Time is money: general practitioners' reflections on the fee-for-service system.

BACKGROUND: Fee-for-service is a common payment model for remunerating general practitioners (GPs) in OECD countries. In Norway, GPs earn two-thirds of their income through fee-for-service, which is determined by the number of consultations and procedures they register as fees. In general, fee-for-service incentivises many and short consultations and is associated with high service provision. GPs act as gatekeepers for various treatments and interventions, such as addictive drugs, antibiotics, referrals, and sickness certification. This study aims to explore GPs' reflections on and perceptions of the fee-for-service system, with a specific focus on its potential impact on gatekeeping decisions. METHODS: We conducted six focus group interviews with 33 GPs in 2022 in Norway. We analysed the data using thematic analysis. RESULTS: We identified three main themes related to GPs' reflections and perceptions of the fee-for-service system. First, the participants were aware of the profitability of different fees and described potential strategies to increase their income, such as having shorter consultations or performing routine procedures on all patients. Second, the participants acknowledged that the fees might influence GP behaviour. Two perspectives on the fees were present in the discussions: fees as incentives and fees as compensation. The participants reported that financial incentives were not directly decisive in gatekeeping decisions, but that rejecting requests required substantially more time compared to granting them. Consequently, time constraints may contribute to GPs' decisions to grant patient requests even when the requests are deemed unreasonable. Last, the participants reported challenges with remembering and interpreting fees, especially complex fees. CONCLUSIONS: GPs are aware of the profitability within the fee-for-service system, believe that fee-for-service may influence their decision-making, and face challenges with remembering and interpreting certain fees. Furthermore, the fee-for-service system can potentially affect GPs' gatekeeping decisions by incentivising shorter consultations, which may result in increased consultations with inadequate time to reject unnecessary treatments.

Enterprise innovation and audit pricing: An evidence study from China's A-share listed companies.

Driven by innovation strategy, Chinese enterprises' innovation investment, and research and development capability have been continuously improved, and the audit risk caused by this has attracted widespread attention from the academic community. This study takes China's A-share listed companies from 2013 to 2021 as samples to empirically test the relationship between innovation input and audit pricing of Chinese enterprises. Research shows that the higher the innovation investment, the higher the audit cost. High-quality corporate governance, sufficient research and development personnel, research and development subsidies, and operating cash flow can all play a negative moderating role. A good innovation environment will weaken the positive influence between innovation input and audit fees. This study theoretically confirms the risk-oriented audit pricing mechanism, which is of great significance for optimizing enterprise innovation risk management and improving audit service levels.

International accounting network memberships and audit fees: Evidence from China.

This paper investigates the international accounting network memberships' impact on audit fees. We find that, firstly, the audit fees charged by the member audit firms are significantly higher; secondly, if the revenue, ranking or audit and accounting business share of the international network the audit firm join is higher, the charge is also higher. Additional results show that economic policy uncertainty will intensify this positive relationship, and member audit firms charge higher fees by improving their overseas expertise. We also find that international network memberships will reduce abnormal audit fees, and improve the quality of financial reports.

Graphical Association Analysis for Identifying Variation in Provider Claims for Joint Replacement Surgery.

Identifying potentially fraudulent or wasteful medical insurance claims can be difficult due to the large amounts of data and human effort involved. We applied unsupervised machine learning to construct interpretable models which rank variations in medical provider claiming behaviour in the domain of unilateral joint replacement surgery, using data from the Australian Medicare Benefits Schedule. For each of three surgical procedures reference models of claims for each procedure were constructed and compared analytically to models of individual provider claims. Providers were ranked using a score based on fees for typical claims made in addition to those in the reference model. Evaluation of the results indicated that the top-ranked providers were likely to be unusual in their claiming patterns, with typical claims from outlying providers adding up to 192% to the cost of a procedure. The method is efficient, generalizable to other procedures and, being interpretable, integrates well into existing workflows.

Physician responses to insurance benefit restrictions: The case of ophthalmology.

This study examines the impact of social insurance benefit restrictions on physician behaviour, using ophthalmologists as a case study. We examine whether ophthalmologists use their market power to alter their fees and rebates across services to compensate for potential policy-induced income losses. The results show that ophthalmologists substantially reduced their fees and rebates for services directly targeted by the benefit restriction compared to other medical specialists' fees and rebates. There is also some evidence that they increased their fees for services that were not targeted. High-fee charging ophthalmologists exhibited larger fee and rebate responses while the low-fee charging group raise their rebates to match the reference price provided by the policy environment.

Going the extra mile? General practitioners' upcoding of fees for home visits.

General practitioners' (GPs') income often relies on self-reported activities and performances. They can therefore 'game the system' to maximize their remuneration. We investigate whether Danish GPs game their travel fees for home visits. Combining administrative and geographical data, we measure the difference between GPs' traveled and billed distances. We exploit a rise in the fees for home visits. If there is a link between the rise in fees and upcoding, we interpret this finding as indicative of gaming behavior. We find that upcoding occurs slightly more often than downcoding (16% vs. 13% of visits) for visits that can be both upcoded and downcoded. Using linear probability models with GP fixed effects, we find that the fee rise is associated with a reduction in upcoding of 0.6% of home visits (2.8% for visits where upcoding is feasible) and no change in downcoding. Importantly, we find no statistically significant differences in the reduction in upcoding across distance bands despite large differences in their fee rises. We therefore conclude that there is no causal evidence of GPs gaming their fees.

Pratiques de prise en charge de l'hypertension artérielle au Centre Hospitalier et Universitaire d' Abomey-Calavi au Bénin / NA

L'hypertension artérielle est une maladie à forte progression reste un problème de santé publique. Mais, les pratiques de sa prise en charge se heurtent à différents obstacles. Cette recherche questionne les problèmes qui caractérisent les pratiques de prise en charge de l'hypertension artérielle au Centre Hospitalier et Universitaire d'Abomey-Calavi au Bénin. Pour y parvenir, nous avons opté pour une analyse basée sur les méthodes quantitatives et qualitatives. L'échantillon est constitué de 130 personnes enquêtées. De l'analyse des résultats collectés, des difficultés éprouvées entre patients et agents de santé dans la prise en charge de l'hypertension artérielle, se caractérise par le manque de relation soignant-soigné. De même, 90% des enquêtés estiment avoir peu de ressources humaines qualifiées et du faible pouvoir d'achat des patients pour faire face aux coûts élevés du traitement de l'hypertension (86,75%). Ainsi, le manque de plateau technique et les frais de consultations spécialisées posent problèmes y compris les suivis de l'éducation hygiéno-diététique. Cet état de fait compromet les pratiques de prise en charge et les formations globales que le système soin est supposé assurer aux usagers qui le fréquentent. Ces résultats suggèrent l'urgence de formations pour le renforcement des capacités pour repérer la précarité et la réorganisation des mesures de prise en charge de l' hypertension artérielle dans le périmètre sanitaire béninois.

Arterial hypertension remains a rapidly growing public health problem. However, management practices face a number of obstacles. This research questions the problems that characterize arterial hypertension management practices at the Centre Hospitalier et Universitaire d'Abomey-Calavi in Benin. To achieve this, we opted for an analysis based on quantitative and qualitative methods. The sample consisted of 130 respondents. From the analysis of the results collected, of the difficulties experienced between patients and health workers in the management of arterial hypertension, most of those surveyed claimed to have a complexity that characterizes the training of health workers. Similarly, 90% of respondents felt that they had few non-cardiologist practitioners, and that patients had little purchasing power to meet the high costs of treating hypertension (86.75%). As a result, the cost of specialized consultations and complementary examinations poses a problem, including follow-up health and diet education. This state of affairs compromises management practices and the comprehensive training that the healthcare system is supposed to provide for its users. These results suggest the urgent need for training to identify precariousness, and the reorganization of hypertension management measures within the Beninese health perimeter.

BVA backs profession over fees, but says transparency is key.

As the profession gathered for London Vet Show, another media article (see box) unfairly characterising vets as prioritising profit over welfare landed. We know this is deeply frustrating for vet teams working tirelessly to deliver the very best care for their patients.

Policy-makers' conception of patient non-attendance fees in specialist healthcare: a qualitative document analysis.

OBJECTIVES: Patients missing their scheduled appointments in specialist healthcare without giving notice can undermine efficient care delivery. To reduce patient non-attendance and possibly compensate healthcare providers, policy-makers have noted the viability of implementing patient non-attendance fees. However, these fees may be controversial and generate public resistance. Identifying the concepts attributed to non-attendance fees is important to better understand the controversies surrounding the introduction and use of these fees. Patient non-attendance fees in specialist healthcare have been extensively debated in Norway and Denmark, two countries that are fairly similar regarding political culture, population size and healthcare system. However, although Norway has implemented a patient non-attendance fee scheme, Denmark has not. This study aimed to identify and compare how policy-makers in Norway and Denmark have conceptualised patient non-attendance fees over three decades. DESIGN: A qualitative document study with a multiple-case design. METHODS: A theory-driven qualitative analysis of policy documents (n=55) was performed. RESULTS: Although patient non-attendance fees were seen as a measure to reduce non-attendance rates in both countries, the specific conceptualisation of the fees differed. The fees were understood as a monetary disincentive in Norwegian policy documents. In the Danish documents, the fees were framed as an educative measure to foster a sense of social responsibility, as well as serving as a monetary disincentive. The data suggest, however, a recent change in the Danish debate emphasising fees as a disincentive. In both countries, fees were partly justified as a means of compensating providers for the loss of income. CONCLUSIONS: The results demonstrate how, as a regulative policy tool, patient non-attendance fees have been conceptualised and framed differently, even in apparently similar contexts. This suggests that a more nuanced and complex understanding of why such fees are debated is needed.

How a "Smart regulatory" platform can improve the property fee adjustment dilemma.

In the current process of social and economic development, the cost of living and property management is continuously increasing. In order to maintain the normal operation of property management and provide high-quality services, it is necessary to adjust the property fees reasonably. If the property fees cannot be adjusted for a long time, it will have a detrimental impact on the development of the community. However, the traditional regulatory model has failed to accurately define the quality of property services, leading to information asymmetry and a lack of trust between the two parties, resulting in a deadlock in property fee adjustments. With the rise of intelligent management, a new direction for property fee adjustments has been provided. This article first analyzes the pricing dilemma under traditional regulation through game theory. Then, based on the theory of "Smart regulatory", it proposes the idea of constructing a "Smart regulatory" platform and explores the feasibility of this model using game theory and Matlab simulations. The study found that the "Smart regulatory" platform can resolve information asymmetry and encourage both parties to cooperate in the game. After the establishment of the platform, property fee adjustments are influenced by government supervision, government penalties, and the magnitude of property fee increase.

Trends in dental expenditures in Japan with a universal health insurance system.

BACKGROUND: The government of Japan has spent a significant amount on dental healthcare, but it remains unknown how the spending varies across age, type of service, and time. This study describes trends in dental expenditures in Japan. METHODS: This descriptive study used two national data sources: Estimates of National Medical Care Expenditure and Survey on Economic Conditions in Health Care. We obtained annual total and average per capita dental expenditures by age in Japan from 1984 to 2020 and estimated the proportions of types of service from 1996 to 2021. All costs were adjusted for the 2020 Consumer Price Index (1 US dollar ≈ 100 yen in 2020). RESULTS: Total dental expenditures increased from 1.96 trillion yen in 1984 to 3.00 trillion yen in 2020. In particular, total and average per capita dental spending for older persons showed a rapid increase (total: from 185 billion yen in 1984 to 1.18 trillion yen in 2020; average per capita: from 15,500 yen in 1984 to 32,800 yen in 2020), contributing to the total amount increase. The crown restoration and prosthesis category amounted to 50.3% of the total expenditure in 1996, and this proportion declined to 32.4% by 2021. In 0-14 years persons, expenses on the crown restoration and prosthesis category decreased while the medical management category (mainly including fees for a management plan for oral diseases or oral functions) increased. In persons aged 65 years or older, expenses on the crown restoration and prosthesis category decreased, with increasing expenses in the medical management and at-home treatment categories. CONCLUSION: The amount of dental spending in Japan substantially increased from 1.96 trillion yen in 1984 to 3.00 trillion yen in 2020), a 1.53-fold increase. The observed changes in annual dental spending varied across age groups and types of service.

The impact of changes in a physician fee schedule on medical expenditures, fees, and volume of services. Evidence from a national fee schedule reform in Australia.

We examine the impact of changes to a national physician fee schedule on total medical expenditures, the volume of services, and fees charged. In our context, changes to the fee schedule were designed to promote value-based health care, and so included different types of changes to subsidised medical services, including changes to fees. Using claims data from a sample of doctors linked to a physician survey, we use difference-in-difference methods with a staggered adoption design to compare medical services which were affected with those which were not. We show that medical expenditures and the volume of affected services fell, though there is uncertainty about the magnitude of the fall. For GPs, we find evidence of increases in expenditures and fees and an increase in fees for some services provided by specialists.

[How could forensic psychiatry be made more attractive?] / Hogyan lehetne az igazságügyi pszichiátriát vonzóbbá tenni?

INTRODUCTION: Decrease in the number of forensic psychiatric experts recently reached a critical level. Shortage of forensic experts caused difficulties in the health care as well as in the justice system. OBJECTIVE: Surveying of how the field of forensic psychiatry and the forensic psychiatric expert work can be made more attractive. METHOD: We performed an online survey among forensic psychiatric experts and specialists in psychiatry. We complied a questionnaire that beside demographic data contained questions in 4 areas. The first 2 areas of the questionnaire - simplifying the forensic psychiatry training (10 items), decreasing the cost of the forensic psychiatry training (5 items) - consisted of simple tatements. Responders had to indicate on a 10-point Likert scale their level of agreement. In the last 2 areas, participants were asked to describe in unstructured format whether they see any circumstance that makes forensic psychiatry attractive or unattractive. The questionnaire was sent out in electronic form to the forensic psychiatric experts on the mailing list of the Hungarian Forensic Expert Chamber, and all specialists in psychiatry on the mailing list of the Hungarian Medical Chamber. RESULTS: Altogether 171 persons filled in the questionnaire with a mean age of 57.26 ± 11.57 years. There were 122 (71.3%) females among the participants. The following proposals received the highest ratings from the forensic psychiatric experts as well as from the specialists in psychiatry: increasing the number of the training institutes; decreasing the costs of the training; making the Hungarian Forensic Expert Chamber course free of charge; and introducing a stipend to cover the costs of the training. DISCUSSION: Results of the survey indicate that active forensic psychiatric experts and specialists in psychiatry representing a potential professional resource, concur that forensic psychiatry training can be made more attractive mainly with increasing the number of training institutes and decreasing the total costs of the training which is compiled from different constituents. CONCLUSION: Due to the critical lack of necessary professionals, urgent action is needed to make forensic psychiatry more popular and the forensic psychiatry qualification easier to obtain. Orv Hetil. 2023; 164(35): 1373-1380.

Forgotten but not gone: A multi-state analysis of modern-day debt imprisonment.

In almost every state, courts can jail those who fail to pay fines, fees, and other court debts-even those resulting from traffic or other non-criminal violations. While debtors' prisons for private debts have been widely illegal in the United States for more than 150 years, the effect of courts aggressively pursuing unpaid fines and fees is that many Americans are nevertheless jailed for unpaid debts. However, heterogeneous, incomplete, and siloed records have made it difficult to understand the scope of debt imprisonment practices. We culled data from millions of records collected through hundreds of public records requests to county jails to produce a first-of-its-kind dataset documenting imprisonment for court debts in three U.S. states. Using these data, we present novel order-of-magnitude estimates of the prevalence of debt imprisonment, finding that between 2005 and 2018, around 38,000 residents of Texas and around 8,000 residents of Wisconsin were jailed each year for failure to pay (FTP), with the median individual spending one day in jail in both Texas and Wisconsin. Drawing on additional data on FTP warrants from Oklahoma, we also find that unpaid fines and fees leading to debt imprisonment most commonly come from traffic offenses, for which a typical Oklahoma court debtor owes around $250, or $500 if a warrant was issued for their arrest.

Regional impact of aging population on carbon dioxide emissions in China: Evidence from panel threshold regression (PTR).

Carbon dioxide emission is a high-profile issue that can affect both the human economy and human existence, but few scholars have studied the relationship between these two. Therefore, this study constructs the panel threshold regression (PTR) based on the National Bureau of Statistics of China's panel data from 2002 to 2019 in 19 regions. One of the advantages of PTR is to leverage segmented functions, allowing for a more detailed analysis of the data. Besides, by introducing the idea of a threshold, PTR can effectively avoid structural changes in the data. The different between this study and other research is that this study divides 19 regions into two parts: Eastern China and Central China. Based on that, this study researches and compares the different influences of the aging population on carbon emissions in these two regions. The results show that although the Environment Kuznets Curve has been confirmed in both Eastern China and Central China, with the development of the economy, the carbon emissions will increase in Eastern China and decrease in Central China, respectively. In addition, the key factors affecting carbon emissions in Eastern China and Central China are trade dependence and urbanization rate separately. Hence, this study suggests that the regional governments in Eastern China may guide and encourage more international trading companies to move to Central China, and at the same time, the regional governments in Central China should issue more policies to attract these companies, such as: reducing land lease fees and building better transportation infrastructure. Apart from that, the governments in Central China should vigorously increase the rate of urbanization to reduce energy consumption and improve energy efficiency.

The Impact of Unexpected Billing in Spine Surgery and How the Price Calculator Can Improve Patient Care.

STUDY DESIGN: Survey study. OBJECTIVE: The objective of this study was to determine the impact of unexpected in-network billing on the patient experience after spinal surgery. SUMMARY OF BACKGROUND DATA: The average American household faces difficulty paying unexpected medical bills. Although legislative efforts have targeted price transparency and rising costs, elective surgical costs continue to rise significantly. Patients are therefore sometimes still responsible for unexpected medical costs, the impact of which is unknown in spine surgery. METHODS: Patients who underwent elective spine surgery patients from January 2021 to January 2022 at a single institution were surveyed regarding their experience with the billing process. Demographic characteristics associated with unexpected billing situations, patient satisfaction, and financial distress, along with utilization and evaluation of the online price estimator, were collected. RESULTS: Of 818 survey participants, 183 (22.4%) received an unexpected in-network bill, and these patients were younger (56.7 vs. 63.4 y, P <0.001). Patients who received an unexpected bill were more likely to feel uninformed about billing (41.2% vs. 21.7%, P <0.001) and to report that billing impacted surgical satisfaction (53.8% vs. 19.1%, P <0.001). However, both groups reported similar satisfaction postoperatively (Likert >3/5: 86.0% vs. 85.5%, P =0.856). Only 35 (4.3%) patients knew of the price estimator's existence. The price estimator was reported to be very easy or easy (N=18, 78.2%) to understand and very accurate (N=6, 35.3%) or somewhat accurate (N=8, 47.1%) in predicting costs. CONCLUSIONS: Despite new regulations, a significant portion of patients received unexpected bills leading to financial distress and affecting their surgical experience. Although most patients were unaware of the price estimator, almost all patients who did know of it found it to be easy to use and accurate in cost prediction. Patients may benefit from targeted education efforts, including information on the price estimator to alleviate unexpected financial burden.

A Novel Pediatric Surgery Division Incentive Program Engaging Faculty, Advanced Practice Providers and Staff Around a Single Financial Growth Target.

BACKGROUND: Productivity-based financial incentive programs for faculty are common. We implemented a novel Division wide clinical productivity incentive sharing professional fee collections across faculty, nurses, and staff with half of bonuses reserved to be given out proportionally to achievement of the annual growth target. METHODS: A novel bonus plan was formulated to incentivize collection of professional fees to achieve a 15% annual growth target. The 15% was divided equally between the clinical provider, the responsible provider's center(s) of excellence, and all Division members. 50% of the bonus pool was paid out monthly and the remaining 50% was held for an end of the year payout proportional to achievement of the Divisional professional fee collection annual growth target. PRINCIPAL FINDINGS: During the initial year of the program, overall Division collections and charges grew 30% and 17%, respectively. Average monthly bonuses paid through the new incentive program for faculty, advanced practice providers, and staff were $1,700, $700, and $200, respectively. The program cost $525,000 in additional bonuses over the previous year while the Division saw an increase of 2 million dollars in collections over the previous year. CONCLUSION: A clinical productivity incentive program based upon professional fee collections distributed across faculty, nurses, and staff was feasible and successful in its first year. Collections increased by a significantly higher percentage than charges, we believe collections incentive including support staff will be most useful in practices with lower rates of charge collection. Further study is needed to measure the effects of different components of the program. LEVEL OF EVIDENCE: Level IV. STUDY TYPE: Cost Effectiveness Study.