The market for paid sick leave

In many countries, general practitioners (GPs) are assigned the task of controlling the validity of their own patients’ insurance claims. At the same time, they operate in a market where patients are customers free to choose their GP. Are these roles compatible? Can we trust that the gatekeeping decisions are untainted by private economic interests? Based on administrative registers from Norway with records on sick pay certification and GP-patient relationships, we present evidence to the contrary: GPs are more lenient gatekeepers the more competitive is the physician market, and a reputation for lenient gatekeeping increases the demand for their services.     

Competition and dental services

Dental services for adults are different from all other Norwegian health services in that they are provided by private producers (dentists) who have full freedom to establish a practice. They have had this freedom since the end of World War II. A further liberalization of the market for dental services occurred in November 1995, when the so-called normal tariff was repealed. The system changed from a fixed fee system to a deregulated fee system. In principle, the market for dental services for adults operates as a free competitive market, in which dentists must compete for a market share. The aim of this study was to study the short-term effects of competition. A comprehensive set of data on fees, practice characteristics, treatment profiles and factors that dentists take into account when determining fees was analysed. The main finding was that competition has a weak effect. No support was found for the theory that the level of fees is the result of monopolistic competition or monopoly. The results also provided some evidence against the inducement hypothesis. At this stage, it is interesting to notice that dentists do not seem to exploit the power they have to control the market. One explanation, which is consistent with the more recent literature, is that physicians' behaviour to a large extent is influenced by professional norms and caring concerns about their patients. Financial incentives are important, but these incentives are constrained by norms other than self-interest. The interpretation of the results should also take into account that the deregulation has operated for a short time and that dentists and patients may not yet have adjusted to changes in the characteristics of the market.     

Specialist and general practice views on routine follow-up of breast cancer patients in general practice

The practice of routinely following-up breast cancer in hospitalclinics is of widespread concern: studies have shown that itis not an effective way of detecting recurrent disease and itplaces great strain on cancer services which are already overstretched.A general practice centred system of routine follow-up may bea solution to this problem in those countries which have a strongprimary care base. Such a system would have other benefits suchas continuity of care for the patient. The objective of thisstudy was to determine the views of general practitioners andspecialists on follow-up of patients with breast cancer in remission,with special emphasis on their views on the transfer of routinefollow-up from the hospital to general practice. A postal questionnairesurvey of British breast cancer specialists (response rate 77.0%)and a personal interview survey of British general practitioners(response rate 81.8%) were conducted. The results show thatBritish general practitioners are willing to take on greaterresponsibility for the routine follow-up care of their patientswith breast cancer. However, there was frequently a mis-matchbetween specialists' and general practitioners' views on thissubject.     

Towards an economic model of the Dutch health care sector

This paper describes the construction of a model of the Dutch health care sector. It discusses the behaviour of patients, general practitioners, medical specialists and hospital managers. It also analyses the various ways the actors interact, such as general practitioners supplying the services demanded by patients, specialists dispatching referrals made by general practitioners or hospital managers boosting output to match an increasing amount of specialist services. Numerical simulations illustrate the various mechanisms in the model. © 1997 John Wiley & Sons, Ltd.     

Latent class versus two-part models in the demand for physician services across the European Union

Using three waves of data from the European Community Household Panel, this paper estimates demand for physician services equations for 12 European countries. We focus on the selection of the most appropriate econometric specification for visits to general practitioners and to specialists among two-part and latent class models. The distinction between the demand of services from these two types of physicians allows us to distinguish cases in which two-part perform better than latent class models, evidence which is different from previous findings in the literature. The results suggest that latent class models are more appropriate than two-part models to estimate general practitioners utilisation while the opposite is found for visits to the specialists.     

Determinants of access to physician services in Italy: a latent class seemingly unrelated probit approach

We examine access to general practitioners and specialists who work in the public and private sectors in Italy using a seemingly unrelated system of probits. We use a latent class formulation that provides a rich and flexible functional form and can accommodate non-normality of response probabilities. The empirical analysis shows that patient behavior can be clustered in two latent classes. We find that income strongly influences the mix of services. Richer individuals are less likely to seek care from GP's and more likely to seek care from specialists, and especially private specialists. Health status and societal vulnerability are the most important indicators of class membership.     

Specialists visiting rural general practices in Norway

The amount of ambulatory care shared between general practitioners and specialists varies widely, especially in Scandinavia. The policy of encouraging specialists to consult through referral in primary medical care has been recommended by governments for many years. One such study in Norway has been most encouraging.     

Factors involved in the diagnosis of oral squamous cell carcinoma in Malaysia

The delay in the diagnosis of oral cancer has been variously reported as being contributed by the clinicians, patients or both. The purpose of this study was to evaluate the referral pattern of 65 patients eventually diagnosed as having oral squamous cell carcinoma. The results showed that 50% of the patients delayed seeking professional help for more than 3 months after being aware of the lesion. The majority of the patients consulted medical practitioners as the first source of help. The mean clinicians' and patients' delay were 10.3 weeks and 28.9 weeks respectively. Dental practitioners showed a tendency to refer more advanced lesions compared to the medical practitioners. The findings raise the concern that lack of patients' awareness, misdiagnosis by clinicians and late detection by dental practitioners prevail thus calling for urgent measures towards early detection of the disease.     

Physicians' views on joint treatment guidelines for primary and secondary care.

OBJECTIVE: Joint drug formularies and treatment guidelines have been developed to reduce problems arising at the interface between primary and secondary care. The aim is to compare the willingness of hospital specialists and general practitioners to use joint treatment guidelines, and to determine the most relevant barriers and facilitators. STUDY DESIGN: A structured survey, consisting of questions about the use of guidelines and formularies in general, and possible barriers and facilitators for using a specific joint guideline. These specific guidelines concerned the treatment of hypertension, heart failure, or diabetes mellitus. SETTING AND STUDY PARTICIPANTS: One hundred and ninety-seven general practitioners and 34 general internists and cardiologists from the north of the Netherlands. RESULTS: Most hospital specialists relied for their prescribing on international guidelines and agreements within their own department, while general practitioners relied more on national and regional guidelines. General practitioners were more supportive than specialists of the initiative to develop joint treatment guidelines, although both groups had concerns regarding the development process. An important barrier for specialists was that they did not perceive a need for these guidelines. As enabling factors, physicians stated that these joint guidelines can lead to harmonization between specialists and general practitioners, and that they can be useful as an educational tool. CONCLUSION: Specialists are less ready to adopt joint treatment guidelines than general practitioners, indicating the need for a different approach to implement such guidelines in the two sectors.     

以全科医生为核心新型转诊模式的实践与研究

目的通过对上海浦东医院全科统筹门诊实施的研究,探讨以全科医生为核心、全专协同的新型转诊模式的可行性。方法收集2016—2018年全科统筹门诊工作量,了解全科统筹门诊接诊患者的基本情况以及最终转归,并进行电话满意度调查。结果 3年间全科统筹门诊患者接诊量增多,但上升幅度有限;接诊的患者中,全科医生独立完成接诊任务占80%以上;接诊的患者中,以心脑血管系统疾病最多,其他疾病依次为呼吸系统疾病、内分泌系统疾病和消化系统疾病;在满意度调查方面,全科医生、专科医生均在90%以上。相关辅助检查使用情况的满意度都在80%以上。结论通过全科医生的精准筛查引导患者至全科统筹门诊就诊,为签约患者提供全程、有效的医疗服务,不仅提高了全科医生的临床技能,增强了全科医生的获得感,而且极大地方便了患者转诊。     

分工视角下的全科与专科医学服务分化研究

全科与专科医学服务分工形成是建立全科医生制度的重要环节,利用分工理论分析全科与专科分工演进的机理,并据此分析影响我国全科与专科医学服务分化的主要原因。结果发现,我国患者接受全科医学服务的交易费用并未远低于接受专科医疗服务的交易费用,患者更愿意在医院首诊,加之转诊交易费用较高而收益较低,均导致了全科与专科医学服务不仅无法形成分工而且存在竞争,全科医学专业化难以建立,更无法推动全科医学服务水平及效率提高;全科与专科医学服务收益差距较大,激励医学生更愿意从事专科而非全科事业,全科医学人才匮乏更加大了全科医生与专科医生技术水平的差距,从而导致患者接受全科医疗的交易费用继续上升,形成恶性循环。     

A qualitative study of communication during joint teleconsultations at the primary-secondary care interface

It has been suggested that joint teleconsultations can improve communication at the primary-secondary care interface. We examined data from a qualitative analysis of social interactions in teleconsultations between specialists and general practitioners. The primary interaction was between specialists and patients. The general practitioners mostly adopted a 'back seat role', listening and observing, but not becoming actively involved. Teleconsultations create a number of interactional difficulties, which are likely to impede implementation and sustainability.     

Use of videoconferencing for consultation in dental prosthetics and oral rehabilitation

We conducted a 13-month study to investigate whether videoconferencing could be used for diagnosis and for making treatment plans for patients requiring prosthetic or oral rehabilitation treatment. The consultations took place between a specialist dental treatment unit in a central hospital and general dental practitioners in seven regional health centres. Videoconferencing was conducted using standard commercial units via an IP network, at bandwiths of 762 kbit/s - 2 Mbit/s. In total, 24 patients and 25 professionals (18 dentists, 2 dental hygienists and 5 nurses) took part. There were no technical problems. In 24 out of 27 teleconsultations, a diagnosis or treatment plan could be made. All participating dentists were satisfied with the consultation process and indicated that the technology used was of sufficient quality for clinical purposes. A patient satisfaction questionnaire indicated that patients were also satisfied. Videoconsultation in dentistry has the potential to increase the total number of dental specialist services in sparsely populated areas, such as those in Finland.     

A political economic theory of the dental care market.

A theory of the dental care market is introduced which proposes that the vertically integrated (local/state/national) structure of the profession services as an organizational vehicle both for intra-professional debate and for developing provider-oriented dental care policy. We suggest that a special relationship exists between professionalism and professional regulation. Such regulation has functioned simultaneously to limit competition and to foster a prized consumption commodity for providers: professionalism and professional esteem. The organized pursuit of this commodity inherently dampens competition. Professionalism itself plays a crucial role in: 1) securing for organized dentistry a form of state regulation in which the providers themselves are the principal decision-makers; and 2) influencing provider and consumer market behavior in several significant respects, the net result being the formation of maintenance of a type of "leadership cartel" in the local market. Thus, a political-economic theory of the dental care market formally acknowledges professionalism as valued by established dentists and recent graduates as a central determining influence. Traditional models of pure competition and monopoly emerge as special, extreme cases of the general theory. Hypotheses are offered regarding consumer and provider behavior, market dynamics, and health policy and regulation.     

Learning from contract change in primary care dentistry: A qualitative study of stakeholders in the north of England

The aim of this research was to explore and synthesise learning from stakeholders (NHS dentists, commissioners and patients) approximately five years on from the introduction of a new NHS dental contract in England. The case study involved a purposive sample of stakeholders associated with a former NHS Primary Care Trust (PCT) in the north of England. Semi-structured interviews were conducted with 8 commissioners of NHS dental services and 5 NHS general dental practitioners. Three focus group meetings were held with 14 NHS dental patients. All focus groups and interviews were audio recorded and transcribed verbatim. The data were analysed using a framework approach. Four themes were identified: ‘commissioners’ views of managing local NHS dental services’; ‘the risks of commissioning for patient access’; ‘costs, contract currency and commissioning constraints’; and ‘local decision-making and future priorities’. Commissioners reported that much of their time was spent managing existing contracts rather than commissioning services. Patients were unclear about the NHS dental charge bands and dentists strongly criticised the contract's target-driven approach which was centred upon them generating ‘units of dental activity’. NHS commissioners remained relatively constrained in their abilities to reallocate dental resources amongst contracts. The national focus upon practitioners achieving their units of dental activity appeared to outweigh interest in the quality of dental care provided.     

The rise and decline of the early HMOs: some international experiences

Consumer-controlled health insurance groups in northern Europe in the late nineteenth and early twentieth centuries resembled modern American HMOs in many ways. Fierceness of competition hindered European doctors' control of their own services, prompting them to organize physician-dominated insurance groups and to extend their power through means of licensure, boycott, and supportive government regulation. While patients thus gained the right to choose their own doctor, physicians were able to negotiate more favorable payment standards, including price discrimination by patients' income levels. The experience may foreshadow more ruthless operation of market principles among American HMOs, and raise questions about the HMO model's viability for Europe today.     

What a difference a place makes: dental attendance and self-rated oral health among adults in three counties in Norway

Through a multilevel approach, the study explores the relationships of dental attendance and self-rated oral health (SROH) to individual and structural factors among adults in Norway. The individual factors include various socio-demographic characteristics. The structural ones are population density and dentist density. The sample was recruited from three counties that represent three different combinations of population density and dentist density. There were significant differences in both dental attendance and SROH between the counties. The findings support the theory of a structural explanation of the observed differences and indicate evidence of supplier-suppressed demand. Access to dental services could be improved either by regulating the supply side of dentistry or by compensating patients for travel costs incurred in accessing dental services.     

Competing for patients: understanding consumer evaluation of primary care

The introduction of a competitive market into primary care means that general practitioners must consider the way in which their patients evaluate the service which they receive. Reports the results of an exploratory study carried out in Scotland to investigate the evaluative strategies used by patients in assessing the service they receive. Identifies six particular dimensions of the care process which have implications for GPs protecting their existing patient lists and in understanding how to attract new patients. Suggests through its results that while communicating certain features of the service to potential patients is relatively straightforward, the experiential nature of primary care services leads to a reliance on word-of-mouth communication which depends on ensuring that existing patients are satisfied.     

The benefits of a qualitative approach to telemedicine research

We used qualitative research to evaluate the experience of the participants in teleconsultations between primary and secondary care. Semistructured interviews were conducted with 15 hospital specialists, 24 general practitioners and 30 patients. Focus groups were also held with hospital specialists (two groups), general practitioners (six groups) and administrative staff (five groups). Sixty teleconsultations in six different specialties were video-recorded. Early findings show that the participants (hospital specialists, general practitioners and patients) had different perceptions of the same teleconsultations. Furthermore, the participants perceptions of consultations differed from those of the researchers.