Revenue of consultant physicians for private out-patient consultations.

Objective The aim of this study was to determine the revenue to consultant physicians for private out-patient consultations. Specifically, the study determined changing patterns in revenue from 2011 to 2015 after accounting for bulk-billing rates, changes in gap fees and inflation. Methods An analysis was performed of consultant physician Medicare claims data from 2011 to 2015 for initial (Item 110) and subsequent (Item 116) consultations and, for patients with multiple morbidities, initial management planning (Item 132) and review consultations (Item 133). The analysis included 12 medical specialties representative of common adult non-surgical medical care. Revenue to consultant physicians was calculated for initial consultations (Item 110: standard; Item 132: complex) and subsequent consultations (Item 116: standard; Item 133: complex) accounting for bulk-billing rates, changes in gap fees and inflation. Results From 2011 to 2015, there was a decrease in inflation-adjusted revenue from standard initial and subsequent consultations (mean -$2.69 and -$1.03 respectively). Accounting for an increase in the use of item codes for complex consultations over the same time period, overall revenue from initial consultations increased (mean +$2.30) and overall revenue from subsequent consultations decreased slightly (mean -$0.28). All values reported are in Australian dollars. Conclusions The effect of the multiyear Medicare freeze on consultant physician revenue has been partially offset by changes in billing practices. What is known about the topic? There was a 'freeze' on Medicare schedule fees for consultations from November 2012 to July 2018. Concerns were expressed that the schedule has not kept pace with inflation and does not represent appropriate payments to physicians. What does this paper add? Accounting for bulk-billing, changes in gap fees and inflation, revenue from standard initial and subsequent consultations decreased from 2011 to 2015. Use of item codes for complex consultations (which have associated higher schedule fees) increased from 2011 to 2015. When standard and complex consultation codes are analysed together (and accounting for bulk-billing, changes in gap fees and inflation), revenue from initial consultations increased and revenue from subsequent consultations decreased slightly. What are the implications for practitioners? Efforts to control government expenditure through Medicare rebate payment freezes may result in unintended consequences. Although there were no overall decreases in bulk-billing rates, the shift to higher-rebate consultations was noticeable.

General paediatrics outpatient consultation fees, bulk billing rates and service use patterns in Australia.

OBJECTIVE: To determine: 1) the mean, median and range of fees for initial and subsequent private outpatient consultations with a general paediatrician in Australia; 2) any variation in fees and bulk billing rates between states/territories; and 3) volume of outpatient general paediatric specialist consultations relative to child population. METHODS: Analysis of Medicare claims data from the years 2011 and 2014 for initial consultations (items 110 and 132), subsequent consultations (items 116 and 133), and autism or pervasive developmental disorder (PDD) initial consultation (item 135) with a general paediatrician. RESULTS: Fees for initial and subsequent general paediatric outpatient consultations varied within, and between, states and territories. Fees increased slightly from 2011 to 2014, after accounting for inflation. The volume of consultations relative to child population varied markedly across states and territories, as did bulk billing rates. Use of item codes for patients with multiple morbidities (132 and 133) increased significantly from 2011 to 2014. Autism/PDD consultation service use (item 135) and fees remained relatively stable. CONCLUSIONS: There was variation in service use, fees and bulk billing within, and between, states and territories, and across time and consultation types. Implications for public health: Future studies should assess the impact of such variation on access to paediatric services and the relationship, if any, to variation in state investment in public paediatric outpatient services.

Integrated care of muscular dystrophies in Italy. Part 2. Psychological treatments, social and welfare support, and financial costs.

This paper describes the psycho-social treatments received by 502 patients with MDs and their relatives, and the costs for care sustained by the families in the previous six month period. Data were collected by the MD-Care Schedule (MD-CS) and the Family Problems Questionnaire (FPQ). Psycho-educational interventions were provided to 72 patients (14.3%), and social/welfare support to 331 patients (65.9%). Social/welfare support was higher in patients with DMD or LGMD, in those showing more severe disability, and in patients who were in contact with centres located in Northern Italy. Psycho-educational interventions were received by 156 (31%) relatives, and social/welfare support by 55 (10.9%) and mainly provided by Family/Patients Associations (83.6%). Relatives with higher educational levels, who spent more daily hours in the assistance of patients with DMD, and in contact with centres in Central Italy more frequently benefited from psycho-educational interventions. In the previous year, costs for care were sustained by 314 (63.9%) relatives. Financial difficulties related to patient's condition, were higher in families of patients who needed more intensive rehabilitation and daily hours of caregiving, and in families who lived further away from the reference's centre. These results showed that psycho-social aspects of MDs care are only partially met in Italy, and that ad hoc supportive interventions for these patients and their families should be potentiated.

Variation in outpatient consultant physician fees in Australia by specialty and state and territory.

OBJECTIVES: To determine the mean, median and 10th and 90th percentile levels of fees and out-of-pocket costs to the patient for an initial consultation with a consultant physician; to determine any differences in fees and bulk-billing rates between specialties and between states and territories. DESIGN, PARTICIPANTS AND SETTING: Analysis of 2015 Medicare claims data for an initial outpatient appointment with a consultant physician (Item 110) in 11 medical specialties representative of common adult non-surgical medical care (cardiology, endocrinology, gastroenterology, geriatric medicine, haematology, immunology/allergy, medical oncology, nephrology, neurology, respiratory medicine and rheumatology). MAIN OUTCOME MEASURES: Mean, median, 10th and 90th percentile levels for consultant physician fees and out-of-pocket costs, by medical specialty and state or territory; bulk-billing rate, by medical specialty and state/territory. RESULTS: Bulk-billing rates varied between specialties, with only haematology and medical oncology bulk-billing more than half of initial consultations. Bulk-billing rates also varied between states and territories, with rates in the Northern Territory (76%) nearly double those elsewhere. Most private consultations require a significant out-of-pocket payment by the patient, and these payments varied more than fivefold in some specialties. CONCLUSION: Without data on quality of care in private outpatient services, the rationale for the marked variations in fees within specialties is unknown. As insurers are prohibited from providing cover for the costs of outpatient care, the impact of out-of-pocket payments on access to private specialist care is unknown.

Effects of asymmetric medical insurance subsidy on hospitals competition under non-price regulation.

BACKGROUND: Poor medical care and high fees are two major problems in the world health care system. As a result, health care insurance system reform is a major issue in developing countries, such as China. Governments should take the effect of health care insurance system reform on the competition of hospitals into account when they practice a reform. This article aims to capture the influences of asymmetric medical insurance subsidy and the importance of medical quality to patients on hospitals competition under non-price regulation. METHODS: We establish a three-stage duopoly model with quantity and quality competition. In the model, qualitative difference and asymmetric medical insurance subsidy among hospitals are considered. The government decides subsidy (or reimbursement) ratios in the first stage. Hospitals choose the quality in the second stage and then support the quantity in the third stage. We obtain our conclusions by mathematical model analyses and all the results are achieved by backward induction. RESULTS: The importance of medical quality to patients has stronger influence on the small hospital, while subsidy has greater effect on the large hospital. Meanwhile, the importance of medical quality to patients strengthens competition, but subsidy effect weakens it. Besides, subsidy ratios difference affects the relationship between subsidy and hospital competition. Furthermore, we capture the optimal reimbursement ratio based on social welfare maximization. More importantly, this paper finds that the higher management efficiency of the medical insurance investment funds is, the higher the best subsidy ratio is. CONCLUSIONS: This paper states that subsidy is a two-edged sword. On one hand, subsidy stimulates medical demand. On the other hand, subsidy raises price and inhibits hospital competition. Therefore, government must set an appropriate subsidy ratio difference between large and small hospitals to maximize the total social welfare. For a developing country with limited medical resources and great difference in hospitals such as China, adjusting the reimbursement ratios between different level hospitals and increasing medical quality are two reasonable methods for the sustainable development of its health system.

[System-immanent incentives in the remuneration for psychiatry and psychosomatics : Analysis exemplified by treatment of alcohol-related disorders]. / Systemimmanente Anreize im PEPP : Analyse am Beispiel der Behandlung alkoholbezogener Störungen.

BACKGROUND: The German fixed rate remuneration system in psychiatry and psychosomatics (PEPP) has been criticized by many specialty associations because negative effects on mental healthcare are expected through economic incentives. OBJECTIVE: Through analysis of performance data in the treatment of alcohol dependency at the Evangelical Hospital Bielefeld (Evangelisches Krankenhaus Bielefeld, EvKB) from 2014 and various simulations, the incentives of the PEPP (version 2015) were analyzed and its potential impact on patient care was evaluated. METHODS: Groups of cases were created based on the clinical data. Various parameters were evaluated, such as duration of treatment, PEPP coding, loss of income by merging cases and case remuneration. Additionally, changes in the duration of treatment, the intensity of treatment and the intensity of care were simulated. RESULTS: In the simulations a reduction in the duration of treatment by 16.1 % led to additional revenues of 1.9 % per treatment day. The calculated additional costs of 1:1 care and intensive nursing care were not completely covered by the additional revenues, whereas psychotherapeutic inpatient treatment programs showed positive profit contributions. Complicated cases with increased merging of cases showed lower revenues but with above average expenditure of efforts. CONCLUSION: The current version of the PEPP leads to misdirected incentives in patient care. This is caused, for example, by the fact that higher profit contributions can be realized in some patient groups and intensive nursing care of patients is insufficiently represented. It is not clear whether these incentives will persist or can be compensated in subsequent versions of the system.

Variations in Patterns of Utilization and Charges for the Care of Headache in North Carolina, 2000-2009: A Statewide Claims' Data Analysis.

OBJECTIVES: The purpose of the study was to compare patterns of utilization and charges generated by medical doctors (MDs), doctors of chiropractic (DCs), and physical therapists (PTs) for the treatment of headache in North Carolina. METHODS: Retrospective analysis of claims data from the North Carolina State Health Plan for Teachers and State Employees from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the North Carolina State Health Plan using International Classification of Diseases, Ninth Revision, diagnostic codes for headache. The claims were separated by individual provider type, combination of provider types, and referral patterns. RESULTS: The majority of patients and claims were in the MD-only or MD plus referral patterns. Chiropractic patterns represented less than 10% of patients. Care patterns with single-provider types and no referrals incurred the least charges on average for headache. When care did not include referral providers or services, MD with DC care was generally less expensive than MD care with PT. However, when combined with referral care, MD care with PT was generally less expensive. Compared with MD-only care, risk-adjusted charges (available 2006-2009) for patients in the middle risk quintile were significantly less for DC-only care. CONCLUSIONS: Utilization and expenditures for headache treatment increased from 2000 to 2009 across all provider groups. MD care represented the majority of total allowed charges in this study. MD care and DC care, alone or in combination, were overall the least expensive patterns of headache care. Risk-adjusted charges were significantly less for DC-only care.

Variations in Patterns of Utilization and Charges for the Care of Neck Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis.

OBJECTIVES: The purpose of the study was to compare utilization and charges generated by medical doctors (MD), doctors of chiropractic (DC) and physical therapists (PT) by provider patterns of care for the treatment of neck pain in North Carolina. METHODS: This was an analysis of neck-pain-related closed claim data from the North Carolina State Health Plan for Teachers and State Employees (NCSHP) from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the NCSHP using ICD-9 diagnostic codes for uncomplicated neck pain (UNP) and complicated neck pain (CNP). RESULTS: Care patterns with single-provider types and no referrals incurred the least average charges for both UNP and CNP. When care did not include referral providers or services, for either UNP or CNP, MD care with PT was generally less expensive than MD care with DC care. However, when care involved referral providers or services, MD and PT care was on average more expensive than MD and DC care for either UNP or CNP. Risk-adjusted charges for patients in the middle quintile of risk (available 2006-2009) were lower for chiropractic patients with or without medical care or referral care to other providers. CONCLUSIONS: Chiropractic care alone or DC with MD care incurred appreciably fewer charges for UNP or CNP compared to MD care with or without PT care, when care included referral providers or services. This finding was reversed when care did not include referral providers or services. Risk-adjusted charges for UNP and CNP patients were lower for DC care patterns.

Variations in Patterns of Utilization and Charges for the Care of Low Back Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis.

OBJECTIVES: The purpose of the study was to compare utilization and charges generated by medical doctors (MD), doctors of chiropractic (DC) and physical therapists (PT) by patterns of care for the treatment of low back pain in North Carolina. METHODS: This was an analysis of low-back-pain-related closed claim data from the North Carolina State Health Plan for Teachers and State Employees from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the North Carolina State Health Plan using International Classification of Diseases, 9th Revision diagnostic codes for uncomplicated low back pain (ULBP) and complicated low back pain (CLBP). RESULTS: Care patterns with single-provider types and no referrals incurred the least charges on average for both ULBP and CLBP. When care did not include referral providers or services, for ULBP, MD and DC care was on average $465 less than MD and PT care. For CLBP, MD and DC care averaged $965 more than MD and PT care. However, when care involved referral providers or services, MD and DC care was on average $1600 less when compared to MD and PT care for ULBP and $1885 less for CLBP. Risk-adjusted charges (available 2006-2009) for patients in the middle quintile of risk were significantly less for DC care patterns. CONCLUSIONS: Chiropractic care alone or DC with MD care incurred appreciably fewer charges for ULBP than MD care with or without PT care. This finding was reversed for CLBP. Adjusted charges for both ULBP and CLBP patients were significantly lower for DC patients.

Street-level workers' criteria for identifying indigents to be exempted from user fees in Burkina Faso.

OBJECTIVES: Universal healthcare coverage cannot be achieved in Africa as long as the indigent, the poorest, are unable to access healthcare systems. This study was carried out in Burkina Faso to obtain street-level workers' perspectives on what criteria should be used to select indigents to be exempted from user fees. METHODS: Two group consensus techniques were used (Delphi and Concept Mapping). The participants were nurses (CM; n = 24), midwives (CM; n = 23) from a rural district and Social Action agents (CM; n = 31) and healthcare workers (Delphi n = 23) in training at two national schools. RESULTS: Altogether, 446 criteria were proposed. The nurses put forward criteria related to being ill without support and being a victim of society. The midwives focused more on the disabled poor and those who were ill and unsupported. The healthcare workers in training mentioned disabled persons and the elderly with no family support. The Social Action agents spoke about vulnerability related to illness or disability and the fact of being excluded or being a disaster victim. CONCLUSIONS: These criteria proposed by street-level workers add to other studies conducted in Burkina Faso and should help the State to improve indigents' access to care.

Consumer price sensitivity in Dutch health insurance.

AIM: To estimate the price sensitivity of consumer choice of health insurance firm. METHOD: Using paneldata of the flows of insured between pairs of Dutch sickness funds during the period 1993-2002, we estimate the sensitivity of these flows to differences in insurance premium. RESULTS: The price elasticity of residual demand for health insurance was low during the period 1993-2002, confirming earlier findings based on annual changes in market share. We find small but significant elasticities for basic insurance but insignificant elasticities for supplementary insurance. Young enrollees are more price sensitive than older enrollees. CONCLUSION: Competition was weak in the market for health insurance during the period under study. For the market-based reforms that are currently under way, this implies that measures to promote competition in the health insurance industry may be needed.

Studentized maximum root procedures for coherent analyses of two-factor fixed-effects designs.

The authors provide generalizations of R. J. Boik's (1993) studentized maximum root (SMR) procedure that allow for simultaneous inference on families of product contrasts including simple effect contrasts and differences among simple effect contrasts in coherent analyses of data from 2-factor fixed-effects designs. Unlike the F-based simultaneous test procedures (STPs) proposed by M. A. Betz and K. R. Gabriel (1978) for coherent analyses allowing for inferences on all factorial contrasts, SMR STPs are designed for analyses where each contrast of interest is a product contrast, which is usually the case in analyses of data from factorial experiments. When both factors have more than 2 levels, SMR STPs always provide more power and precision than F STPs for inferences on product contrasts.