Quality of Diabetes Care in Blended Fee-for-Service and Blended Capitation Payment Systems.

OBJECTIVES: In the middle to late 2000s, many family physicians switched from a Family Health Group (FHG; a blended fee-for-service model) to a Family Health Organization (FHO; a blended capitation model) in Ontario, Canada. The evidence on the link between physician remuneration schemes and quality of diabetes care is mixed in the literature. We examined whether physicians who switched from the FHG to FHO model provided better care for individuals living with diabetes relative to those who remained in the FHG model. METHODS: Using longitudinal health administrative data from 2006 to 2016, we investigated the impact of physicians switching from FHG to FHO on 8 quality indicators related to diabetes care. Because FHO physicians are likely to be systematically different from FHGs, we employed propensity-score-based inverse probability-weighted fixed-effects regression models. All analyses were conducted at the physician level. RESULTS: We found that FHO physicians were more likely to provide glycated hemoglobin testing by 2.75% (95% confidence interval [CI], 1.89% to 3.60%), lipid assessment by 2.76% (CI, 1.95% to 3.57%), nephropathy screening by 1.08% (95% CI, 0.51% to 1.66%) and statin prescription by 1.08% (95% CI, 0.51% to 1.66%). Patients under FHOs had a lower estimated risk of mortality by 0.0124% (95% CI, 0.0123% to 0.0126%) per physician per year. However, FHG and FHO physicians were similar for annual eye examination, prescription of angiotensin-converting enzyme inhibitors (or angiotensin II receptor blockers) and patients' risk of avoidable diabetes-related hospitalizations. CONCLUSIONS: Compared with blended fee-for-service, blended capitation payment is associated with a small, but statistically significant, improvement in some aspects of diabetes care.

Keep it simple? Predicting primary health care costs with clinical morbidity measures.

Models of the determinants of individuals' primary care costs can be used to set capitation payments to providers and to test for horizontal equity. We compare the ability of eight measures of patient morbidity and multimorbidity to predict future primary care costs and examine capitation payments based on them. The measures were derived from four morbidity descriptive systems: 17 chronic diseases in the Quality and Outcomes Framework (QOF); 17 chronic diseases in the Charlson scheme; 114 Expanded Diagnosis Clusters (EDCs); and 68 Adjusted Clinical Groups (ACGs). These were applied to patient records of 86,100 individuals in 174 English practices. For a given disease description system, counts of diseases and sets of disease dummy variables had similar explanatory power. The EDC measures performed best followed by the QOF and ACG measures. The Charlson measures had the worst performance but still improved markedly on models containing only age, gender, deprivation and practice effects. Comparisons of predictive power for different morbidity measures were similar for linear and exponential models, but the relative predictive power of the models varied with the morbidity measure. Capitation payments for an individual patient vary considerably with the different morbidity measures included in the cost model. Even for the best fitting model large differences between expected cost and capitation for some types of patient suggest incentives for patient selection. Models with any of the morbidity measures show higher cost for more deprived patients but the positive effect of deprivation on cost was smaller in better fitting models.

Age equity in different models of primary care practice in Ontario.

OBJECTIVE: To assess whether the model of service delivery affects the equity of the care provided across age groups. DESIGN: Cross-sectional study. SETTING: Ontario. PARTICIPANTS: One hundred thirty-seven practices, including traditional fee-for-service practices, salaried community health centres (CHCs), and capitation-based family health networks and health service organizations. MAIN OUTCOME MEASURES: To compare the quality of care across age groups using multilevel linear or logistic regressions. Health service delivery measures and health promotion were assessed through patient surveys (N = 5111), which were based on the Primary Care Assessment Tool, and prevention and chronic disease management were assessed, based on Canadian recommendations for care, through chart abstraction (N = 4108). RESULTS: Older individuals reported better health service delivery in all models. This age effect ranged from 1.9% to 5.7%, and was larger in the 2 capitation-based models. Individuals aged younger than 30 years attending CHCs had more features of disadvantage (ie, living below the poverty line and without high school education) and were more likely than older individuals to report discussing at least 1 health promotion subject at the index visit. These differences were deemed an appropriate response to greater needs in these younger individuals. The prevention score showed an age-sex interaction in all models, with adherence to recommended care dropping with age for women. These results are largely attributable to the fact that maneuvers recommended for younger women are considerably more likely to be performed than other maneuvers. Chronic disease management scores showed an inverted U relationship with age in fee-for-service practices, family health networks, and health service organizations but not in CHCs. CONCLUSION: The salaried model might have an organizational structure that is more conducive to providing appropriate care across age groups. The thrust toward adopting capitation-based payment is unlikely to have an effect on age disparities.

Modelling the ability of risk adjusters to reduce adverse selection in managed care.

Population-based risk adjustment, as applied to reimbursement in managed care settings, may reduce pressures for adverse selection by managed care organisations. Using insurance claims data from 184 340 plan members, we compared the performance of three risk-adjustment methods. We present a model for measuring the impact of risk adjustment on the likelihood that individual members will be at risk for adverse selection. These results are compared with resource allocation based on age/sex. The predictive ability of alternative allocation schemes increased from an R(2) of 1.2% for age-sex allocation to 11.4% based on risk adjustment using diagnostic cost groups. However, the impact of risk adjustment on the proportion of members at risk for adverse selection was small. At an absolute threshold loss of $US2400 per year, 8.3% to 8.6% of members were at risk for adverse selection compared with 9.3% based on age-sex allocation. The limited impact of risk adjustment on the likelihood of adverse selection suggests that other strategies for reducing adverse selection may be required.

Success under capitation is no secret: bolster your data, build financial reserves.

Capitated groups continue to make basic mistakes in managing contracts, although a growing number are learning from their blunders, according to a leading consultant who shares her list of top problem areas under capitation--and what to do about them.

Quality standards and incentives in managed care organizations' specialty contracts for behavioral health.

BACKGROUND: In the US, most privately insured individuals are enrolled with managed care organizations (MCOs), and a majority of these organizations have subcontracted responsibility for behavioral health care to specialized vendors. Based on economic theory, we anticipate that MCOs should be more likely to require quality standards in contracts that transfer all financial risk to the vendor. AIMS OF THE STUDY: To test whether use of quality standards in behavioral health subcontracts differs between MCOs that transfer full financial risk and other MCOs. Similarly, to test for differences between for-profit and nonprofit MCOs. METHODS: Bivariate tests and logistic regression analysis of the use of five quality-related standards, and the use of any standard, in a nationally representative sample of commercial MCO products in 60 US market areas. Statistical controls include MCO size, chain affiliation, region and market size. RESULTS: All five standards we examined were widely used in behavioral health subcontracts (varying from 47% to 70% of products). However, contrary to our hypothesis, the standards are not more commonly used by MCO products with unlimited capitated contracts for behavioral health. In most cases the opposite is true. In addition, for-profit plans were more rather than less likely to use several of the standards. DISCUSSION: MCOs that transfer full risk may be using mechanisms other than quality standards (e.g. periodic rebidding) to prevent skimping; may be less concerned about quality anyway; or may be more skeptical about the value of existing standards. The fact that for-profit plans are equally or more likely to use these standards may reveal that their objectives are not different from those of nonprofits, or that competition is constraining them to adopt standards anyway. Limitations of this study include the lack of more detailed data on the nature of financial risk-sharing, and on the types of financial penalties associated with each standard. IMPLICATIONS FOR HEALTH POLICY: Pressure for accreditation appears to be an effective vehicle for encouraging the spread of standards. It would be useful to know how far use of these quality standards in contracts is linked to better quality of care. IMPLICATIONS FOR FUTURE RESEARCH: Further studies should examine the relationship between quality standards and quality of care

[Current knowledge among students of the Silesian Medical Academy about the importance and role of medical care funds]. / Ocena stanu wiedzy studentów Slaskiej Akademii Medycznej na temat roli i znaczenia kas chorych.

The purpose of this research was verification and comparison of the present state of knowledge among the students of different departments and years of study. The questions concerned the role of Medical Care Funds in the up-to-now healthcare system and the patient's rights as far as the students' future professions as doctors, dentists, healthcare managers and medical rescuers is concerned. The questionnaire included 15 questions referring to the problem of functioning of the medical care institutions after the reform of healthcare services introduced in 1999. Distinct from most of the published works of this kind, the authors adopted a uniform "assessment" method following the principles of didactic measurement. The researchers calculated: Range, Modal, Mediana, Arithmetic Average, Variance, Standard Deviation, Easiness of the Task, Difficulty of the Task, Skip Fraction, the Task's Differentiating Power, Reliability Coefficient of the Test. The calculation was conducted with the use of the Excel programme modified by the researchers to suit the needs of didactic measurement. The survey included 104 students of the 3rd year of Dental Department, 116 of the students 4th year of Dental Department, 31 students of Bachelor's Medical Rescue Studies by the Medical Department in Zabrze, 18 students of Post-Graduate Management and Administration in Healthcare by the Medical Department in Zabrze and Silesian Technical University, 151 4th year students of the Medical Department in Zabrze and 121 6th year students of the Medical Department in Zabrze. It has been proved that between the particular groups there are significant differences as far as the students' knowledge is concerned ("the healthcare managers" demonstrated quite a high knowledge ratio). And that the questions were at different difficulty levels depending on the branch and year of study represented by the respondents.

Capitated reimbursement for medical services returns control of the patient to the surgeon.

Limiting the spending on healthcare services is a societal necessity, whether externally budget-driven with reduced fee for service or salary, or internally controlled through prospective payment capitation. No reimbursement system is inherently good or bad. Ethical physicians will place patient well-being first and focus on the delivery of quality care, regardless of the payment method. There are several methods for the distribution of capitation payments to physicians, each with different levels of financial incentive to provide services. In one fully evolved embodiment of capitation, a payer carves out the entire orthopedic disease segment and contracts with an orthopedic organization for all musculoskeletal services within a defined geographic region. This form of capitation offers the advantage of returning control of patient care to the orthopedic surgeon.