William J. Bicknell

Physicians' responses to financial incentives : evidence from a for-profit ambulatory care center

Health Stop is a major chain of ambulatory care centers operating for profit. Until 1985 its physicians were paid a flat hourly wage. In the middle of that year, a new compensation plan was instituted to provide doctors with financial incentives to increase revenues. Physicians could earn bonuses the size of which depended on the gross incomes they generated individually. We compared the practice patterns of 15 doctors, each employed full time at a different Health Stop center in the Boston area, in the same winter months before and after the start of the new arrangement. During the periods compared, the physicians increased the number of laboratory tests performed per patient visit by 23 percent and the number of x-ray films per visit by 16 percent. The total charges per month, adjusted for inflation, grew 20 percent, mostly as a result of a 12 percent increase in the average number of patient visits per month. The wages of the seven physicians who regularly earned the bonus rose 19 percent. We conclude that substantial monetary incentives based on individual performance may induce a group of physicians to increase the intensity of their practice, even though not all of them benefit from the incentives.

Physician satisfaction in a major chain of investor-owned walk-in centers

This article describes physicians at a major chain of investor-owned freestanding walk-in centers and reports on their job satisfaction. They derived satisfaction from a sense of autonomy and the corporations reliable provision of staff and supplies. Their job dissatisfaction results from the corporate emphasis on generating revenue and the lack of opportunity for professional interaction with colleagues.

As children survive: Dilemmas of aging in the developing world

The decline in infant mortality now occurring in the developing world assures a growing population of older persons with a chronic disease morbidity burden that is predictable and costly. The health needs and related social requirements of the elderly are not always well met even in countries where resources are substantial. In the developing world, this morbidity burden can quickly overwhelm fragile and often underfinanced health infrastructures already unable to meet fully the prevention and treatment needs of a younger population with relatively low-cost, easy-to-prevent, easy-to-treat illnesses. Inappropriate application of costly technology could easily result, accompanied by diversion of resources from existing primary-care services, and paradoxically poor service to the emerging aging population. This paper examines the dilemma, and spells out the issues by examining several chronic diseases in detail. We conclude with suggestions for a policy-oriented research agenda aimed at the development of affordable and humane approaches to the health needs of aging populations, and the prevention and care of chronic diseases in the developing world.

Good governance and budget reform in Lesotho Public Hospitals: performance, root causes and reality

Lesotho has been implementing financial management reforms, including performance-based budgeting (PBB) since 2005 in an effort to increase accountability, transparency and effectiveness in governance, yet little is known about how these efforts are affecting the health sector. Supported by several development partners and

The patient population of a major chain of investor-owned ambulatory care walk-in centers

24 million in external resources, the PBB reform is intended to strengthen government capacity to manage aid funds directly and to target assistance to pressing social priorities. This study designed and tested a methodology for measuring implementation progress for PBB reform in the hospital sector in Lesotho. We found that despite some efforts on the national level to promote and support reform implementation, staff at the hospital level were largely unaware of the purpose of the reform and had made almost no progress in transforming institutions and systems to fully realize reform goals. Problems can be traced to a complex reform design, inadequate personnel and capacity to implement, professional boundaries between financial and clinical personnel and weak leadership. The Lesotho reform experience suggests that less complex designs for budget reform, better adapted to the context and realities of health sectors in developing countries, may be needed to improve governance. It also highlights the importance of measuring reform implementation at the sectoral level.

Quality of acute episodic care in investor-owned ambulatory health centers

In sum, people go to a walk-in office for quick, convenient service, and overall they are happy with their experience. Although we cannot generalize from this case study of one chain of walk-in centers to walk-ins nationally, results from other studies of walk-in patient populations are approximately similar to ours.

Caveat emptor: exporting the U.S. medical model.

This article examines the quality of acute episodic care for five diagnostic categories amenable to one-visit diagnosis and treatment at the nations largest chain of investor-owned ambulatory care centers. A total of 803 medical records were audited for five common conditions and measured against specific protocols. In four of the five diagnostic categories studied—pharyngitis, otitis media, vaginitis, and use of tetanus immunization—42–97% of patients received care that met or exceeded the standards set by a panel of practicing academic physicians. In follow-up of an incidental high blood pressure reading, however, study physicians met the standard only 24% of the time. Some overprescribing and overtreatment with immunizations were detected. As far as comparison is possible to other studies, results suggest that care in this setting falls within the range of experience that has been reported for other types of practices. In spite of direct economic incentives to increase volume, little evidence was found of overuse of ancillary tests or unnecessary scheduling of repeat visits.

Policy analysis for end-stage renal disease in Jamaica

Abstract Deficiencies in the gold-plated U.S. health care delivery system suggest the necessity for caution in exporting U.S. concepts and methods to less developed countries. American medical education and a penchant for high technology have created a system which, though rich in resources, has serious shortcomings. Although inefficiencies, irrationalities and inequalities pervade the U.S. system, some successful innovations may warrant emulation. However, Western medical advisors and officials in developing countries need to recognize the shortcomings of the U.S. model and to select from it those programs and delivery systems capable of deriving maximum gain from limited resources.

The Case for Voluntary Smallpox Vaccination

We developed and applied methods for policy analysis for end-stage renal disease (ESRD) in Jamaica. Our emphasis was on methods useful for situations often found in developing countries, where both resources and data may be limited. Many countries are experimenting with ESRD treatment options, but little analysis has been done regarding how developing countries should approach policy decisions for ESRD. Methods for policy analysis in high-income countries often rely on large data sets that may be unavailable or only partially available in developing countries. We conducted technical analysis applicable in these circumstances and emphasized a process for including a wide range of policymakers and other stakeholders in both quantitative and qualitative aspects of the analysis. Our methods may also be applicable in other developing countries and for other chronic diseases. Our analysis included eight issues: (1) a review of currently available clinical and scientific understanding regarding ESRD; (2) a review of country-specific socioeconomic and clinical issues relevant to ESRD in Jamaica; (3) estimates of the magnitude of the need for treatment in the Jamaican population; (4) comparison of the need with available treatment capacity; (5) cost analysis related to options for expansion of treatment capacity; (6) comparison of costs to government budget resources and other potential sources of financing; (7) development of policy options; and (8) sensitivity testing of policy scenarios and trade-offs with competing priorities. We also identified several key decisions most developing country governments will face in setting health policy for ESRD. These include allocating funds for ESRD, identifying and selecting cost-saving clinical strategies, rationing available treatment capacity, and identifying the appropriate role for public education.