BACKGROUND Performance measures are often neglected during the transition period of national health insurance scheme implementation in many low and middle income countries. These measurements evaluate the extent to which various aspects of the schemes meet their key objectives. This study assesses the implementation of a health insurance scheme using optimal resource use domains and examines po...

Where a provider is excluded from a managed care payor network, patients are often required to pay a much higher “out-of-network” co-payment if they choose to be treated at such provider. In such a case, it may be viewed as a potential kickback, insurance fraud or grounds for disciplinary action against a physician to waive the co-payment, co-insurance or deductible.1 Further, a provider’s waiv...

This article reviews methodologies and international experience related to costing and pricing health services for health care purchasers. The main factors affecting price-setting methods are: (1) provider payment systems; (2) information available on actual costs, service volumes and outcomes; and (3) characteristics of providers and purchasers. These factors are strongly interrelated. Provide...

The starting point of the debate about the pros and cons of multipayer systems is the suspicion that in many health care systems, consumers do not get sufficient value for money. This contribution argues that one cause may be a nonoptimal choice of payment systems. Optimal payment of health care providers importantly depends on the amount of information available to the (prospective) patient. I...

In a community-based health insurance (CBHI) introduced in 2004 in Nouna health district, Burkina Faso, poor perceived quality of care by CBHI enrollees has been a key factor in observed high drop-out rates. The poor quality perceptions have been previously attributed to health worker dissatisfaction with the provider payment method used by the scheme and the resulting financial risk of health ...

Diverse provider payment systems create incentives that affect the quantity and quality of health care services provided. Payments can be based on provider characteristics, which tend to minimize incentives for quality and quantity. Or payments can be based on quantities of services provided and patient characteristics, which provide stronger incentives for quality and quantity. Payments method...

BACKGROUND In 2004, a community-based health insurance scheme (CBI) was introduced in Nouna health district, Burkina Faso. Since its inception, coverage has remained low and dropout rates high. One important reason for low coverage and high dropout is that health workers do not support the CBI scheme because they are dissatisfied with the provider payment mechanism of the CBI. METHODS A discr...

Healthcare reimbursements in the US have been traditionally based upon a fee-for-service (FFS) scheme, providing incentives for high volume of care, rather than efficient care. The new healthcare legislation tests new payment models that remove such incentives, such as the bundled payment (BP) system. We consider a population of patients (beneficiaries). The provider may reject patients based o...

In 2009, the methods for paying SHI-affiliated physicians in ambulatory care were changed. The era of capitation fees and strict budgeting is over. GPs and specialists are now paid on a capped fee-for-service basis, with a payment ceiling that is set for each doctor and adjusted for specialization, the number of cases and patient age. Instead of a floating-point fee schedule, a fee schedule wit...