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Broyles RS, Tyson JE, Heyne ET, Heyne RJ, Hickman JF, Swint M, Adams SS, West LA, Pomeroy N, Hicks PJ, Ahn C. Comprehensive follow-up care and life-threatening illnesses among high-risk infants: A randomized controlled trial. JAMA 2000; 284:2070-6. [PMID: 11042755 DOI: 10.1001/jama.284.16.2070] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Inner-city high-risk infants often receive limited and fragmented care, a problem that may increase serious illness. OBJECTIVE To assess whether access to comprehensive care in a follow-up clinic is cost-effective in reducing life-threatening illnesses among high-risk, inner-city infants. DESIGN Randomized controlled trial. SETTING AND PARTICIPANTS A total of 887 very-low-birth-weight infants born in a Texas county hospital between January 1988 and March 1996 and followed up in a children's hospital clinic. One hundred four infants who became ineligible or died after randomization but before nursery discharge were excluded from the analysis. INTERVENTIONS Infants were randomly assigned to receive routine follow-up care (well-baby care and care for chronic illnesses; n = 441) or comprehensive care (which included the components of routine care plus care for acute illnesses, with 24-hour access to a primary caregiver; n = 446). MAIN OUTCOME MEASURES Life-threatening illnesses (ie, causing death or hospital admission for pediatric intensive care) occurring between nursery discharge and age 1 year, assessed by blinded evaluators from inpatient charts and state Medicaid and vital statistics records; and hospital costs (estimated from department-specific cost-to-charge ratios). RESULTS Comprehensive care resulted in a mean of 3.1 more clinic visits and 6.7 more telephone conversations with clinic staff (P<.001 for both). One-year outcomes were unknown for fewer comprehensive-care infants than routine-care infants (9 vs 28; P =.001). Identified deaths were similar (11 in comprehensive care vs 13 in routine care; P =.68). The comprehensive-care group had 48% fewer life-threatening illnesses (33 vs 63; P<.001), 57% fewer intensive care admissions (23 vs 53; P =.003), and 42% fewer intensive care days (254 vs 440; P =.003). Comprehensive care did not increase the mean estimated cost per infant for all care ($6265 with comprehensive care and $9913 with routine care). CONCLUSION Comprehensive follow-up care by experienced caregivers can be highly effective in reducing life-threatening illness without increasing costs among high-risk inner-city infants. JAMA. 2000;284:2070-2076.
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Barsi E. Comprehensive care of the older patient--taking the quantum leap. HEALTHCARE LEADERSHIP & MANAGEMENT REPORT 2000; 8:4-7. [PMID: 11183297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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103
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Vilsack T. High-quality, affordable health care. IOWA MEDICINE : JOURNAL OF THE IOWA MEDICAL SOCIETY 2000; 90:4. [PMID: 10778016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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104
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Robinson J, Karon SL. Modeling Medicare costs of PACE (Program of All-Inclusive Care for the Elderly) populations. HEALTH CARE FINANCING REVIEW 2000; 21:149-70. [PMID: 11481753 PMCID: PMC4194674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Historically, Medicare has paid PACE providers a monthly capitated rate equal to 95 percent of the site's county AAPCC multiplied by a PACE-specific frailty adjuster of 2.39. The Balanced Budget Act of 1997 makes PACE a permanent provider category and mandates that future Medicare payments be based upon the rate structure of the Medicare+Choice payment system, adjusted for the comparative frailty of PACE enrollees and other factors deemed to be appropriate by the Secretary of Health and Human Services. This study revisits the calculation of the PACE frailty adjuster and explores the effect of risk adjustment on that frailty adjuster.
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Bucklitsch M, Lichte T. [Comprehensive diabetes therapy despite budget controls. Challenges for the general practice team]. MMW Fortschr Med 1999; 141:41. [PMID: 10904597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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106
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Abstract
Comprehensive case management has become an industry standard and its pervasiveness raises questions about the ubiquitous need for this service. Analyzed from the perspective of transaction cost analysis and access, we argue that in some cases comprehensive case management is an avoidable cost incurred because of system problems that limit access to otherwise eligible clients. Implications are discussed.
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Rollins G. Newly recognized PACE (Programs of All-Inclusive Care for the Elderly) programs benefit patients, providers, payers. EXECUTIVE SOLUTIONS FOR HEALTHCARE MANAGEMENT 1999; 2:13-6. [PMID: 10538254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
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108
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Gundling RL. PACE adds flexibility to providing senior care. HEALTHCARE FINANCIAL MANAGEMENT : JOURNAL OF THE HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION 1999; 53:80. [PMID: 10558175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
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109
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Huba GJ, Melchior LA, De Veauuse NF, Hillary K, Singer B, Marconi K. A national program of innovative AIDS care projects and their evaluation. Home Health Care Serv Q 1999; 17:3-30. [PMID: 10338806 DOI: 10.1300/j027v17n01_02] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
As the number of people seeking HIV care in the U.S. has grown, the demand has increased not only for medical care, but also for a wide range of supportive services. This in turn has increased the need for demonstrated and tested HIV care service models that can address a comprehensive set of needs. The Special Projects of National Significance (SPNS) Program's HIV Innovative Models of Care Initiative funded by the Health Resources and Services Administration (HRSA) began on October 1, 1994. This initiative is an effort by 27 HRSA-funded projects to jointly establish goals and objectives, develop common evaluation methods, and produce comparable and measurable outcomes for innovative models of HIV care. The five projects of the SPNS Program Capitated Care Work Group share, as a central theme, the study of the health care provided to individuals with HIV disease under models where the health care is capitated, or paid on a "flat fee" basis per patient per month. These projects differ in the ways that they provide health care, ranging from community- and university-based clinics to a home-based hospice to a statewide health care system. Each of the projects shares the goals of determining costs for providing health care services to AIDS patients under a capitated care system and of ensuring that high quality care is provided under such a system.
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110
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Buchanan RJ. State-funded medical assistance programs: sources of coverage for HIV-related health care. JOURNAL OF HEALTH AND HUMAN SERVICES ADMINISTRATION 1999; 21:3-29. [PMID: 10345538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Preliminary research found that a number of states implement medical assistance programs (MAPs) funded only with state and/or local government funds. A review of the literature was unable to discover any published research that discusses state-funded MAPs. The objective of this article is to describe these MAPs and to discuss how these programs can be used to provide health services to people infected with HIV who lack other coverage. A two-step survey process was used to identify 20 states implementing MAPs and to identify eligibility criteria, the health services covered, and payment-level policies. Typically, MAPs implement restrictive eligibility policies and set low reimbursement levels for the care covered. However, most MAPs cover a comprehensive range of health services needed by people inflected with HIV, including community-based care and support services.
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111
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Mukamel DB, Temkin-Greener H, Clark ML. Stability of disability among PACE enrollees: financial and programmatic implications. HEALTH CARE FINANCING REVIEW 1999; 19:83-100. [PMID: 10345415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
This article examines the experience of the first 11 Program of All-inclusive Care for the Elderly (PACE) programs. It investigates changes in functional status of participants in relation to length of enrollment in the program and individual risk characteristics. Our findings indicate that mature programs experience stable disability mix over time, supporting the rationale for the current PACE payment method. However, significant differences exist between programs, suggesting that payment rates could be more program specific. Analysis of the effect of patient characteristics at admission on the likelihood of improvement in functional status identified areas for quality improvement. The implications of this study have increasing importance in light of the expected expansion of PACE to approximately 100 sites by the year 2000.
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Abstract
As health care moves from a free-for-service environment to a capitated arena, outcome measurements must change. ABC Children's Medical Center is challenged with developing comprehensive outcome measures for an employed physician group. An extensive literature review validates that physician outcomes must move beyond revenue production and measure all aspects of care delivery. The proposed measurement model for this physician group is a trilogy model. It includes measures of cost, quality, and service. While these measures can be examined separately, it is imperative to understand their integration in determining an organization's competitive advantage. The recommended measurements for the physician group must be consistent with the overall organizational goals. The long-term impact will be better utilization of resources. This will result in the most cost effective, quality care for the health care consumer.
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113
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Amaro H. An expensive policy: the impact of inadequate funding for substance abuse treatment. Am J Public Health 1999; 89:657-9. [PMID: 10224973 PMCID: PMC1508710 DOI: 10.2105/ajph.89.5.657] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Coburn AF, Mueller KJ. Legislative and policy strategies for supporting rural health network development: lessons from the 103rd Congress. J Rural Health 1999; 11:22-31. [PMID: 10141276 DOI: 10.1111/j.1748-0361.1995.tb00393.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
There was considerable support in most major health reform bills considered by the 103rd Congress for the development of rural integrated service networks. The demise of comprehensive health reform, together with the pace of current market-driven changes in the health care system, suggests the need to assess the impact of specific policy strategies considered in the last Congress on rural integrated service network development. Toward this end, this article evaluates the rural health policy strategies of the major bills in relation to three essential preconditions for the development of rural integrated service networks: (1) the need for a more stable financial base for rural providers; (2) the need for administrative, service and clinical capacity to mount a successful network; and finally, (3) the need for appropriate market areas to ensure fair competition among networks and plans. Key policy strategies for supporting rural network development include reform of insurance and payment policies, expansion of targeted support and technical assistance to the underserved, limited-capacity rural areas, and policies governing purchasing groups or alliances that will ensure appropriate treatment of rural providers and networks.
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Cohen LJ. Using the latest tools will promote recovery. BEHAVIORAL HEALTHCARE TOMORROW 1999; 8:26, 41. [PMID: 10351296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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117
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Weisburd DE. What about the patient? J Clin Psychiatry 1999; 60 Suppl 3:38-41. [PMID: 10073376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Our mental health care system fails to serve the very people whose suffering that system ostensibly exists to alleviate. This article relates the stories of 3 people who fell through the cracks of this system. An alternative approach, the Integrated Services Agency (ISA), has been implemented in California and offers hope to persons with schizophrenia. The ISA approach focuses on the expressed needs of the members it exists to serve, and both members and staff have experienced changes in their roles and expectations. Staff and members have learned that engagement with the "outside world" involves taking risks but that risk avoidance only perpetuates the status quo. The ISA approach rewards growth and patients' being well rather than rewarding docility and illness. Medication is neither ordered nor assigned, but chosen in a collaboration between staff and members. ISAs have returned care to the mental health care system.
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Leutz WN. Five laws for integrating medical and social services: lessons from the United States and the United Kingdom. Milbank Q 1999; 77:77-110, iv-v. [PMID: 10197028 PMCID: PMC2751110 DOI: 10.1111/1468-0009.00125] [Citation(s) in RCA: 388] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Because persons with disabilities (PWDs) use health and social services extensively, both the United States and the United Kingdom have begun to integrate care across systems. Initiatives in these two countries are examined within the context of the reality that personal needs and use of systems differ by age and by type and severity of disability. The lessons derived from this scrutiny are presented in the form of five "laws" of integration. These laws identify three levels of integration, point to alternative roles for physicians, outline resource requirements, highlight friction from differing medical and social paradigms, and urge policy makers and administrators to consider carefully who would be most appropriately selected to design, oversee, and administer integration initiatives. Both users and caregivers must be involved in planning to ensure that all three levels of integration are attended to and that the borders between medical and other systems are clarified.
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Poindexter CC. Promises in the plague: passage of the Ryan White Comprehensive AIDS Resources Emergency Act as a case study for legislative action. HEALTH & SOCIAL WORK 1999; 24:35-41. [PMID: 14533418 DOI: 10.1093/hsw/24.1.35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
In a conservative political climate, it is very important that social workers and others who are concerned with social welfare understand how to affect social change through legislative advocacy. This article presents a case study in successful intervention using the passage by the Congress of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990. The major influences in the passage of this landmark bill were building a diverse coalition that provided a very broad base of advocacy; securing bipartisan support; using recognizable personalities to call attention to the problem; and defining the issue as one that affected people from all socioeconomic and ethnic groups.
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Radhakrishnan K, Nayak SD, Kumar SP, Sarma PS. Profile of antiepileptic pharmacotherapy in a tertiary referral center in South India: a pharmacoepidemiologic and pharmacoeconomic study. Epilepsia 1999; 40:179-85. [PMID: 9952264 DOI: 10.1111/j.1528-1157.1999.tb02072.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE To study the current pharmacotherapy practices of epilepsy and its economics in a developing country by correlating the epidemiology and economics of antiepileptic drug (AED) treatment in general epilepsy care and comprehensive epilepsy care. METHODS We compared the AED-use profiles, efficacy, and tolerability at entry and at last follow-up for 972 patients seen at a comprehensive epilepsy care program in South India from 1993 to 1995. The relative cost was expressed as the average percentage of the per capita gross national product (GNP/capita) each individual spent for AED treatment. RESULTS At entry, 562 (57.8%) subjects were receiving polytherapy; at last follow-up, 743 (76.4%) patients were receiving monotherapy, an increase of 34.3% in the use of monotherapy. One or more adverse drug reactions were reported by 28.6% of patients at entry and by 19.8% at last follow-up. The proportion of patients who were seizure free increased from 29.0 to 44.8%. Carbamazepine (CBZ) was the most frequently used AED, followed by diphenylhydantoin (DPH), valproate (VPA), and phenobarbitone (PB). The relative cost (% GNP/capita) for standard AEDs were as follows: PB, 4.4%; DPH, 7.1%; CBZ, 16.8%; and VPA, 29.5%. The average annual cost of AED treatment per patient in U.S. dollars was $64.32 at entry and $47.73 at last follow-up. Reduction in polytherapy resulted in the net annual saving of $16,128 ($16.59 per patient, or 5.4% GNP/capita). CONCLUSIONS The more frequent use of relatively expensive drugs like CBZ and VPA and the use of polytherapy-still quite prevalent in developing countries-has escalated the cost of AED therapy. Although in recent years AEDs have become more available in developing regions, primary and secondary care physicians have not been adequately educated about the current trends in the pharmacotherapy of epilepsy.
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121
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Boult C, Pacala JT. Integrating healthcare for older populations. THE AMERICAN JOURNAL OF MANAGED CARE 1999; 5:45-52. [PMID: 10345966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The complex array of needs posed by older adults has frequently produced fragmentation of care in traditional fee-for-service systems. Integration of care components in newer health systems will maximize patient benefits and organizational efficiency. This article outlines the major issues involved in integration of care for older populations. A health system must integrate its care of older adults in many ways: among providers, both in primary care and specialty services; with community-based sources of care; and across sites of care (clinic, hospital, emergency department, and nursing home). Integrating reimbursement structures for various services will serve to create a client-oriented system, as opposed to a finance-centered system, thereby enhancing coordination of care. The extent to which two experimental comprehensive systems, PACE (Program of All-inclusive Care of the Elderly) and SHMO II (Social Health Maintenance Organization), have achieved clinical and financial integration are discussed in detail. Healthcare organizations are encouraged to create integrated models of care and to study the effects of integration on patient outcomes.
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Call KT, Dowd B, Feldman R, Maciejewski M. Selection experiences in Medicare HMOs: pre-enrollment expenditures. HEALTH CARE FINANCING REVIEW 1999; 20:197-209. [PMID: 11482122 PMCID: PMC4194606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Using 1993 and 1994 data, the authors examine whether beneficiaries who enroll in a Medicare health maintenance organization (HMO), including those enrolling for only a short period of time, have lower expenditures than continuous fee-for-service (FFS) beneficiaries the year prior to enrollment. We also test whether biased selection varies by the level of HMO market penetration and the rate of market-share growth. We find favorable selection associated with enrollment into Medicare HMOs, which declines as market share increases but does not disappear. Among short-term enrollees, we find unfavorable selection, however, selection bias was not sensitive to market characteristics.
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123
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Dowd B, Hillson S, VonSternberg T, Fischer LR. S/HMO versus TEFRA HMO enrollees: analysis of expenditures. HEALTH CARE FINANCING REVIEW 1999; 20:7-23. [PMID: 11482126 PMCID: PMC4194607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
This study compares expenditures on health care services for enrollees in a social health maintenance organization (S/HMO) and a Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)-risk Medicare health maintenance organization (HMO). In addition to the traditional Medicare services covered by the TEFRA HMO, the S/HMO provided a long-term care (LTC) benefit and case management services for chronic illness. There do not appear to be any overall savings associated with S/HMO membership, including any savings from substitution of S/HMO-specific services for other, traditional services covered by both the S/HMO and the TEFRA HMO.
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Telen MJ, Harris G, Whitworth E. Caring for patients with sickle cell disease in North Carolina. N C Med J 1999; 60:14-7. [PMID: 9951281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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125
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Roland M. [Capitation contract financing of primary health care: a possible alternative to traditional payment for service--part 1]. REVUE MEDICALE DE BRUXELLES 1998; 19:483-93. [PMID: 9916495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Worldwide health systems are faced with additive and complex problems: a cost containment willingness, growing expenses for the health care budgets particularly in relation with the new technologies, questioning about true quality of provided care from results indicators. Health care financing is one of the major determinants of the nature and the comprehensive quality of the system: its aim to promote suitable processes and behaviors, to dissuade inadequate ones, in a context of efficiency (efficacy with minimal cost), as for politic decidors, as for the patients, as for the providers, as for the insurers/funders. A comparative and critical approach of the international scientific literature shows that partial fixed capitation payment is an interesting alternative for the total fee for service. Taking into account many experiences, a proposal for a cumulated financing for the practices is made: a structural part, a fixed capitation payment (the most important), a fee for service one, a target payment one, and a patient personal participation.
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