Physicians self selection of a payment mechanism: Capitation versus fee-for-service

The main question raised in this paper is whether GPs should self select their paymentmechanism or not. To answer it, we model GPs' behavior under the most commonpayment schemes (capitation and fee-for-service) and when GPs can select one amongthose. Our analysis considers GPs heterogeneity in terms of both ability and sense ofprofessional duty. We conclude that when savings on specialists costs are the mainconcern of a regulator, GPs should be paid on a fee-for-service basis. Instead, whenfailures to identify severe conditions are the main concern, then payment self selection byGPs can be optimal.GPs; gatekeeping; payment scheme; self selection; ability; professional duty

Provider Competition in a Dynamic Setting

In this paper, we examine provider and patient behaviour where effort is non-contractible and where competition between providers is modeled in an explicit way. More specifically, we construct a model where physicians repeatedly compete for patients and where patients’ outside options are solved for in equilibrium. In our model, physicians are characterized by an individual-specific ethical constraint which allows for unobserved heterogeneity in the physicians market. By doing so, we introduce uncertainty in the patient’s likely treatment if he were in fact to leave his current physician to seek care elsewhere. We find that competition between providers may serve as an important incentive for physicians in treating their patients with desired levels of care.Physician Payment Mechanisms, Physician heterogeneity, Competition, Information Asymmetry, Insurance.

Treatment and referral decisions under different physician payment mechanisms

International audienceThis paper analyzes and compares the incentive properties of some common payment mechanisms for GPs, namely fee for service (FFS), capitation and fundholding. It focuses on gatekeeping GPs and it specically recognizes GPs heterogeneity in both ability and altruism. It also allows inappropriate care by GPs to lead to more serious illnesses. The results are as follows. Capitation is the payment mechanism that induces the most referrals to expensive specialty care. Fundholding may induce almost as much referrals as capitation when the expected costs of GPs care are high relative to those of specialty care. Although driven by nancial incentives of different nature, the strategic behaviours associated with fundholding and FFS are very much alike. Finally, whether a regulator should use one or another payment mechanism for GPs will depend on (i) his priorities (either cost-containment or quality enhancement) which, in turn, depend on the expected cost difference between GPs care and specialty care, and (ii) the distribution of proles (diagnostic ability and altruism levels) among GPs

Le régime d'imposition simplifié du Québec : est-ce vraiment plus simple?

La présente étude vise à évaluer dans quelle mesure le régime d’imposition simplifié du Québec a atteint les objectifs qu’il visait lors de son introduction, en 1998, à savoir la simplification du processus de préparation de la déclaration de revenus et l’amélioration de l’équité du régime d’imposition. Suite à une analyse empirique et à une analyse systématique, l’étude conclut que le régime simplifié n’a pas atteint ces objectifs. D’une part, le choix entre le régime simplifié et le régime général s’avère trop complexe dans de nombreuses situations, obligeant les contribuables à de nombreux calculs et même à remplir deux déclarations de revenus afin d’effectuer le choix le plus avantageux. D’autre part, le régime simplifié souffre de problèmes d’équité, le montant forfaitaire ne procurant pas les mêmes économies d’impôt à des contribuables ayant une capacité contributive égale, dans certaines situations. L’étude propose l’abolition pure et simple du régime d’imposition simplifié et l’ajout du montant forfaitaire au montant de base dans le régime général, en remplacement des crédits pour contributions au Régime des rentes du Québec, à l’assurance-emploi et au Fonds des services de santé. Tous les autres crédits et déductions seraient disponibles pour tous les contribuables

Archaeal Methane Cycling Communities Associated with Gassy Subsurface Sediments of Marennes-Oléron Bay (France)

En libre-accès sur Archimer : http://archimer.ifremer.fr/doc/2009/publication-6165.pdfInternational audienceIn Marennes-Oleacuteron Bay, a macro-tidal bay located on the French Atlantic coast, kilometer-scale acoustic turbidity reveals an accumulation of free gas in the sediment. Large concentrations of organic matter and rapid sedimentation rates provide ideal settings for biogenic methane cycling. We integrate seismic, sedimentologic, biogeochemical and molecular genetic approaches to determine whether microbial methane cycling is involved in this process. Here we show that the acoustic turbidity upper boundary matched with X-ray facies displaying fissures with the highest methane concentrations, demonstrating the existence of methane bubbles in the sediment. 16S rRNA and mcrA gene clone libraries were dominated by sequences affiliated to the three known ANME lineages and to putative methanogens. Sequences related to the marine benthic group B (MBG-B) and miscellaneous crenarchaeotal group (MCG) were also detected. However, the highest methane concentration facies was the only section where active Archaea were detected, using reverse-transcribed rRNA, indicating that these communities were involved either directly or indirectly in the methane cycling process. Moreover, three metabolically active novel uncultivated lineages, related to putative methane cycling Archaea, could be specifically associated to these methane bearing sediments. As methane cycling Archaea are commonly retrieved from deep subseafloor and methane seep sediment, the study of coastal gassy sediments, could therefore help to define the biogeochemical habitats of deep biosphere communities

End-of-life care in long-term care homes : a scoping review protocol

Background: Quality end-of-life (EOL) care is essential in long-term care homes (LTCHs), as the average survival time of newly admitted residents is estimated to be around 2 to 2.5 years. However, significant challenges exist when it comes to providing EOL clinical care in LTCHs, and the available empirical evidence does not offer a clear idea of the best practices to adopt. Aim: To systematically map the state of knowledge on EOL clinical care in LTCHs, as it relates to people receiving care, family care partners, health care professionals, the characteristics of the organization, the social context, and the implementation of guides. Methods: The scoping review method by Levac et al. (2010) will be used. Data will be collected from multiple sources, including eleven databases using a combination of keywords and descriptors, references list, prospective and manual searches, and by consulting clinicians and managers from LTCHs for additional publications. The literature from 2012 and onwards will be selected if it directly concerns EOL care in LTCHs, with no restriction on the age of residents or on the type of health care professionals or family care partners. The screening and data extraction will be performed by two people independently and any discrepancies will be resolved by consensus. We will also assess the quality of publication with the critical appraisal tools developed by the Joanna Briggs Institute. We will synthesize the extracted data using content analysis and consult stakeholders in LTCHs when a first version of the data synthesis is available to enhance the interpretation of the results based on their experience. We will present results in narrative form with tables and graphs. Discussion: The results will provide evidence-based recommendations for clinical practice when available findings are conclusive and will allow identifying knowledge gaps to orient future research programs focusing specifically on EOL clinical care in LTCHs

Metabolomics in Ecology and Bioactive Natural Products Discovery: Challenges and Prospects for a Comprehensive Study of the Specialised Metabolome

Metabolomics is playing an increasingly prominent role in chemical ecology and in the discovery of bioactive natural products (NPs). The identification of metabolites is a common/central objective in both research fields. NPs have significant biological properties and play roles in multiple chemical-ecological interactions. Classically, in pharmacognosy, their chemical structure is determined after a complex process of isolating and interpreting spectroscopic data. With the advent of powerful analytical techniques such as liquid chromatography-mass spectrometry (LC-MS) the annotation process of the specialised metabolome of plants and microorganisms has improved considerably. In this article, we summarise the possibilities opened by these advances and illustrate how we harnessed them in our own research to automate annotations of NPs and target the isolation of key compounds. In addition, we are also discussing the analytical and computational challenges associated with these emerging approaches and their perspective

Estimating Attributable Mortality Due to Nosocomial Infections Acquired in Intensive Care Units

Background. The strength of the association between intensive care unit (ICU)-acquired nosocomial infections (NIs) and mortality might differ according to the methodological approach taken. Objective. TO assess the association between ICU-acquired NIs and mortality using the concept of population-attributable fraction (PAF) for patient deaths caused by ICU-acquired NIs in a large cohort of critically ill patients. Setting. Eleven ICUs of a French university hospital. Design. We analyzed surveillance data on ICU-acquired NIs collected prospectively during the period from 1995 through 2003. The primary outcome was mortality from ICU-acquired NI stratified by site of infection. A matched-pair, case-control study was performed. Each patient who died before ICU discharge was defined as a case patient, and each patient who survived to ICU discharge was denned as a control patient. The PAF was calculated after adjustment for confounders by use of conditional logistic regression analysis. Results. Among 8,068 ICU patients, a total of 1,725 deceased patients were successfully matched with 1,725 control Patients. The adjusted PAF due to ICU-acquired NI for patients who died before ICU discharge was 14.6% (95% confidence interval [CI], 14.4%—14.8%). Stratified by the type of infection, the PAF was 6.1% (95% CI, 5.7%-6.5%) for pulmonary infection, 3.2% (95% CI, 2.8%-3.5%) for central venous catheter infection, 1.7% (95% CI, 0.9%-2.5%) for bloodstream infection, and 0.0% (95% CI, -0.4% to 0.4%) for urinary tract infection. Conclusions. ICU-acquired NI had an important effect on mortality. However, the statistical association between ICU-acquired NI and mortality tended to be less pronounced in findings based on the PAF than in study findings based on estimates of relative risk. Therefore, the choice of methods does matter when the burden of NI needs to be assesse