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1.  Capitation and enhanced fee-for-service models for primary care reform: a population-based evaluation 
Primary care reform in Ontario, Canada, included the initiation of a blended capitation model in 2001–2002 and an enhanced fee-for-service model in 2003. Both models involve patient rostering, incentives for preventive care and requirements for after-hours care. We evaluated practice characteristics and patterns of care under both models.
Using administrative data, we identified physicians belonging to either the capitation or the enhanced fee-for-service group throughout the period from Sept. 1, 2005, to Aug. 31, 2006, and their enrolled patients. Practices were stratified by location (urban v. rural). We compared the groups in terms of practice characteristics and patterns of care, including comprehensiveness of care, continuity of care, after-hours care, visits to the emergency department and uptake of new patients.
Patients in the capitation and enhanced fee-for-service practices had similar demographic characteristics. Patients in capitation practices had lower morbidity and comorbidity indices. Comprehensiveness and continuity of care were similar between the 2 groups. Compared with patients in enhanced fee-for-service practices, those in capitation practices had less after-hours care (adjusted rate ratio [RR] 0.68, 95% confidence interval [CI] 0.61–0.75) and more visits to emergency departments (adjusted RR 1.20, 95% CI 1.15–1.25). Overall, physicians in the capitation group enrolled fewer new patients than did physicians in the enhanced fee-for-service group (37.0 v. 52.0 per physician); the same was true of new graduates (60.3 v. 72.1 per physician).
Physicians enrolled in the capitation model had different practice characteristics than those in the enhanced fee-for-service model. These characteristics appeared to be pre-existing and not due to enrolment in a new model. Although the capitation model provides an alternative to fee-for-service practice, its characteristics should be the focus of future policy development and research.
PMCID: PMC2683211  PMID: 19468106
2.  Challenges of scaling up and of knowledge transfer in an action research project in Burkina Faso to exempt the worst-off from health care user fees 
Systems to exempt the indigent from user fees have been put in place to prevent the worst-off from being excluded from health care services for lack of funds. Yet the implementation of these mechanisms is as rare as the operational research on this topic. This article analyzes an action research project aimed at finding an appropriate solution to make health care accessible to the indigent in a rural district of Burkina Faso.
This action research project was initiated in 2007 to study the feasibility and effectiveness of a community-based, participative and financially sustainable process for exempting the indigent from user fees. A interdisciplinary team of researchers from Burkina Faso and Canada was mobilized to document this action research project.
Results and knowledge sharing
The action process was very well received. Indigent selection was effective and strengthened local solidarity, but coverage was reduced by the lack of local financial resources. Furthermore, the indigent have many other needs that cannot be addressed by exemption from user fees. Several knowledge transfer strategies were implemented to share research findings with residents and with local and national decision-makers.
Partnership achievements and difficulties
Using a mixed and interdisciplinary research approach was critical to grasping the complexity of this community-based process. The adoption of the process and the partnership with local decision-makers were very effective. Therefore, at the instigation of an NGO, four other districts in Burkina Faso and Niger reproduced this experiment. However, national decision-makers showed no interest in this action and still seem unconcerned about finding solutions that promote access to health care for the indigent.
Lessons learned
The lessons learned with regard to knowledge transfer and partnerships between researchers and associated decision-makers are: i) involve potential users of the research results from the research planning stage; ii) establish an ongoing partnership between researchers and users; iii) ensure that users can participate in certain research activities; iv) use a variety of strategies to disseminate results; and v) involve users in dissemination activities.
PMCID: PMC3247840  PMID: 22166085
3.  Maintaining quality of health services after abolition of user fees: A Uganda case study 
It has been argued that quality improvements that result from user charges reduce their negative impact on utilization especially of the poor. In Uganda, because there was no concrete evidence for improvements in quality of care following the introduction of user charges, the government abolished user fees in all public health units on 1st March 2001. This gave us the opportunity to prospectively study how different aspects of quality of care change, as a country changes its health financing options from user charges to free services, in a developing country setting. The outcome of the study may then provide insights into policy actions to maintain quality of care following removal of user fees.
A population cohort and representative health facilities were studied longitudinally over 3 years after the abolition of user fees. Quantitative and qualitative methods were used to obtain data. Parameters evaluated in relation to quality of care included availability of drugs and supplies and; health worker variables.
Different quality variables assessed showed that interventions that were put in place were able to maintain, or improve the technical quality of services. There were significant increases in utilization of services, average drug quantities and stock out days improved, and communities reported health workers to be hardworking, good and dedicated to their work to mention but a few. Communities were more appreciative of the services, though expectations were lower. However, health workers felt they were not adequately motivated given the increased workload.
The levels of technical quality of care attained in a system with user fees can be maintained, or even improved without the fees through adoption of basic, sustainable system modifications that are within the reach of developing countries. However, a trade-off between residual perceptions of reduced service quality, and the welfare gains from removal of user fees should guide such a policy change.
PMCID: PMC2397390  PMID: 18471297
4.  User fee exemptions and excessive household spending for normal delivery in Burkina Faso: the need for careful implementation 
In 2006, the Parliament of Burkina Faso passed a policy to reduce the direct costs of obstetric services and neonatal care in the country’s health centres, aiming to lower the country’s high national maternal mortality and morbidity rates. Implementation was via a “partial exemption” covering 80% of the costs. In 2008 the German NGO HELP launched a pilot project in two health districts to eliminate the remaining 20% of user fees. Regardless of any exemptions, women giving birth in Burkina Faso’s health centres face additional expenses that often represent an additional barrier to accessing health services. We compared the total cost of giving birth in health centres offering partial exemption versus those with full exemption to assess the impact on additional out-of-pocket fees.
A case–control study was performed to compare medical expenses. Case subjects were women who gave birth in 12 health centres located in the Dori and Sebba districts, where HELP provided full fee exemption for obstetric services and neonatal care. Controls were from six health centres in the neighbouring Djibo district where a partial fee exemption was in place. A random sample of approximately 50 women per health centre was selected for a total of 870 women.
There was an implementation gap regarding the full exemption for obstetric services and neonatal care. Only 1.1% of the sample from Sebba but 17.5% of the group from Dori had excessive spending on birth related costs, indicating that women who delivered in Sebba were much less exposed to excessive medical expenses than women from Dori. Additional out-of-pocket fees in the full exemption health districts took into account household ability to pay, with poorer women generally paying less.
We found that the elimination of fees for facility-based births benefits especially the poorest households. The existence of excessive spending related to direct costs of giving birth is of concern, making it urgent for the government to remove all direct fees for obstetric and neonatal care. However, the policy of completely abolishing user fees is insufficient; the implementation process must have a thorough monitoring system to reduce implementation gaps.
PMCID: PMC3512510  PMID: 23171417
5.  Survival of Older Patients With Cancer in the Veterans Health Administration Versus Fee-for-Service Medicare 
Journal of Clinical Oncology  2012;30(10):1072-1079.
The Veterans Health Administration (VHA) provides high-quality preventive chronic care and cancer care, but few studies have documented improved patient outcomes that result from this high-quality care. We compared the survival rates of older patients with cancer in the VHA and fee-for-service (FFS) Medicare and examined whether differences in the stage at diagnosis, receipt of guideline-recommended therapies, and unmeasured characteristics explain survival differences.
Patients and Methods
We used propensity-score methods to compare all-cause and cancer-specific survival rates for men older than age 65 years who were diagnosed or received their first course of treatment for colorectal, lung, lymphoma, or multiple myeloma in VHA hospitals from 2001 to 2004 to similar FFS-Medicare enrollees diagnosed in Surveillance, Epidemiology, and End Results (SEER) areas in the same time frame. We examined the role of unmeasured factors by using sensitivity analyses.
VHA patients versus similar FFS SEER-Medicare patients had higher survival rates of colon cancer (adjusted hazard ratio [HR], 0.87; 95% CI, 0.82 to 0.93) and non–small-cell lung cancer (NSCLC; HR, 0.91; 95% CI, 0.88 to 0.95) and similar survival rates of rectal cancer (HR, 1.05; 95% CI, 0.95 to 1.16), small-cell lung cancer (HR, 0.99; 95% CI, 0.93 to 1.05), diffuse large–B-cell lymphoma (HR, 1.02; 95% CI, 0.89 to 1.18), and multiple myeloma (HR, 0.92; 95% CI, 0.83 to 1.03). The diagnosis of VHA patients at earlier stages explained much of the survival advantages for colon cancer and NSCLC. Sensitivity analyses suggested that additional adjustment for the severity of comorbid disease or performance status could have substantial effects on estimated differences.
The survival rate for older men with cancer in the VHA was better than or equivalent to the survival rate for similar FFS-Medicare beneficiaries. The VHA provision of high-quality care, particularly preventive care, can result in improved patient outcomes.
PMCID: PMC3341151  PMID: 22393093
6.  Impact on child mortality of removing user fees: simulation model 
BMJ : British Medical Journal  2005;331(7519):747-749.
Objective To estimate how many child deaths might be prevented if user fees were removed in 20 African countries
Design Simulation model combining evidence on key health interventions' impacts on reducing child mortality with analysis of the effect of fee abolition on access to healthcare services.
Results Elimination of user fees could prevent approximately 233 000 (estimate range 153 000-305 000) deaths annually in children aged under 5 in 20 African countries.
Conclusion Given the relatively low cost of abolition, replacing user fees with alternative financing mechanisms should be seen as an effective first step towards improving households' access to health care and achieving the millennium development goals for health.
PMCID: PMC1239978  PMID: 16195292
7.  Restructuring Primary Health Care Markets in New Zealand: from Welfare Benefits to Insurance Markets 
New Zealand's Primary Health Care Strategy (NZPHCS) was introduced in 2002. Its features are substantial increases in government funding delivered as capitation payments, and newly-created service-purchasing agencies. The objectives are to reduce health disparities and to improve health outcomes.
The NZPHCS changes New Zealand's publicly-funded primary health care payments from targeted welfare benefits to universal, risk-rated insurance premium subsidies. Patient contributions change from fee-for-service top-ups to insurance premium top-ups, and are collected by service providers who, depending upon their contracts with purchasers, may also be either insurance agents or risk-bearing insurance companies. The change invokes the tensions associated with allocating risk-bearing amongst providers, patients and insurance companies that accompany all insurance-based funding instruments. These include increases in existing incentives for over-consumption and new incentives for insurers to limit their exposure to variations in patient health states by engaging in active patient pool selection.
The New Zealand scheme is complex, but closely resembles United States insurance-based, risk-rated managed care schemes. The key difference is that unlike classic managed care models, where provider remuneration is determined by the insurer, the historic right for general practitioners to autonomously set patient charges alters the fiscal incentives normally available to managed care organisations. Consequently, the insurance role is being devolved to individual service providers with very small patient pools, who must recoup the premium top-ups from insured individuals. Premium top-ups are being collected only from those individuals consuming care, in proportion to the number of times care is sought. Co-payments thus constitute perfectly risk-rated premium levies set by inefficiently small insurers, raising questions about the efficiency and equity of a 'universal' insurance system pooling total population demands and costs. The efficacy of using financial incentives to constrain costs and encourage innovation when providers retain the right to arbitrarily recoup costs directly from patients, is also questioned.
Initial evidence suggests that total costs are higher than initially expected, and prices to some patients have risen substantially under the NZPHCS. Limited competition and NZPHCS governance requirements mean current institutional arrangements are unlikely to facilitate efficiency improvements. System design changes therefore appear indicated.
PMCID: PMC1224852  PMID: 16144544
8.  Assessing the Elimination of User Fees for Delivery Services in Laos 
PLoS ONE  2014;9(3):e89784.
A pilot eliminating user fees associated with delivery at the point of services was introduced in two districts of Laos in March 2009. Following two years of implementation, an evaluation was conducted to assess the pilot impact, as well as to document the pilot design and implementation challenges. Study results show that, even in the presence of the substantial access and cultural barriers, user fees associated with delivery at health facilities act as a serious deterrent to care seeking behavior. We find a tripling of facility-based delivery rates in the intervention areas, compared to a 40% increase in the control areas. While findings from the control region suggest that facility-based delivery rates may be on the rise across the country, the substantially higher increase in the pilot areas highlight the impact of financial burden associated with facility-based delivery fees. These fees can play an important role in rapidly increasing the uptake of facility delivery to reach the national targets and, ultimately, to improve maternal and child health outcomes. The pilot achieved important gains while relying heavily on capacity and systems already in place. However, the high cost associated with monitoring and evaluation suggest broad-scale expansion of the pilot activities is likely to necessitate targeted capacity building initiatives, especially in areas with limited district level capacity to manage funds and deliver detailed and timely reports.
PMCID: PMC3954553  PMID: 24632592
9.  Effect of Delivery Care User Fee Exemption Policy on Institutional Maternal Deaths in the Central and Volta Regions of Ghana 
Ghana Medical Journal  2007;41(3):118-124.
To improve access to skilled attendance at delivery and thereby reduce maternal mortality, the Government of Ghana introduced a policy exempting all women attending health facilities from paying delivery care fees.
To examine the effect of the exemption policy on delivery-related maternal mortality.
Maternal deaths in 9 and 12 hospitals in the Central Region (CR) and the Volta Region (VR) respectively were analysed. The study covered a period of 11 and 12 months before and after the introduction of the policy between 2004 and 2006. Maternal deaths were identified by screening registers and clinical notes of all deaths in women aged 15–49 years in all units of the hospitals. These deaths were further screened for those related to delivery. The total births in the study period were also obtained in order to calculate maternal mortality ratios (MMR).
A total of 1220 (78.8%) clinical notes of 1549 registered female deaths were retrieved. A total of 334 (21.6%) maternal deaths were identified. The delivery-related MMR decreased from 445 to 381 per 100,000 total births in the CR and from 648 to 391 per 100,000 total births in the VR following the implementation of the policy. The changes in the 2 regions were not statistically significant (p=0.458) and (p=0.052) respectively. No significant changes in mean age of delivery-related deaths, duration of admission and causes of deaths before and after the policy in both regions.
The delivery-related institutional maternal mortality did not appear to have been significantly affected after about one year of implementation of the policy.
PMCID: PMC2279091  PMID: 18470329
Exemption policy; maternal death; institutional maternal deaths; Central Region; Volta Region; Ghana
10.  General practice and the New Zealand health reforms – lessons for Australia? 
New Zealand's health sector has undergone three significant restructures within 10 years. The most recent has involved a Primary Health Care Strategy, launched in 2001. Primary Health Organisations (PHOs), administered by 21 District Health Boards, are the local structures for implementing the Primary Health Care Strategy. Ninety-three percent of the New Zealand population is now enrolled within 79 PHOs, which pose a challenge to the well-established Independent Practitioner Associations (IPAs).
Although there was initial widespread support for the philosophy underlying the Primary Health Care Strategy, there are concerns amongst general practitioners (GPs) and their professional organisations relating to its implementation. These centre around 6 main issues:
1. Loss of autonomy
2. Inadequate management funding and support
3. Inconsistency and variations in contracting processes
4. Lack of publicity and advice around enrolment issues
5. Workforce and workload issues
6. Financial risks
On the other hand, many GPs are feeling positive regarding the opportunities for PHOs, particularly for being involved in the provision of a wider range of community health services. Australia has much to learn from New Zealand's latest health sector and primary health care reforms.
The key lessons concern:
• the need for a national primary health care strategy
• active engagement of general practitioners and their professional organisations
• recognition of implementation costs
• the need for infrastructural support, including information technology and quality systems
• robust management and governance arrangements
• issues related to critical mass and population/distance trade offs in service delivery models
PMCID: PMC1291356  PMID: 16262908
11.  Scattering of primary care: Doctor switching and utilization of health care by children on fee-for-service medicaid 
To determine whether children on fee-for-service Medicaid who switch primary care doctors use less health care and are less up to date with preventive care visits than children who do not switch primary care doctors.
Retrospective cohort study using Medicaid claims data.
51,027 children enrolled on Medicaid in Monroe County, New York.
14,187 children enrolled continuously on fee-for-service Medicaid between January 1992 and December 1994.
Main Outcome Measures
Utilization of primary care, emergency department (ED) services, and specialty care and proportion up to date with preventive care visits according to American Academy of Pediatrics guidelines.
During the 2-year study period, 22% of children switched primary care doctors. Compared with children who did not switch primary care doctors, those who switched had more primary care visits (4.7 vs. 3.2 visits/year,P<.01), age-adjusted preventive care visits (1.2 vs. 1.0 visits/year), ED visits (0.72 vs. 0.47 visits/year,P<.01), and specialist visits (0.99 vs. 0.31,P<.01). On multivariate analysis, doctor switching was associated with increased odds of being up to date with preventive care visits (odds ratio [OR]=1.7; 95% confidence interval [CI] 1.3 to 2.1). However, on multivariate analysis stratified by age, the association was significant only for older children (ages 11 to 14). Altogether, 68% of all children and 44% of infants less than 1 year old made the recommended number of preventive care visits during the study period.
All groups of children received less preventive care than recommended by the American Academy of Pediatrics. Children who switched primary care doctors had higher utilization of health care, including primary care, ED, and specialty care. Contrary to expectations, they were more likely to be up to date with preventive care visits. The heavy utilization of health services by doctor switchers indicates that this subgroup of children on Medicaid may not be at risk for poor access to health care, but additional research is needed to determine whether the quality of care is related to doctor switching.
PMCID: PMC3456833  PMID: 12607899
12.  Economic efficiency of gatekeeping compared with fee for service plans: a Swiss example 
Study objective
The impact of isolated gatekeeping on health care costs remains unclear. The aim of this study was to assess to what extent lower costs in a gatekeeping plan compared with a fee for service plan were attributable to more efficient resource management, or explained by risk selection.
Year 2000 costs to the Swiss statutory sick funds and potentially relevant covariates were assessed retrospectively from beneficiaries participating in an observational study, their primary care physicians, and insurance companies. To adjust for case mix, two‐part regression models of health care costs were fitted, consisting of logistic models of any costs occurring, and of generalised linear models of the amount of costs in persons with non‐zero costs. Complementary data sources were used to identify selection effects.
A gatekeeping plan introduced in 1997 and a fee for service plan, in Aarau, Switzerland.
Of each plan, 905 randomly selected adult beneficiaries were invited. The overall participation rate was 39%, but was unevenly distributed between plans.
Main results
The characteristics of gatekeeping and fee for service beneficiaries were largely similar. Unadjusted total costs per person were Sw fr231 (8%) lower in the gatekeeping group. After multivariate adjustment, the estimated cost savings achieved by replacing fee for service based health insurance with gatekeeping in the source population amounted to Sw fr403–517 (15%–19%) per person. Some selection effects were detected but did not substantially influence this result. An impact of non‐detected selection effects cannot be ruled out.
This study hints at substantial cost savings through gatekeeping that are not attributable to mere risk selection.
PMCID: PMC2465536  PMID: 16361451
economics; health care costs; managed care programmes; gatekeeping
13.  Poverty, user fees and ability to pay for health care for children with suspected dengue in rural Cambodia 
User fees were introduced in public health facilities in Cambodia in 1997 in order to inject funds into the health system to enhance the quality of services. Because of inadequate health insurance, a social safety net scheme was introduced to ensure that all people were able to attend the health facilities. However, continuing high rates of hospitalization and mortality from dengue fever among infants and children reflect the difficulties that women continue to face in finding sufficient cash in cases of medical emergency, resulting in delays in diagnosis and treatment. In this article, drawing on in-depth interviews conducted with mothers of children infected with dengue in eastern Cambodia, we illustrate the profound economic consequences for households when a child is ill. The direct costs for health care and medical services, and added indirect costs, deterred poor women from presenting with sick children. Those who eventually sought care often had to finance health spending through out-of-pocket payments and loans, or sold property, goods or labour to meet the costs. Costs were often catastrophic, exacerbating the extreme poverty of those least able to afford it.
PMCID: PMC2386469  PMID: 18439268
14.  Payment by salary or fee-for-service. Effect on health care resource use in the last year of life. 
Canadian Family Physician  1999;45:2091-2096.
OBJECTIVE: To investigate the effect of physician payment method on use of health care resources. DESIGN: Retrospective analysis of patient health care data collected for 3 years (1994 to 1996) from the Vital Statistics Department of the British Columbia Ministry of Health. Billing numbers identified physician payment method. SETTING: Salaried and fee-for-service primary care practices in the Capital Region District of Victoria, BC. PARTICIPANTS: A total of 582 patients in their last year of life: 106 were attended by salaried family physicians at a community health clinic; 476 were attended by fee-for-service practitioners. Groups were comparable in age, sex, and geographical location. MAIN OUTCOME MEASURES: Number and cost of specialist and diagnostic services and medications, number of days in hospital (acute and extended care), and main causes of death. RESULTS: None of the dependent measures showed any statistically significant differences based on comparisons between many variables for patients in the two groups. Costs of pharmaceutical, specialist, and diagnostic services were not significantly different for the two groups. There were three main causes of death, according to codes on death certificates: heart disease, malignant neoplasms, and cerebrovascular disease. CONCLUSION: Whether physicians were paid by salary or fee-for-service had no empirical effect on health care resource use.
PMCID: PMC2328544  PMID: 10509221
15.  Do health service organizations and community health centres have higher disease prevention and health promotion levels than fee-for-service practices? 
We interviewed health care providers representing 23 fee-for-service (FFS) practices, 19 health service organizations (HSOs) and 11 community health centres (CHCs) in Ontario to compare self-reported approaches to disease prevention and health promotion. Few significant differences were found across practice types in the presence of recall systems for screening or in knowledge of, compliance with or estimated coverage for selected preventive maneuvers recommended by the Canadian Task Force on the Periodic Health Examination. CHCs reported a significantly greater variety of formal health promotion programs and a greater tendency to use nonphysician health care personnel to carry out both prevention and health promotion activities. The results must be interpreted with caution because of the use of self-reported data, the low response rate for FFS practices and the use of a restrictive definition of disease prevention tied to evidence from the reports of the task force. Thus, the results cast some doubt on the common assumption that increasing the population served by alternative modes of delivery such as HSOs and CHCs necessarily increases the level of disease prevention and health promotion activity.
PMCID: PMC1451897  PMID: 2311035
16.  Better Quality of Care or Healthier Patients? Hospital Utilization by Medicare Advantage and Fee-for-Service Enrollees 
Do differences in rates of use among managed care and Fee-for-Service Medicare beneficiaries reflect selection bias or successful care management by insurers? I demonstrate a new method to estimate the treatment effect of insurance status on health care utilization. Using clinical information and risk-adjustment techniques on data on acute admission that are unrelated to recent medical care, I create a proxy measure of unobserved health status. I find that positive selection accounts for between one-quarter and one-third of the risk-adjusted differences in rates of hospitalization for ambulatory care sensitive conditions and elective procedures among Medicare managed care and Fee-for-Service enrollees in 7 years of Healthcare Cost and Utilization Project State Inpatient Databases from Arizona, Florida, New Jersey and New York matched to Medicare enrollment data. Beyond selection effects, I find that managed care plans reduce rates of potentially preventable hospitalizations by 12.5 per 1,000 enrollees (compared to mean of 46 per 1,000) and reduce annual rates of elective admissions by 4 per 1,000 enrollees (mean 18.6 per 1,000).
PMCID: PMC3923607  PMID: 24533012
17.  Issues surrounding chiropractic fee negotiations in Saskatchewan † 
Chiropractic fee negotiations in Saskatchewan utilize the Chiropractic Compensation Review Committee with recourse to the Chiropractic Consultation Committee. Health care professionals who practise on a fee for service basis provide the government with a budgetary problem. Although the fees are set, the health care provider can determine his own income by deciding how many visit services he/she wishes to provide. In the fiscal years 1981-82 to 1990-91, chiropractors earned $699.00 per year more than one would expect given the increases in fee schedules. Each chiropractor earned $2,329.00 per year more than was necessary to make up for losses due to inflation. The allegation that unnecessary treatments were performed on patients is countered by analysis of the services per discrete patient values by mode of practice. The increased earnings of chiropractors was accomplished by treating an increasing percentage of the population who sought health care. Comparative information was obtained from the four western provinces.
PMCID: PMC2484779
chiropractic fee negotiations; copayment; services per discrete patient; professional practice; physician’s practice patterns; chiropractic; manipulation
18.  Fees for Service in Medical Library Networks 
In 1969 the Cleveland Health Sciences Library began an Institutional Membership. This was to be a fee-for-service arrangement to provide for library service, consultation on library and related matters, and development of educational programs for a wide range of institutional staff. Over fifty institutions now belong. Experience suggests that serious questions are raised by such a relationship between a resource library and libraries in a number of institutions. The membership involves a per capita cost for Cleveland hospitals with house staff, and a cost-plus-fixed-fee for others. Total access has been provided in hopes that experience in use can lead to the development of costs and policies.
PMCID: PMC197691  PMID: 16017608
19.  Family practitioner committee records — a neglected resource. 1. An information service for general practitioners based on claims for fees 
Data held by a London family practitioner committee for the purpose of paying general practitioners' capitation and item of service fees were analysed every quarter for one year to provide an information service for general practices in the area. Each practice received a quarterly printout showing the age structure of its patient population, the numbers of new registrations and removals and data about items of service. These were expressed as rates which could be compared with those of the area as a whole, and with the highest and lowest rates found in individual practices. A survey at the end of the year showed that the service was welcomed and found useful by the practices. A fully computerized family practitioner committee could provide a similar service without great difficulty, and could make it more informative by linking items of service to specific age groups; data about prescribing and use of hospital and district services could also be incorporated when the relevant agencies are fully computerized too.
PMCID: PMC1960498  PMID: 3712346
20.  Learning from the Legal History of Billing for Medical Fees 
Journal of General Internal Medicine  2008;23(8):1257-1260.
When patients pay for care out-of-pocket, physicians must balance their professional obligations to serve with the commercial demands of medical practice. Consumer-directed health care makes this problem newly pressing, but law and ethics have thought for millennia about how doctors should bill patients.
Historical Background
At various points in European history, the law restricted doctors’ ability to bill for their services, but this legal aversion to commercializing medicine did not take root in the American colonies. Rather, US law has always treated selling medical services the way it treats other sales. Yet doctors acted differently in a crucial way. Driven by the economics of medical practice before the spread of health insurance, doctors charged patients according to what they thought each patient could afford. The use of sliding fee scales persisted until widespread health insurance drove a standardization of fees.
Current Practice
Today, encouraged by Medicare rules and managed care discounts, providers use a perverse form of a sliding scale that charges the most to patients who can afford the least. Primary care physicians typically charge uninsured patients one third to one half more than they receive from insurers for basic office or hospital visits, and markups are substantially higher (2 to 2.5 times) for high-tech tests and specialists’ invasive procedures.
Ethical and professional principles might require providers to return to discounting fees for patients in straitened circumstances, but imposing such a duty formally (by law or by ethical code) on doctors would be harder both in principle and in practice than to impose such a duty on hospitals. Still, professional ethics should encourage physicians to give patients in economic trouble at least the benefit of the lowest rate they accept from an established payer.
PMCID: PMC2517971  PMID: 18414955
medical fees; billing; law; ethics
21.  Effectiveness of diabetes resource nurse case management and physician profiling in a fee-for-service setting: a cluster randomized trial 
Nurses with advanced training—diabetes resource nurses (DRNs)—can improve care for people with diabetes in capitated payment settings. Their effectiveness in fee-for-service settings has not been investigated. We conducted a 12-month practice-randomized trial involving 22 practices in a fee-for-service metropolitan network with 92 primary care physicians caring for 1891 Medicare patients ≥65 years with diabetes mellitus. Each practice was randomized to one of three intervention groups: physician feedback on process measures using Medicare claims data; Medicare claims feedback plus feedback on clinical measures from medical record (MR) abstraction; or both types of feedback plus a practice-based DRN. The primary endpoint investigated was hemoglobin A1c level. Other measures were low-density lipoprotein (LDL) cholesterol level, blood pressure, annual hemoglobin A1c testing, annual LDL screening, annual eye exam, annual foot exam, and annual renal assessment. Data were collected from medical chart abstraction and Medicare claims. The number of patients with hemoglobin A1c <9% increased by 4 (0.9%) in the Claims group; 9 (2.1%) in the Claims + MR group (comparison with Claims: P = 0.97); and 16 (3.8%) in the DRN group (comparison with Claims: P = 0.31). Results were similar for the other clinical outcomes, with no differences significant at P = 0.10. For process of care measures, decreases were seen in all groups, with no significant differences in change scores. Quality improvement strategies must be evaluated in the appropriate setting. Initiatives that have been effective in capitated systems may not be effective in fee-for-service environments.
PMCID: PMC1426180  PMID: 16609732
22.  Preventive attitudes, beliefs, and practices of physicians in fee-for-service and health maintenance organization settings. 
Western Journal of Medicine  1989;150(2):221-225.
To identify the self-reported differences in preventive practices, attitudes, and beliefs of physicians practicing in fee-for-service (FFS) and health maintenance organization (HMO) settings, we surveyed a 100% sample of primary care physicians practicing in a large, urban, closed-panel HMO and a random sample of physicians, in the same county, who were in an FFS practice. The FFS physicians were more likely to consider behavioral risk factors important than were HMO physicians, and they were more likely to ask their patients about behavioral risk factors. Fee-for-service physicians were more likely than HMO physicians to use continuing medical education courses to upgrade their skills in modifying behavioral risk factors. There was little difference in the self-reported proportion of patients with specific behavioral risks in the FFS and HMO practices. Also, both groups were comparable in their perception of their ability to do behavioral counseling and their perceived success in such counseling. We conclude that FFS physicians are more likely to have positive preventive beliefs, attitudes, and practices than are HMO physicians.
PMCID: PMC1026358  PMID: 2728448
23.  A Comparison of Two Approaches to Increasing Access to Care: Expanding Coverage versus Increasing Physician Fees 
Health Services Research  2012;47(3 Pt 1):963-983.
To compare the effects of a coverage expansion versus a Medicaid physician fee increase on children's utilization of physician services.
Primary Data Source
National Health Interview Survey (1997–2009).
Study Design
We use the Children's Health Insurance Program, enacted in 1997, as a natural experiment, and we performed a panel data regression analysis using the state-year as the unit of observation. Outcomes include physician visits per child per year and the following indicators of access to primary care: whether the child saw a physician, pediatrician, or visited an ER in the last year, and whether the parents reported experiencing a non-cost-related access problem. We analyzed these outcomes among all children, and separately among socioeconomic status (SES) quartiles defined based on family income and parents' education.
Principal Findings
Children's Health Insurance Program had a major impact on the extent and nature of children's insurance coverage. However, it is not associated with any change in the aggregate quantity of physician services, and its associations with indicators of access are mixed. Increases in physician fees are associated with broad-based improvements in indicators of access.
The findings suggest that (1) coverage expansions, even if they substantially reduce patient cost sharing, do not necessarily increase physician utilization, and (2) increasing the generosity of provider payments in public programs can improve access among low-SES children, and, through spillover effects, increase higher-SES children as well.
PMCID: PMC3423185  PMID: 22299763
Children's Health Insurance Program; physician utilization; physician fees; coverage expansion; access
24.  Health worker perspectives on user fee removal in Zambia 
User fees for primary care services were removed in rural districts in Zambia in 2006. Experience from other countries has suggested that health workers play a key role in determining the success of a fee removal policy, but also find the implementation of such a policy challenging. The policy was introduced against a backdrop of a major shortage in qualified health staff.
As part of a larger study on the experience and effect of user fee removal in Zambia, a number of case studies at the facility level were conducted. As part of these, quantitative and qualitative data were collected to evaluate health workers’ satisfaction and experiences in charging and non-charging facilities.
Our findings show that health-care workers have mixed feelings about the policy change and its consequences. We found some evidence that personnel motivation was higher in non-charging facilities compared to facilities still charging. Yet it is unclear whether this effect was due to differences in the user fee policy or to the fact that a lot of staff interviewed in non-charging facilities were working in mission facilities, where we found a significantly higher motivation. Health workers expressed satisfaction with an apparent increase in the number of patients visiting the facilities and the removal of a deterring factor for many needy patients, but also complained about an increased workload. Furthermore, working conditions were said to have worsened, which staff felt was linked to the absence of additional resources to deal with the increased demand or replace the loss of revenue generated by fees.
These findings highlight the need to pay attention to supply-side measures when removing demand-side barriers such as user fees and in particular to be concerned about the burden that increased demand can place on already over-stretched health workers.
PMCID: PMC3507712  PMID: 23110690
User fees; Motivation; Human resources; Health financing; Free care; Zambia
25.  A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa) 
African policy-makers are increasingly considering abolishing user fees as a solution to improve access to health care systems. There is little evidence on this subject in West Africa, and particularly in countries that have organized their healthcare system on the basis of the Bamako Initiative. This article presents a process evaluation of an NGO intervention to abolish user fees in Niger for children under five years and pregnant women.
The intervention was launched in 2006 in two health districts and 43 health centres. The intervention consisted of abolishing user fees and improving the quality of services (drugs, ambulance, etc.). We carried out a process evaluation in April 2007 using qualitative and quantitative data. Three data collection methods were used: i) individual in-depth interviews (n = 85) and focus groups (n = 8); ii) participant observation in 12 health centres; and iii) self-administered structured questionnaires (n = 51 health staff).
The population favoured abolition; health officials and local decision-makers were in favour, but they worried about its sustainability. Among health workers, opposition to providing free services was more widespread. The strengths of the process were: a top-down phase of information and raising community awareness; appropriate incentive measures; a good drug supply system; and the organization of a medical evacuation system. The major weaknesses of the process were: the perverse effects of incentive bonuses; the lack of community-based management committees' involvement in the management; the creation of a system running in parallel with the BI system; the lack of action to support the service offer; and the poor coordination of the availability of free services at different levels of the health pyramid. Some unintended outcomes are also documented.
The linkages between systems in which some patients pay (Bamako Initiative) and some do not should be carefully considered and organized in accordance with the local reality. For the poorest patients to really benefit, it is essential that, at the same time, the quality of services be improved and mechanisms be put in place to prevent abuses. Much remains to be done to generate knowledge on the processes for abolishing fees in West Africa.
PMCID: PMC2698841  PMID: 19493354

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