Primary physicians’ response to changes in fees

The study examines how the service production of primary physicians in Norway is influenced by changes in fees. The data represent about 2,650 fee-for-service physicians for the years 1995--2000. We constructed a variable that made it possible to estimate income effects of fee changes on service levels. Service production was measured by the number of consultations per physician, the number of laboratory tests per consultation and the proportion of consultations lasting more than 20 min. Our main finding is that fee changes have no income effect on service production. Our results imply that fee regulation can be an effective means of controlling physicians' income, and therefore government expenditure, on primary physician services.     

Competition and supplier-induced demand in a health care system with fixed fees.

The present paper examines whether supplier-induced demand exists for primary physician services in Norway. The research design is adapted to the institutional setting of Norwegian primary physician services, where there is a fixed fee schedule. More than 50% of primary care physicians receive a payment for treatment from the National Insurance Administration on a fee-for-item basis. The results showed that increased competition, measured as a high physician:population ratio, led to a decline in the number of consultations per contract physician. However, the contract physicians in high physician density areas did not compensate for the lack of patients by providing more items of treatment in order to maintain their income. Contract physicians' revenue from items of treatment per consultation were unaffected both by physician density and by the number of consultations per contract physician. These results are further corroborated by data that showed that contract physicians' gross revenue and profits were declining functions of physician density. This paper argues that, from an efficiency point of view, a deregulated health care market with fixed fees may operate well.     

Effects of changes in incomes and practice circumstances on physicians' decisions to treat charity and Medicaid patients

CONTEXT: The decline over the past decade in the percentage of physicians providing care to charity and Medicaid patients has been attributed to both financial pressure and the changing practice environment. Policymakers should be concerned about these trends, since private physicians are a major source of medical care for low-income persons. This study examines how changes in physicians' practice income, ownership, and size affect their decisions to stop or start treating charity care and Medicaid patients. METHODS: This study uses panel data from four rounds of the Community Tracking Study Physician Survey. The dependent variables are the likelihood of physicians' (1) dropping charity care, (2) starting to provide charity care, (3) no longer accepting new Medicaid patients, and (4) starting to accept new Medicaid patients. The primary independent variables are changes in physicians' practice income, ownership, and practice type/size. Multivariate analysis controls for the effects of other physician practice characteristics, health policies, and health care market factors. FINDINGS: A decline in physicians' income increased the likelihood that a physician would stop accepting new Medicaid patients but had no effect on his or her decision to provide charity care. Those physicians who switched from being owners to employees or from small to larger practices were more likely to drop charity care and to start accepting Medicaid patients, and physicians who made the opposite practice changes did the reverse. CONCLUSIONS: Changes in their income and practice arrangements make physicians less willing to accept Medicaid and uninsured patients. Moreover, physicians moving into different practice arrangements treat charity and Medicaid patients as substitutes rather than as similar types of patients. To reverse these trends, policymakers should consider raising Medicaid reimbursement rates and subsidizing organizations that encourage private physicians to provide charity care.     

Medicare payment changes and physicians' incomes

An effort to control the physician portion of Medicare expenditures and to narrow the income gap between primary care and procedure-based physicians was effected through t he enactment of the Medicare Fee Schedule (MFS). To determine whether academic and private sector physicians' incomes had demonstrated changes consistent with payment changes, we collected income information from surveys of private sector physicians and academic physicians in six specialties: (1) family practice; (2) general internal medicine; (3) psychiatry; (4) general surgery; (5) radiology; and (6) anesthesiology. With the exception of general internal medicine, the anticipated changes in Medicare revenue were not closely associated with income changes in either the academic or private sector group. Academic physicians were underpaid, relative to their private sector counterparts, but modestly less so at the end of the period examined. Our findings suggest that using changes in payment schedules to change incomes in order to influence the attractiveness of different specialties, even with a very large payer, may be ineffective. Should academic incomes remain uncompetitive with private sector incomes, it may be increasingly difficult to persuade physicians to enter academic careers.     

Service production and contract choice in primary physician services

Since payment systems for physicians may affect the efficiency of health care service provision, the design of compensation schemes is a major policy concern. According to standard labour economics and agency theory, fee-for-service contracts are likely to induce higher service production than salary contracts and (pure) capitation contracts. Payment systems may also influence service quality and the overall cost control. Despite the obvious policy significance of these issues, the available empirical research is very limited. This paper is an attempt to remedy this situation by addressing the impact of alternative contracts and payment systems on primary care physicians' service supply. The Norwegian primary physician service is an ideal setting for exploring the impact of payment systems. It is a centralised scheme where health services are mostly publicly financed. Until the June 1st 2001, there were two main types of primary care physicians: local government employees remunerated by a fixed salary, and contract physicians mostly financed by fee-for-service payments. We find that physicians with a fee-for-service contract produce a higher number of consultations and other patient contacts than physicians with a fixed salary. This difference is mostly due to longer working hours, but time efficiency is greater as well. Moreover, a part of the difference is due to a selection effect: salaried physicians prefer shorter working hours and prefer to work less intensively. When these and other effects are taken into account, we find that a change from a salary contract to a fee-for-service contract will increase service production by 20-40%.     

Primary physician services-list size and primary physicians' service production

The regular general practitioner scheme was introduced in Norway in 2001. A patient list system in combination with a partial per capita financing system for primary physician services was then introduced. The focus of this research was to study how the patient list system influences patients' accessibility to primary physicians, and how the system influences primary physicians' service production. We studied two possibilities: First, some physicians can have an incentive to acquire a long patient list in order to ensure a high unearned income from per capita payment. This can lead to rationing of consultations. Second, physicians with short lists can have an incentive to increase their service production per consultation in order to compensate for lack of income. This leads to increased costs. The research questions were investigated empirically using two large sets of national data. Two of the main findings were that long lists do not lead to rationing, and short lists do not increase service production per consultation.     

Physicians' acceptance of an alternative to fee-for-service payment: a possible source of change in Quebec medicine

This article reports on a survey conducted on a sample of Quebec physicians at the end of 1981. The objective of the study was to assess the acceptance by physicians of a possible change in their current mode of remuneration and to identify the consequences of such a change on the physicians' practice and on the attainment of broader health care objectives. The results presented in this article seem to indicate that neither the present fee-for-service mode of payment nor a change to time-based remuneration can reconcile both professional and broader health care objectives. Implications of these findings for health policies are discussed.     

Back in the driver's seat: specialists regaining autonomy

Between 1997 and 2001, the proportion of specialists reporting more freedom to make clinical decisions that meet their patients' needs increased significantly, much more so than among primary care physicians (PCPs), according to a new study by the Center for Studying Health System Change (HSC). Specialists now are also more likely to believe they can make clinical decisions in the best interest of their patients without reducing their income and can maintain continuing relationships with their patients to promote high-quality care. In contrast, PCPs' views on these issues have changed little. These findings about physicians' perceptions are likely a reflection of recent changes in managed care. Responding to a strong consumer and physician backlash, health plans gave consumers a broader choice of physicians and eased restrictions on care in the late 1990s     

Influence exercised by physicians on the vaccination rate

This paper deals with the question whether physicians promote vaccinations among their patients. Besides this, we analyse which determinants influence the acceptance of vaccination among physicians. The investigations are based on data of a project granted by the DFG (Deutsche Forschungsgemeinschaft; "Munich Vaccination Study 2001"). Within this study physicians as well as parents have been interviewed. The vaccination rate of the physicians' patients are influenced by attitudes of the physician and the attitudes he/she believes his/her patients have, but not so much by aspects of his/her behaviour. How many pamphlets and posters about vaccination are available in the doctors' practice or how long consultations about vaccination last on average has only marginal effects on the rate of vaccination among the doctors' patients. If it is a political aim to enlarge vaccination rates steps should concentrate on changing relevant attitudes.     

From socialist principles to motorcycle maintenance: the origin and development of the salaried physician model in the Israeli Public Health Services, 1918 to 1998.

For more than 70 years, physicians in the Israeli health care system have been employed on a fixed salary rather than on a fee-for-service basis. The present report is a brief review of the origin and development of this unique salaried physician model and its effect on the terms of physicians' employment. Archival documents were reviewed. The salaried physician model was introduced to ensure egalitarian health care for patients rather than equal payment for physicians. It was accepted by physicians because it guaranteed their employment and income. However, over the years, the salaried physician model has evolved into a complex wage scale, with multiple fringe benefits that bypass formal agreements in order to reward individual physicians. In addition, the salaried physician model has encouraged illegal private practice, which is viewed today as one of the major problems of the Israeli Public Health Services.     

The influence of payer mix on electronic health record adoption by physicians

BACKGROUND: Numerous studies have examined the relationship between physician practice characteristics and electronic health record (EHR) adoption. Little is known about how payer mix influences physicians' decisions to implement EHR systems. PURPOSE: This study examines how different proportions of Medicare, Medicaid, and privately insured patients in physicians' practices influence EHR adoption. METHODOLOGY: Data from a large-scale survey of physician's use of information technologies in Florida were analyzed. Physicians were categorized based on their responses to questions regarding the proportion of patients in their practice that use Medicare, Medicaid, or private insurance products. The binary dependent variable of interest was EHR adoption among physicians. Adjusted odds ratios (ORs) were computed using logistic regression modeling techniques. The model examined the effect of changes in each payer type on EHR adoption, controlling for various practice characteristics. FINDINGS: Physicians with the highest percentage of Medicaid patients in their practices were significantly less likely to indicate using an EHR system when compared with those in the low-volume Medicaid group (OR = 0.690; 95% confidence interval [CI] = 0.50-0.95). No differences in EHR adoption were detected among physicians in the low, median, and high Medicare volume classifications. Among the private payer classifications, physicians whose practices were in the median group indicated significantly greater EHR use than those with relatively low levels of privately insured patients (OR = 1.62; 95% CI = 1.16-2.27). Those in the high-volume private payer group were also more likely than the low-volume group to have an EHR system, but this trend did not reach statistical significance (OR = 1.44; 95% CI = 0.96-2.16). PRACTICE IMPLICATIONS: Governmental insurance programs are either not influencing or negatively influencing EHR adoption among physicians in Florida. Given the quality and cost benefits associated with EHR use (particularly for health care payers), policymakers should consider strategies to incentivize or reward EHR adoption among doctors who care for Medicare and Medicaid patients.     

Public versus private health care in a national health service

This paper studies the interaction between public and private health care provision in a National Health Service (NHS), with free public care and costly private care. The health authority decides whether or not to allow private provision and sets the public sector remuneration. The physicians allocate their time (effort) in the public and (if allowed) in the private sector based on the public wage income and the private sector profits. We show that allowing physician dual practice 'crowds out' public provision, and results in lower overall health care provision. While the health authority can mitigate this effect by offering a higher wage, we find that a ban on dual practice is more efficient if private sector competition is weak and public and private care are sufficiently close substitutes. On the other hand, if private sector competition is sufficiently tough, a mixed system, with physician dual practice, is always preferable to a pure NHS system.     

Factors associated with workers' perceived helpfulness of and need for health consultations given by an occupational physician at a Japanese manufacturing plant

OBJECTIVE: The aim of this study was to clarify measures for improving the functionality of health consultations by occupational physicians, by examining factors associated with workers' perceived helpfulness of, and need for, these consultations. METHODS: An anonymous self-administered questionnaire survey was conducted at a Japanese manufacturing plant. RESULTS: Multiple regression analyses showed that workers' perceived helpfulness of, and need for, health consultations given by an occupational physician was held in common and significantly associated with the occupational physician's dedication and complete protection of privacy. CONCLUSIONS: For health consultations given by occupational physicians to be effective, it is necessary to help employees realize the physicians' outstanding dedication and to convey to the workers the absolute assurance of their privacy protection.     

Satisfaction with organizational aspects of health care provision among Lithuanian physicians

BACKGROUND: Physician satisfaction is considered an important factor influencing quality of health care provision, patient compliance, and costs to health care systems. Dissatisfaction leads to an increase in turnover of physicians and early retirement, which has a negative impact on continuity and quality of health care. Physician dissatisfaction with certain aspects of health care provision may also help to identify potential weaknesses in satisfactory functioning of health care systems. The aim of the current research project is to study the satisfaction with different organizational aspects of health care provision in Lithuania as judged by a selection of physicians. METHOD: The study was conducted in Lithuania in June 2004. Physicians in randomly selected health care centers were invited to take part in the survey, 505 primary and secondary care physicians were interviewed by external interviewers during the study period. Physicians were asked to express their satisfaction on items presented in a questionnaire. The questionnaire consisted of 22 questions, evaluating different aspects of health care services - working conditions, workload, financial remuneration, organization of health care infrastructure and availability of laboratory services. Answers were presented by the 5 point Likert type scale, ranging from "very satisfied" (5) to "very dissatisfied" (1). RESULTS: Physicians who were most satisfied with their working conditions were working in private primary health care practices (91.1% satisfied or very satisfied), as compared with 54% of physicians working in state-owned primary care institutions and 49.7% in hospitals. Physicians working in cities and regional centers or towns were more satisfied with organizational aspects of health care services than physicians working in rural health care centers. Satisfaction with their financial remuneration showed that 74% of respondents stated they were "dissatisfied" or "very dissatisfied". While asked about potential deficiencies in their health care institutions, the most important identified by respondents in all localities was a perceived lack of financial support for these institutions. CONCLUSIONS: There is a significant difference in the perception of physicians in private and state health care institutions with regard to financial remuneration as well as availability of laboratory diagnostic and treatment equipment and working conditions. Based on the study findings, possibilities to increase Primary Care financing should be considered in order to improve the quality of the delivery of health care services as well as retain physicians within the health care system. Results of this study demonstrate a need of further research to quantify what could be reasonably expected from diagnostic and investigative resources to support health care in Lithuania in current economic situation.     

Multifactor productivity in physicians' offices: an exploratory analysis

This article constructs measures of multifactor productivity (MFP) for physicians' offices using a variation of the productivity methodology developed by the U.S. Bureau of Labor Statistics (BLS) for other industries. Two alternatives measures are presented and both yield positive gains in physicians' office MFP over the study period. These increases lie below MFP rates for the general economy (private non-farm business sector). During 1983-1992, physicians' office MFP growth exceeded general economy MFP. For 1993-2000, physicians' office MFP growth was both negative and below general economy rates. For the most recent period analyzed, 2001-2004, physician's office MFP grew nearly as quickly as the general economy.     

Unrelated business income tax: an update

To meet spiraling costs, tax-exempt hospitals increasingly are operating businesses unrelated to direct patient care. Knowing which activities may be open to challenge by the Internal Revenue Service (IRS) is essential to avoid the unrelated business income (UBI) tax. Three criteria must be met for an activity to be taxable as UBI: It must constitute a trade or business; It must be regularly carried on; and It must be unrelated to the organization's exempt purpose. The Internal Revenue Code and IRS rulings clearly exclude the following areas from UBI taxation: Activities performed by unpaid volunteers (e.g., hospital auxiliaries' fund-raising dinners and bazaars and the operation of thrift stores); Operations conducted for the convenience of the organization's members, students, patients, or employees (e.g., gift shops, cafeterias, coffee shops, parking lots, lounges, vending machines, pharmaceutical sales to inpatients and emergency room outpatients, and research activities for students' benefit; The sale of merchandise that has been received by gift (e.g., flea markets, baked goods sales, book sales, and rummage sales); Investment income such as dividends, interest, annuities, royalties, certain rents, and capital gains from the sale of investment assets; Gifts or contributions made directly to the facility; and Bingo games that are conducted commercially. Areas which may be subject to UBI taxation, or in which there have been controversial or contradictory court rulings, include: Pharmaceutical sales to the public or private physicians' patients; and Laboratory services provided to private physicians for treating their patients. IRS private letter rulings, though not precedential, have excluded from UBI taxation the x-ray income from a hospital's branch facility and rental income from property leased for use as a clinic or medical office building that is substantially related to the hospital's exempt functions. Private letter rulings have subjected to UBI taxation the income for a professional standards review organization's private review activities and debt-financed income from property that is not substantially related to the organization's exempt purpose.     

Changing treatment regimens for HIV infection: impact on referral patterns and training needs of family physicians

BACKGROUND: New antiviral medications and laboratory testing have revolutionized the care of patients infected with the human immunodeficiency virus (HIV). The development of complex treatment regimens has intensified debate about whether care should be restricted to experts in HIV care. Few studies detail how these new treatment regimens are affecting family physicians' desire to continue providing care or need for additional training. METHODS: A questionnaire eliciting personal, training, and practice demographics and attitudinal information was distributed to family physicians attending the 1996 Scientific Assembly of the American Academy of Family Physicians who completed an HIV continuing education workshop. RESULTS: The questionnaires were completed by 202 family physicians from 48 states. More than 60 percent had received training or had practiced in states with a high rate of HIV, and 143 (70 percent) had cared for at least 1 HIV-infected patient in the previous 6 months. Ninety-five percent did not expect to curtail their provision of care and believed that family physicians should become more active in the care of HIV-infected patients. Medical journals were the most requested format for ongoing education in this area, with combination antiviral therapy and new staging laboratory tests the most requested topics. CONCLUSION: The recent changes in HIV care regimens did not appear to have a major impact on family physicians' desire to continue to provide care for HIV-infected patients. Professional societies responsible for certification and continuing education might be interested in additional surveys to validate these results among larger samples nationwide.     

A model of teaching-learning transactions in generalist-specialist consultations

INTRODUCTION: A new paradigm in continuing medical education is characterized by emphasis on physicians' learning in practice. Consistent with this paradigm, our study examined a subset of clinical practice--generalist-specialist consultations--from an educational perspective. METHODS: We applied the grounded-theory method with semistructured interviews. Ten primary care physicians and 9 internal medicine subspecialists were interviewed regarding their approaches to learning and teaching during generalist-specialist consultations. RESULTS: Based on 48 formal and informal consultations reported by physicians, we developed a theory of teaching-learning transactions in generalist-specialist consultations. DISCUSSION: As a teaching-learning transaction, the mutual learning process in generalist-specialist consultations involves 3 components: needs assessment, dialogue, and sufficiency. Providers of continuing medical education may use the proposed theoretical framework to help clinicians and health care organizations analyze and enhance educationally valuable interactions at the interface of primary and secondary care.