RESUMO
BACKGROUND: Capitation models of care in dentistry started around 1973 with varying degrees of success in meeting the needs of the individuals and expectations of the participating private practitioners. These studies mostly identified that capitation payments resulted in under treatment whilst fee-for-service models often led to over treatment. The objective of this study was to develop a new way of doing business using an outsourcing capitation model of care to meet population health needs and activity-based funding requirements of rural Local Health Districts with a local university dental school. This payment model is an alternate referral pathway for public oral health practitioners from the existing New South Wales Oral Health Fee-for-Service Scheme that focuses on urgent treatment to one that offers an all-inclusive preventive approach that concentrates on sustaining good long-term oral health for the individual. METHOD: The reflective study analysed various adult age cohorts (18-24, 25-34, 35-44, 45-54, 55-64, 65-74 and 75 + years) based on 950 participants randomly selected from the Greater Southern adult public dental waiting lists. The study's capitation formula was derived from NSW government adult treatment items (n = 447,625). Dental care was provided through the local university's dental clinics utilising only dental students under clinical supervision. All data were sourced from NSW Oral Health Data Warehouse during 1 January 2012-30 June 2018 and analysed by using SAS 9.3 and Version 13 Microsoft Excel. RESULTS: There were 10,305 dental care items and 1129 capitation courses of care totalling A$599,026. This resulted in an average of 11 dental care items being provided to each participant. The capitation payment formula utilising the most provided dental care items of 100 individual patients proved to be economical and preventive focused. CONCLUSION: The systematic reflection showed that this unique methodology in developing an adult capitation payment formula associated to diagnostic pathways that resulted in: (i) more efficient usage of government expenditure on public dental services, (ii) provision of person-centred courses of dental care, and (iii) utilisation of university dental education programs to best practice treatment and holistic care.
Assuntos
Capitação , Universidades , Adolescente , Adulto , Austrália , Planos de Pagamento por Serviço Prestado , Humanos , Saúde Bucal , Adulto JovemAssuntos
Medicare Part C , Cobertura Universal do Seguro de Saúde , Capitação , Financiamento Pessoal , Planos de Assistência de Saúde para Empregados , Gastos em Saúde , Humanos , Seguro de Saúde (Situações Limítrofes)/economia , Medicare Part C/economia , Medicare Part C/organização & administração , Medicare Part C/estatística & dados numéricos , Programas Nacionais de Saúde/organização & administração , Política , Estados Unidos , Cobertura Universal do Seguro de Saúde/economia , Cobertura Universal do Seguro de Saúde/organização & administraçãoRESUMO
[RESUMEN]. Los países de América Latina y el Caribe necesitan aumentar sus recursos públicos en salud para ampliar el acceso equitativo y eficiente a la salud. El aumento debe financiar un modelo específico que ha mostrado evidencia de eficacia, como el de redes integradas de servicios de salud (RISS) basadas en atención primaria de salud. La literatura global no ha prestado suficiente atención al financiamiento a las RISS; más bien se ha focalizado en establecimientos y agentes aislados, así como en mecanismos específicos. Sin embargo, en la Región de las Américas su desarrollo es una necesidad desde hace años. Una RISS es un conjunto de organizaciones de salud que ofrece intervenciones y servicios de salud coordinados a una población bajo su cargo y asume la responsabilidad de salud y económica en el logro de mejores resultados de salud. Un sistema de pago a una RISS debe ir dirigido a promover la integralidad de la atención y a fomentar un enfoque centrado en el ciclo de vida de las personas, la articulación y la coordinación de servicios. El presupuesto poblacional ajustado por riesgos se muestra como un mecanismo posible y potente para apoyar el logro de los objetivos. Su desarrollo requiere reconocer que la forma de financiamiento no responderá por sí sola a los desafíos y que se necesita, a la vez, de la planificación y de la gestión sanitarias. Se requiere abordar los desafíos técnicos, políticos e institucionales para tener éxito en este esfuerzo, que a su vez debe estar inserto en el proceso global de transformación de los sistemas de salud hacia la salud universal.
[ABSTRACT]. The countries of Latin America and the Caribbean need to increase their public resources in health to expand equitable and efficient access to health. The increase should finance a specific model with proven effectiveness, such as integrated health service networks (IHSN) based on primary health care. The global literature has not paid sufficient attention to financing IHSN; rather, it has focused on isolated facilities and agents, as well as on specific mechanisms. However, in the Region of the Americas, their development has been a necessity for years. An IHSN is a group of health organizations that offers coordinated health interventions and services to a population under their charge and assumes health and economic responsibility for achieving better health outcomes. A system of payment to an IHSN should be aimed at promoting the integrality of care and encouraging a focus on the life cycle of individuals, the articulation and the coordination of services. The risk-adjusted population budget is a possible and powerful mechanism to support the achievement of the objectives. Its development requires the recognition that the type of financing alone will not respond to the challenges and that there is a need for both health planning and health management. The technical, political and institutional challenges need to be addressed to succeed in this effort, which in turn must be embedded in the overall process of transforming health systems towards universal health.
Assuntos
Alocação de Recursos para a Atenção à Saúde , Capitação , Sistemas de Saúde , Financiamento da Assistência à Saúde , América , Alocação de Recursos para a Atenção à Saúde , Capitação , Sistemas de Saúde , Financiamento da Assistência à Saúde , AméricaRESUMO
BACKGROUND & AIMS: Use of monitored anesthesia care (MAC) for gastrointestinal endoscopy has increased in the Veterans Health Administration (VHA) as in fee-for-service environments, despite the absence of financial incentives. We investigated factors associated with use of MAC in an integrated health care delivery system with a capitated payment model. METHODS: We performed a retrospective cohort study using multilevel logistic regression, with MAC use modeled as a function of procedure year, patient- and provider-level factors, and facility effects. We collected data from 2,091,590 veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy during fiscal years 2000-2013 at 133 facilities. RESULTS: The adjusted rate of MAC use in the VHA increased 17% per year (odds ratio for increase, 1.17; 95% confidence interval, 1.09-1.27) from fiscal year 2000 through 2013. The most rapid increase occurred starting in 2011. VHA use of MAC was associated with patient-level factors that included obesity, obstructive sleep apnea, higher comorbidity, and use of prescription opioids and/or benzodiazepines, although the magnitude of these effects was small. Provider-level and facility factors were also associated with use of MAC, although again the magnitude of these associations was small. Unmeasured facility-level effects had the greatest effect on the trend of MAC use. CONCLUSIONS: In a retrospective study of veterans who underwent outpatient esophagogastroduodenoscopy and/or colonoscopy from fiscal year 2000 through 2013, we found that even in a capitated system, patient factors are only weakly associated with use of MAC. Facility-level effects are the most prominent factor influencing increasing use of MAC. Future studies should focus on better defining the role of MAC and facility and organizational factors that affect choice of endoscopic sedation. It will also be important to align resources and incentives to promote appropriate allocation of MAC based on clinically meaningful patient factors.
Assuntos
Assistência Ambulatorial/tendências , Anestesia/tendências , Anestesiologistas/tendências , Capitação/tendências , Prestação Integrada de Cuidados de Saúde/tendências , Endoscopia Gastrointestinal/tendências , Gastroenterologistas/tendências , Padrões de Prática Médica/tendências , Avaliação de Processos em Cuidados de Saúde/tendências , Idoso , Assistência Ambulatorial/economia , Anestesia/efeitos adversos , Anestesia/economia , Anestesiologistas/educação , Prestação Integrada de Cuidados de Saúde/economia , Registros Eletrônicos de Saúde , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/economia , Feminino , Gastroenterologistas/economia , Pesquisa sobre Serviços de Saúde , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Padrões de Prática Médica/economia , Avaliação de Processos em Cuidados de Saúde/economia , Estudos Retrospectivos , Fatores de Risco , Estados Unidos , United States Department of Veterans Affairs/economia , United States Department of Veterans Affairs/tendênciasAssuntos
Assistência de Longa Duração/organização & administração , Assistência Terminal/organização & administração , Diretivas Antecipadas , Negro ou Afro-Americano , Moradias Assistidas , Canadá , Capitação , Ensaios de Uso Compassivo , Comportamento do Consumidor , Aconselhamento , Demência/terapia , Depressão , Europa (Continente) , Custos de Cuidados de Saúde , Hispânico ou Latino , Cuidados Paliativos na Terminalidade da Vida , Humanos , Reembolso de Seguro de Saúde , Maconha Medicinal , Medicare/economia , Musicoterapia , Enfermagem , Casas de Saúde , Cuidados Paliativos , Planejamento de Assistência ao Paciente , Direitos do Paciente , Prisioneiros , Qualidade da Assistência à Saúde , Ordens quanto à Conduta (Ética Médica) , Cônjuges , Governo Estadual , Suicídio Assistido , Telemedicina , Doente Terminal , Obtenção de Tecidos e Órgãos , Estados Unidos , Veteranos , População Branca , Recursos HumanosRESUMO
BACKGROUND: The South African government intends to contract with 'accredited provider groups' for capitated primary care under National Health Insurance (NHI). South African solo general practitioners (GPs) are unhappy with group practice. There is no clarity on the views of GPs in group practice on contracting to the NHI. OBJECTIVES: To describe the demographic and practice profile of GPs in group practice in South Africa, and evaluate their views on NHI, compared to solo GPs. METHODS: This was a descriptive survey. The population of 8721 private GPs in South Africa with emails available were emailed an online questionnaire. Descriptive statistical analyses and thematic content analysis were conducted. RESULTS: In all, 819 GPs responded (568 solo GPs and 251 GPs in groups). The results are focused on group GPs. GPs in groups have a different demographic practice profile compared to solo GPs. GPs in groups expected R4.86 million ($0.41 million) for a hypothetical NHI proposal of comprehensive primary healthcare (excluding medicines and investigations) to a practice population of 10 000 people. GPs planned a clinical team of 8 to 12 (including nurses) and 4 to 6 administrative staff. GPs in group practices saw three major risks: patient, organisational and government, with three related risk management strategies. CONCLUSIONS: GPs can competitively contract with NHI, although there are concerns. NHI contracting should not be limited to groups. All GPs embraced strong teamwork, including using nurses more effectively. This aligns well with the emergence of family medicine in Africa.
Assuntos
Atitude do Pessoal de Saúde , Clínicos Gerais/psicologia , Prática de Grupo/economia , Adulto , Capitação , Medicina de Família e Comunidade/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde/economia , Mecanismo de Reembolso , África do Sul , Inquéritos e QuestionáriosRESUMO
Policy makers in low and middle-income countries are frequently confronted with challenges of increasing health access for poor populations in a sustainable manner. After several years of trying out different health financing mechanisms, health insurance has recently emerged as a pro-poor health financing policy. Capitation, a fixed fee periodically paid to health service providers for anticipated services, is one of the payment policies in health insurance. This article examines claims and counter-claims made by coalitions and individual stakeholders in a capitation payment policy debate within Ghana's National Health Insurance Scheme. Using content analysis of public and parliamentary proceedings, we situate the debate within policy making and health insurance literature. We found that the ongoing capitation payment debate stems from challenges in implementation of earlier health insurance claims payment systems, which reflect broader systemic challenges facing the health insurance scheme in Ghana. The study illustrates the extent to which various sub-systems in the policy debate advance arguments to legitimize their claims about the contested capitation payment system. In addition, we found that the health of poor communities, women and children are being used as surrogates for political and individual arguments in the policy debate. The article recommends a more holistic and participatory approach through persuasion and negotiation to join interests and core evidence together in the capitation policy making in Ghana and elsewhere with similar contexts.
Assuntos
Capitação , Financiamento Governamental/economia , Acessibilidade aos Serviços de Saúde , Programas Nacionais de Saúde/organização & administração , Formulação de Políticas , Coleta de Dados , Gana , Política de Saúde , Humanos , Qualidade da Assistência à SaúdeAssuntos
Prestação Integrada de Cuidados de Saúde , Assistência Odontológica , Programas de Assistência Gerenciada , Capitação , Prestação Integrada de Cuidados de Saúde/organização & administração , Assistência Odontológica/organização & administração , Odontólogos/economia , Registros Eletrônicos de Saúde , Odontologia Baseada em Evidências , Conselho Diretor , Nível de Saúde , Humanos , Programas de Assistência Gerenciada/organização & administração , Oregon , Planejamento de Assistência ao Paciente , Segurança do Paciente , Satisfação do Paciente , Garantia da Qualidade dos Cuidados de Saúde , Participação no Risco Financeiro , Salários e Benefícios , WashingtonRESUMO
OBJECTIVE: To analyse and synthesize available international experiences and information on the motivation for, and effects of using capitation as provider payment method in country health systems and lessons and implications for low/middle-income countries. METHODS: We did narrative review and synthesis of the literature on the effects of capitation payment on primary care. RESULTS: Eleven articles were reviewed. Capitation payment encourages efficiency: drives down cost, serves as critical source of income for providers, promotes adherence to guidelines and policies, encourages providers to work better and give health education to patients. It, however, induces reduction in the quantity and quality of care provided and encourages skimming on inputs, underserving of patients in bad state of health, "dumping" of high risk patients and negatively affect patient-provider relationship. CONCLUSION: The illustrative evidence adduced from the review demonstrates that capitation payment in primary care can create positive incentives but could also elicit un-intended effects. However, due to differences in country context, policy makers in Ghana and other low/middle-income countries may only be guided by the illustrative evidence in their design of a context-specific capitation payment for primary care. FUNDING: Netherlands Fellowship Programme (NFP), Fellowship number: NFP-PhD.12/352.
Assuntos
Capitação , Países em Desenvolvimento , Gastos em Saúde , Atenção Primária à Saúde/economia , Gana , Humanos , Programas Nacionais de SaúdeRESUMO
BACKGROUND: Diabetes mellitus contributes substantially to the non-communicable disease burden in South Africa. The proposed National Health Insurance system provides an opportunity to consider the development of a cost-effective capitation model of care for patients with type 2 diabetes. The objective of the study was to determine the potential cost-effectiveness of adapting a private sector diabetes management programme (DMP) to the South African public sector. METHODS: Cost-effectiveness analysis was undertaken with a public sector model of the DMP as the intervention and a usual practice model as the comparator. Probabilistic modelling was utilized for incremental cost-effectiveness ratio analysis with life years gained selected as the outcome. Secondary data were used to design the model while cost information was obtained from various sources, taking into account public sector billing. RESULTS: Modelling found an incremental cost-effectiveness ratio (ICER) of ZAR 8 356 (USD 1018) per life year gained (LYG) for the DMP against the usual practice model. This fell substantially below the Willingness-to-Pay threshold with bootstrapping analysis. Furthermore, a national implementation of the intervention could potentially result in an estimated cumulative gain of 96 997 years of life (95% CI 71 073 years - 113 994 years). CONCLUSIONS: Probabilistic modelling found the capitation intervention to be cost-effective, with an ICER of ZAR 8 356 (USD 1018) per LYG. Piloting the service within the public sector is recommended as an initial step, as this would provide data for more accurate economic evaluation, and would also allow for qualitative analysis of the programme.
Assuntos
Capitação , Análise Custo-Benefício , Diabetes Mellitus Tipo 2/economia , Modelos Econômicos , Setor Público , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde , Setor Privado , África do SulRESUMO
Caring for the 9 million low-income elderly or disabled adults who are eligible for full benefits under both Medicare and Medicaid can be extremely costly. As part of the federal Financial Alignment Initiative, states have the opportunity to test care models for dual-eligibles that integrate acute care, behavioral health and mental health services, and long-term services and supports, with the goals of enhancing access to services, improving care quality, containing costs, and reducing administrative barriers. One of the challenges in designing these demonstrations is choosing and applying measures that accurately track changes in quality over timeessential for the rapid identification of effective innovations. This brief reviews the quality measures chosen by eight demonstration states as of December 2013. The authors find that while some quality domains are well represented, others are not. Quality-of-life measures are notably lacking, as are informative, standardized measures of long-term services and supports.
Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Elegibilidade Dupla ao MEDICAID e MEDICARE , Programas de Assistência Gerenciada/organização & administração , Indicadores de Qualidade em Assistência à Saúde , Adulto , Idoso , Idoso de 80 Anos ou mais , Capitação/organização & administração , Planos de Pagamento por Serviço Prestado/organização & administração , Humanos , Assistência de Longa Duração , Pessoa de Meia-Idade , Projetos Piloto , Qualidade de Vida , Governo Estadual , Estados UnidosAssuntos
Reforma dos Serviços de Saúde , Equipe de Assistência ao Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Capitação , Prestação Integrada de Cuidados de Saúde/economia , Prestação Integrada de Cuidados de Saúde/organização & administração , Humanos , Assistência Centrada no Paciente , Papel do Médico , Médicos de Atenção Primária , Atenção Primária à Saúde/economia , Mecanismo de Reembolso , Estados UnidosAssuntos
Prestação Integrada de Cuidados de Saúde , Medicaid/economia , Medicare/economia , Idoso , Capitação , Pessoas com Deficiência , Definição da Elegibilidade , Planos de Pagamento por Serviço Prestado , Gastos em Saúde/estatística & dados numéricos , Humanos , Medicaid/organização & administração , Medicare/organização & administração , Estados UnidosAssuntos
Capitação , Prestação Integrada de Cuidados de Saúde , Reforma dos Serviços de Saúde , Atenção Primária à Saúde/economia , Reembolso de Incentivo , Participação da Comunidade , Planos Médicos Alternativos/economia , Análise Custo-Benefício , Tomada de Decisões , Prestação Integrada de Cuidados de Saúde/economia , Prestação Integrada de Cuidados de Saúde/normas , Competição Econômica , Planos de Assistência de Saúde para Empregados , Reforma dos Serviços de Saúde/economia , Reforma dos Serviços de Saúde/legislação & jurisprudência , Acessibilidade aos Serviços de Saúde , Humanos , Assistência Médica/legislação & jurisprudência , Autonomia Pessoal , Qualidade da Assistência à Saúde , Estados UnidosAssuntos
Centros Médicos Acadêmicos/organização & administração , Prestação Integrada de Cuidados de Saúde/organização & administração , Centros Médicos Acadêmicos/economia , Baltimore , Capitação , Redução de Custos , Medicare/economia , Medicare/organização & administração , Cultura Organizacional , Inovação Organizacional , Equipe de Assistência ao Paciente , Mecanismo de Reembolso , Estados UnidosAssuntos
Capitação , Prestação Integrada de Cuidados de Saúde/economia , Idoso Fragilizado , Programas de Assistência Gerenciada/economia , Medicaid/economia , Medicare/economia , Idoso , Doença Crônica , Definição da Elegibilidade , Reforma dos Serviços de Saúde , Humanos , Governo Estadual , Estados UnidosAssuntos
Medicina de Família e Comunidade/organização & administração , Equipe de Assistência ao Paciente , Assistência Centrada no Paciente , Atenção Primária à Saúde/organização & administração , Mecanismo de Reembolso , Fatores Etários , Capitação , Feminino , Humanos , Masculino , Programas Nacionais de Saúde , Ontário , Atenção Primária à Saúde/legislação & jurisprudência , Recursos HumanosRESUMO
Economics influences how medical care is delivered, organized, and progresses. Fee-for-service payment encourages delivery of services. Fee-for-individual-service, however, offers no incentives for clinicians to efficiently organize the care their patients need. Global capitation provides such incentives; it works well in highly integrated practices but not for independent practitioners. The failures of utilization management in the 1990s demonstrated the need for a third alternative to better align incentives, such as bundling payment for an episode of care. Building on Medicare's approach to hospital payment, one can define expanded diagnosis-related groups that include all hospital, physician, and other costs during the stay and appropriate preadmission and postdischarge periods. Physicians and hospitals voluntarily forming a new entity (a care delivery team) would receive such bundled payments along with complete flexibility in allocating the funds. Modifications to gainsharing and antikickback rules, as well as reforms to malpractice liability laws, will facilitate the functioning of the care delivery teams. The implicit financial incentives encourage efficient care for the patient; the episode focus will facilitate measuring patient outcomes. Payment can be based on the resources used by those care delivery teams achieving superior outcomes, thereby fostering innovation improving outcomes and reducing waste.
Assuntos
Prestação Integrada de Cuidados de Saúde/economia , Regulamentação Governamental , Custos de Cuidados de Saúde , Reforma dos Serviços de Saúde/economia , Política de Saúde/economia , Seguro Saúde/economia , Planos de Incentivos Médicos/economia , Reembolso de Incentivo/economia , Artroplastia do Joelho/economia , Capitação , Redução de Custos , Análise Custo-Benefício , Prestação Integrada de Cuidados de Saúde/legislação & jurisprudência , Prestação Integrada de Cuidados de Saúde/organização & administração , Planos de Pagamento por Serviço Prestado , Custos de Cuidados de Saúde/legislação & jurisprudência , Reforma dos Serviços de Saúde/organização & administração , Gastos em Saúde , Humanos , Seguro Saúde/legislação & jurisprudência , Objetivos Organizacionais , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Equipe de Assistência ao Paciente/economia , Planos de Incentivos Médicos/legislação & jurisprudência , Planos de Incentivos Médicos/organização & administração , Qualidade da Assistência à Saúde/economia , Reembolso de Incentivo/legislação & jurisprudência , Reembolso de Incentivo/organização & administração , Resultado do TratamentoRESUMO
BACKGROUND: Lengthy recovery and treatment times following cardiosurgical interventions were the motivation for introducing a pilot procedure to integrate acute and rehabilitative treatment structures. The advantage of such a pilot procedure is the medico-economic link between direct transition from acute care to rehabilitation treatment and cutting average case costs. With this in mind, shared case fees for patients following cardiosurgery are being agreed in a pilot project between health insurance companies, acute-care hospitals and rehabilitation clinics. The aim of this study was thus to investigate whether rehabilitation directly after cardiosurgery without prior transferral to an acute-care hospital is comparable with the conventional procedure involving acute care. METHODS: A total of 221 patients were included in the investigation. The pilot project group comprised 159 patients (mean age 70 +/- 6 yrs, 117 men and 42 women) who were transferred directly to rehabilitation following cardiosurgery. The control group, comprising 62 patients (mean age = 71 +/- 6 yrs, 42 men and 20 women), was transferred to an acute-care hospital following cardiosurgery before commencing rehabilitation. Sociodemographic and clinical data were comparable between the two groups. RESULTS: At the end of rehabilitation, the mean maximum ergometric performance in the pilot group was 96 +/- 33 W, significantly higher than the control group's performance of 81 +/- 31 W. One difference between the two groups related to complications. During rehabilitation, complications occurred more frequently within the pilot group. In the pilot group, compared to the control group, postcardiotomy syndrome occurred in 45.3 versus 25.8% and impaired wound healing in 10.1 versus 4.8% of cases. Despite these results, the pilot group demonstrated a significantly shorter overall hospital stay of 39.5 +/- 7.5 days compared to the control group stay of 45.7 +/- 9.7 days. CONCLUSION: Compared to the control group, the pilot group was at no disadvantage with regard to clinical or performance data by the end of rehabilitation. Cardiac complications occur more often during rehabilitation taking place directly after cardiosurgery than with the conventional procedure. These can be viewed, however, as complications occurring directly in temporal conjunction with the operation and as to be expected. Complications attributed directly to fast-track rehabilitation can be excluded. In the pilot group the overall hospital stay was thus shortened. In an environment of legislative restructuring within the healthcare sector, this shows that adequate treatment of cardiosurgical patients is still guaranteed with fast-track rehabilitation.