In this paper a doctor acts as a perfect agent for a group of patients in an environment where the health service is funded by a group of contributors. The contributor group donates resources to the health sector in accordance with its split preferences about the health care services which they would like for themselves and those which they would like for others. We show that the size of the health budget is endogenous and depends on the choices made by the doctor. The focus is on the division of the budget between health enhancing and non-health enhancing health care.
In 2014 presumably healthy men aged 40-59 yr the prevalence of previously undiagnosed angina pectoris was assessed by two angina questionnaires: (1) World Health Organization Questionnaire (WHO-Q) and (2) Greater New York Health Insurance Plan Survey Questionnaire (NY-Q). The angina prevalence given by the questionnaires singly or in combination varied between 1.15 and 4.7% (lowest prevalence by the WHO-Q interview version (WHO-Qi) and highest by the WHO-Q self-administered version and the NY-Q in combination), indicating a considerable variation in prevalence with variation in criteria used. Validation of the questionnaires by means of (1) coronary angiography, and (2) follow-up in selected cases, indicated NY-Q superiority over WHO-Q in predicting the presence of coronary heart disease (CHD). WHO-Qi had a particularly low sensitivity without being more specific. However, CHD-risk factor patterns in subgroups of individuals classified as angina-positive or -negative by the respective questionnaires were similar.
Canadian physicians only need look to the south to see that capitation can control not only their fees but also the amount of resources they use, the amount of care their patients can expect and the way doctors and patients relate to one another. In the US, capitation is rewarding doctors for doing less and penalizing them if they do too much. "Instead of a being cash source," says Dr. John Verhoff, a family practitioner in Columbus, Ohio, "a patient visit is a cash drain." Milan Korcok looks at the ways capitation is changing medicine in the US.
Budget constraints, technological advances and a growing elderly population have resulted in major reforms in health care systems across Canada. This has led to fewer and smaller acute care hospitals and increasing pressure on the primary care and continuing care networks. The present system of care for the frail elderly, who are particularly vulnerable, is characterized by fragmentation of services, negative incentives and the absence of accountability. This is turn leads to the inappropriate and costly use of health and social services, particularly in acute care hospitals and long-term care institutions. Canada needs to develop a publicly managed community-based system of primary care to provide integrated care for the frail elderly. The authors describe such a model, which would have clinical and financial responsibility for the full range of health and social services required by this population. This model would represent a major challenge and change for the existing system. Demonstration projects are needed to evaluate its cost-effectiveness and address issues raised by its introduction.
To compare primary healthcare (PHC) provided by an independent not-for-profit organization (INPO) with that provided by two public municipal organizations (MO1 and MO2), in terms of clients' perceptions of performance, acceptance, and trust.
A survey using a pre-tested questionnaire to all clients visiting a health centre (HC) doctor or nurse during one week in 2000 (n = 511, 51% response rate) and 2002 (n = 275, 47%). The data were analysed by descriptive statistics and cumulative logistic regression analysis.
The INPO differed from both publicly provided services in accessibility, consistency of service, and outcomes. Clients reported lower trust in HC provided by public organizations compared with the INPO. Trust was higher if clients also reported experiencing "very good" or "moderate" organizational access--or if general satisfaction was "very high" or "moderate" or if they experienced outcomes as "very good" or "moderate" compared with the "very poor or low" situation. Women reported lower trust in HC than men. When the family doctor was included in the same logistic regression model with the service provider, only the family doctor was a significant explanatory variable. Reported acceptance of private alternative service providers among clients was similar between the study organizations.
Clients of the INPO generally rated the service more positively than clients of publicly provided services. The results indicate that trust in HC depends more on a family doctor system than a service provider.
To conduct a population-based study on the provision of large bowel endoscopic services in Ontario.
Data from the following databases were analyzed: the Ontario Health Insurance Plan, the Institute for Clinical Evaluative Sciences Physicians Database and Statistics Canada. The flexible sigmoidoscopy and colonoscopy rates per 10,000 persons (50 to 74 years of age) by region between April 1, 2001, and March 31, 2002, were calculated, as well as the numbers and types of physicians who performed each procedure.
In 2001/2002, a total of 172,108 colonoscopies and 43,400 flexible sigmoidoscopies were performed in Ontario for all age groups. The colonoscopy rate was approximately five times that of flexible sigmoidoscopy; rates varied from 463.1 colonoscopies per 10,000 people in the north to 286.8 colonoscopies per 10,000 people in the east. Gastroenterologists in all regions tended to perform more procedures per physician, but because of the large number of general surgeons, the total number of procedures performed by each group was almost the same.
Population-based rates of colonoscopies and flexible sigmoidoscopies are low in Ontario, as are the procedure volumes of approximately one-quarter of physicians.
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A series of studies conducted in the same region found that programmatic, community-based health and social service interventions have a positive impact on client well-being. These proactive interventions, designed to address the full range of health and social needs, were usually provided at the same--or even lower--costs as uncoordinated, illness-focused care. The results of this series suggest that across-the-board health care reduction, at least in a system of national health insurance, will produce poorer results, at higher cost, for people with chronic conditions living in the community. Policy planners need more research that concentrates on comparisons of outcomes between and within different models of health and social service delivery. The studies should be designed to help them determine who benefits from different service configurations carried out within a range of policy environments at various costs.
To determine if there are differences in physician services in different health care systems, we compared ambulatory visit rates and procedure rates for three surgical procedures in the province of Manitoba, Canada; Kaiser Permanente Health Maintenance Organization; and the United States. The KP system, with its single payer and low financial barriers, is not unlike the Canadian system. But, for most of the United States, the primary payment mechanism is fee-for-service, with the patient paying a significant amount, thereby militating against preventive and early primary care. Manitoba and KP data were extracted from computerized administrative records. U.S. data were obtained from publicly available reports. Manitoba provides 1.8 times and KP 1.2 times (1.4 when allied health visits are included) as many primary care physician visits as the United States. For the surgical procedures studied, U.S. rates were higher than those in either the KP HMO or in Manitoba. We conclude that (1) the U.S. system leads to more surgical intervention, and (2) removal of financial barriers leads to higher use of primary care services where more preventive and ameliorative care can occur.
Neonatal intensive care is expensive. In the current era of intense cost containment in hospital care, neonatologists and hospital administrators are under intense pressure to find strategies for cost reduction for neonatal services. Few neonatal clinicians are trained in economics, management, or accounting, and few hospital administrators are familiar with neonatal intensive care. In this review, we describe the structure and sources of hospital costs and the accounting systems needed to isolate and measure such costs. We discuss where efficiencies might be found and consider specific issues in capitated settings such as health maintenance organizations in the United States, the Canadian health care system and the National Health System in the United Kingdom.
In a model incorporating uncertainty and state-dependent utility of health services, as well as information asymmetry between patients/buyers and physicians/sellers, two types of equilibria are compared: (1) when consumers have conventional third-party insurance and doctors are paid on the basis of fee-for-service; and (2) when insurance is through an HMO which provides health services through its own doctors. Conditions are found under which contractual or legal incentives can overcome the information asymmetry problem and bring about an efficient allocation of resources to health services provision.