The impact of the fee-for-service reimbursement system on the utilisation of health services: Part I. A review of the determinants of doctors' practice patterns

The impact of different methods of reimbursement on the practice patterns of doctors has received little attention in the local literature. This series of three papers attempts to address this gap.Here the international evidence on this issue is reviewed. The 'information gap' between doctors and their patients allows doctors to induce demand for their services. This leads to the potential for doctors to increase the supply of services when they stand to gain financially from doing so, as is the case in the fee-for-service system.There is extensive international evidence, at both national and micro levels, of the link between increased utilisation and the fee-for-service payment system. This is in contrast with the pattern noted in the salary system, used in some health maintenance organisations (HMOs) in the USA, or in the capitation system, used in the British National Health Service.The 'practice setting' in which doctors operate also affects patterns of practice. In the local fee-for-service sector, 'third-party payment' means that both doctors and patients have little awareness of the direct costs of services. In other systems, such as HMOs, there is a strong cost consciousness on the part of practitioners. These differences in practice setting account in part for the different patterns of utilisation in these systems.The fee-for-service system, as it is structured in South Africa, thus leads to extreme inefficiency, and the development of alternatives is becoming an urgent necessity. All systems of reimbursement have certain problems, and some combination may be the best solution

The impact of the fee-for-service reimbursement system on the utilisation of health services: Part II. Comparison of utilisation patterns in medical aid schemes and a local health maintenance organisation

This study reports the results of a retrospective analysis of the use of a range of inpatient and outpatient services by the members of a health maintenance organisation (HMO), in which most providers are salaried, and by the members of three medical aid schemes in which providers are paid on a fee-far-service basis. The analysis shows significantly higher utilisation of all services by medical aid scheme members than by HMO members. Medical aid scheme patients saw all doctors 33% more often than their HMO counterparts. For general practitioners and specialists specifically, the differences were 36% and 18% respectively. Doctors looking after medical aid scheme beneficiaries ordered 133% more radiological procedures and 14% more pathological investigations than did those caring for HMO beneficiaries. Hospital utilisation was also higher for medical aid patients. While quality of care is difficult to measure, there are no reasons to suspect that significant differences in quality exist between the two systems described here.One factor that may contribute to the higher utilisation rates in the medical aid group is the higher average income of this group. However, these results also demonstrate that providers working in the fee-for-service system are likely to increase the supply of services compared with providers who are salaried. The different methods of reimbursement are compounded by the different practice settings in which these groups of doctors work; the HMO generates an awareness of costs that is absent from the independent practice, 'third-party payment' system of the medical aid schemes.These differences in utilisation represent millions of rand in unnecessary expenditure that results from the current organisation of the private health sector. In view of the current shortage of resources for health care, this is unjustifiable. The fee-for-service system, and other structural aspects of the private health sector, require urgent attention

Nonlocal Effects and Shrinkage of the Vortex Core Radius in YNi2B2C Probed by muSR

The magnetic field distribution in the vortex state of YNi2B2C has been probed by muon spin rotation (muSR). The analysis based on the London model with nonlocal corrections shows that the vortex lattice has changed from hexagonal to square with increasing magnetic field H. At low fields the vortex core radius, rho_v(H), decreases with increasing H much steeper than what is expected from the sqrt(H) behavior of the Sommerfeld constant gamma(H), strongly suggesting that the anomaly in gamma(H) primarily arises from the quasiparticle excitations outside the vortex cores.Comment: 4 pages, 4 figures, submitted to Phys. Rev.

Changes in the firn structure of the western Greenland Ice Sheet caused by recent warming

Atmospheric warming over the Greenland Ice Sheet during the last 2 decades has increased the amount of surface meltwater production, resulting in the migration of melt and percolation regimes to higher altitudes and an increase in the amount of ice content from refrozen meltwater found in the firn above the superimposed ice zone. Here we present field and airborne radar observations of buried ice layers within the near-surface (0–20 m) firn in western Greenland, obtained from campaigns between 1998 and 2014. We find a sharp increase in firn-ice content in the form of thick widespread layers in the percolation zone, which decreases the capacity of the firn to store meltwater. The estimated total annual ice content retained in the near-surface firn in areas with positive surface mass balance west of the ice divide in Greenland reached a maximum of 74 ± 25 Gt in 2012, compared to the 1958–1999 average of 13 ± 2 Gt, while the percolation zone area more than doubled between 2003 and 2012. Increased melt and column densification resulted in surface lowering averaging −0.80 ± 0.39 m yr−1 between 1800 and 2800 m in the accumulation zone of western Greenland. Since 2007, modeled annual melt and refreezing rates in the percolation zone at elevations below 2100 m surpass the annual snowfall from the previous year, implying that mass gain in the region is retained after melt in the form of refrozen meltwater. If current melt trends over high elevation regions continue, subsequent changes in firn structure will have implications for the hydrology of the ice sheet and related abrupt seasonal densification could become increasingly significant for altimetry-derived ice sheet mass balance estimates

Emigration of doctors, military and alternative service service Some proposals based on a survey of medical students

In the face of a critical shortage of skilled medical personnel, especially in the rural areas of South Africa, and high rates of emigration of doctors, a survey was conducted in 1989 of white male medical stl!dents at the University of the Witwatersrand to assess their intentions to emigrate, their reasons for emigrating and their attitudes to alternative civilian service. Ninety-five per cent of respondents still had military service obligations; 39% said they were considering emigrating. Military service was ranked as the first or second most important reason by 59% of those intending to emigrate and 47% said they would remain in South Africa if alternative service were available. The majority of those willing to do alternative service were also willing to do this in rural areas. The introduction of the option of alternative service would reduce emigration, increase the provision of medical care in rural areas, and acknowledge the right of individuals to serve the country in a non-militar: capacity

Vertical Confinement and Evolution of Reentrant Insulating Transition in the Fractional Quantum Hall Regime

We have observed an anomalous shift of the high field reentrant insulating phases in a two-dimensional electron system (2DES) tightly confined within a narrow GaAs/AlGaAs quantum well. Instead of the well-known transitions into the high field insulating states centered around $\nu = 1/5$, the 2DES confined within an 80\AA-wide quantum well exhibits the transition at $\nu = 1/3$. Comparably large quantum lifetime of the 2DES in narrow well discounts the effect of disorder and points to confinement as the primary driving force behind the evolution of the reentrant transition.Comment: 5 pages, 4 figure

Sea level rise and a Florida mortuary pond: how oysters (crassostrea virginica) reveal past climate change at the Manasota key offshore archaeologyical site

The Manasota Key Offshore archaeological site (Florida, USA) is a mortuary pond dated to 7214 ± 30 cal BP and consisting of modified wooden stakes and human burials preserved in peat. At the time, this freshwater pond was located inland of the coast and used as a place of interment by Florida’s indigenous population. Over the intervening years, sea levels altered the landscape and affected the mortuary pond, which is now in an offshore context. Archaeological excavations revealed oysters (Crassostrea virginica) attached to human skeletal and cultural material— a direct line of evidence of past sea level rise. Morphometric analysis, sclerochronology, radiocarbon dating, and stable isotope analysis of eight oysters demonstrated there were two distinct environments at the time of oyster growth, each representing separate time periods and water parameters. The earlier oyster group indicated fresher water parameters, and the later hinted at hypersaline conditions. Oysters expired at ages between one and three, suggesting delicate human skeletal material was exposed to the water column for equally as long and yet remained preserved. This is the first time oysters attached to Archaic period skeletal material were used to draw wider conclusions about past marine transgression and environmental change.English This research was made possible by funding from: the State of Florida, Department of Environmental Protection, Agreement Number CZ327; the Florida Gulf Coast Community Foundation; and the Alliance for Weedon Island Archaeological Research and Education, Inc. in partnership with the Levett Foundation. Dutch Dit onderzoek werd mogelijk gemaakt door financiering door: de staat Florida, ministerie van milieubescherming, overeenkomst nummer CZ327; de Florida Gulf Coast Community Foundation; en de Alliance for Weedon Island Archaeological Research and Education, Inc. in samenwerking met de Levett Foundation.Archaeology of the America

The private health sector in South Africa - current trends and future developments

The private health sector is experiencing a crisis of spiralling costs, with average annual cost increases of between 13% and 32% over the decade 1978 - 1988. This trend is partly explained by the high utilisation rates that result from the combination of the 'fee-for-service' system and the 'third-party' payment structure of the sector.Medical schemes have responded by promoting the idea of 'flexible packages', and have won the right to 'risk-rate' prospective members. It is argued that these measures will undermine the principle of equity in health care, and will not solve the problems of the private sector. Instead, a more significant restructuring of the sector is likely to emerge. This may take the form of 'managed care' structures, along the lines of the health maintenance organisation model from the USA.The principles, advantages and problems of 'managed care' structures are described. These are shown to be potentially more rational and efficient than the current structure of the private sector. Although some resistance to 'managed care' structures can be expected, the convergence of interests of large employers and trade unions in containing health care costs suggests that their emergence is a likely development

Isothermal Plasma Wave Properties of the Schwarzschild de-Sitter Black Hole in a Veselago Medium

In this paper, we study wave properties of isothermal plasma for the Schwarzschild de-Sitter black hole in a Veselago medium. We use ADM 3+1 formalism to formulate general relativistic magnetohydrodynamical (GRMHD) equations for the Schwarzschild de-Sitter spacetime in Rindler coordinates. Further, Fourier analysis of the linearly perturbed GRMHD equations for the rotating (non-magnetized and magnetized) background is taken whose determinant leads to a dispersion relation. We investigate wave properties by using graphical representation of the wave vector, the refractive index, change in refractive index, phase and group velocities. Also, the modes of wave dispersion are explored. The results indicate the existence of the Veselago medium.Comment: 24 pages, 12 figures, accepted for publication in Astrophys. Space Sci. arXiv admin note: text overlap with arXiv:1101.0884 and arxiv:1007.285

Using 206/207Pb isotope ratios to estimate phosphorus sources in historical sediments of a lowland river system

Purpose Engineering and dredging strategies to manage sediment, along with river-scouring, can reveal older sediments. These present a unique opportunity to assess past sources of phosphorus (P) inputs into river sediments. We used the sediment concentrations of P, lead (Pb) and 206/207Pb isotopes to produce ‘first-order’ estimates of the source (diffuse agricultural or sewage treatment) of phosphorus. Materials and methods Sediment cores (n = 30) were collected from the length of the non-tidal River Nene, a lowland river in eastern England. Cores were analysed for sediment elemental concentrations and Pb isotopes. Principal component analysis and linear regression modelling were used to assess the relationships between P, Pb and Pb isotopes. Monte-Carlo simulations and boot-strapping were undertaken to estimate, with 95% confidence intervals, the source of P in these sediments. Results and discussion Analysis of the relationships between PTotal, PbTotal and 206/207Pb isotope ratios suggested that sediments were deposited largely prior to the phasing out of tetra-ethyl Pb (PbBHT) from petrol. Regression models showed positive correlations between PTotal and PbTotal (R2 = 0.85). Principal component analysis suggested a strong sewage treatment signal for Pb and P enrichment. In the rural upper three water bodies, little sewage treatment work (STW)-derived P was found in the sediment, a consequence of limited STW input and greater sediment transport. In the more urbanised water bodies 4–6, ‘first-order estimates’ of STW P suggest that median concentrations were 30–40% of PTotal. Conclusions The strong relationships between Pb and P concentrations in river water provided the opportunity to use 206/207Pb isotope ratios to calculate ‘first-order’ estimates of the proportion of P released from STWs in the historical sediment. Understanding the sources of historical sediment P can be used to assess the success of current sediment management strategies and to base further mitigation measures. Results suggest that whilst much recent sediment P is removed, the legacy sediment remains to contribute P to the water body. Thus, options regarding the practical removal of these sediments and the extent to which this would improve water P status need to be assessed and balanced against options such as further decreasing soil P or STW P stripping