Immunology, Norwegian Institute of Public Health, Oslo, Norway
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Walbert H. [General practitioner can offer compression therapy]. MMW Fortschr Med 2016; 158:30. [PMID: 27071575 DOI: 10.1007/s15006-016-8050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Azuma K, Ohta S. [Relations with emergency medical care and primary care doctor, home health care]. Nihon Rinsho 2016; 74:203-214. [PMID: 26915240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Medical care for an ultra-aging society has been shifted from hospital-centered to local community-based. This shift has yielded the so-called Integrated Community Care System. In the system, emergency medical care is considered important, as primary care doctors and home health care providers play a crucial role in coordinating with the department of emergency medicine. Since the patients move depending on their physical condition, a hospital and a community should collaborate in providing a circulating service. The revision of the medical payment system in 2014 clearly states the importance of "functional differentiation and strengthen and coordination of medical institutions, improvement of home health care". As part of the revision, the subacute care unit has been integrated into the community care unit, which is expected to have more than one role in community coordination. The medical fee has been set for the purpose of promoting the home medical care visit, and enhancing the capability of family doctors. In the section of end-of-life care for the elderly, there have been many issues such as reduction of the readmission rate and endorsement of a patient's decision-making, and judgment for active emergency medical care for patient admission. The concept of frailty as an indicator of prognosis has been introduced, which might be applied to the future of emergency medicine. As described above, the importance of a primary doctor and a family doctor should be identified more in the future; thereby it becomes essential for doctors to closely work with the hospital. Advancing the cooperation between a hospital and a community for seamless patient-centered care, the emergency medicine as an integrated community care will further develop by adapting to an ultra-aging society.
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Bailie J, Schierhout G, Laycock A, Kelaher M, Percival N, O'Donoghue L, McNeair T, Bailie R. Determinants of access to chronic illness care: a mixed-methods evaluation of a national multifaceted chronic disease package for Indigenous Australians. BMJ Open 2015; 5:e008103. [PMID: 26614617 PMCID: PMC4663407 DOI: 10.1136/bmjopen-2015-008103] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Indigenous Australians have a disproportionately high burden of chronic illness, and relatively poor access to healthcare. This paper examines how a national multicomponent programme aimed at improving prevention and management of chronic disease among Australian Indigenous people addressed various dimensions of access. DESIGN Data from a place-based, mixed-methods formative evaluation were analysed against a framework that defines supply and demand-side dimensions to access. The evaluation included 24 geographically bounded 'sentinel sites' that included a range of primary care service organisations. It drew on administrative data on service utilisation, focus group and interview data on community members' and service providers' perceptions of chronic illness care between 2010 and 2013. SETTING Urban, regional and remote areas of Australia that have relatively large Indigenous populations. PARTICIPANTS 670 community members participated in focus groups; 374 practitioners and representatives of regional primary care support organisations participated in in-depth interviews. RESULTS The programme largely addressed supply-side dimensions of access with less focus or impact on demand-side dimensions. Application of the access framework highlighted the complex inter-relationships between dimensions of access. Key ongoing challenges are achieving population coverage through a national programme, reaching high-need groups and ensuring provision of ongoing care. CONCLUSIONS Strategies to improve access to chronic illness care for this population need to be tailored to local circumstances and address the range of dimensions of access on both the demand and supply sides. These findings highlight the importance of flexibility in national programme guidelines to support locally determined strategies.
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Affiliation(s)
- Jodie Bailie
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Gill Schierhout
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Alison Laycock
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Margaret Kelaher
- Centre for Health Policy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nikki Percival
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Lynette O'Donoghue
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Tracy McNeair
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Ross Bailie
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
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Zimmermann GW. [GOÄ: special services to be billed alongside counseling]. MMW Fortschr Med 2015; 157 Spec No 2:31. [PMID: 26953462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Abstract
Prices are the major driver of why the United States spends so much more on health care than other countries do. The pricing power that hospitals have garnered recently has resulted from consolidated delivery systems and concentrated markets, leading to enhanced negotiating leverage. But consolidation may be the wrong frame for viewing the problem of high and highly variable prices; many "must-have" hospitals achieve their pricing power from sources other than consolidation, for example, reputation. Further, the frame of consolidation leads to unrealistic expectations for what antitrust's role in addressing pricing power should be, especially because in the wake of two periods of merger "manias" and "frenzies" many markets already lack effective competition. It is particularly challenging for antitrust to address extant monopolies lawfully attained. New payment and delivery models being pioneered in Medicare, especially those built around accountable care organizations (ACOs), offer an opportunity to reduce pricing power, but only if they are implemented with a clear eye on the impact on prices in commercial insurance markets. This article proposes approaches that public and private payers should consider to complement the role of antitrust to assure that ACOs will actually help control costs in commercial markets as well as in Medicare and Medicaid.
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Affiliation(s)
- David M Cutler
- Department of Economics, Harvard University, Cambridge, Massachusetts
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