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1.  Footing the bill: the introduction of Medicare Benefits Schedule rebates for podiatry services in Australia 
The introduction of Medicare Benefits Schedule items for allied health professionals in 2004 was a pivotal event in the public funding of non-medical primary care services. This commentary seeks to provide supplementary discussion of the article by Menz (Utilisation of podiatry services in Australia under the Medicare Enhanced Primary Care program, 2004-2008 Journal of Foot and Ankle Research 2009, 2:30), by placing these findings within the context of the podiatry profession, clinical decision making and the broader health workforce and government policy.
doi:10.1186/1757-1146-2-36
PMCID: PMC2796998  PMID: 19968885
2.  High-billing general practitioners and family physicians in Ontario: how do they do it? An analysis of practice patterns of GP/FPs with annual billings over $400,000. 
BACKGROUND: To better understand the reasons why some fee-for-service physicians have high billing levels, the authors compared the practice and demographic characteristics of general practitioners and family physicians (GP/FPs) who submitted over $400,000 in annual Ontario Health Insurance Plan (OHIP) fee-for-service claims in 1994-95 with those of GP/FPs who billed between $35,000 and $400,000. METHODS: The authors describe the OHIP billing and physician characteristic data for fiscal year 1994-95. They used multivariate logistic regression to determine factors independently associated with high billing status. RESULTS: A total of 219 GP/FPs (2.5% of the GP/FPs in Ontario) billed over $400,000 in 1994-95. Of these, 14 had billing patterns similar to those of specialists, and 27 billed predominantly for diagnostic and therapeutic procedures (particularly physiotherapy). The remaining 178 (81.3%) billed for a mix of services similar to that of other GP/FPs but on average had 2.6 times the volume of patient assessments and a greater share of their total billings derived from diagnostic and therapeutic procedures (9.1% v. 5.6%). Multivariate analysis indicated that these high-volume GP/FPs were less likely than GP/FPs who billed between $35,000 and $400,000 to be 60 years of age or older (odds ratio [OR] 0.09, p < 0.05) and female (OR 0.21) and were more likely to be foreign graduates (OR 1.85) and practising in a region with low physician supply (OR 0.45 for each increase of 1 physician per 1000 population). Metropolitan Toronto was an outlier to the latter relation and was more likely to have high-volume GP/FPs (OR 16.89). INTERPRETATION: High-billing GP/FPs attained their high billing levels by maintaining large numbers of patient visits and by performing procedures. Further research is needed to determine the time spent per patient and the quality of care delivered by these physicians as well as the appropriateness of the procedures that they perform.
PMCID: PMC1229097  PMID: 9538852
3.  Perceived, Actual, and Desired Knowledge Regarding Medicare Billing and Reimbursement 
BACKGROUND
Economics and reimbursement have become a daily part of practicing physicians' lives. Yet, few internal medicine (IM) programs have offered formal curricula during residency about practice management or economics.
OBJECTIVE
To determine perceived, desired, and actual knowledge of Medicare billing and reimbursement among residents compared with community-based General Internists.
DESIGN AND PARTICIPANTS
Cross-sectional needs assessment survey of community and university-based second-year IM residents from 4 geographic regions of the United States.
RESULTS
One hundred and thirty-three second-year IM residents completed the questionnaire. Residents rated their level of knowledge about Medicare as a 2.0 (SD = 0.9) on a Likert scale (1 = “very low,” 5 = “very high”). Residents agreed that Medicare reimbursement should be taught in residency with a score of 4.0 (SD = 1.1; 1 = “strongly disagree,” 5 = “strongly agree” SD = 1.1). On the knowledge assessment portion of the questionnaire, residents scored significantly lower than a group of general IM physicians who completed the same questions (percent correct = 41.8% vs 59.0%, P<.001). Residents' scores correlated with their self-assessed level of knowledge (P = .007).
CONCLUSIONS
Our study demonstrates that second year IM residents feel they have a low level of knowledge regarding outpatient Medicare billing, and have a lower test score than practicing Internists to back up their feelings. The residents also strongly agree that they do not receive enough education about Medicare reimbursement, and believe it should be a requirement in residency training.
doi:10.1111/j.1525-1497.2006.00428.x
PMCID: PMC1484800  PMID: 16704389
internship and residency; curriculum; medicare; needs assessment
4.  Australian primary care policy in 2004: two tiers or one for Medicare? 
The recent primary care policy debate in Australia has centred on access to primary medical (general practice) services. In Australia, access is heavily influenced by Commonwealth Government patient rebates that provide incentives for general practitioners not to charge copayments to patients (bulk billing). A steady decline in key access indicators (bulk billing) has led the Howard Government to introduce a set of changes that move Medicare from a universal scheme, to one increasingly targeted at providing services to more disadvantaged Australians. In doing so, another scene in the story of the contest between universal health care and selective provision in Australia has been written. This paper explores the immediate antecedents and consequences of the changes and sets them in the broader context of policy development for primary care in Australia.
doi:10.1186/1743-8462-1-2
PMCID: PMC544961  PMID: 15679930
5.  Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals? 
Background
In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005.
Results
Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices.
Conclusion
The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care.
doi:10.1186/1743-8462-5-24
PMCID: PMC2588611  PMID: 18990236
6.  Toxic compensation bills. 
Congress has demonstrated interest in toxic compensation legislation, but not enough agreement to make significant progress. Advocates of reform claim that the legal system is heavily weighed against victims who seek compensation through the courts. Proposed reforms include a compensation fund and a cause of action in federal court. Critics have questioned whether these changes in the law would represent an improvement. Existing income replacement, medical cost reimbursement, and survivor insurance programs largely cover the losses of individuals with chronic disease. Thus, the need for an additional compensation is not clear. Furthermore, experience with compensation funds such as the Black Lung Fund suggests that political rather than scientific criteria may be used to determine eligibility. Finally, under the proposed financing mechanisms the compensation funds that are being debated would not increase incentives for care in the handling of hazardous wastes or toxic substances.
PMCID: PMC1568718  PMID: 4085440
7.  Childhood asthma surveillance using administrative data: Consistency between medical billing and hospital discharge diagnoses 
BACKGROUND:
The absence of ongoing surveillance for childhood asthma in Montreal, Quebec, prompted the present investigation to assess the validity and practicality of administrative databases as a foundation for surveillance.
OBJECTIVE:
To explore the consistency between cases of asthma identified through physician billings compared with hospital discharge summaries.
METHODS:
Rates of service use for asthma in 1998 among Montreal children aged one, four and eight years were estimated. Correspondence between the two databases (physician billing claims versus medical billing claims) were explored during three different time periods: the first day of hospitalization, during the entire hospital stay, and during the hospital stay plus a one-day margin before admission and after discharge (‘hospital stay ± 1 day’).
RESULTS:
During 1998, 7.6% of Montreal children consulted a physician for asthma at least once and 0.6% were hospitalized with a principal diagnosis of asthma. There were no contemporaneous physician billings for asthma ‘in hospital’ during hospital stay ± 1 day for 22% of hospitalizations in which asthma was the primary diagnosis recorded at discharge. Conversely, among children with a physician billing for asthma ‘in hospital’, 66% were found to have a contemporaneous in-hospital record of a stay for ‘asthma’.
CONCLUSIONS:
Both databases of hospital and medical billing claims are useful for estimating rates of hospitalization for asthma in children. The potential for diagnostic imprecision is of concern, especially if capturing the exact number of uses is more important than establishing patterns of use.
PMCID: PMC2677950  PMID: 18551199
Administrative data; Childhood asthma; Hospital admissions; Medical visits; Surveillance
8.  Correlates of certification in family medicine in the billing patterns of Ontario general practitioners. 
There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.
PMCID: PMC1451452  PMID: 2804847
9.  Do Electronic Health Records Standards Help Implementing Patient Bill of Rights in Hospitals? 
Acta Informatica Medica  2013;21(1):20-22.
Introduction
Patient bill of rights (PBR) calls for equal rights to access health services for all patients. It makes a foundation for preserving good relationships between patients, doctors and other healthcare staffs. Third Edition of national PBR was published in Iran in 2009. On the other hand, developing national wide Electronic Health Records (EHR) is now one of the strategic goals of Iran Ministry of Health and Medical Education. EHR as a basic repository for all related information provides access to the necessary data to organize, store and manage them. It also makes an additional support to the legal aspects of healthcare services, increases staff information about patient rights, and raises them to respect these rights. This article reviews how EHR standards can help to institutionalize the PBR.
Methods
To do that, we have collected some important topics of PBR in Iran. Then we used some valid references on Electronic health record standards like ASTM, ISO, HL7 and CEN to review existing standards. The Main issues regarding patient rights derived from these standards were: privacy, confidentiality, and secrecy, access levels to patient information, medical care in emergency situations, patient autonomy and authentication (electronic signature). In each topic, the most relevant standard phrases are marked.
Results
Developing EHR creates an opportunity to establish patient rights in its structure. To internalize them, there are some reliable EHR standards like ASTM and ISO 13606-1 that implementing them could be very fruitful.
doi:10.5455/AIM.2012.21.20-22
PMCID: PMC3610580  PMID: 23572856
EHR; standard; patient bill of rights; Hospital
10.  Protecting Adolescents' Right to Seek Treatment for Sexually Transmitted Diseases without Parental Consent: The Arizona Experience with Senate Bill 1309 
Public Health Reports  2012;127(3):253-258.
In 2010, Senate Bill 1309 included language to repeal an existing Arizona law that enables minors younger than 18 years of age to seek diagnosis and treatment of sexually transmitted diseases (STDs) without parental consent. Numerous implications were identified that would have stemmed from parental consent provisions originally proffered in Senate Bill 1309. These implications included diminished access to essential health services among minors, exacerbated existing health disparities, increased health-care spending costs, and thwarted efforts to curb the spread of STDs. Lastly, minors would have been deprived of existing privacy protections concerning their STD-related medical information. This case study describes how collaborative advocacy efforts resulted in the successful amendment of Senate Bill 1309 to avert the negative sexual and reproductive health outcomes among adolescents stemming from the potential repeal of their existing legal right to seek STD treatment without parental consent.
PMCID: PMC3314068  PMID: 22547855
11.  Adapting to a Changing World: Unraveling the Role of Man-Made Habitats as Alternative Feeding Areas for Slender-Billed Gull (Chroicocephalus genei) 
PLoS ONE  2012;7(10):e47551.
Current rates of wildlife habitat loss have placed increasing demands on managers to develop, validate and implement tools aimed at improving our ability to evaluate such impacts on wildlife. Here, we present a case study conducted at the Natural Area of Doñana (SW Spain) where remote sensing and stable isotope (δ13C, δ15N) analyses of individuals were combined to unravel (1) the effect of variations in availability of natural food resources (i.e. from natural marshes) on reproductive performance of a Slender-billed Gull (Chroicocephalus genei) population, and (2) the role of two adjacent, artificial systems (a fish farm and saltmines) as alternate anthropogenic feeding areas. Based on long-term (1983–2004) remote-sensing, we inferred the average extent of flooded area at the marshland (a proxy to natural resource availability) annually. Estimated flooded areas (ranging from extreme drought [ca. 151 ha, 1995] to high moisture [15,049 ha, 2004]) were positively related to reproductive success of gulls (estimated for the 1993–2004 period, and ranging from ca. 0 to 1.7 fledglings per breeding pairs), suggesting that habitat availability played a role in determining their reproductive performance. Based on blood δ13C and δ15N values of fledglings, 2001–2004, and a Bayesian isotopic mixing model, we conclude that saltmines acted as the main alternative foraging habitat for gulls, with relative contributions increasing as the extent of marshland decreased. Although adjacent, anthropogenic systems have been established as the preferred breeding sites for this gull population, dietary switches towards exploitation of alternative (anthropogenic) food resources negatively affected the reproductive output of this species, thus challenging the perception that these man-made systems are necessarily a reliable buffer against loss of natural feeding habitats. The methodology and results derived from this study could be extended to a large suite of threatened natural communities worldwide, thus providing a useful framework for management and conservation.
doi:10.1371/journal.pone.0047551
PMCID: PMC3477125  PMID: 23094062
12.  Patient identified needs for chronic obstructive pulmonary disease versus billed services for care received 
The American Lung Association of Minnesota (ALAMN) was granted access to a 2004 administrative claims data from an upper mid-Western, independent practice association model health plan. Claims information, including demographics, prevalence, medication and oxygen therapy, and health care utilization, was extracted for 7,782 patients with COPD who were 40 years of age and older. In addition, ALAMN conducted a survey of 1,911 patients from Minnesota diagnosed with COPD. The survey queried the patients about demographics, treatment, medications, limitations, wants, and needs. This article compares and contrasts the information gained through the health plan administrative claims database with the findings from the COPD patient survey in areas of age, gender, types of provider primarily responsible for COPD care, spirometry use, medication therapy, pulmonary rehabilitation, oxygen therapy, and health care utilization. Primary care practitioners provided a majority of the COPD-related care. The claims evidence of spirometry use was 16%–62% of COPD patients had claims evidence of COPD-related medications. 25% of patients reported, and 23% of patients had claims evidence of, a hospitalization during the observation year. 16% of patients reported using pulmonary rehabilitation programs. The results indicate there is an opportunity to improve COPD diagnosis and management.
PMCID: PMC2629976  PMID: 18990969
chronic obstructive pulmonary disease; oxygen therapy; medication therapy; spirometry; chronic care; assessment
13.  Access to general practitioner services amongst underserved Australians: a microsimulation study 
Background
One group often identified as having low socioeconomic status, those living in remote or rural areas, are often recognised as bearing an unequal burden of illness in society. This paper aims to examine equity of utilisation of general practitioner services in Australia.
Methods
Using the 2005 National Health Survey undertaken by the Australian Bureau of Statistics, a microsimulation model was developed to determine the distribution of GP services that would occur if all Australians had equal utilisation of health services relative to need.
Results
It was estimated that those who are unemployed would experience a 19% increase in GP services. Persons residing in regional areas would receive about 5.7 million additional GP visits per year if they had the same access to care as Australians residing in major cities. This would be a 18% increase. There would be a 20% increase for inner regional residents and a 14% increase for residents of more remote regional areas. Overall there would be a 5% increase in GP visits nationally if those in regional areas had the same access to care as those in major cities.
Conclusion
Parity is an insufficient goal and disadvantaged persons and underserved areas require greater access to health services than the well served metropolitan areas due to their greater poverty and poorer health status. Currently underserved Australians suffer a double disadvantage: poorer health and poorer access to health services.
doi:10.1186/1478-4491-10-1
PMCID: PMC3292913  PMID: 22264385
14.  Balance billing: the patients' perspective 
We study the effects of 'balance billing', i.e., allowing physicians to charge a fee from patients in addition to the fee paid by Medicare. First, we show that on pure efficiency grounds the optimal Medicare fee under balance billing is zero. An active Medicare policy thus can only be justified when distributional concerns are accounted for. Extending the analysis by Glazer and McGuire, we therefore analyze the optimal policy from the patients' point of view. We demonstrate that, from the patients' perspective, a positive fee can be superior under balance billing. Furthermore, patient welfare can be lower if balance billing is prohibited. In particular, this is the case if the administrative costs of Medicare are large. However, we cannot rule out that prohibiting balance billing may be superior. Finally, we show that payer fee discrimination increases patient welfare if Medicare's administrative costs are high or if Medicare's optimal fee under balance billing implies lower quality for fee-only patients.
JEL-classification: I11, I18, H51
doi:10.1186/2191-1991-1-14
PMCID: PMC3496471  PMID: 22827899
physician reimbursement; price controls; Medicare
15.  Geographic and Sociodemographic Disparities in PET Use by Medicare Beneficiaries With Cancer 
Journal of the American College of Radiology : JACR  2012;9(9):10.1016/j.jacr.2012.05.005.
Purpose
PET use for cancer care has increased unevenly, possibly because of regional health care market characteristics or underlying population characteristics. The aim of this study was to examine variation in advanced imaging use among individuals with cancer in relation to population and hospital service area (HSA) characteristics.
Methods
A retrospective national study of fee-for-service Medicare beneficiaries with diagnoses of 1 of 5 cancers covered by Medicare for PET (2004-2008) was conducted. Crude and adjusted rates of PET, CT, and MRI were estimated for HSAs and sociodemographic subgroups. Generalized linear mixed models were used to assess the effects of race/ethnicity, area-level income, and HSA-level physician supply and spending on imaging utilization.
Results
On the basis of an annual average of 116,452 beneficiaries with cancer, adjusted PET rates (imaging days per person-year) showed significantly higher use for whites compared with blacks in both 2004 (whites, 0.35 [95% confidence interval, 0.34-0.36]; blacks, 0.31 [95% confidence interval, 0.30-0.33]) and 2008 (whites, 0.64 [95% confidence interval, 0.63-0.65]; blacks, 0.57 [95% confidence interval, 0.55-0.59]). This trend was similar for the highest quartile of group-level median household income but was opposite for CT use, with blacks having higher rates than whites. The highest Medicare-spending HSAs had significantly higher adjusted PET rates compared with lower spending areas (0.57 [95% confidence interval, 0.55-0.60] vs 0.69 [95% confidence interval, 0.67-0.71] imaging days/person-year).
Conclusions
The use of PET among Medicare beneficiaries with cancer increased from 2004 to 2008, with higher rates observed among whites, among higher socioeconomic groups, and in higher Medicare spending areas. Sociodemographic differences in advanced imaging use are modality specific.
doi:10.1016/j.jacr.2012.05.005
PMCID: PMC3830950  PMID: 22954545
PET; cancer; imaging; variation; Medicare; race
16.  C3: A comprehensive physician activity and billing tool 
Purpose: The Clinical Charge Capture system (C3) was developed at the University of Michigan to increase the efficiency and accuracy with which information about physician activity and billing is tracked in academic medical centers. Description: This Oracle-based, Visual Basic system integrates the operating room scheduling system, transcription database, clinical data repository, referring physician database, and IDX to allow physicians and staff to perform paperless and on-line standard tasks such as preauthorizing procedures; creating a bill which describes the charges for procedures performed along with their supporting diagnoses; identifying inpatient daily care and consult charges; dictating, editing, signing, and providing attestations for procedural and inpatient notes (menu-driven boilerplate notes are used for common procedures); submitting of charges on-line to IDX; and downloading of payment data from IDX. A messaging system between physicians and billing specialists allows questions to be posed regarding coding issues and options. Summary information about charges is presented and the status of the bill as it progresses through the internal review and billing process is demonstrated. Any missing data are flagged such that delivery of a bill is accurate, timely, and complete. Outpatient clinic visit charges are acquired on line using bar code technology with direct download of clinic charges to IDX. Generation of charges and referral letters may be performed immediately following the performance of a procedure or patient encounter or subsequently in the office. Resident activity is also tracked. Finally, search functions are provided which allow the program to serve as a clinical information research database. Results: The time to bill submission for operative procedures in fiscal year 1996 (Pre-C3) when compared to 1999 (Post-C3) decreased in each individual surgical division (See figure)as well as for the overall Department (Total: mean Pre-C3=40 days, mean Post-C3=8 days). The average bill was increased by 9% for each primary charge submitted. Conclusions: We conclude that this system has the potential to enhance the efficiency, accuracy, and organization of routine physician documentation, billing, and data collection activities.
PMCID: PMC2243784  PMID: 11080025
17.  Evidence of the Royal College of General Practitioners to the Select Committee of Parliament on the Abortion (Amendment) Bill 
The Royal College of General Practitioners is, of course, fully aware that the regulation of the conditions for abortion is inevitably difficult and complex and that opinions are often difficult to reconcile.
Nevertheless, the College has been able to establish the grave concern of many of its members at the proposals outlined in this Bill. The College has not received one single letter in support of the Abortion (Amendment) Bill.
The College notes that the Lane Committee (1974) carried out a very full and detailed review of the working of the Abortion Act and published its view only last year. The College notes that the Lane Committee took evidence from those with every shade of opinion, examined in detail virtually every published scientific report on abortion in this country, and, furthermore, commissioned and published specific evidence about the working of the 1967 Abortion Act.
The College notes that the Lane Committee contained members, in addition to general practitioners, who were lawyers, administrative medical officers, psychiatrists, gynaecologists, social workers, and women representing the public, and that its work took about three years to carry out.
The Royal College of General Practitioners endorses the work of the Lane Committee and therefore recommends that the recommendations of that Committee should be implemented instead of the proposals in the Abortion (Amendment) Bill.
PMCID: PMC2157831  PMID: 1195240
18.  How Much Is Postacute Care Use Affected by Its Availability? 
Health Services Research  2005;40(2):413-434.
Objective
To assess the relative impact of clinical factors versus nonclinical factors—such as postacute care (PAC) supply—in determining whether patients receive care from skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after discharge from acute care.
Data Sources and Study Setting
Medicare acute hospital, IRF, and SNF claims provided data on PAC choices; predictors of site of PAC chosen were generated from Medicare claims, provider of services, enrollment file, and Area Resource File data.
Study Design
We used multinomial logit models to predict PAC use by elderly patients after hospitalizations for stroke, hip fractures, or lower extremity joint replacements.
Data Collection/Extraction Methods
A file was constructed linking acute and postacute utilization data for all medicare patients hospitalized in 1999.
Principal Findings
PAC availability is a more powerful predictor of PAC use than the clinical characteristics in many of our models. The effects of distance to providers and supply of providers are particularly clear in the choice between IRF and SNF care. The farther away the nearest IRF is, and the closer the nearest SNF is, the less likely a patient is to go to an IRF. Similarly, the fewer IRFs, and the more SNFs, there are in the patient's area the less likely the patient is to go to an IRF. In addition, if the hospital from which the patient is discharged has a related IRF or a related SNF the patient is more likely to go there.
Conclusions
We find that the availability of PAC is a major determinant of whether patients use such care and which type of PAC facility they use. Further research is needed in order to evaluate whether these findings indicate that a greater supply of PAC leads to both higher use of institutional care and better outcomes—or whether it leads to unwarranted expenditures of resources and delays in returning patients to their homes.
doi:10.1111/j.1475-6773.2005.00365.x
PMCID: PMC1361149  PMID: 15762900
postacute care; provider supply; Medicare; rehabilatation; nursing homes
19.  One state's response to the malpractice insurance crisis: North Carolina's Rural Obstetrical Care Incentive Program. 
Public Health Reports  1992;107(5):523-529.
In the period 1985-89, there was a severe drop in obstetrical services in rural areas of North Carolina, partly because of rising malpractice insurance rates. The State government responded with the Rural Obstetrical Care Incentive (ROCI) Program that provides a malpractice insurance subsidy of up to $6,500 per participating physician per year. Enacted into law in 1988, the ROCI Program was expanded in 1991, making certified nurse midwives eligible to receive subsidies of up to $3,000 per year. To participate, practitioners must provide obstetrical care to all women, regardless of their ability to pay for services. Total funding for the program has increased from $240,000 to $840,000, in spite of extreme budgetary constraints faced by the State. The program and how its implementation has maintained or increased access to obstetrical care in participating counties are described on the basis of site visits to local health departments in participating counties and data from the North Carolina Division of Maternal and Child Health. The program is of significance to policy makers nationwide as both a response to rising malpractice insurance rates and reduced access to obstetrical care in rural areas, and as an innovative, nontraditional State program in which the locus of decision making is at the county level.
PMCID: PMC1403693  PMID: 1410232
20.  Automated Support of Medical Decision-Making in Workers' Compensation: Adjudication and Bill Payment Decisions 
Medically related decision-making in workers' compensation, especially in areas of patient eligibility for benefits and determination of exact medical and compensation benefits, differs significantly from similar decisions in clinical practice and acute care payment. A government-sponsored program has been developing guidelines and decision algorithms to aid in decision-making in these areas, focusing on occupational diseases. These decision algorithms are now being automated to support national implementation of the guidelines by Federal agencies and to encourage their adoption by the private sector.
PMCID: PMC2203906
21.  Agency and Market Area Factors Affecting Home Health Agency Supply Changes 
Health Services Research  2006;41(5):1847-1875.
Objective
To use the natural experiment created by the Medicare interim payment system (IPS) to study supply change behavior of home health agencies (HHAs) in local market areas.
Data Sources
One hundred percent Medicare home health claims for 1996 and 1999, linked with Medicare Provider of Service and Denominator files, and the Area Resource File.
Study Design
Medicare home health care (HHC) claims data were used to distinguish HHAs that changed the local market supply of Medicare HHC by their market exit or by significant expansion or contraction of their geographic service area between 1996 and 1999 from other HHAs. Multinomial logit models were estimated to analyze how characteristics of agencies and the market areas in which they served were associated with these different agency-level supply changes.
Principal Findings
Changes in local HHA supply stemming from geographic service area expansions and contractions rivaled those owing to agency closures and market entries. Agencies at greater risk of closure and service area contraction tended to be smaller, newer, freestanding agencies, operating with more visit-intensive practice styles in markets with more competitor agencies. Except for having much less visit-intensive practice styles, similar attributes characterized agencies that increased local supply through service area expansion.
Conclusions
Supply changes by HHAs largely reflected rational market responses by agencies to significant changes in financial incentives associated with the Medicare IPS. Recently certified agencies were among the most dynamic providers. Supply changes were more likely among agencies operating in more competitive market environments.
doi:10.1111/j.1475-6773.2006.00561.x
PMCID: PMC1955289  PMID: 16987305
Home health care; Medicare; geographic service area; supply behavior
22.  Overcoming the limitations of proprietary computerized billing systems to enhance patient care. 
Most physician offices have proprietary computerized billing systems, but these are not designed for monitoring utilization or addressing patient care issues, and they are difficult or impossible to modify. These systems do, however, contain valuable diagnosis and demographic information. An open-ended, relational x-base system is described that downloads this billing information and combines it with additional input to provide the practitioner with: current problem lists; medication and allergy lists; health screening reminders that are age, sex and disease specific; and commonly used demographic information. Several popular query/reporting tools are used to generate standard reports and ad hoc inquiries that relate directly to patient care. Two studies, one involving alerting physicians to possible adverse medication effects on specific patients, and one investigating appropriate use and billing of stool occult blood testing are summarized. In the constantly evolving arenas of utilization, outcomes research and cost efficiency, such an open ended, time efficient system has unlimited potential to improve patient care.
PMCID: PMC2579188  PMID: 8563384
23.  How can good general practitioner care be achieved? 
It has been shown that to provide a high standard of care general practitioners probably need to book consultations at intervals of at least 10 minutes. In this study the maximum list size for which a general practitioner might be expected to provide a high standard of care was determined from calculations of the time spent consulting, based on various consultation rates and list sizes and assuming that consultations were 10 minutes long. If good quality care is to be provided and is to include the range of services suggested in the government's recent green paper average list sizes should probably be no more than 1750, and lower in areas of high demand and high need. In addition to this, minimum standards could be determined for such measures as facilities available in surgeries, practice records, and accessibility of doctors to ensure that basic services were offered by all general practitioners.
PMCID: PMC1245168  PMID: 3109549
24.  Patient, physician, encounter, and billing characteristics predict the accuracy of syndromic surveillance case definitions 
BMC Public Health  2012;12:166.
Background
Syndromic surveillance systems are plagued by high false-positive rates. In chronic disease monitoring, investigators have identified several factors that predict the accuracy of case definitions based on diagnoses in administrative data, and some have even incorporated these predictors into novel case detection methods, resulting in a significant improvement in case definition accuracy. Based on findings from these studies, we sought to identify physician, patient, encounter, and billing characteristics associated with the positive predictive value (PPV) of case definitions for 5 syndromes (fever, gastrointestinal, neurological, rash, and respiratory (including influenza-like illness)).
Methods
The study sample comprised 4,330 syndrome-positive visits from the claims of 1,098 randomly-selected physicians working in Quebec, Canada in 2005-2007. For each visit, physician-facilitated chart review was used to assess whether the same syndrome was present in the medical chart (gold standard). We used multivariate logistic regression analyses to estimate the association between claim-chart agreement about the presence of a syndrome and physician, patient, encounter, and billing characteristics.
Results
The likelihood of the medical chart agreeing with the physician claim about the presence of a syndrome was higher when the treating physician had billed many visits for the same syndrome recently (ORper 10 visit, 1.05; 95% CI, 1.01-1.08), had a lower workload (ORper 10 claims, 0.93; 95% CI, 0.90-0.97), and when the patient was younger (ORper 5 years of age, 0.96; 95% CI, 0.94-0.97), and less socially deprived (ORmost versus least deprived, 0.76; 95% CI, 0.60-0.95).
Conclusions
Many physician, patient, encounter, and billing characteristics associated with the PPV of surveillance case definition are accessible to public health, and could be used to reduce false-positive alerts by surveillance systems, either by focusing on the data most likely to be accurate, or by adjusting the observed data for known biases in diagnosis reporting and performing surveillance using the adjusted values.
doi:10.1186/1471-2458-12-166
PMCID: PMC3378465  PMID: 22397597
25.  Are acoustical parameters of begging call elements of thin-billed prions related to chick condition? 
Acta Ethologica  2010;13(1):1-9.
Chicks of burrowing petrels use begging calls to advertise their hunger levels when parents arrived at the nest. In a previous study, adult thin-billed prions Pachyptila belcheri responded to higher begging call rates of their single chick by regurgitating larger meals. We tested whether acoustic parameters of begging call elements may also be involved in signalling. To describe variation in begging, we determined begging session parameters, namely the duration, number of calls and the mean and maximum rate of calling. We then digitised calls and carried out a semi-automatic extraction of six acoustic parameters of call elements, including mean and maximum acoustic frequency, the length of call elements and the location of the maximum frequency and amplitude within calls. Chicks showed strong individual differences in all parameters. While the session parameters were correlated with body condition and with the meal size the chick received, none of the acoustic parameters were related to body condition and provisioning. A cross-fostering experiment showed the same pattern, as only session parameters changed related to an experimentally altered body condition, while acoustical cues appear to play no role in signalling hunger levels. We suggest that this may be explained by the absence of sibling competition in these birds. As parents do not need to decide which chick to feed, immediate information on condition at the time of adult arrival may not be required.
doi:10.1007/s10211-009-0066-5
PMCID: PMC3150793  PMID: 21841890
Parent–offspring communication; Signalling; Provisioning; Pachyptila belcheri; Seabirds

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