Effects of a fundholding discontinuation. An Israeli health maintenance organization natural experiment.

OBJECTIVE: To evaluate the effects of fundholding on cost containment and after termination of the project. DESIGN AND SETTING: Primary care practices participating in the project were allocated an itemized budget. Practices assumed authority for hospitalization, drugs, ambulatory medical diagnostic, consultant services and acquisition of minor equipment. Financial incentives were offered, but no penalties were imposed on practices where expenditure exceeded budget. SUBJECTS: Nine primary care practices in southern Israel. MAIN OUTCOME MEASURE: Total expenditure and a breakdown of expenditure per capita. RESULTS: Fundholding practice expenditure was compared with expenditure in the district as a whole. During the study period, total expenditure in fundholding practices rose by 12%, whereas that of the district rose by 37%. With discontinuation of the project, expenditure of the designated practices returned to the original levels, equivalent to those of the district. CONCLUSION: Fundholding is an efficient method of cost-containment. The effect will be long lasting only if motivation is maintained.

The prescription pattern of oral nitrates in coronary artery disease. Appropriateness and cost considerations.

OBJECTIVES: To evaluate the prescription patterns of oral nitrates in terms of appropriateness and cost in a community setting. METHODS: A period prevalence, descriptive, applied study. Data including age, gender, type of medication, dosage and cost were extracted from the database of the largest health maintenance organisation (HMO) in Israel. The study population included enrollees over 35 years of age who received oral nitrates at least once during the 12-month study period. RESULTS: Oral nitrates were prescribed for 8007 patients (mean age 72.85+/-9.59 years, male:female ratio 1:1). A total of 52,694 prescriptions were issued for 56,553 medications, of these 88.1% for mononitrates, which constituted 95% of the annual cost for patients and the HMO. The mean prescribed daily dose for the various drugs ranged from 30% less than to 50% more than the recommended dose. Combination therapy with at least two nitrates, which is not the recommended treatment, was given to 5% of the patients. The recommended alternative treatment will alleviate the financial burden for providers and patients. CONCLUSIONS: Improved prescription habits can provide enhanced quality as well as cost savings for patients and providers.