Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2007 rates; fiscal year 2007 occupational mix adjustment to wage index; health care infrastructure improvement program; selection criteria of loan program for qualifying hospitals engaged in cancer-relate End Stage Renal Disease and Medicare A randomized controlled trial of co-payment elimination: the CHORD trial. The Effect of the Medicare Part D Prescription Benefit on Drug Utilization and Expenditures The financial incentive for hospitals to prevent nosocomial infections under the prospective payment system. An empirical determination from a nationally representative sample. Payment to healthcare professionals for patient recruitment to trials: systematic review and qualitative study. Do heart failure disease management programs make financial sense under a bundled payment system? Prepayment with office-based physicians in publicly funded programs: results from the Children's Medicaid Program. The impact of the National Essential Medicines Policy on prescribing behaviours in primary care facilities in Hubei province of China. How to build and evaluate an integrated health care system for chronic patients: study design of a clustered randomised controlled trial in rural China Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. Economic impact of tuberculosis at the household level. Washington State CARE Project: downstream cost changes associated with the provision of cognitive services by pharmacists. Empirical assessment of whether moderate payments are undue or unjust inducements for participation in clinical trials. A randomized study of financial incentives to increase physical activity among sedentary older adults. Assessing the Effect of Taiwan’s Outpatient Prescription Drug Copayment Policy in the Elderly
We are revising the Medicare hospital inpatient prospect i ve payment systems ( IPPS ) for operating and capital-related costs to implement changes arising from our continuing experience with these systems , and to implement a number of changes made by the Deficit Reduction Act of 2005 ( Pub . L. 109 - 171 ) . In addition , in the Addendum to this final rule , we describe the changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs . We also are setting forth rate-of-increase limits as well as policy changes for hospitals and hospital units excluded from the IPPS that are paid in full or in part on a reasonable cost basis subject to these limits . These changes are applicable to discharges occurring on or after October 1 , 2006 . In this final rule , we discuss public comments we received on our proposals to refine the diagnosis-related group ( DRG ) system under the IPPS to better recognize severity of illness among patients --to use a hospital-specific relative value ( HSRV ) cost center weighting methodology to adjust DRG relative weights ; and to implement consoli date d severity-adjusted DRGs or alternative severity adjustment methods . Among the other policy changes that we are making are those changes related to : limited revisions of the reclassification of cases to DRGs ; the long-term care (LTC)-DRGs and relative weights ; the wage data , including the occupational mix data , used to compute the wage index ; applications for new technologies and medical services add-on payments ; payments to hospitals for the direct and indirect costs of graduate medical education ; su bmi ssion of hospital quality data ; payments to sole community hospitals and Medicare-dependent , small rural hospitals ; and provisions governing emergency services under the Emergency Medical Treatment and Labor Act of 1986 ( EMTALA ) . We are responding to requested public comments on a number of other issues that include performance-based hospital payments for services and health information technology , as well as how to improve health data transparency for consumers . In addition , we are responding to public comments received on a proposed rule issued in the Federal Register on May 17 , 2006 that proposed to revise the methodology for calculating the occupational mix adjustment to the wage index for the FY 2007 hospital inpatient prospect i ve payment system by applying an adjustment to 100 percent of the wage index using new 2006 occupational mix survey data collected from hospitals . We are finalizing two policy documents published in the Federal Register relating to the implementation of the Health Care Infrastructure Improvement Program , a hospital loan program for cancer research , established under the Medicare Prescription Drug , Improvement , and Modernization Act of 2003 . This final rule also revises the definition of the term " unit " to specify the exclusion of units of drugs sold to approved Medicare Competitive Acquisition Program ( CAP ) vendors for use under the CAP from average sales price ( ASP ) calculations for a period of up to 3 years , at which time we will reevaluate our policy Since 1972 all persons with end stage renal disease ( ESRD ) eligible for Social Security are entitled to all Medicare benefits , regardless of age . ESRD patients need continual renal replacement therapy to survive . Although only 1 percent of Medicare beneficiaries suffer from ESRD , they account for roughly 9 percent of all Medicare payments . ESRD patients tend to be economically disadvantaged and belong to ethnic and racial minorities . CMS has developed many programs and regulations specifically for ESRD patients design ed to improve care , pay providers fairly , and minimize government expenditures . Currently , most ESRD patients are covered through a mix of mechanisms within the traditional fee-for-service ( FFS ) payment system , including : The composite rate covers services generally part of a single in-center hemodialysis treatment . The monthly capitation payment , which reimburses the physician , such as a nephrologist , who prescribes and monitors the patient 's dialysis . The payment amount for erythropoietin ( EPO ) to treat anemia is set by Congress at an allowed charge of $ 10 per thous and units . The first two methods act as prospect i ve payment systems ( PPSs ) for the services covered by the payments . Hospitalizations for ESRD patients are paid through the same PPS as all Medicare patients . Dialysis , hospitalizations , and physicians ' dialysis services comprise over 80 percent of Medicare expenditures for the care of dialysis patients . The traditional FFS system for dialysis patients is , in effect , a system of partial capitation . Medicare is the primary insurer for dialysis patients . Providers , patients , and nonprofit organizations take an active interest in any changes or potential changes to CMS payment or coverage policies . Other insurers and State Medicaid Programs often base their own procedures on those developed by CMS . Research into the efficient care of dialysis and transplant patients is of great interest to Medicare policymakers . Therefore , many people in and out of the government follow and contribute to research issues related to ESRD policy . This issue of the Review contains seven articles reporting findings from policy-relevant research . The first four articles derive from the independent evaluation of the ESRD managed care demonstration conducted by a team from The Lewin Group and the University Renal Research and Education Association . These articles are a subset of the topics covered in the joint final evaluation report ( The Lewin Group and the University Renal Research and Education Association , 2002 ) and the Secretary 's Report to Congress ( Centers for Medicare & Medicaid Services , 2002 ) . Next , the Kidney Epidemiology and Cost Center at the University of Michigan presents initial results suggesting that data of adequate quality exist to develop a risk-adjustment system for an exp and ed composite rate bundle . The last two articles deal with long-term issues important to ESRD patients :  improving the quality of care for dialysis patients  and increasing the number of kidneys donated and recovered for transplantation OBJECTIVES Efforts to improve adherence by reducing co-payments through value-based insurance design are become more prevalent despite limited evidence of improved health outcomes . The objective of this study was to determine whether eliminating patient co-payments for blood pressure medications improves blood pressure control . STUDY DESIGN R and omized controlled trial . METHODS The Collaboration to Reduce Disparities in Hypertension ( CHORD ) was a r and omized controlled trial with 12 months ' follow-up conducted among patients from the Philadelphia and Pittsburgh Veterans Administration Medical Centers . We enrolled 479 patients with poorly controlled systolic blood pressure . Participants were r and omly assigned to : a ) receive reductions in co-payments from $ 8 to $ 0 per medication per month for each antihypertensive prescription filled , b ) a computerized behavioral intervention ( CBI ) , c ) both co-pay reduction and CBI , or d ) usual care . Our main outcome measure was change in systolic blood pressure from enrollment to 12 months post enrollment . We also measured adherence using the medication possession ratio in a subset of participants . RESULTS There were no significant interactions between the co-payment interventions and the CBI interventions . There was no relative difference in the change in medication possession ratio between baseline and 12 months ( 0.05 % and -0.90 % in control and incentive groups , respectively ; P = .74 ) or in continuous medication gaps of 30 , 60 , or 90 days . Blood pressure decreased among all participants , but to a similar degree between the financial incentive and control groups . Systolic pressure within the incentive group dropped 13.2 mm Hg versus 15.2 mm Hg for the control group ( difference = 2.0 ; 95 % CI , -2.3 to 6.3 ; P = .36 ) . The proportion of patients with blood pressure under control at 12 months was 29.5 % in the incentive group versus 33.9 in the control group ( odds ratio , 0.8 ; 95 % CI , 0.5 - 1.3 ; P = .36 ) . CONCLUSIONS Among patients with poorly controlled blood pressure , financial incentives-as implemented in this trial-that reduced patient cost sharing for blood pressure medications did not improve medication adherence or blood pressure control Context In 2006 ,  Medicare  inaugurated a  drug benefit for older adults . Contribution Using data from a r and om sample of pharmacy customers who were beneficiaries of the program after the enrollment deadline , the authors estimate that the drug benefit saved people about $ 9 a month and gave them an extra 14 days of pills , on average . Caution The authors did not examine effects of the doughnut hole and did not look at specific drugs or drug classes . Implication The Medicare drug benefit has led to modest decreases in expense and increases in drug use for older adults . The Editors The Medicare Modernization Act Prescription Drug Benefit ( Part D ) established a prescription drug benefit for all 43 million Medicare beneficiaries in the United States . This is the largest change to Medicare since the program began several decades ago ( 1 ) . The prescription benefit has increased the proportion of Medicare enrollees with prescription drug coverage ( 2 ) , and the Centers for Medicaid & Medicare Services report that among seniors eligible for Medicare , Part D enrollees save on out-of-pocket expenses compared with those not enrolled in Part D ( 3 , 4 ) . Previous reports also have examined enrollment and used surveys to examine beneficiaries ' beliefs and experiences ( 57 ) . Although these reports and others ( 8 , 9 ) point to positive effects of the Part D benefit , several questions remain unanswered about its overall effect on prescription utilization and expenditures . This is because studies have tended to focus only on beneficiaries who have enrolled in a Medicare Part D plan . Changes in drug utilization or expenditures measured in these studies could represent Part D coverage , trends in prescription drug use unrelated to Part D , or differences between beneficiaries who enrolled in Part D and those who did not . A 2004 projection suggested that the Medicare drug benefit would reduce average out-of-pocket expenditures by about 14 % among elderly persons with Medicare coverage and by about 47 % among elderly persons without preexisting drug coverage , result ing in an overall increase in total drug spending of about 6 % ( 10 ) . This prediction was mainly driven by the fact that almost three fourths of elderly persons in the United States already had some kind of drug coverage and that Medicare Part D would have a small effect on their expenditures and utilization . Yet with the exception of 1 recent study ( 11 ) , little work has been done to empirically estimate the effect of the Part D benefit on prescription drug utilization and expenditures . We sought to address these limitations by analyzing pharmacy cl aims from a national pharmacy chain accounting for approximately one eighth of the market share of prescription medicines in the United States . Although this sample may not be nationally representative , it offers an opportunity to study the effect of Part D on a broad and heterogeneous population that accounts for a substantial portion of the entire Medicare population . Our analyses compare the effect of Part D on prescription drug utilization and expenditures among persons eligible for the benefit who enrolled in a Part D plan , persons eligible for the benefit who did not enroll , and noneligible persons . We also distinguish between the overall effect of Part D during the penalty-free enrollment period and the postpenalty-free period , when enrollment was stable , to determine the steady-state effect of Part D , independent of enrollment dynamics . Methods Sample and Measurements We selected a 5 % r and om sample of unique pharmacy customers who filled at least 1 prescription during both the 2005 and the 2006 calendar years through the Walgreens pharmacy chain , whether at a retail store or by mail order . For each person in our sample , we obtained cl aims data for every prescription filled between 1 September 2004 and 31 April 2007 . For each prescription cl aim , we obtained data on the cl aim ant 's demographic characteristics ( age , sex , language preference , ZIP code of residence ) , insurance characteristics ( whether the cl aim was paid through a prescription drug plan , method of payment ) , pharmacy characteristics ( ZIP code location ) , prescription characteristics ( National Drug Code , therapeutic class , drug dose , number of treatment days , date dispensed , number of refills ) , and expenditures ( amount paid out of pocket , amount paid by third party ) . We used data on cl aim ants ' ZIP code of residence  ( the residence recorded at the person 's first pharmacy cl aim in 2005 ) to link the pharmacy cl aims data to data from the 2000 U.S. Census , including information on the total population , median household income , income per capita , proportion of urban residents , proportion of African-American persons , unemployment rate , and poverty rate within the ZIP code of residence ( 12 , 13 ) . We also used data from the Behavioral Risk Factor Surveillance System ( BRFSS ) to compare the characteristics of our sample with those of all Medicare beneficiaries . We used simple descriptive statistics to compare the age and sex distribution of our sample with those of persons age 60 to 63 years and 66 to 79 years in the BRFSS . We also linked BRFSS data to 2000 U.S. Census data to examine whether the ZIP codelevel demographic characteristics of our pharmacy sample were similar to those of the nationally representative BRFSS sample in the same age groups , and whether the characteristics of our sample were similar to those of only BRFSS respondents who lived in the same geographic areas as our pharmacy sample . We excluded persons 80 years of age or older because the proportion of persons in nursing homes is higher among this age group and because changes in the Medicare Modernization Act regarding persons receiving nursing home care and long-term care ( 14 ) do not extend to the majority of the Medicare population . Outcomes Our 2 outcomes were monthly average out-of-pocket prescription costs and prescription utilization , as measured by the quantity of a prescription medicine sufficient for 1 day of therapy ( pill-day ) . Each person in our sample contributed 32 observations corresponding to 32 months of data . We divided the 32 months into 3 periods : the prePart D period ( September 2004 to December 2005 ) ; the ramp-up postPart D period , during which seniors could enroll in Part D plans without penalty ( January 2006 to May 2006 ) ; and the stable postPart D period , after the deadline for penalty-free Part D enrollment ( June 2006 to April 2007 ) . Because we aim ed to estimate the effect of Part D , we sought to compare observed trends in out-of-pocket costs and utilization among seniors eligible for the benefit ( the Part Deligible group , consisting of persons age 66 to 79 years as of 1 January 2006 ) with predicted counterfactual trends for the same group of seniors had Part D not been enacted . Thus , we sought to estimate the effect of Part D on expenditures and utilization netting out contemporaneous changes to the outcome variable due to factors unrelated to Part D ( 15 , 16 ) . To estimate counterfactual trends , we used the contemporaneous time profile of the corresponding outcomes in a control group of persons age 60 to 63 years who were not yet eligible for the benefit ( the Part Dineligible group ) . We dropped persons ages 64 and 65 years as of 1 January 2006 from the sample because they had partial-year Medicare eligibility during the study period . We first confirmed that the trends in outcomes in persons 60 to 63 years of age provided an adequate control for persons in the eligible group during the prePart D era ( September 2004 to December 2005 ) by examining both the statistical significance and magnitude of the coefficients in our regression model that represented the differential trends between the Part Deligible and Part Dineligible groups during the prePart D era . We then used the counterfactual control trends in the ramp-up period and in the stable enrollment period after the Part D enrollment deadline in May 2006 to represent the counterfactual trends in outcomes for the Part Deligible group assuming Part D had not been enacted . Statistical Analysis We estimated trends and generated predictions by using generalized estimating equations ( GEEs ) . We adjusted for sample demographic characteristics ( sex , English-speaking status , Medicaid coverage , age ) , ZIP codelevel characteristics ( total population , median household income , per-capita income , proportion of urban residents , proportion of African-American persons , unemployment rate , poverty rate ) , fixed effects for calendar months ( January to December ) , study period ( prePart D , ramp-up postPart D , and stable postPart D ) , and Part Deligible group . Moreover , we explored a variety of splines for representing differential time trends between periods ; we ultimately used cubic splines because they produced the best fit for both the prePart D and the stable postPart D periods . A linear spline was used for the ramp-up postPart D period because this period was short . We added up to 3-way interactions between study period and Part Deligible group fixed effects and the splines over time . We assessed overall model fit by using a variety of goodness-of-test criteria . We used gamma distribution to model out-of-pocket expenditures and negative binomial distribution to model pill-days . All estimators used log-link models . In addition , we explored the correlation structure between monthly observations within participants and used a first-order autoregressive correlation structure for out-of-pocket costs and an unstructured correlation matrix for pill-days . We had 2 main goals . First , we sought to estimate the policy effect of Part D coverage during both the ramp-up and stable postPart D periods . These effects represent the mean differences in the monthly outcomes between the observed factual trends and predicted counterfactual trends if Part D had not been enacted over these 2 periods . The Appendix Figure provides details about the specifications of these models and how the To clarify the financial incentives for hospitals to prevent nosocomial infections , we analyzed 9423 nosocomial infections identified in 169 526 admissions selected r and omly from the adult admissions to a r and om sample of US hospitals . By classifying each admission into a baseline diagnosis related group ( DRG ) ( after first excluding all diagnoses of nosocomial infection ) and a final DRG ( after including these diagnoses ) , we found that only 5 % to 18 % of nosocomial infections would have caused the admission to be reclassified to a higher-paying DRG , depending on the extent to which physicians recorded nosocomial infection diagnoses in patients ' medical records . The extra payment from the reclassification , averaged over all nosocomial infections , would have been no more than $ 93 per infection ( in 1985 reimbursement rates ) , constituting only 5 % of the hospitals ' costs for treating these infections . Thus , at least 95 % of the cost savings obtained from preventing nosocomial infections represents financial gains to the hospital OBJECTIVES To review UK guidelines regarding the use of financial incentives for healthcare professionals to become involved in clinical trials , and to survey perceptions and current practice . DATA SOURCES Electronic data bases were search ed from inception to June 2006 . Interviews were held with NHS healthcare professionals , research managers from the pharmaceutical industry and members of the public . REVIEW METHODS From the search es , 634 identified studies were assessed for inclusion in the systematic review , but only three met the criteria for data extraction . Fifty-eight individuals were interviewed : 38 chief investigators , six non- research active clinicians , eight public and six pharmaceutical managers . Investigators were selected from those funded by the HTA Programme , the other by ' snowballing ' and personal contact . RESULTS The evidence from the literature was limited and inconclusive . In UK guidelines , the issues around payments to clinicians or patients were implied rather than stated , usually linked to discussion of conflict of interest and disclosure of any such conflicts . Developments in NHS research governance had led to increased transparency in all payments for research participation and for payments to be made to NHS Trusts rather than individual clinicians . While reimbursement of costs incurred by research was strongly supported by the interviewees , payments to incentivise recruitment were not . A code of practice was suggested for payments in publicly funded trials , which was closely linked to the principles of Good Clinical Practice in research . Factors such as interest in the topic , scope for patient benefit and good communication were considered more important than payment . Interviews with the general public indicated low levels of awareness of the existence of payments to clinicians linked to patient recruitment in trials , and unanimous support for full disclosure . Interviews with managers in the pharmaceutical industry showed greater familiarity with payments for research involvement . GPs were seen as the only group for whom scope existed for individual payments . Concerns were expressed by the pharmaceutical company interviewees at the rising cost of research and unnecessary bureaucracy . CONCLUSIONS The ethical stances outlined in Good Clinical Practice in research were widely endorsed by the three groups interviewed . These allow reasonable payments to clinicians , subject to disclosure of any possible conflicts of interest . The potential for incentivising clinicians to recruit was limited as any payments should be based on the cost of inputs and should not be made to individuals but to their host organisation . NHS professionals were concerned that payments could damage the quality of research and also considered full disclosure to patients as challenging . Patients and members of the public favoured full disclosure and payment of expenses to patients involved in research . Pharmaceutical company interviewees viewed payment to the NHS for all research activities as normal and highly regulated . They complained that the prices charged were high and so variable that they required benchmarking . Considerable scope exists for compiling data on the factors that help and hinder the progress of clinical trials and also for experimenting with different incentives to encourage involvement in clinical research . Further research should focus on improved reporting of those organisational aspects of trials that are known to affect recruitment ; retrospective analysis of the factors associated with different levels of recruitment to RCTs ; prospect i ve comparative research on trial recruitment ; qualitative research on participants ' experiences of being involved in different kinds of trials , and proposals to include within trials experiments with payments methods BACKGROUND Policy makers have proposed bundling payments for all heart failure ( HF ) care within 30 days of an HF hospitalization in an effort to reduce costs . Disease management ( DM ) programs can reduce costly HF readmissions but have not been economically attractive for caregivers under existing fee-for-service payment . Whether a bundled payment approach can address the negative financial impact of DM programs is unknown . METHODS Our study determined the cost-neutral point for the typical DM program and examined whether published HF DM programs can be cost saving under bundled payment programs . We used a decision analytic model using data from retrospective cohort studies , meta-analyses , 5 r and omized trials evaluating DM programs , and inpatient cl aims for all Medicare beneficiaries discharged with an HF diagnosis from 2001 to 2004 . We determined the costs of DM programs  and  inpatient care  over 30 and 180 days . RESULTS With a baseline readmission rate of 22.9 % , the average cost for readmissions over 30 days was $ 2,272 per patient . Under base-case assumptions , a DM program that reduced readmissions by 21 % would need to cost $ 477 per patient to be cost neutral . Among evaluated published DM programs , 2 of the 5 would increase provider costs ( + $ 15 to $ 283 per patient ) , whereas 3 programs would be cost saving ( -$241 to $ 347 per patient ) . If bundled payments were broadened to include care over 180 days , then program saving estimates would increase , ranging from $ 419 to $ 1,706 per patient . CONCLUSIONS Proposed bundled payments for HF admissions provide hospitals with a potential financial incentive to implement DM programs that efficiently reduce readmissions This paper is a report of the results of a demonstration design ed to provide empirical evidence regarding the effects of alternative approaches to paying physicians for serving children in the Medicaid program : ( 1 ) visit fees set at twice regular Medicaid fees in return for physician agreement to manage utilization and ( 2 ) capitation and financial risk-sharing along with the same physician agreement to manage utilization .  Participating physicians were assigned r and omly to either of the two payment groups . Comparisons of utilization and expenditures were made between these two plans and the regular Medicaid program ( fee-for-service , low fees ) . Results showed no adverse effect of capitation payments on primary care visits to office-based physicians . Capitation physician referrals to specialists decreased relative to all other groups studied , consistent with the theory that the financial incentives in capitation will lead primary care physicians to reduce referrals to specialists AIM To assess the impact of the National Essential Medicines Policy ( NEMP ) on the use of medicines in government-owned primary care institutions in Hubei province of China . STUDY DESIGN Quasi-experimental design and time-trend analysis . METHODS A systematic r and om sampling strategy was employed to select 55,800 prescriptions from 18 primary care organizations who progressively implemented the NEMP from January 2009 to July 2011 . We examined the change of patterns of prescriptions . The facilities that implemented the NEMP at a later stage served as control . RESULTS An immediate increased uptake of essential medicines of all drugs prescribed which ultimately neared 95 % . In total , 38,151 prescriptions ( 68 % ) involved antibiotics , and we found no evidence of reduction after the NEMP interventions . A high percentage ( 59 - 66 % ) of prescription drugs were administered through parenteral routes and no reduction was found after the NEMP interventions . Although the average number of medicines per prescription remained unchanged ( nearly four ) , the average cost per prescription declined significantly after the NEMP interventions ( ¥ 44.67 vs ¥ 26.67 CNY , P < 0.03 ) . CONCLUSIONS The NEMP interventions reduced the average cost per prescription ; however , the irrational use of antibiotics and unnecessary parenteral administration remains prevalent . The goals of the NEMP are partially achieved ; we therefore recommend a strategic approach involving all stakeholders to comprehensively achieve all aspirations Background While integrated health care system has been proved an effective way to help improving patient health and system efficiency , the exact behaviour model and motivation approach are not so clear in poor rural areas where health human re sources and continuous service provision are urgently needed . To gather solid evidence , we initiated a comprehensive intervention project in Qianjiang District , southwest part of rural China in 2012 . And after one-year 's pilot , we developed an intervention package of team service , comprehensive pathway and prospect ive- and performance-based payment system . Methods To testify the potential influence of payment interventions , we use clustered r and omised controlled trial , 60 clusters are grouped into two treatment groups and one control group to compare the time and group differences . Difference-in-differences model and structural equation modelling will be used to analyse the intervention effects and pathway . The outcomes are : quality of care , disease burden , supplier cooperative behaviour and patient utilisation behaviour and system efficiency . Repeated multivariate variance analysis will be used to statistically examine the outcome differences . Discussion This is the first trial of its kind to prove the effects and efficiency of integrated care . Though we adopted r and omised controlled trial to gather the highest rank of evidence , still the fully r and omisation was hard to realise in health policy reform experiment . To compensate , the design er should take efforts on control for the potential confounders as much as possible . With this trial , we assume the effects will come from : ( 1 ) improvement on the quality of life through risk factors control and lifestyles change on patient 's behaviours ; ( 2 ) improvement on quality of care through continuous care and coordinated supplier behaviours ; ( 3 ) improvement on the system efficiency through active interaction between suppliers and patients . Conclusion The integrated care system needs collaborative work from different levels of caregivers . So it is extremely important to consider the supplier cooperative behaviour . In this trial , we introduced payment system to help the delivery system integration through providing financial incentives to motivate people to play their roles . Also , the multidisciplinary team , the multi-institutional pathway and system global budget and pay-for-performance payment system could afford as a solution CONTEXT A prior national survey documented the high prevalence and costs of  alternative medicine use in the United States in 1990 . OBJECTIVE To document trends in alternative medicine use in the United States between 1990 and 1997 . DESIGN Nationally representative r and om household telephone surveys using comparable key questions were conducted in 1991 and 1997 measuring utilization in 1990 and 1997 , respectively . PARTICIPANTS A total of 1539 adults in 1991 and 2055 in 1997 . MAIN OUTCOMES MEASURES Prevalence , estimated costs , and disclosure of alternative therapies to physicians . RESULTS Use of at least 1 of 16 alternative therapies during the previous year increased from 33.8 % in 1990 to 42.1 % in 1997 ( P < or = .001 ) . The therapies increasing the most included herbal medicine , massage , megavitamins , self-help groups , folk remedies , energy healing , and homeopathy . The probability of users visiting an alternative medicine practitioner increased from 36.3 % to 46.3 % ( P = .002 ) . In both surveys alternative therapies were used most frequently for chronic conditions , including back problems , anxiety , depression , and headaches . There was no significant change in disclosure rates between the 2 survey years ; 39.8 % of alternative therapies were disclosed to physicians in 1990 vs 38.5 % in 1997 . The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 ( 64.0 % ) and 1997 ( 58.3 % ) ( P=.36 ) . Extrapolations to the US population suggest a 47.3 % increase in total visits to alternative medicine practitioners , from 427 million in 1990 to 629 million in 1997 , thereby exceeding total visits to all US primary care physicians . An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and /or high-dose vitamins ( 18.4 % of all prescription users ) . Estimated expenditures for alternative medicine professional services increased 45.2 % between 1990 and 1997 and were conservatively estimated at $ 21.2 billion in 1997 , with at least $ 12.2 billion paid out-of-pocket . This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations . Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $ 27.0 billion , which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services . CONCLUSIONS  Alternative medicine use and expenditures increased substantially between 1990 and 1997 , attributable primarily to an increase in the proportion of the population seeking alternative therapies , rather than increased visits per patient OBJECTIVE Previous economic analyses of tuberculosis control interventions have focused on the provider perspective . To assess the overall economic impact of the disease and the adequacy of current control strategies from a societal viewpoint , the determination of direct and indirect patient costs is required . SETTING AND DESIGN In a cross-sectional survey , all adult tuberculosis patients who completed treatment between August 1996 and February 1997 at 16 r and omly selected government health care facilities in Thail and ( n = 673 ) were interviewed using a structured question naire . Information were obtained on direct and indirect patient costs before and after diagnosis , and on financing methods and changes in household consumption patterns . All results were stratified for three levels of patient household income : above national average , below national average but above the poverty line , and below the poverty line . RESULTS Illness-related costs particularly affected patients with incomes below the poverty line ( n = 153 ) . In this group , average out-of-pocket expenditures for the disease amounted to more than 15 % of annual household income , while incomes were reduced by 5 % due to illness-related effects . Expenditures were most frequently financed from household savings or transfer payments from community members and relatives . However , 11.8 % of patient households took out bank loans , and 15.9 % sold part of their property . CONCLUSION The current low case detection and treatment completion rates for tuberculosis patients in Thail and may partly be due to the inability of poor patients to cope with the economic consequences of diagnosis and treatment . Suggested improvements include the strict enforcement of an existing government policy of free care , the further de central ization of services to reduce travel costs and work absences , and social security payments for patients undergoing treatment OBJECTIVE To determine the changes in drug costs associated with drug therapy changes result ing from pharmacists ' cognitive services ( CS ) provided to Medicaid recipients during a 1-year period following the documented CS . DESIGN A study -control group analysis of documented pharmacists ' CS interventions linked to Medicaid prescription cl aims . Each CS result ing in a drug therapy change was linked to an index prescription cl aim and all refills for the same drug within 365 days . The drug cost change associated with the CS was calculated as the difference between the estimated cost of the prescription as originally written less the actual cost to Medicaid for the stream of refills dispensed . SETTING Pharmacies serving ambulatory Medicaid patients in the state of Washington , excluding staff-model health maintenance organization pharmacies and pharmacies predominantly serving long-term care residents . PARTICIPANTS Approximately 200 community pharmacies participating in the Washington State Cognitive Activities and Reimbursement Effectiveness ( CARE ) Project . Pharmacies were r and omly assigned to a group that was paid a fee for each CS provided or a group that was not paid . INTERVENTION Payment for CS . MAIN OUTCOME MEASURES Downstream drug costs associated with CS result ing in a drug therapy change . RESULTS CS result ing in drug therapy changes accounted for 5,417 out of 20,240 ( 27 % ) documented CS in the CARE Project . Of the 2,002 CS records analyzed in this study , 76 % indicated a change in the prescribed drug or drug regimen , 9 % indicated that a drug was added , 5 % indicated that a current drug was discontinued , and 10 % indicated that an originally prescribed drug was never dispensed . Only 9 % involved generic substitution ; all other changes would have necessitated prior prescriber approval . Overall , CS result ing in a drug therapy change generated a mean drug cost savings of $ 13.05 per CS intervention . There were no significant differences in average savings per intervention between the paid and nonpaid groups . CONCLUSION For all result categories except " add drug therapy , " the extrapolated cost savings in the paid group exceeded the savings estimated from the nonpaid group , sometimes by a considerable amount . At the payment rate used in this study , paying for CS that result in a drug therapy change ( except add drug therapy ) is estimated to save an additional $ 10 per 1,000 prescriptions dispensed . Those CS that result in addition of drug therapy are estimated to add an incremental cost of about $ 13 per 1,000 prescriptions . A sensitivity analysis revealed that a higher intervention rate would lead to a higher potential savings . This finding suggests that efforts to encourage CS interventions may lead to greater savings BACKGROUND Paying patients to participate in clinical trials is ethically controversial . However , there has been no empirical documentation regarding whether payment represents an undue or unjust inducement . METHODS To evaluate these questions , we described hypothetical placebo-controlled trials of a new antihypertensive drug to 126 patients with mild-to-moderate hypertension recruited from hypertension and general medicine clinics at a university hospital . Using a 3 x 3 , within-subjects design , we altered a risk to participation ( either adverse effect rate or rate of r and omization to placebo ) and the payment participants would receive ( $ 100 , $ 1000 , and $ 2000 ) and asked patients to indicate their  willingness  to participate ( WTP ) in each trial using a 6-point scale . RESULTS Clustered ordinal logistic regression models revealed that patients ' WTP decreased with higher risk of adverse effects ( P<.001 ) , higher risk of being assigned to placebo ( P = .02 ) , and lower payment level ( P<.001 ) . There were no significant interactions between payment level and either risk variable , suggesting that increasing payments do not alter peoples ' perceptions of risk . There was a trend toward a positive interaction between income and the influence of payment on WTP ( P = .09 ) , suggesting that payment more strongly influences WTP  among wealthier people . Wealthier patients were more likely to state that payment was important in their participation decision ( 37 % vs 20 % , P = .05 ) . CONCLUSION Although higher payment motivates research participation , we found no evidence that commonly used payment levels represent undue or unjust inducements OBJECTIVE Less than half of all U.S. adults meet public health recommendations for physical activity , and even fewer older adults ( aged 50 years and over ) are sufficiently active . Because inactivity increases the risk of costly medical complications , successful efforts to increase physical activity among older adults may potentially be cost-effective . We sought to test if financial incentives for walking could increase physical activity among sedentary older adults . METHODS We conducted a 4-week r and omized controlled study using pedometers .  A total of 51 adults age 50 + from the Raleigh-Durham area of North Carolina participated in the study in April-May 2007 . Individuals were r and omized into one of two arms . The control group received a fixed payment of $ 75 ; the intervention group received a fixed payment of $ 50 plus up to $ 25 more per week depending on the number of weekly aerobic minutes  , defined as 10 + minutes of continuous walking or jogging . RESULTS The control group logged 2.3 h per week , on average . The intervention group logged 4.1 h per week and received an additional weekly payment of $ 17.50 , on average . CONCLUSION Modest financial incentives tied to aerobic minutes are an effective , and potentially cost-effective , approach for increasing physical activity among sedentary older adults Objectives . This study uses variance cost analysis and regression analysis as tools for investigating the initial effects of Taiwan ’s outpatient prescription drug copayment program in the elderly . Under its new National Health Insurance program , Taiwan implemented a  prescription drug cost-sharing program  August 1 , 1999 . We compare an elderly population ’s prescription drug use after the policy  was implemented with an elderly population ’s prescription drug use before the policy change to describe initial and general consequences of the drug cost-sharing program . Methods . Approximately 240,000 patients aged 65 and over representing 1,600,000 outpatient prescriptions were drawn from 21 hospitals in the Taipei area for the study using a stratified r and om sampling method . Variance analysis , as used primarily in accounting , was applied to decompose overall cost variance of the policy into the sum of variances of several specific factors that are important to policymakers . The cost variances of each specific factor can be further decomposed into sublevels of analyses . Regression analysis is then applied to better underst and covariates that might influence drug cost variances of significant magnitude . Results . The initial effects of the policy change did not reverse the trend of drug cost increases . Instead , there was a significant increase in total prescription drug costs in the cost-sharing group ( approximately 12.86 % ) and an even higher increase rate in the non-cost-sharing group ( approximately 51.42 % ) . The main reason for the drug cost increase for the cost-sharing group was attributed to an increase in average drug costs per prescription ( explaining 69.20 % of the variance ) . We found physicians seemed to prescribe more expensive drugs and extend prescription duration , especially when drug costs exceed the upper bound of the cost-sharing schedule . By contrast , the main factor contributing to the increase in drug costs for the non-cost-sharing group was an increase in average prescription duration ( explaining 64.98 % of the variance ) . The increase mainly results from the effect of extended prescriptions for chronic diseases that were design ed to reduce unnecessary visits for refills . Discussion . The significant increase in average drug price per prescription indicates that many prescriptions could move above the upper bound of the cost-sharing schedule . The results suggest that the Bureau of National Health Insurance should increase the upper bound . We do not think these effects are unique to Taiwan . Rather , these effects should be considered as countries change their outpatient drug benefit programs . We also found a decrease in utilization of essential drugs with an increase in utilization of nonessential drugs for patients subject to copayments . The results suggest potential adverse effects on patients ’ health outcome
Increasing the amount of money that people pay for medicines may reduce insurers ' medicine expenditures and may reduce patients ' medicine use .
These types of interventions may lead to small decreases in or uncertain effects on healthcare utilisation .
Cap and co-payment polices may reduce the use of medicines and reduce medicine expenditures for health insurers .
However , they may also reduce the use of life-sustaining medicines or medicines that are important in treating chronic , including symptomatic , conditions and , consequently , could increase the use of healthcare services .
Fixed co-payment with a ceiling and tiered fixed co-payment may be less likely to reduce the use of essential medicines or to increase the use of healthcare services
BACKGROUND Growing expenditures on prescription medicines represent a major challenge to many health systems .
Cap and co-payment policies are intended as an incentive to deter unnecessary or marginal utilisation , and to reduce third-party payer expenditures by shifting parts of the financial burden from insurers to patients , thus increasing their financial responsibility for prescription medicines .
Direct patient payment policies include caps ( maximum numbers of prescriptions or medicines that are reimbursed ) , fixed co-payments ( patients pay a fixed amount per prescription or medicine ) , co-insurance ( patients pay a percentage of the price ) , ceilings ( patients pay the full price or part of the cost up to a ceiling , after which medicines are free or are available at reduced cost ) and tier co-payments ( differential co-payments usually assigned to generic and br and medicines ) .
This is the first up date of the original review .
OBJECTIVES To determine the effects of cap and co-payment ( cost-sharing ) policies on use of medicines , healthcare utilisation , health outcomes and costs ( expenditures ) .