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.

Platelets, Puppies, and Payment: How Surveys can be Misleading in the Remuneration Debate

In a recent article ("The current state of the platelet supply in the US and proposed options to decrease the risk of critical shortages") published in Transfusion, Stubbs et al. have argued that platelet donors should be paid. Dodd et al. have argued against this proposal, supporting their response with survey data that shows that blood donors (and by extension platelet donors) and potential platelet donors are uninterested in receiving incentives to encourage them to donate. Instead, argue Dodd et al., prospective platelet donors are motivated more by the ease of donation than the prospect of payment. This article defends Stubbs et al. from the criticisms of Dodd et al. It first argues that the preferences that persons state they have in response to survey questions might not reflect the preferences that their actions would reveal they have in actual rather than hypothetical situations. This hypothetical bias is especially likely when persons respond to surveys that ask them about the performance of morally commendable actions (such as platelet donation). This article then argues that the survey that Dodd et al. rely on exhibits serious selection bias with respect to the set of persons it considers to be potential platelet donors.

Health expenditure: how much is spent on health and care worker remuneration? An analysis of 33 low- and middle-income African countries

OBJECTIVES

To assess the amount spent on health and care workforce (HCW) remuneration in the African countries, its importance as a proportion of country expenditure on health, and government involvement as a funding source.

METHODS

Calculations are based on country-produced disaggregated health accounts data from 33 low- and middle-income African countries, disaggregated wherever possible by income and subregional economic group.

RESULTS

Per capita expenditure HCW remuneration averaged US$ 38, or 29% of country health expenditure, mainly coming from domestic public sources (three-fifths). Comparable were the contributions from domestic private sources and external aid, measured at around one-fifth each-23% and 17%, respectively. Spending on HCW remuneration was uneven across the 33 countries, spanning from US$ 3 per capita in Burundi to US$ 295 in South Africa. West African countries, particularly members of the West African Economic and Monetary Union (WAEMU), were lower spenders than countries in the Southern African Development Community (SADC), both in terms of the share of country health expenditure and in terms of government efforts/participation. By income group, HCW remuneration accounted for a quarter of country health expenditure in low-income countries, compared to a third in middle-income countries. Furthermore, an average 55% of government health expenditure is spent on HCW remuneration, across all countries. It was not possible to assess the impact of fragile and vulnerable countries, nor could we draw statistics by type of health occupation.

CONCLUSIONS

The results clearly show that the remuneration of the health and care workforce is an important part of government health spending, with half (55%) of government health spending on average devoted to it. Comparing HCW expenditure components allows for identifying stable sources, volatile sources, and their effects on HCW investments over time. Such stocktaking is important, so that countries, WHO, and other relevant agencies can inform necessary policy changes.

The impact of funding models on the integration of Ontario midwives: a qualitative study

BACKGROUND

Nearly 30 years post legalisation and introduction, midwifery is still not optimally integrated within the health system of Canada's largest province, Ontario. Funding models have been identified as one of the main barriers.

METHODS

Using a constructivist perspective, we conducted a qualitative descriptive study to examine how antepartum, intrapartum, and postpartum funding arrangements in Ontario impact midwifery integration. We conceptualized optimal 'integration' as circumstances in which midwives' knowledge, skills, and model of care are broadly respected and fully utilized, interprofessional collaboration and referral support the best possible care for patients, and midwives feel a sense of belonging within hospitals and the greater health system. We collected data through semi-structured telephone interviews with midwives, obstetricians, family physicians, and nurses. The data was examined using thematic analysis.

RESULTS

We interviewed 20 participants, including 5 obstetricians, 5 family physicians, 5 midwives, 4 nurses, and 1 policy expert. We found that while course-of-care-based midwifery funding is perceived to support high levels of midwifery client satisfaction and excellent clinical outcomes, it lacks flexibility. This limits opportunities for interprofessional collaboration and for midwives to use their knowledge and skills to respond to health system gaps. The physician fee-for-service funding model creates competition for births, has unintended consequences that limit midwives' scope and access to hospital privileges, and fails to appropriately compensate physician consultants, particularly as midwifery volumes grow. Siloing of midwifery funding from hospital funding further restricts innovative contributions from midwives to respond to community healthcare needs.

CONCLUSIONS

Significant policy changes, such as adequate remuneration for consultants, possibly including salary-based physician funding; flexibility to compensate midwives for care beyond the existing course of care model; and a clearly articulated health human resource plan for sexual and reproductive care are needed to improve midwifery integration.

Global landscape of community pharmacy services remuneration: a narrative synthesis of the literature

Community pharmacists form a vital part of the health system all around the globe. Pharmacy remuneration models are aimed to ensure that pharmacies are sustained, and pharmacists could provide cost-effective services to the patients. This review summarizes the pharmacy services remuneration systems from different parts of the globe. Some countries have well-established reimbursement systems that recognize and compensate community pharmacies for their services, others are in the process of expanding the scope of reimbursable services. It further concludes by highlighting the ongoing efforts to incorporate pharmacist-provided services into reimbursement schemes and the need for standardized and consistent approaches to pharmacy remuneration globally.

What do pharmacy users think of free pharmacy services? Investigating pharmacy users' perceptions, attitudes and willingness to pay for free healthcare from pharmacies

Background

Evidence exists of pharmacists providing free or partially subsidised clinical services in order to meet patient healthcare needs. Little is known about how patients perceive the quality and importance of such unfunded services to their healthcare.

Objectives

To explore pharmacy user perspectives about unfunded services such as their valuation, why they chose to access these services from the pharmacy as well as their willingness to pay should pharmacies need to start charging for the provision of such services owing to budgetary constraints.

Methods

This study was nested in a larger nationwide study where 51 pharmacies were recruited across fourteen locations across New Zealand . Semi-structured interviews were conducted with patients who had accessed unfunded services in community pharmacies. Patients were followed up to identify their percieved health outcomes resulting from accessing the unfunded service.

Results

A total of 253 patient interviews were conducted on-site across 51 pharmacies in New Zealand. Two main themes were identified pertaining to (1) patient-provider relationship and (2) Willingness to pay. A total of fifteen different considerations were found to influence pharmacy users' decisions to access health services from the pharmacy. It was found that 62.8% of patients were willing to pay for unfunded services and the majority paying NZD$10.

Conclusion

Patients positively rate these services and largely deem them important for their healthcare. Willingness to pay for services were also variable between patients and were dependant on the type of service accessed.

[Outpatient parathyroid gland operations in the German system-Feasible and useful?]

BACKGROUND

In 2019 approximately 7500 procedures were carried out for parathyroid diseases in Germany (Statistisches Bundesamt 2020, https://www.destatis.de/DE/ ). All operations were performed as inpatient procedures. The catalogue of outpatient procedures for 2023 does not include operations on the parathyroid glands.

OBJECTIVE

Which conditions are prerequisites for parathyroid surgery on an outpatient basis?

MATERIAL AND METHODS

Published data on outpatient parathyroid surgery were analyzed with respect to the underlying disease, procedures performed and patient-specific circumstances.

RESULTS

Initial operations for localized sporadic primary hyperparathyroidism (pHPT) seem to be suitable for outpatient surgery, provided that affected patients fulfil the general prerequisites for an outpatient operation. The procedures focused parathyroidectomy and unilateral exploration can be carried out using local or general anesthesia and have a very low risk for postoperative complications. The organization of the day of the operation and the postoperative treatment of the patient should be organized within a detailed standard of procedure. The remuneration for an outpatient parathyroidectomy is not included in the German outpatient surgery catalogue and is therefore currently not adequately financially reimbursed.

CONCLUSION

In selected patients a limited initial intervention for primary hyperparathyroidism can be safely performed on an outpatient basis; however, the present German reimbursement modalities have to be revised so that the cost of these outpatient operations can be adequately covered.

[Inguinal hernia operations-Always outpatient?]

Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.

Investigating the provision, nature and associated costs of unfunded pharmacy services: A nationwide study

BACKGROUND

There is increasing evidence of pharmacists providing free or partially subsidised patient-focused services in order to meet healthcare needs. Limited information exists about the types of unfunded services and their value.

OBJECTIVES

(1) Identify the types of unfunded services provided nationally in New Zealand (NZ) and (2) Determine the costs associated with service provision.

METHODS

A continuous observation time-motion study was conducted across New Zealand to characterise the provision of unfunded pharmacy services and the labour costs associated with their provision. The time-motion study spanned one business day (between seven to eight hours) in each participating pharmacy. The primary investigator (YA) spent one business day in each participating pharmacy (n = 51) and recorded details about the patient-focused services that were provided. Details included the type of service provided, approximate duration of the service and out-of-pocket costs borne by the patient.

RESULTS

A total of 660 observations of unfunded services were recorded across the 51 pharmacies where 360 observation hours were carried out. Twenty-three types of unfunded services were identified, where minor ailments accounted for over half of the total observations. Labour costs associated with service provision were variable.

CONCLUSION

Pharmacies across New Zealand are providing patient-focused services for which no funding is being provided.

How a compensated kidney donation program facilitates the sale of human organs in a regulated market: the implications of Islam on organ donation and sale

BACKGROUND

Advocates for a regulated system to facilitate kidney donation between unrelated donor-recipient pairs argue that monetary compensation encourages people to donate vital organs that save the lives of patients with end-stage organ failure. Scholars support compensating donors as a form of reciprocity. This study aims to assess the compensation system for the unrelated kidney donation program in the Islamic Republic of Iran, with a particular focus on the implications of Islam on organ donation and organ sales.

METHODS

This study reviews secondary documents for philosophical argumentation and ethical analysis of human organ donation and sale for transplantation.

RESULTS AND DISCUSSION

According to Islamic law, organ donation is an act of sadaqatul jariyah, and individuals are permitted to donate organs with the intention of saving lives. The commercialization of humans as organ sellers and buyers is contrary to the Islamic legal maxim eethaar, undermining donors of 'selfless' or 'altruistic' motivations. Such an act should be considered immoral, and the practice should not be introduced into other countries for the sake of protecting human dignity, integrity, solidarity, and respect. I, therefore, argue that Iran's unrelated kidney donation program not only disregards the position of the Islamic religion with respect to the provision or receipt of monetary benefits for human kidneys for transplantation but that it also misinterprets the Islamic legal proscription of the sale of human organs. I also argue that the implementation of Iran's unrelated kidney donor transplantation program is unethical and immoral in that potential donors and recipients engage in a bargaining process akin to that which sellers and buyers regularly face in regulated commodity exchange markets. Conversely, I suggest that a modest fixed monetary remuneration as a gift be provided to a donor as a reward for their altruistic organ donation, which is permissible by Islamic scholars. This may remove the need to bargain for increased or decreased values of payment in exchange for the organ, as well as the transactional nature of 'buyer and seller', ensuring the philosophy of 'donor and recipient' is maintained.

CONCLUSIONS

Offering a fixed modest monetary incentive to organ donors would serve to increase organ supply while protecting donors' health and reducing human suffering without legalizing the human organ trade.

Work-related factors affecting the retention of medical officers in the preventive health sector in Sri Lanka

BACKGROUND

Retention of human resources in the healthcare system, particularly doctors at district level is a great challenge faced by the decentralized health systems in poorly resourced countries. Medical Officers of Health (MOH), medical doctors who provide preventive health services, are a particularly important human resource in the preventive health sector in Sri Lanka. This study explores the relative importance of different factors affecting the retention of MOHs in the preventive health sector of Sri Lanka.

METHODS

A descriptive cross-sectional study was carried out among Medical Officers of Health in the Colombo district with 18 MOH Offices with 74 medical officers. A pre-tested self-administered questionnaire was used as the study instrument. Data were analyzed using descriptive statistics, correlation and regression analyses.

RESULTS

Of the 74 medical officers 64 responded with a response rate of response rate of 86.5%. Regression analysis showed that all four variables; recognition, work schedule, remuneration and responsibility are positively and significantly correlated with retention of Medical Officers of Health in the preventive health sector. The variable 'work schedule' showed the highest impact on the retention of Medical Officers of Health.

CONCLUSIONS

In order to retain trained Medical Officers of Health in the Sri Lankan preventive health sector, health authorities should address the factors identified in this study. If policymakers fail to address these factors, preventive health services will face negative implications due to the shortage of key service providers.

[Practical use of digital health applications (DiGA) in internal medicine]

Since 2020 physicians can prescribe digital health applications (DiGA), also colloquially known as apps on prescription, which are reimbursed by the statutory health insurance when they are approved by the Federal Institute for Drugs and Medical Devices (BfArM) and are included in the DiGA Ordinance. Currently, there is one approved DiGA (indication obesity) for internal medicine. There are many questions on the practical use of the DiGA, ranging from the prescription, the effectiveness, the complexities and reimbursement as well as the liability risks. The DiGA are innovative new means, which maybe support internal medicine physicians in the diagnostics and treatment in the future. The benefits in this field of indications are limited by unclarified issues, especially on the prescription practice and the currently low number of DiGA available in internal medicine.

[Admission diagnosis contusion: etiology, epidemiology and cost-causing factors]

BACKGROUND

The admission of patients with minor injuries, such as contusions is a regular practice in acute care hospitals. The pathophysiological changes resulting from the accident are seldom the primary reason for hospitalization. The aim of this retrospective monocentric study was therefore to examine the etiology as well as the cost-causing factors and refinancing on admission.

METHODS

Patients were identified due to a retrospective query in the hospital information system (HIS) according to the ICD-10 German modification codes at discharge. A total of 117 patients were enrolled over a period of 2 years. The classification was carried out according to the accident mechanism and the division into age groups. In addition, the cost calculation was based on department and clinic-specific daily rates.

RESULTS

In terms of etiology low impact falls in the domestic environment were the most common cause (48.7%), followed by high-energy trauma (22.8%). Within the group with domestic falls, the mean age was 77.8 years. This group also showed the longest length of stay (LOS) with 5.2 days. As part of the calculated costs, the group of domestic falls showed the highest costs of 2596.24 € with an average DRG cost revenue of 1464.51 €.

DISCUSSION

The evaluation of the clinic internal data confirmed the subjective perception that the majority of patients admitted with the diagnosis of contusions came from the age group >65 years. Admission is primarily based on the increasing comorbidities and to avert secondary diseases and the consequences of immobilization. It could also be shown that the resulting costs are relevant to health economics and that the treatment does not appear to cover the costs.

[The MDK Reform Act and its effect on outpatient potential : Risk or opportunity for urology?]

BACKGROUND

With the introduction of the MDK (Medizinischer Dienst der Krankenversicherung) Reform Act, there have been multiple new regulations for hospitals, some of which are confusing and interact with one another. A major focus of the legal changes is directly or indirectly on expanding the provision of outpatient services.

OBJECTIVES

It can be assumed that-as a result of the new version of the framework conditions and the AOP catalog-the relevant OPS list will be expanded in the future. With the revision of the AOP catalog and the effects of the MDK Reform Act, the number of cases with outpatient potential will increase. Can the effects and challenges for hospitals and especially urology be identified?

METHODS

Evaluation of official statistics of inpatient and outpatient treatments. Focusing on the problem based on a fictitious practical example from urology.

RESULTS

A strategy is developed for dealing with cases with outpatient potential and identification of different solutions to compensate for this shift in services and enabling an increase in performance or a deliberate reduction in the provision of services.

CONCLUSIONS

The choice of the type of service provision is increasingly no longer an issue, and the short-term inpatient treatment of many urological cases is coming under considerable pressure due to political measures such as the MDK Reform Act and the demands of health insurance companies. The reduction of different parts of the inpatient reimbursement for special patient groups must be anticipated. Individual strategies will range from simply not providing outpatient services to complex models of cooperation. This change also means opportunities for hospitals!

Are professional pharmacy services being offered for free in pharmacies? A feasibility study exploring the use of a time motion study in New Zealand

Background

Pharmacists report to be providing patient-focused clinical services for which they receive no remuneration. Limited literature exists about unfunded services leading to difficulties in ascertaining an appropriate study design for such research.

Objective

This study aims to assess the appropriateness of a proposed study design before launching a nationwide study to investigate the provision of unfunded patient care services.

Methods

A multi-methods approach was utilised consisting of (1) continuous time motion study in community pharmacies (2) semi structured patient interviews (3) patient follow up (4) semi structured interviews with pharmacy owners/managers. All observations of unfunded patient care services were recorded, numerically coded and descriptively analysed. Semi structured interviews were audio recorded and transcribed verbatim. A semantic thematic analysis was carried out. Appropriateness of study design was dictated by the ability to characterise services and obtain patient perceptions.

Results

Ten pharmacies took part in the feasibility study, across the city of Dunedin, New Zealand, representing a range of different practice settings and demographics. Ten patients were interviewed and six responded to follow up. Both pharmacy and patient recruitment proved challenging due to concerns around disruption to workflow and patient privacy. A continuous observation time motion study was found to be appropriate as it minimises disruption to workflow with no additional work required from the pharmacy teams.

Conclusions

A continuous observation time motion study proved to be an appropriate method to investigate the provision of unfunded services on a national scale. The findings of the study suggest design changes such as length of observation time, increasing patient recruitment and additional patient questions to enhance the nationwide study.

Why do pharmacists leave the profession? A mixed-method exploratory study

Background:

Recent New Zealand policy documents aim for pharmacists to be retained, and promote the provision of extended clinical pharmacy services. However, younger pharmacists have expressed dissatisfaction with the profession on informal social for a.

Objectives:

To explore the characteristics, and perspectives of pharmacy as a career, of recent Bachelor of Pharmacy (BPharm, four-year degree) graduates who have left, or are seriously considering leaving the New Zealand pharmacy profession in the near future and where they have gone, or plan to go.

Methods:

We conducted a cross-sectional study with a mixed-method explanatory sequential design. An anonymous online survey among those who completed their pharmacy undergraduate degree (BPharm or equivalent) in 2003 or later and who had left or who were seriously considering leaving the New Zealand pharmacy profession in the next five years, was open from 1^st December 2018 to 1^st February 2019. Recruitment occurred via University alumni databases, pharmacy professional organisations, pharmaceutical print media, social media and word-of-mouth. Ten semi-structured interviews were then conducted with a purposive sample of survey respondents. Descriptive statistics were generated from the quantitative data and qualitative data were analysed using manifest content analysis.

Results:

We received 327 analysable surveys of which 40.4% (n=132) were from those who had already left the New Zealand pharmacy sector at the time of the data collection and the rest (59.6% n=195) were those working within the sector, but seriously considering leaving the profession. Reasons most commonly reported for studying pharmacy were having an interest in health and wanting to work with people. The most common reasons for leaving, or wanting to leave, were dissatisfaction with the professional environment, including inadequate remuneration, and a perceived lack of career pathways or promotion opportunities. A wide range of career destinations were declared, with medicine being most frequently reported.

Conclusions:

Most of the reasons for leaving/considering leaving the profession reported relate to the values and features of the pharmacy profession such as the professional environment, remuneration and career pathways. These findings are consistent with other studies and may represent a barrier to achieving the aims of recent health policy documents.

The perceptions and expectations of chemotherapy nurses in gynaecology wards about their remuneration

Chemotherapy as an important therapy for gynaecological cancer needs nurses' high performances. Thus, remuneration as a factor influencing nurses' work motivation needs to be considered. The purpose of this study was to explore the perceptions and expectations of chemotherapy nurses in gynaecology wards about remuneration. This study was a qualitative research with phenomenological design. Data were collected by FGD involving 15 chemotherapy nurses in a hospital in Indonesia. The themes produced were as follows: (1) Nurses perceived themselves as chemotherapy nurses with special knowledge and skills and high-risk job, (2) Chemotherapy nurses perceived that the remuneration system is not transparent, unfair, and demotivate them, (3) Chemotherapy nurses expected that the remuneration system could be implemented fairly and transparently, with support of adequate information system. It is recommended to improve the implementation of the remuneration with an appropriate information system, in order to increase chemotherapy nurses' work performance in gynaecology services.

"A decade's worth of work in a matter of days": The journey to telehealth for the whole population in Australia

Introduction

Internationally the COVID-19 pandemic has triggered a dramatic and unprecedented shift in telehealth uptake as a means of protecting healthcare consumers and providers through remote consultation modes. Early in the pandemic, Australia implemented a comprehensive and responsive set of policy measures to support telehealth. Initially targeted at protecting vulnerable individuals, including health professionals, this rapidly expanded to a “whole population” approach as the pandemic evolved. This policy response supported health system capacity and community confidence by protecting patients and healthcare providers; creating opportunities for controlled triage, remote assessment and treatment of mild COVID-19 cases; redeploying quarantined or isolated health care workers (HCWs); and maintaining routine and non-COVID healthcare.

Purpose

This paper provides a review of the literature regarding telephone and video consulting, outlines the pre-COVID background to telehealth implementation in Australia, and describes the national telehealth policy measures instituted in response to COVID-19. Aligned with the existing payment system for out of hospital care, and funded by the national health insurance scheme, a suite of approximately 300 temporary telehealth Medicare-subsidised services were introduced. Response to these initiatives was swift and strong, with 30.01 million services, at a cost of AUD $1.54 billion, claimed in the first six months.

Findings

This initiative has been a major policy success, ensuring the safety of healthcare consumers and healthcare workers during a time of great uncertainty, and addressing known financial risks and barriers for health service providers. The risks posed by COVID-19 have radically altered the value proposition of telehealth for patients and clinicians, overcoming many previously encountered barriers to implementation, including willingness of clinicians to adopt telehealth, consumer awareness and demand, and the necessity of learning new ways of conducting safe consultations. However, ensuring the quality of telehealth services is a key ongoing concern.

Conclusions

Despite a preference by policymakers for video consultation, the majority of telehealth consults in Australia were conducted by telephone. The pronounced dominance of telephone item numbers in early utilisation data suggests there are still barriers to video-consultations, and a number of challenges remain before the well-described benefits of telehealth can be fully realised from this policy and investment. Ongoing exposure to a range of clinical, legislative, insurance, educational, regulatory, and interoperability concerns and solutions, driven by necessity, may drive changes in expectations about what is desirable and feasible – among both patients and clinicians.

[Cost factor "outpatient wound care" in the emergency department : Cost-revenue deficit of outpatient wound treatment in a German university hospital]

BACKGROUND

In addition to highly specialized medicine, the initial treatment of wounds and minor surgical interventions are generally necessary basic services of emergency care in hospitals. The reimbursement of outpatient emergency services for persons with statutory insurance is currently based on the uniform assessment standard (EBM), where the recording of business expenses in the private practice sector serves as the basis for the calculation. Hospitals have considerably higher maintenance costs than medical practices.

OBJECTIVE

In this article the resulting cost-revenue ratio of outpatient wound care in an emergency department is analyzed through the reimbursement according to EBM.

MATERIAL AND METHODS

The data were collected in the emergency surgical department of the University Hospital Frankfurt am Main over 12 months. Included were all patients who received sutured wound care during this period. The costs incurred were compared to the remuneration according to EBM 01210 (or 01212) with the additional flat rate for small surgical procedures EBM 02301.

RESULTS

During the observation period 1548 patients were treated, i.e. 19.52% of all trauma surgery cases. The resulting costs of a standard wound care of 45.40 € are offset by a remuneration of 31.83 €. The calculation of the total revenue shows a deficit amount of 13.57 € per outpatient case, this corresponds to an annual deficit of 21,006.36 €.

CONCLUSION

It could be shown that even without consideration of the relevant holding costs, cost coverage cannot be achieved in any case. The previous reimbursement of outpatient wound care on the basis of the EBM appears to be inadequate. In the future, an adjustment or supplementary remuneration seems to be necessary in order to ensure sufficient quality of care.

Validity of the Best Practice Tariff in paediatric major trauma: A retrospective cohort study from a level 1 children's major trauma centre

INTRODUCTION

The Best Practice Tariff (BPT) in major trauma awards Major Trauma Centres (MTCs) a financial incentive when predefined standards of care are met. However, no tailored criteria exist with regards to the reimbursement policy in paediatric major trauma. In this study, we aim to examine the utility of the paediatric Major Trauma BPT and identify predictors of additional resource utilisation.

MATERIALS AND METHODS

This cohort study encompassed all paediatric major trauma calls (N = 682) presenting to a designated combined adult and paediatric MTC between July 2014 and June 2017. Patient demographics, admission pattern, injury parameters, length of stay (LOS) and the need for operative management were collected. Patients approved for the BPT uplift payment (BPT group) were compared with the cohort of children not qualifying (non-BPT group).

RESULTS

Overall, less than a quarter (23.2%) of the trauma population qualified for the BPT. The proportion of patients requiring operative intervention and CT scanning in the BPT group was significantly higher (p<0.001). These children also attained a higher ISS (median, 13.5 vs. 0, p <0.001) and required longer hospitalisation. Following a Receiver Operator Characteristic (ROC) curve analysis, a cut off ISS score > 8 demonstrated an excellent predictive value in identifying children qualifying for BPT (true positive and false positive rates: 90% and 10.7%). However, a subgroup analysis including the more severely injured children (ISS >8) not qualifying for the uplift payment revealed that equally substantial resource went into their management - 42.9% needed surgical intervention and 57.1% a CT scan.

DISCUSSION

This study demonstrated that BPT in paediatric major trauma is a valuable reimbursement; however, our findings also unveiled a cohort deemed ineligible for BPT despite the high costs accrued. Re-evaluation of the remuneration criteria of paediatric major trauma networks with an alternative, more inclusive reimbursement policy is needed.

Developments in oral health care in the Netherlands between 1995 and 2018

Background

Over the past several decades, changes in legislation and regulations have been implemented in oral health care in the Netherlands. In 1995, for example, a major transformation in the funding of oral health care was implemented, after which most oral health care for adults was no longer covered by national insurance. In 1997, the Individual Healthcare Professions Act, in which the authorizations of care providers were described, was established. The Healthcare Quality, Complaints and Disputes Act, established in 2016, concerns the accountability of professional behavior. Regulations concerning employment have changed several times since 1995. These changes have affected the work and practice situation of oral health care providers.

Methods

Data from many publicly available sources were gathered and combined with internal reports mainly derived from the Data Stations project of the Royal Dutch Dental Association. This project was established in 1995 and, since its initiation, 6716 dentists have participated an average of 6.7 times.

Results

Between 1995 and 2018, nearly all professional groups in oral health care increased, particularly those of dental hygienists and prevention assistants. The number of dental practices decreased, but practices got larger in terms of dental units, number of patients, and personnel. The percentage of inhabitants visiting oral health care professionals remained unchanged, but the type of care provided moved towards more prevention. Oral health care providers exploited new opportunities to enhance and express their professional behavior.

Conclusions

Oral health care in the Netherlands has evolved in recent years toward more collaboration in teams, and professions have established institutions to promote the quality and safety of care. Greater emphasis has been placed on prevention of dental diseases. These processes were influenced by new legislation and regulations, demographic changes within professional groups, and other social developments.

What free services do pharmacists offer? Investigating the provision of unfunded pharmacy services in community pharmacies

BACKGROUND

Globally, pharmacists report to be providing free or partially subsidised patient-focused services in order to meet healthcare needs of their communities. Budget cuts to pharmacy contracts are reported to challenge the provision of such services. Limited information exists identifying the types of unfunded services provided in community pharmacies.

OBJECTIVES

To identify the types of services which pharmacists report to provide that are not reimbursed by the government, insurance companies or paid for by the patient.

METHODS

Semi-structured focus group discussions with pharmacists were conducted stimulating narratives from community pharmacists across New Zealand about the types of unfunded pharmacy services they provide. Discussions were audio recorded and transcribed verbatim. Inductive coding of the data was carried out using QSR International Nvivo 11 for Windows. A semantic thematic analysis was carried out.

RESULTS

Twenty-four pharmacists took part in the focus groups across five regions in both the North and South Islands of New Zealand. Key themes identified from focus groups were: 'Standalone unfunded services', 'Services funded elsewhere' and 'Leakages from the current funding model'. Pharmacists reported that unfunded patient-focused services accounted for 15%-50% of their daily activities. Pharmacists stated that they believed these services often led to reduction of disease progression, hospitalisations and improved quality of life. Pharmacists also stated that given budget cuts, these services are not sustainable.

CONCLUSIONS

Pharmacists report to offer many professional services without remuneration. In some cases, these services make up a substantial part of the pharmacist's time. Further budgetary constraints and increased competition may put these services at risk of being lost. Findings from this study can be applied to unfunded pharmacy services elsewhere, as worldwide pharmacy faces many similar challenges, particularly where there are budget cuts and decreasing revenue in other jurisdictions.

Estimating the productivity of radiologists in Brazil: the search for a benchmark

Objective

To determine the average productivity of radiologists, as measured by number of reports issued per 6-h shift, evaluating variables that could affect the results.

Materials and Methods

This was a study utilizing an online questionnaire sent to radiologists affiliated with the Brazilian College of Radiology and Diagnostic Imaging. The questions were related to the demographic profile and professional practice characteristics (form of remuneration, primary imaging method employed, and subspecialty) of the radiologists, as well as their individual productivity (average personal productivity) and the productivity considered reasonable in a 6-h shift. The association between productivity and the practice characteristics of the radiologists was determined by using Poisson regression to calculate the prevalence ratio.

Results

A total of 510 radiologists completed the questionnaire. The great majority of the respondents (84%) reported that their remuneration is directly related to their productivity. The productivity varied according to the subspecialty, work environment, and remuneration model.

Conclusion

We demonstrated that the productivity of radiologists is associated with the characteristics of their employment. We hope that this study will encourage other studies aimed at evaluating the productive capacity of the radiologists in Brazil, addressing the various functions they perform in their daily routine, including activities other than issuing reports.

Remuneration committees, executive remuneration, and firm performance in Indonesia

Indonesia is currently in the process of mandating the establishment of Remuneration Committees (RCs) for all listed companies. However, little is known about the effectiveness of RCs in Indonesia. This study sheds light on this issue, by examining the relationships between RCs, executive and board of director remuneration, and firm performance in Indonesia. This study uses 847 observations of firms listed on the Indonesian Stock Exchange (IDX) during 2014-2017. Our results indicate that RCs are positively related to executives remuneration and firm performance. In particular, higher remuneration is only linked to higher performance in firms that have established a remuneration committee. This study documents the interactions between RCs, remuneration levels of senior company officers and firm performance in an emerging market setting with voluntary formation of RCs. This study has implications for regulators and company management in Indonesia (and other emerging markets), as the existence of remuneration committees is found to be associated with more effective remuneration packages and higher firm performance.

[Reimbursement differences in the ambulatory specialized care (ASV) compared to the previous care system. An exemplary analysis in medical oncology treating gastrointestinal malignancies]

INTRODUCTION AND AIM

The ambulatory specialized care (ASV) act (Sect. 116b of the Social Code Fifth Book [SGB V]) is intended to enable patients with a rare disease or a special course of disease or patients needing a highly specialized treatment to get access to outpatient care by office-based as well as hospital doctors. Data concerning care, service performance and fees - in comparison to the usual contract with the statutory insurance or the former Sect. 116b SGB V - are lacking. We explored the question whether differences in reimbursement between ASV and the previous system exist and which factors are influencing them.

METHODS

We analyzed ICD-10 diagnoses, performance parameters as well as budgets and service fees in the former care system of medical oncologists in the institutions of three ASV participants of two federal countries treating gastrointestinal malignancies. We compared the results (fees, remuneration) to those from the statutory contract system and the former ambulatory care of hospitals and calculated the differences. Data were analyzed descriptively and analytically using SPSS.

RESULTS

The analyses showed significant differences in the reimbursement rates between both office-based teams due to different budgets in the statutory contract system of the different federal countries. This led to additional remuneration of 12.5 to 49 % in ASV. The increase in fees of the hospital-guided team was exclusively due to the ASV-only fees of chapter 51 of EBM since there were no limitations of budgets even in the former system.

DISCUSSION AND CONCLUSION

Exemplified with the ASV subgroup GIT, our study shows for the analyzed medical specialty that the difference in reimbursement in ASV is mostly due to the federal country-specific budgets and that the increase in honoraria can be substantial. Due to differences in budgets and quota systems, there may be different results in other ASV indications and specialist groups as well as in other federal states. Irrespective of these arguments, further aspects need to be taken into account when participation in ASV is considered.

Income inequality among general practitioners in Iran: a decomposition approach

BACKGROUND

General practitioners (GPs) are among the most important resources of healthcare system and public health is considerably influenced by the function of this group. Income inequality among GPs considerably affects the motivation and performance of this group. The present study aims to examine the income inequality among Iranian GPs in order to provide the necessary evidence for health human resource policy.

METHODS

In this cross-sectional study, the distribution of income and wage inequality among GPs was investigated using income quintiles. We also used the Dagum's model to analyze the inequality between different groups of GPs through the decomposition of the Gini coefficient. Moreover, a regression model was used to determine the effective factors on GPs' income.

RESULTS

The results of this study indicated that income and wages of GPs in the highest quintile were eight times more than those of doctors at the lowest quintile. Regression estimates showed that factors such as gender, practice setting, and activity as the family physician (P < 0.001) were effective on income of GPs; and also male and self-employed GPs had significantly more wage (P < 0.001). Total Gini coefficient of GPs' income and wage were estimated at 0.403 and 0.412, respectively. Highest monthly income was found in GPs with 16-20 years practice experience ($8358) based on Purchasing Power Parity (PPP), male ($8339 PPP), and self-employed GPs ($8134 PPP) subgroup. However, the female ($5389 PPP) and single ($5438 PPP) GPs had the lowest income. Population share; income/wage share; income/wage mean; Gini coefficient; and within, between and overlap decomposed components of Gini coefficient are also reported for each GPs subgroups.

CONCLUSIONS

We found significant inequalities in income and wages among Iranian GPs. Adjustment of income based on working hours indicated that one of the most common causes of income inequality among GPs in Iran was different workloads among different groups. Since the motivation and function of physicians can be influenced by income inequality, policymakers in the health system should consider factors increasing such inequalities.

Salaried and voluntary community health workers: exploring how incentives and expectation gaps influence motivation

BACKGROUND

The recent publication of the WHO guideline on support to optimise community health worker (CHW) programmes illustrates the renewed attention for the need to strengthen the performance of CHWs. Performance partly depends on motivation, which in turn is influenced by incentives. This paper aims to critically analyse the use of incentives and their link with improving CHW motivation.

METHODS

We undertook a comparative analysis on the linkages between incentives and motivation based on existing datasets of qualitative studies in six countries. These studies had used a conceptual framework on factors influencing CHW performance, where motivational factors were defined as financial, material, non-material and intrinsic and had undertaken semi-structured interviews and focus group discussions with CHWs, supervisors, health managers and selected community members.

RESULTS

We found that (a mix of) incentives influence motivation in a similar and sometimes different way across contexts. The mode of CHW engagement (employed vs. volunteering) influenced how various forms of incentives affect each other as well as motivation. Motivation was negatively influenced by incentive-related "expectation gaps", including lower than expected financial incentives, later than expected payments, fewer than expected material incentives and job enablers, and unequally distributed incentives across groups of CHWs. Furthermore, we found that incentives could cause friction for the interface role of CHWs between communities and the health sector.

CONCLUSIONS

Whether CHWs are employed or engaged as volunteers has implications for the way incentives influence motivation. Intrinsic motivational factors are important to and experienced by both types of CHWs, yet for many salaried CHWs, they do not compensate for the demotivation derived from the perceived low level of financial reward. Overall, introducing and/or sustaining a form of financial incentive seems key towards strengthening CHW motivation. Adequate expectation management regarding financial and material incentives is essential to prevent frustration about expectation gaps or "broken promises", which negatively affect motivation. Consistently receiving the type and amount of incentives promised appears as important to sustain motivation as raising the absolute level of incentives.

[Current legal and jurisdictional questions from the perspective of the German Federal Association for Geriatrics : Practical report]

The article discusses the questions of the arbitration bodies according to § 111b SGB V (Volume V of the Social Insurance Code) in the individual federal states from the perspective of geriatric rehabilitation hospitals. The content of the agreement of reimbursement between a rehabilitation hospital and health insurance will be targeted as well as the question whether the entire content of the agreements of reimbursement can be negotiated at the arbitration body. In addition, the authors describe the consequences of the jurisprudence of the Federal Social Court on § 301 I. S. 1 no. 8 SGB V and the reaction of the lawgiver. Furthermore the authors describe the effects of the jurisprudence of the Federal Social Court regarding the minimum age associated with complex geriatric treatment (OPS 8-550).

A cross-sectional study of the income sources of primary care health workers in the Democratic Republic of Congo

BACKGROUND

In the Democratic Republic of Congo (DRC), the state system to remunerate health workers is poorly functional, encouraging diversification of income sources and corruption. Given the central role that health workers play in health systems, policy-makers need to ensure health workers are remunerated in a way which best incentivises them to provide effective and good quality services. This study describes the different sources and quantities of income paid to primary care health workers in Equateur, Maniema, Kasai Occidental, Province Orientale and Kasai Oriental provinces. It also explores characteristics associated with the receipt of different sources of income.

METHODS

Quantitative data on the income received by health workers were collected through baseline surveys. Descriptive statistics explored the demographic characteristics of health workers surveyed, and types and amounts of incomes received. A series of regression models were estimated to examine the health worker and facility-level determinants of receiving each income source and of levels received. Qualitative data collection was carried out in Kasai Occidental province to explore perceptions of each income source and reasons for receiving each.

RESULTS

Nurses made up the majority of workers in primary care. Only 31% received a government salary, while 75% reported compensation from user fees. Almost half of all nurses engaged in supplemental non-clinical activities. Receipt of government payments was associated with income from private practice and non-clinical activities. Male nurses were more likely to receive per diems, performance payments, and higher total remuneration compared to females. Contextual factors such as provincial location, presence of externally financed health programmes and local user fee policy also influenced the extent to which nurses received many income sources.

CONCLUSIONS

The receipt of government payments was unreliable and had implications for receipt of other income sources. A mixture of individual, facility and geographical factors were associated with the receipt of various income sources. Greater co-ordination is needed between partners involved in health worker remuneration to design more effective financial incentive packages, reduce the fragmentation of incomes and improve transparency in the payment of workers in the DRC.

Performance-based financing in the context of the complex remuneration of health workers: findings from a mixed-method study in rural Sierra Leone

Background

There is growing interest on the impact of performance-based financing (PBF) on health workers’ motivation and performance. However, the literature so far tends to look at PBF payments in isolation, without reference to the overall remuneration of health workers. Taking the case of Sierra Leone, where PBF was introduced in 2011, this study investigates the absolute and relative contribution of PBF to health workers’ income and explores their views on PBF bonuses, in comparison to and interaction with other incomes.

Methods

The study is based on a mixed-methods research consisting in a survey and an 8-week longitudinal logbook collecting data on the incomes of primary health workers (n = 266) and 39 in-depth interviews with a subsample of the same workers, carried out in three districts of Sierra Leone (Bo, Kenema and Moyamba).

Results

Our results show that in this setting PBF contributes about 10 % of the total income of health workers. Despite this relatively low contribution, their views on the bonuses are positive, especially compared to the negative views on salary. We find that this is because PBF is seen as a complement, with less sense of entitlement compared to the official salary. Moreover, PBF has a specific role within the income utilization strategies enacted by health workers, as it provides extra money which can be used for emergencies or reinvested in income generating activities. However, implementation issues with the PBF scheme, such as delays in payment and difficulties in access, cause a series of problems that limit the motivational effects of the incentives. Overall, staff still favor salary increases over increases in PBF.

Conclusions

The study confirms that the remuneration of health workers is complex and interrelated so that the different financial incentives cannot be examined independently from one. It also shows that the implementation of PBF schemes has an impact on the way it does or does not motivate health workers, and must be thoroughly researched in order to assess the impact of PBF.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1546-8) contains supplementary material, which is available to authorized users.

[Current state of compensation of on-duty and on-call urologists in France: a study from AFUF]

INTRODUCTION

The French Association of Urologists-in-training (AFUF) aimed to assess the current state of remunerations of on-call and on-duty residents, assistants and lecturers in urology in France.

MATERIAL AND METHODS

Data were collected from February to May 2013 through a questionnaire sent to all members of the AFUF (327 members). Remunerations were given in gross values.

RESULTS

Forty-three residents took part in the study, 16 assistants and 16 lecturers, representing 62 % of the whole centers (54 hospitals out of the 92 centers practicing urology in France). Most of responders were on security or operational on-call. Twenty hospitals were practicing multi-organ removal. Median remunerations of residents were about 59.51€ per on-call when moving at hospital for work and about 119.02€ per onsite duty. Assistants and lecturers were paid a flat fee rate for 37.5 % of them (140€ for assistants [with variability from 40 to 195€] and 130€ for lecturers [42.5-180]) or an hourly rate depending on the hours spent at hospital for the others (62.5 %): first, second move or move<3h were paid 100€ for assistants and 65€ for lecturers, 233.5€ and 236€ respectively for the third one or above 3h, 365€ and 473€ respectively above 8h. Multi-organ removals were paid a flat fee rate (60 %) or an hourly rate (40 %) as well. Beyond a threshold of 2-3hours, the hourly rate was more interesting than the flat fee rate.

CONCLUSION

There were disparities in remuneration of on-call and on-duty urologists. Greater variability affected on-call flat fee rate remuneration beyond a certain threshold of hours and remuneration of multi-organ removal. These disparities should be considered in order to get a national harmonization.

Pharmacists remuneration models in iran and selected countries: a comparative study

Pharmacists are members of the healthcare teams that provide valuable services to society. Their incentive to deliver such services is influenced by remuneration methods. In this study, we aimed to review the remuneration models for pharmacists' services and the factors affecting the profitability of pharmacies in some selected countries, including France, Ireland, Canada and Turkey, and compared them to Iran. International data were collected by literature review on Google, Google scholar, PubMed and Scopus. In addition, domestic data were collected by contacting relevant organizations. There is no payment for pharmacists' cognitive services in Iran and in the countries investigated, except for some Canadian provinces. The dispensing fee system in Iran does not seem to be adequate, especially considering that most of the insurers do not cover these fees. The pricing method in Iran has resulted in a low price level, in comparison to the other countries, and this issue has dramatically affected the profitability of pharmacies in standard practice. It could be concluded that changing the current formulation for the dispensing fee to a more appropriate one, defining a remuneration system for non-owner pharmacists other than salary and implementing the new pricing method are necessary in order to improve the services provided by pharmacies.