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Family medicine can be strengthened by networking with other service providers, especially in an aging population. The aim of this qualitative study was to explore attitudes towards cooperation, the role of information exchange and considerations regarding financial reimbursement from different provider perspectives. Methods A qualitative study design was used. Family physicians, their representatives, experienced managers of outpatient nursing services and welfare organizations in Lower Saxony and North Rhine-Westphalia were interviewed. The focus of the interviews were about attitudes towards cooperation, importance of the exchange of information and appropriate financial reimbursement. The collected data was evaluated using qualitative content analysis. Results 39 people took part in the study. Each of the participants stated that cooperation was important for patient care. Moreover, the participants expressed the desire for appreciation and a permanent contact person to provide continuity of patient care. Furthermore, financial reimbursement seems to be important for good cooperation. Family physicians and outpatient nursing services wished an extra payment for the cooperation. Conclusions The stakeholders and those directly involved in care emphasize that cooperation and the mutual exchange of information in the treatment process represent an essential, care-relevant aspect, especially for special patient groups. However, financial reimbursement of cooperation, relevant for patient care remains to be determined. [ABSTRACT FROM AUTHOR]

Background Additional payment approach has been one of the most important incentives in long-term care (LTC) systems for the past 20 years in Japan. Objective To estimate the effect of additional payments on functional decline in long-term care health facility (LTCHF) residents of Japan. Design A 24-month retrospective cohort study. Setting and subjects Residents aged ≥65 years who were newly admitted to LTCHFs in the 2014 fiscal year. Methods National LTC claims data were linked to the survey of institutions and establishments for LTC. Competing risk regression was performed with functional decline as the primary outcome, and additional payments as exposure, controlling for individual and facility characteristics. The level of LTC needs certified in the LTC insurance system was applied as a proxy of functional ability. Death, hospitalisation, discharge to home and transfer to other LTC facilities were treated as competing events. Individual- and facility-level additional payments were presented as binary variables: being reimbursed or not during the follow-up period. Results At baseline, 146,311 residents from 3,724 LTCHFs were included. The vast majority of additional payments were associated with a lower risk of functional decline at follow-up. At the individual level, additional payment for pre/post admission instructions had the strongest association with a lower risk of functional decline. Despite this, only 8% of residents were reimbursed for this additional payment. At the facility level, residents in LTCHFs with additional payments for support for home-life resumption and nutritional management were associated with a decreased risk of functional decline. Conclusions The results of our study may be of particular interest to policymakers in monitoring and evaluating additional payment approaches and provide insight into improving quality of care. [ABSTRACT FROM AUTHOR]

Abstract Background General Practitioners’ (GPs) readiness to implement screening and brief intervention (SBI) to treat patients with excessive alcohol consumption is low. Several studies identified crucial barriers such as insufficient financial reimbursement. In contrast to the barriers-account, we assume that low implementation readiness of GPs may be less attributed to external barriers but rather more so to inherent characteristics of SBI. To test our assumption, we conducted a vignette study assessing the GPs’ readiness to implement SBI in comparison to a pharmacological intervention also designed for the treatment of excessive drinkers in relation to standard or above-standard financial reimbursement. According to our hypothesis GPs should be less ready to implement SBI regardless of financial reimbursement. Methods A convenience sample of GPs was recruited to answer the questionnaire. To assess the GPs’ implementation readiness a 4-item 6-point Likert scale was developed and pretested. Results One hundred forty GPs completed the questionnaire. GPs were more ready to implement the pharmacological intervention than SBI, F(1,132) = 27.58, p > .001 (main effect). We found no effect for financial reimbursement, F(1,132) = 3.60, ns, and no interaction effect, F(1,132) = 2.20, ns. Conclusions Further research should investigate more thoroughly the crucial characteristics of SBI to initiate a modification process finally leading to more effective primary care dependency prevention.

Objective: Assess the relationships between case total work relative value units (wRVU), patient frailty, and the physiologic stress of surgical interventions. Summary of Background Data: Surgeon reimbursement is frequently apportioned by wRVU. These subjective, procedure-specific valuations generated by physician survey estimate the intensity and time for typical patient care services. We hypothesized wRVU would not adequately account for patient-specific factors, such as frailty, that modify the required physician work, regardless of procedural complexity. Methods: Using National and Veterans Affairs Surgical Quality Improvement Programs (2015–2018), we evaluated the correlation between case total wRVU, patient frailty (risk analysis index) and physiologic surgical stress (operative stress score). Results: Of 4,111,371 (86%) cases, the correlation between total wRVU and operative stress was moderate [ρs = 0.587 (95% confidence interval, 0.586–0.587)], but negligible with frailty ρ = 0.177 (95% confidence interval, 0.176–0.178)]. Very high operative stress procedures [n = 34,047 (1%)] generated a mean total wRVU of 55.1 (standard deviation, 12.9), comprising 7%, 2%, and 1% of thoracic, vascular, and general surgical cases, respectively. Very frail patients [n = 152,535 (4%)] accounted for 9% of thoracic, 9% of vascular, 4% of general, 5% of urologic, and 4% of neurologic surgical cases, generating 21.0 (standard deviation, 12.4) mean total wRVU. Some nonfrail patients undergoing low operative stress procedures [n = 60,128 (2%)] nonetheless generated the highest quintile wRVU; these comprised >15% of plastic, gynecologic, and urologic surgical cases. Conclusions: Surgeon reimbursement correlates with operative stress but not patient frailty. The total wRVU does not adequately reflect patient-specific factors that increase the physician workload required to render optimal care to complex patients. [ABSTRACT FROM AUTHOR]

Abstract Background Armenia has an upward trend in cesarean sections (CS); the CS rate increased from 7.2% in 2000 to 31.0% in 2017. The purpose of this study was to investigate potential factors contributing to the rapidly increasing rates of CS in Armenia and identify the actual costs of CS and vaginal birth (VB), which are different from the reimbursement rates by the Obstetric Care State Certificate Program of the Ministry of Health. Methods This was a partially mixed concurrent quantitative-qualitative equal status study. The research team collected qualitative data via in-depth interviews (IDI) with obstetrician-gynecologists (OBGYN) and policymakers and focus group discussions (FGD) with women. The quantitative phase of the study utilized the bottom-up cost accounting (considering only direct variable costs) from the perspective of providers, and it included self-administered provider surveys and retrospective review of mother and child hospital records. The survey questionnaire was developed based on IDIs with providers of different medical services. Results The mean estimated direct variable cost per case was 35,219 AMD (94.72 USD) for VB and 80,385 AMD (216.19 USD) for CS. The ratio of mean direct variable costs for CS vs. VB was 2.28, which is higher than the government’s reimbursement ratio of 1.64. The amount of bonus payments to OBGYNs was 11 fold higher for CS than for VB indicating that OBGYNs may have significant financial motivation to perform CS without a medical necessity. The qualitative study analysis revealed that financial incentives, maternal request and lack of regulations could be contributing to increasing the CS rates. While OBGYNs did not report that higher reimbursement for CS could lead to increasing CS rates, the policymakers suggested a relationship between the high CS rate and the reimbursement mechanism. The quantitative phase of the study confirmed the policymakers’ concern. Conclusion The study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.

Purpose: We aimed to test whether 3 strategies-training and support, financial reimbursement, and an option to direct screen-positive patients to an Internet-based method of giving brief advice-have a longer-term effect on primary care clinicians' delivery of screening and advice to heavy drinkers operationalized with the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) tool.Methods: We undertook a cluster randomized factorial trial with a 12-week implementation period in 120 primary health care units throughout Catalonia, England, Netherlands, Poland, and Sweden. Units were randomized to 8 groups: care as usual (control); training and support alone; financial reimbursement alone; electronic brief advice alone; paired combinations of these conditions; and all 3 combined. The primary outcome was the proportion of consulting adult patients (aged 18 years and older) receiving intervention-screening and, if screen-positive, advice-at 9 months.Results: Based on the factorial design, the ratio of the log of the proportion of patients given intervention at the 9-month follow-up was 1.39 (95% CI, 1.03-1.88) in units that received training and support as compared with units that did not. Neither financial reimbursement nor directing screen-positive patients to electronic brief advice led to a higher proportion of patients receiving intervention.Conclusions: Training and support of primary health care units has a lasting, albeit small, impact on the proportion of adult patients given an alcohol intervention at 9 months. [ABSTRACT FROM AUTHOR]

Background: Skin and soft tissue infections are among the most prevalent infections requiring medical intervention, with abscesses being a clinically important subset. Identification of a causative organism is useful for clinical decision-making and tailoring infection management. The extent to which causative agents are reflected in clinical coding data has been grossly understudied, despite its importance for statistical and financial purposes. Methods: An audit of admissions to a London hospital, between 1 September 2014 and 31 August 2016, was performed. Analysis was undertaken to identify whether the discharge documentation, clinical coding reports and microbiological results showed concordance in the detailing of causative organisms associated with abscesses. The impact of incongruity on hospital management was reviewed. Results: Of 664 admissions, 309 (46.5%) did not have a microbial swab taken at the site of the abscess. 164 (24.7%) of the admissions had positive results for one or more causative agents. Of these cases, 135 (82.3%) did not have the determined agents captured in the clinical coding reports. Capturing absent agents in the coding reports resulted in 120 Healthcare Resource Group (HRG) changes. Amendments culminated in a 77.1% uplift in total financial reimbursement of £104 190. Conclusion: Causative agents were not consistently recorded in the coding reports for admissions requiring abscess management. Omission carries negative implications for epidemiology, public health planning and financial reimbursement. [ABSTRACT FROM AUTHOR]

Aim To test if training and support, financial reimbursement and option of referring screen-positive patients to an internet-based method of giving advice (eBI) can increase primary health-care providers' delivery of Alcohol Use Disorders Identification Test (AUDIT)-C-based screening and advice to heavy drinkers. Design Cluster randomized factorial trial with 12-week implementation and measurement period. Setting Primary health-care units (PHCU) in different locations throughout Catalonia, England, the Netherlands, Poland and Sweden. Participants A total of 120 PHCU, 24 in each of Catalonia, England, the Netherlands, Poland and Sweden. Interventions PHCUs were randomized to one of eight groups: care as usual, training and support (TS), financial reimbursement (FR) and eBI; paired combinations of TS, FR and eBI, and all of FR, TS and eBI. Measurements The primary outcome measure was the proportion of eligible adult (age 18+ years) patients screened during a 12-week implementation period. Secondary outcome measures were proportion of screen-positive patients advised; and proportion of consulting adult patients given an intervention (screening and advice to screen-positives) during the same 12-week implementation period. Findings During a 4-week baseline measurement period, the proportion of consulting adult patients who were screened for their alcohol consumption was 0.059 per PHCU (95% CI 0.034 to 0.084). Based on the factorial design, the ratio of the logged proportion screened during the 12-week implementation period was 1.48 (95% CI = 1.13-1.95) in PHCU that received TS versus PHCU that did not receive TS; for FR, the ratio was 2.00 (95% CI = 1.56-2.56). The option of referral to eBI did not lead to a higher proportion of patients screened. The ratio for TS plus FR was 2.34 (95% CI = 1.77-3.10), and the ratio for TS plus FR plus eBI was1.68 (95% CI = 1.11-2.53). Conclusions Providing primary health-care units with training, support and financial reimbursement for delivering Alcohol Use Disorders Identification Test-C-based screening and advice to heavy drinkers increases screening for alcohol consumption. Providing primary health-care units with the option of referring screen-positive patients to an internet-based method of giving advice does not appear to increase screening for alcohol consumption. [ABSTRACT FROM AUTHOR]

As a result of the Affordable Care Act, innovative strategies must be developed and initiated to work with the Affordable Care Act in order to diminish fragmentation of care delivery and thereby improve quality and reduce costs. It is imperative for health care organizations to explore options from mergers and acquisitions to affiliation agreements in order to prepare for business transformation. Since financial strength combined with independent governance and retention of cultural identity may be optimal, a legal transactional structure such as an affiliation is sometimes the best course of action for a health system. This article explores the affiliation process for health care organizations. [ABSTRACT FROM AUTHOR]

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Background: The European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers. Methods/design: In a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals' role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling. Discussion: Effective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers. Trial registration: ClinicalTrials.gov. Trial identifier: NCT01501552 [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether adoption of Medicaid case mix reimbursement is associated with greater prevalence of feeding tube use in nursing home (NH) residents. DESIGN: Secondary analysis of longitudinal administrative data about the prevalence of feeding tube insertion and surveys of states' adoption of case mix reimbursement. SETTING: NHs in the United States. PARTICIPANTS: NH residents at the time of NH inspection between 1993 and 2004. MEASUREMENTS: Facility prevalence of feeding tubes reported at the state inspection of NHs reported in the Online Survey, Certification and Reporting database and interviews with state policy makers regarding the adoption of case mix reimbursement. RESULTS: Between 1993 and 2004, 16 states adopted Resource Utilization Group case mix reimbursement. States varied in the prevalence of feeding tubes in their NHs. Although the use of feeding tube increased substantially over the years of the study, once temporal trends and facility fixed effects were accounted for, case mix reimbursement was not associated with greater prevalence of feeding tube use. CONCLUSION: The adoption of Medicaid case mix reimbursement was not associated with an increase in the prevalence of feeding tube use. [ABSTRACT FROM AUTHOR]

Background: Additional payment approach has been one of the most important incentives in long-term care (LTC) systems for the past 20 years in Japan., Objective: To estimate the effect of additional payments on functional decline in long-term care health facility (LTCHF) residents of Japan., Design: A 24-month retrospective cohort study., Setting and Subjects: Residents aged ≥65 years who were newly admitted to LTCHFs in the 2014 fiscal year., Methods: National LTC claims data were linked to the survey of institutions and establishments for LTC. Competing risk regression was performed with functional decline as the primary outcome, and additional payments as exposure, controlling for individual and facility characteristics. The level of LTC needs certified in the LTC insurance system was applied as a proxy of functional ability. Death, hospitalisation, discharge to home and transfer to other LTC facilities were treated as competing events. Individual- and facility-level additional payments were presented as binary variables: being reimbursed or not during the follow-up period., Results: At baseline, 146,311 residents from 3,724 LTCHFs were included. The vast majority of additional payments were associated with a lower risk of functional decline at follow-up. At the individual level, additional payment for pre/post admission instructions had the strongest association with a lower risk of functional decline. Despite this, only 8% of residents were reimbursed for this additional payment. At the facility level, residents in LTCHFs with additional payments for support for home-life resumption and nutritional management were associated with a decreased risk of functional decline., Conclusions: The results of our study may be of particular interest to policymakers in monitoring and evaluating additional payment approaches and provide insight into improving quality of care., (© The Author(s) 2021. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

In this paper, we test path models that study the interrelations between primary health care provider attitudes towards working with drinkers, their screening and brief advice activity, and their receipt of training and support and financial reimbursement. Study participants were 756 primary health care providers from 120 primary health care units (PHCUs) in different locations throughout Catalonia, England, The Netherlands, Poland, and Sweden. Our interventions were training and support and financial reimbursement to providers. Our design was a randomized factorial trial with baseline measurement period, 12-week implementation period, and 9-month follow-up measurement period. Our outcome measures were: attitudes of individual providers in working with drinkers as measured by the Short Alcohol and Alcohol Problems Perception Questionnaire; and the proportion of consulting adult patients (age 18+ years) who screened positive and were given advice to reduce their alcohol consumption (intervention activity). We found that more positive attitudes were associated with higher intervention activity, and higher intervention activity was then associated with more positive attitudes. Training and support was associated with both positive changes in attitudes and higher intervention activity. Financial reimbursement was associated with more positive attitudes through its impact on higher intervention activity. We conclude that improving primary health care providers' screening and brief advice activity for heavy drinking requires a combination of training and support and on-the-job experience of actually delivering screening and brief advice activity.

In order to facilitate effective clinical coding and hence the precise financial reimbursement of acute services, in 2005 Western District Health Service (WDHS) (located in regional Victoria, Australia) undertook a provisional coding trial for inpatient medical episodes to determine the magnitude and accuracy of clinical documentation. Utilising clinical coding software installed on a laptop computer, provisional coding was undertaken for all current overnight inpatient episodes under each physician one day prior to attending their daily ward round. The provisionally coded episodes were re-coded upon the completion of the discharge summary and the final Diagnostic Related Group (DRG) allocation and weight were compared to the provisional DRG assignment. A total of 54 out of 220 inpatient medical episodes were provisionally coded. This represented approximately a 25% cross section of the population selected for observation. Approximately 67.6% of the provisionally allocated DRGs were accurate in contrast to 32.4% which were subject to change once the discharge summary was completed. The DRG changes were primarily due to: disease progression of a patient during their care episode which could not be identified by clinical coding staff due to discharge prior to the following scheduled ward round; the discharge destination of particular patients; and the accuracy of clinical documentation on the discharge summary. The information gathered from the provisional coding trial supported the hypothesis that clinical documentation standards were sufficient and adequate to support precise clinical coding and DRG assignment at WDHS. The trial further highlighted the importance of a complete and accurate discharge summary available during the coding process of acute inpatient episodes.