Role of Cost on Failure to Access Prescribed Pharmaceuticals: The Case of Statins

BACKGROUND

In Australia, as in many other Western countries, patient surveys suggest the costs of medicines lead to deferring or avoiding filling of prescriptions. The Australian Pharmaceutical Benefits Scheme provides approved prescription medicines at subsidised prices with relatively low patient co-payments. The Pharmaceutical Benefits Scheme defines patient co-payment levels per script depending on whether patients are "concessional" (holding prescribed pension or other government concession cards) or "general", and whether they have reached a safety net defined by total out-of-pocket costs for Pharmaceutical Benefits Scheme-approved medicines.

OBJECTIVE

The purpose of this study was to explore the impact of costs on adherence to statins in this relatively low-cost environment.

METHODS

Using data from a large-scale survey of older Australians in the state of New South Wales linked to administrative data from the national medical and pharmaceutical insurance schemes, we explore the relationships between adherence to medication regimes for statins and out-of-pocket costs of prescribed pharmaceuticals, income, other health costs, and a wide set of demographic and socio-economic control variables using both descriptive analysis and logistic regressions.

RESULTS

Within the general non-safety net group, which has the highest co-payment, those with lowest income have the lowest adherence, suggesting that the general safety threshold may be set at a level that forms a major barrier to statin adherence. This is reinforced by over 75% of those who were not adherent before reaching the safety net threshold becoming adherent after reaching the safety net with its lower co-payments.

CONCLUSION

The main financial determinant of adherence is the concessional/general and safety net category of the patient, which means the main determinant is the level of co-payment.

The Value of Evidence in the Decision-Making Process for Reimbursement of Pharmacogenetic Dosing of Warfarin

BACKGROUND

After early clinical trials that evaluated pharmacogenetic (PG) algorithms, many healthcare payers were reluctant to cover this technology and, consequently, PG dosing of warfarin could not be translated into clinical practice.

OBJECTIVE

The aim of this study was to estimate the value of upgrading evidence relating to PG dosing of warfarin from the healthcare payer perspective.

METHODS

Randomized controlled trials (RCTs) that evaluated PG dosing of warfarin were identified through a systematic literature search, and their findings were combined by a cumulative meta-analysis. A health economic model was used to estimate economic outcomes and to calculate the expected value of perfect information (EVPI) as a measure of the value of clinical trials for decision makers.

RESULTS

Nine RCTs were identified and included in our analysis. The estimated difference in the percentage of time in the therapeutic range was 5.6 percentage points in 2007, decreasing to 4.3 percentage points when all studies were included. At a reimbursement price of €160 per PG testing, the EVPI for the clinical benefit was estimated at €80 and €90 per patient in 2007 and 2014, respectively. A reduction in the price of PG testing to €40, which was observed in this period, resulted in an EVPI of €3 per patient.

CONCLUSIONS

The estimated cumulative effect of PG dosing has remained similar since 2007, but additional evidence has contributed to a more precise estimation. While these variations should not affect the reimbursement decision, a large decline in the cost of PG testing in recent years calls for reconsideration.

Medicaid Payment and Delivery System Reform: Early Insights from 10 Medicaid Expansion States

ISSUE

Expanded Medicaid enrollment under the Affordable Care Act has heightened the importance of states’ roles as principal purchasers of health care for low-income and medically vulnerable populations. Concurrently, the federal government has augmented states’ purchasing tools.

GOAL

To examine the evolution of payment and delivery system reform in 10 ACA Medicaid expansion states.

METHODS

Analysis of state managed care policies, including a detailed review of purchasing documents as well as interviews with senior agency officials in 10 states.

FINDINGS AND CONCLUSIONS

States have made health system reform a core element of their Medicaid expansions, with the aim of improving access, quality, efficiency, and population health. States have sought to incorporate evidence-based practice and payment strategies, with an emphasis on populations likely to benefit from improved care management and on better integration of treatment for physical and behavioral health problems. Seven of 10 are directly engaged in provider payment and delivery system reform. Agencies noted the importance of experienced provider networks in addressing complex health and social needs, along with managed care’s role in quality improvement and payment reform. States embrace their roles as payers and health care innovators, identifying stability of both coverage and the underlying federal policy environment as key factors.

Outcomes-Based Pharmaceutical Contracts: An Answer to High U.S. Drug Spending?

ISSUE

Brand-name prescription drug prices are increasing in the United States, putting pressure on payers and patients. Some manufacturers have responded by offering outcomes-based contracts, in which rebate levels are tied to a specified outcome in the target population.

GOAL

To assess the expected benefits and limitations of outcomes-based pharmaceutical contracts in the U.S., including their potential impact on prescription drug spending.

METHODS

Semistructured interviews with payers, manufacturers, and policy experts.

KEY FINDINGS

Pharmaceutical manufacturers and some private payers are increasingly interested in outcomes-based contracts for high-cost brand-name drugs. But the power of these contracts to curb spending is questionable, largely because their applicability is restricted to a small subset of drugs and meaningful metrics to evaluate their impact are limited. There is no evidence that these contracts have resulted in less spending or better quality.

CONCLUSIONS

Outcomes-based contracts are intended to shift pharmaceutical spending toward more effective drugs, but their impact is unclear. Voluntary testing and rigorous evaluation of such contracts in the Medicare and Medicaid programs could increase understanding of this new model.

Prediction of Change in Prescription Ingredient Costs and Co-payment Rates under a Reference Pricing System in South Korea

BACKGROUND

The reference pricing system (RPS) establishes reference prices within interchangeable reference groupings. For drugs priced higher than the reference point, patients pay the difference between the reference price and the total price.

OBJECTIVES

To predict potential changes in prescription ingredient costs and co-payment rates after implementation of an RPS in South Korea.

METHODS

Korean National Health Insurance claims data were used as a baseline to develop possible RPS models. Five components of a potential RPS policy were varied: reference groupings, reference pricing methods, co-pay reduction programs, manufacturer price reductions, and increased drug substitutions. The potential changes for prescription ingredient costs and co-payment rates were predicted for the various scenarios.

RESULTS

It was predicted that transferring the difference (total price minus reference price) from the insurer to patients would reduce ingredient costs from 1.4% to 22.8% for the third-party payer (government), but patient co-payment rates would increase from a baseline of 20.4% to 22.0% using chemical groupings and to 25.0% using therapeutic groupings. Savings rates in prescription ingredient costs (government and patient combined) were predicted to range from 1.6% to 13.7% depending on various scenarios. Although the co-payment rate would increase, a 15% price reduction by manufacturers coupled with a substitution rate of 30% would result in a decrease in the co-payment amount (change in absolute dollars vs. change in rates).

CONCLUSIONS

Our models predicted that the implementation of RPS in South Korea would lead to savings in ingredient costs for the third-party payer and co-payments for patients with potential scenarios.

The Role of Patient-Reported Outcome Measures in Value-Based Payment Reform

The U.S. health care system is currently experiencing profound change. Pressure to improve the quality of patient care and control costs have caused a rapid shift from traditional volume-driven fee-for-service reimbursement to value-based payment models. Under the 2015 Medicare Access and Children's Health Insurance Program Reauthorization Act, providers will be evaluated on the basis of quality and cost efficiency and ultimately receive adjusted reimbursement as per their performance. Although current performance metrics do not incorporate patient-reported outcome measures (PROMs), many wonder whether and how PROMs will eventually fit into value-based payment reform. On November 17, 2016, the second annual Patient-Reported Outcomes in Healthcare Conference brought together international stakeholders across all health care disciplines to discuss the potential role of PROs in value-based health care reform. The purpose of this article was to summarize the findings from this conference in the context of recent literature and guidelines to inform implementation of PROs in value-based payment models. Recommendations for evaluating key perspectives and measurement goals are made to facilitate appropriate use of PROMs to best benefit and amplify the voice of our patients.

The Shifting Landscape in Utilization of Inpatient, Observation, and Emergency Department Services Across Payers

Recent policies by public and private payers have increased incentives to reduce hospital admissions. Using data from four states from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, this study compared the payer-specific population-based rates of adults using inpatient, observation, and emergency department (ED) services for 10 common medical conditions in 2009 and in 2013. Patients had an expected primary payer of private insurance, Medicare, Medicaid, or no insurance. Across all four payer populations, inpatient admissions declined, and care shifted toward treat-and-release observation stays and ED visits. The percentage of hospitalizations that began with an observation stay increased. Implications for quality of care and costs to patients warrant further examination. Journal of Hospital Medicine 2017;12:443-446.

How Can Pricing and Reimbursement Policies Improve Affordable Access to Medicines? Lessons Learned from European Countries

This article discusses pharmaceutical pricing and reimbursement policies in European countries with regard to their ability to ensure affordable access to medicines. A frequently applied pricing policy is external price referencing. While it provides some benchmark for policy-makers and has been shown to be able to generate savings, it may also contribute to delay in product launch in countries where medicine prices are low. Value-based pricing has been proposed as a policy that promotes access while rewarding useful innovation; however, implementing it has proven quite challenging. For high-priced medicines, managed-entry agreements are increasingly used. These agreements allow policy-makers to manage uncertainty and obtain lower prices. They can also facilitate earlier market access in case of limited evidence about added therapeutic value of the medicine. However, these agreements raise transparency concerns due to the confidentiality clause. Tendering as used in the hospital and offpatent outpatient sectors has been proven to reduce medicine prices but it requires a robust framework and appropriate design with clear strategic goals in order to prevent shortages. These pricing and reimbursement policies are supplemented by the widespread use of Health Technology Assessment to inform decision-making, and by strategies to improve the uptake of generics, and also biosimilars. While European countries have been implementing a set of policy options, there is a lack of thorough impact assessments of several pricing and reimbursement policies on affordable access. Increased cooperation between authorities, experience sharing and improving transparency on price information, including the disclosure of confidential discounts, are opportunities to address current challenges.

Tracking rural hospital closures

(1) Over 50 percent of primary care health professional shortage areas (HPSAs) were in rural areas in November 2016, according to the Health Resources and Services Administration. (2) Rural areas face a higher uninsured rate than metropolitan areas. (3) Rural hospitals tend to have low patient volume, a high portion of patients on Medicare and Medicaid, and a high number of uninsured patients.

Gender Differences in Physician Service Provision Using Medicare Claims Data

OBJECTIVE

To determine differences in the provision of Medicare services based on physician gender in the United States.

PATIENTS AND METHODS

Participants included all 2013 Medicare fee-for-service physicians and their patients, a population that is predominantly older than 65 years. The 2013 Medicare Provider Utilization and Payment Data for services rendered between January 1, 2013, and December 31, 2013, were combined with the 2015 Physician Compare National Downloadable files and 2015 Berenson-Eggers Type of Service classification files. Total fee-for-service Medicare payments and Healthcare Common Procedure Coding System procedure codes for all fee-for-service beneficiaries were aggregated according to physician gender, specialty, years since medical school graduation, and type of service classifications.

RESULTS

Excluding drug reimbursement, the mean total Medicare payments per female physician, compared with those for male physicians, were 41% in surgical specialties, 72% in hospital-based specialties, and 55% across all specialties (P<.001). The mean overall number of unique beneficiary visits per female physician was 59% of that for male physicians (P<.001). By using the Berenson-Eggers Type of Service classification, procedures and other services by female physicians were of 54% lower overall average intensity (allowed payments/number of unique patients) compared with those of male physicians. These differences persisted irrespective of years since medical school graduation (P<.001).

CONCLUSION

Female physicians had smaller average total Medicare payments and fewer unique beneficiary visits than male physicians in the care of fee-for-service Medicare beneficiaries in 2013. The differences persisted across specialty types and years in practice. These data can identify variation but cannot determine causation or explain the reasons behind gender differences. These findings suggest, but do not prove, that female physician Medicare payments are lower due to different practice patterns, consisting of fewer patients cared for and lower intensity of care.

Potential impact of Affordable Care Act-related insurance expansion on trauma care reimbursement

BACKGROUND

Nearly one quarter of trauma patients are uninsured and hospitals recoup less than 20% of inpatient costs for their care. This study examines changes to hospital reimbursement for inpatient trauma care if the full coverage expansion provisions of the Affordable Care Act (ACA) were in effect.

METHODS

We abstracted nonelderly adults (ages 18-64 years) admitted for trauma from the Nationwide Inpatient Sample during 2010-the last year before most major ACA coverage expansion policies. We calculated national and facility-level reimbursements and trauma-related contribution margins using Nationwide Inpatient Sample-supplied cost-to-charge ratios and published reimbursement rates for each payer type. Using US census data, we developed a probabilistic microsimulation model to determine the proportion of pre-ACA uninsured trauma patients that would be expected to gain private insurance, Medicaid, or remain uninsured after full implementation of the ACA. We then estimated the impact of these coverage changes on national and facility-level trauma reimbursement for this population.

RESULTS

There were 145,849 patients (representing 737,852 patients nationwide) included. National inpatient trauma costs for patients aged 18 years to 64 years totaled US $14.8 billion (95% confidence interval [CI], 12.5,17.1). Preexpansion reimbursements totaled US $13.7 billion (95% CI, 10.8-14.7), yielding a national margin of -7.9% (95% CI, -10.6 to -5.1). Postexpansion projected reimbursements totaled US $15.0 billion (95% CI, 12.7-17.3), increasing the margin by 9.3 absolute percentage points to +1.4% (95% CI, -0.3 to +3.2). Of the 263 eligible facilities, 90 (34.2%) had a positive trauma-related contribution margin in 2010, which increased to 171 (65.0%) using postexpansion projections. Those facilities with the highest proportion of uninsured and racial/ethnic minorities experienced the greatest gains.

CONCLUSION

Health insurance coverage expansion for uninsured trauma patients has the potential to increase national reimbursement for inpatient trauma care by over one billion dollars and nearly double the proportion of hospitals with a positive margin for trauma care. These data suggest that insurance coverage expansion has the potential to improve trauma centers' financial viability and their ability to provide care for their communities.

LEVEL OF EVIDENCE

Economic analysis, level II.

Some Builders' Remorse: The Rise and Fall of the Oncology Medical Home

Insurers pay for extra services that oncologists deliver in the hope that the investment will save them money down the road. That's the idea, anyway. In practice, payers and providers in general see the concept as another example of how vexing payment reform for cancer care is turning out to be.

The Unsustainable Cost of Medicaid: Insights from a Hospital-Based Academic Dermatology Practice

OBJECTIVE

To investigate the lost revenue associated with Medicaid patients in a university-based dermatology practice over a one-year period compared to non-Medicaid patients. Specifically, the goal was to investigate the change in revenue if Medicaid visits were associated with a range of copayments.

RESULTS

The total billed across all encounters for the 2014 -2015 fiscal year was $31017159, of which $3715393 (13.61%) was for Medicaid. 'he total revenue for all encounters was $12267832, of which $420230 (3.55%) was for Medicaid. After adding potential copayments, the reduced financial impact that such fees would have had on our practice for the past fiscal year ranged from $745.85 at $0.05/visit to $149170 at $10/visit.

CONCLUSION

Adding a small copaymentforMedicaid patients would decrease lost revenue. The degree of financial impact would vary based on the size of the copayment. Broad adoption of such a plan could significantly help hospitals reduce lost revenue.

Complications After Cosmetic Surgery Tourism

Background

Cosmetic surgery tourism characterizes a phenomenon of people traveling abroad for aesthetic surgery treatment. Problems arise when patients return with complications or need of follow-up care.

Objectives

To investigate the complications of cosmetic surgery tourism treated at our hospital as well as to analyze arising costs for the health system.

Methods

Between 2010 and 2014, we retrospectively included all patients presenting with complications arising from cosmetic surgery abroad. We reviewed medical records for patients' characteristics including performed operations, complications, and treatment. Associated cost expenditure and Diagnose Related Groups (DRG)-related reimbursement were analyzed.

Results

In total 109 patients were identified. All patients were female with a mean age of 38.5 ± 11.3 years. Most procedures were performed in South America (43%) and Southeast (29.4%) or central Europe (24.8%), respectively. Favored procedures were breast augmentation (39.4%), abdominoplasty (11%), and breast reduction (7.3%). Median time between the initial procedure abroad and presentation was 15 days (interquartile range [IQR], 9) for early, 81.5 days (IQR, 69.5) for midterm, and 4.9 years (IQR, 9.4) for late complications. Main complications were infections (25.7%), wound breakdown (19.3%), and pain/discomfort (14.7%). The majority of patients (63.3%) were treated conservatively; 34.8% became inpatients with a mean hospital stay of 5.2 ± 3.8 days. Overall DRG-related reimbursement premiums approximately covered the total costs.

Conclusions

Despite warnings regarding associated risks, cosmetic surgery tourism has become increasingly popular. Efficient patients' referral to secondary/tertiary care centers with standardized evaluation and treatment can limit arising costs without imposing a too large burden on the social healthcare system.

Level of Evidence

4.

Issue at the Heart of Advancing the De-Adoption of Low-Value Care. Proceedings from an expert roundtable

Identifying and paying for value has become a recurrent theme of health care reforms. Its corollary, reducing the prevalence of, and resources directed to, ineffective or marginally effective care, has received far less attention. In July 2016, the University of Pennsylvania’s Leonard Davis Institute of Health Economics (LDI) convened a diverse set of national leaders and stakeholders representing industry, think-tanks, provider and patient groups, and academic experts to tackle how health systems, payers, and providers can spur the ‘de-adoption’ of medical practices and technologies no longer considered valuable. While the roundtable of experts unanimously supports the need for de-adoption and current efforts to curb the use of low-value practices or technologies, they identified four specific polarities at the heart of the debate about how best to build the momentum around deadoption, and move it forward. They are: 1) value (targeting ineffective, even harmful, care or expanding efforts to address care of limited value); 2) resource allocation (spending less or redirecting spending); 3) quality improvement (a subset of QI or a distinct process); 4) level of intervention (policy, payment, provider, or organization). In addition to these polarities, several key questions emerged that form practical next steps for advancing de-adoption activities. With an eye toward advancing de-adoption, this brief summarizes the polarities and questions that suggest priorities for a future research agenda and policy-relevant action steps.

Health Care's Other "Big Deal": Direct Primary Care Regulation in Contemporary American Health Law

Direct primary care is a promising, market-based alternative to the fee-for-service payment structure that shapes doctor–patient relationships in America. Instead of billing patients and insurers service by service, direct primary care doctors charge their patients a periodic, prenegotiated fee in exchange for providing a wide range of healthcare services and increased availability compared to traditional practices. This “subscription” model is intended to eliminate the administrative burdens associated with insurer interaction, which, in theory, allows doctors to spend more time with their patients and less time doing paperwork. Direct practices have become increasingly popular since Congress passed the Affordable Care Act (ACA). This growth has been driven by legislation in several states that resolves a number of legal questions that slowed the model’s growth and by the ACA’s recognition of the model as a permissible way to cover primary care in "approved" health plans. Yet legal scholars have hardly focused on direct primary care. Given the model’s growth, however, the time is ripe for a more focused legal inquiry. This Note begins that inquiry. After tracing the model’s evolution and its core components, this Note substantively examines the laws in states that regulate direct practices and analyzes how those laws address a number of potential policy concerns. It then analyzes direct primary care’s broader role in the contemporary American healthcare marketplace. Based upon that analysis, this Note concludes that direct primary care is a beneficial innovation that harmonizes well with a cooperative-federalism-based healthcare policy model.

How Will Repealing the ACA Affect Medicaid? Impact on Health Care Coverage, Delivery, and Payment

ISSUE: The Affordable Care Act enhanced Medicaid's role as a health care purchaser by expanding eligibility and broadening the range of tools and strategies available to states. All states have embraced delivery and payment reform as basic elements of their programs. GOAL: To examine the effects of reducing the size and scope of Medicaid under legislation to repeal the ACA. FINDINGS AND CONCLUSIONS: Were the ACA's Medicaid expansion to be eliminated and were federal Medicaid funding to experience major reductions through block grants or per capita caps, the effects on system transformation would be significant. Over 70 percent of Medicaid spending is driven by enrollment in a program that covers 74 million people; on a per capita basis Medicaid costs less than Medicare or commercial insurance. States would need to absorb major financial losses by reducing the number of people served, reducing the scope of services covered, introducing higher cost-sharing, or further reducing already low payments. Far from improving quality and efficiency, these changes would cause the number of uninsured to rise while depriving health care providers and health plans of the resources needed to care for patients and invest in the tools that are essential to system transformation

Detecting Potential Overbilling in Medicare Reimbursement via Hours Worked

We propose a novel and easy-to-implement approach to detect potential overbilling based on the hours worked implied by the service codes which physicians submit to Medicare. Using the Medicare Part B Fee- for-Service (FFS) Physician Utilization and Payment Data in 2012 and 2013 released by the Centers for Medicare and Medicaid Services, we construct estimates for physicians' hours spent on Medicare beneficiaries. We find that about 2,300 physicians, representing about 3 percent of those with 20 or more hours of Medicare Part B FFS services, have billed Medicare over 100 hours per week. We consider these implausibly long hours.

Medicaid Program; The Use of New or Increased Pass-Through Payments in Medicaid Managed Care Delivery Systems. Final rule

This rule finalizes changes to the pass-through payment transition periods and the maximum amount of pass-through payments permitted annually during the transition periods under Medicaid managed care contract(s) and rate certification(s). This final rule prevents increases in pass-through payments and the addition of new pass-through payments beyond those in place when the pass-through payment transition periods were established, in the final Medicaid managed care regulations effective July 5, 2016.

Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR). Final rule

This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-forservice beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.

The Challenge of Conditional Reimbursement: Stopping Reimbursement Can Be More Difficult Than Not Starting in the First Place!

BACKGROUND

Conditional reimbursement of new health technologies is increasingly considered as a useful policy instrument. It allows gathering more robust evidence regarding effectiveness and cost-effectiveness of new technologies without delaying market access. Nevertheless, the literature suggests that ending reimbursement and provision of a technology when it proves not to be effective or cost-effective in practice may be difficult.

OBJECTIVES

To investigate how policymakers and the general public in the Netherlands value removing a previously reimbursed treatment from the basic benefits package relative to not including a new treatment.

METHODS

To investigate this issue, we used discrete-choice experiments. Mixed multinomial logit models were used to analyze the data. Compensating variation values and changes in probability of acceptance were calculated for withdrawal of reimbursement.

RESULTS

The results show that, ceteris paribus, both the general public (n = 1169) and policymakers (n = 90) prefer a treatment that is presently reimbursed over one that is presently not yet reimbursed.

CONCLUSIONS

Apparently, ending reimbursement is more difficult than not starting reimbursement in the first place, both for policymakers and for the public. Loss aversion is one of the possible explanations for this result. Policymakers in health care need to be aware of this effect before engaging in conditional reimbursement schemes.

Financing of Vaccine Delivery in Primary Care Practices

OBJECTIVE

Vaccines represent a significant portion of primary care practice expenses. Our objectives were to determine among pediatric (Ped) and family medicine (FM) practices: 1) relative payment for vaccine purchase and administration and estimated profit margin according to payer type, 2) strategies used to reduce vaccine purchase costs and increase payment, and 3) whether practices have stopped providing vaccines because of finances.

METHODS

A national survey conducted from April through September 2011 among Ped and FM practitioners in private, single-specialty practices.

RESULTS

The response rate was 51% (221 of 430). Depending on payer type, 61% to 79% of practices reported that payment for vaccine purchase was at least 100% of purchase price and 34% to 74% reported that payment for vaccine administration was at least $11. Reported strategies to reduce vaccine purchase cost were online purchasing (81% Ped, 36% FM), prompt pay (78% Ped, 49% FM), and bulk order (65% Ped, 49% FM) discounts. Fewer than half of practices used strategies to increase payment; in a multivariable analysis, practices with ≥5 providers were more likely to use strategies compared with practices with fewer providers (adjusted odds ratio, 2.65; 95% confidence interval, 1.51-4.62). When asked if they had stopped purchasing vaccines because of financial concerns, 12% of Ped practices and 23% of FM practices responded 'yes,' and 24% of Ped and 26% of FM practices responded 'no, but have seriously considered.'

CONCLUSIONS

Practices report variable payment for vaccination services from different payer types. Practices might benefit from increased use of strategies to reduce vaccine purchase costs and increase payment for vaccine delivery.

Does Physician Reimbursement Correlate to Risk in Orthopaedic Trauma?

This study investigated whether current Medicare reimbursements for orthopaedic trauma procedures correlate with complications. A total of 18,510 patients representing 33 orthopaedic trauma procedures from 2005 to 2011 were studied. Adverse events and Medicare payments for each orthopaedic trauma procedure were collected. Linear regressions determined correlations between complications and Medicare payments for orthopaedic trauma procedures. A weak correlation between Medicare payments and complications was found for all procedures (r = .399, p = .021). A 1.0% increase in complications was associated with a payment increase of only $100. There were no correlations between complications and reimbursements for upper extremity (p = .878) and lower extremity (p = .713) procedures. A strong correlation (r = .808, p = .015) existed for hip and pelvic fractures, but a 1.1% increase in hip and pelvic complications correlated with only an increase of $100 in reimbursements. This study is the first to show that Medicare payments are not strongly correlated with complications, therefore demonstrating the potential risks of a bundled payment system for orthopaedic trauma surgeons.

Hyperbaric medicine today: an historically noble discipline challenged by loss of critical access and overutilization - invited commentary

As the title implies, much appears amiss with hyperbaric medicine. Long recognized for its life-saving, CNS-sparing,infection-fighting and tissue-salving attributes, its current application has been rightly called into question by a broad cross-section of health care delivery system stakeholders [1, 2, 3, 4, 5]. This paper will examine what lies behind the stunning loss of availability for a majority of the Federal Drug Administration-approved uses, arguably those for which patients have the most to gain. It will address overutilization in the context of an erosion of practice standards and widespread manipulation of the reimbursement process. It will make suggestions aimed at restoring its broader availability across the full extent of FDA-approved uses. Finally, it offers guidance to ensure that HBO₂ therapy is employed only when medically necessary by adoption of the drug administration "rights" principle, namely the right indication for the right patient at the right time and only for the right amount of time.

Five Trends in Healthcare that Will Change the Way Managers Manage

The pace of change in the field of medical practice management is unprecedented. Five major trends are affecting the business of healthcare: quality as a criterion for reimbursement; regulatory controls on fees and services; consumer influence on healthcare payments; full disclosure of claims data (i.e., transpar- ency); and increases in active patient load per physician. Successful practice administrators must remain well-informed about these trends in order to guide their practices toward modifications that will allow them to continue to flourish. The changes have been driven by economics, government regulations, and shifts in the country's population. In particular, the aging of the baby boomer generation has opened the eyes of the nation to the potential for costs of healthcare that are unsupportable within the current system: Independent physician practices can still be financially viable if the leadership team becomes nimble in adopting necessary operational changes that support opportunities for revenue optimization.

State Medicaid and private payer reimbursement for telemedicine: An overview

Individual states in the USA were given the option of paying for telemedicine services with Medicaid (i.e. federal health-care funds administered by the state) in 1998, when the Health Care Financing Administration (HCFA) published final rules for Medicare payment for teleconsultations in health professional shortage areas (HPSAs). It was left to telemedicine practitioners in each state to negotiate the scope of the services covered with the state Medicaid office. Three reports of data gathered by 2002–03 surveys on state reimbursement policies have been reviewed, with additional information from a brief informal 2005 survey conducted by the author. In the seven years since 1998, 34 states have added coverage of telemedicine services to their Medicaid programmes, although there are wide variations in service coverage, payment policies, and geographical and other restrictions. There is less published information on private payer reimbursement. One survey performed by AMD Telemedicine (AMD) and the American Telemedicine Association (ATA) showed that over half of the 72 telemedicine programmes in 25 states delivering billable services were being reimbursed by private payers. In 1999, 43% of responding telemedicine networks saw reimbursement as a barrier to long-term sustainability, while in 2004 only 22% did so. It appears that some progress has been made in Medicaid and private payer reimbursement for telemedicine.

Arbitration Board Setting Reimbursement Amounts for Pharmaceutical Innovations in Germany When Price Negations between Payers and Manufacturers Fail: An Empirical Analysis of 5 Years' Experience

BACKGROUND

In Germany, an arbitration board is setting reimbursement amounts for drug innovations when price negations between payers and manufacturers fail.

OBJECTIVE

To empirically analyze all arbitrations since the reform of Germany's Act to Reorganize the Pharmaceuticals' Market in the Statutory Health Insurance System came into effect.

METHODS

All available relevant documents up to January 2016 were screened and the identified contentious issues between the negotiation parties extracted. Reimbursement requests of both the negotiating parties and the arbitrations were transformed into a comparable format on the basis of defined daily doses and then contrasted among each other.

RESULTS

In the given period, 16 arbitrations took place. The arbitration board is implementing the same criteria used in the negotiations between manufacturers and payers. Almost all arbitrations dealt with generic appropriate comparative therapies. Reimbursement amounts set by arbitration were on average 38.4% less than the mean of negotiation parties' requests (69.2% less than the manufacturers' requests). The corresponding prescription volumes were arranged rather centrally. All but one arbitration refer to a 1-year contract period. The arbitration board rarely decided on further technical contentious points. Hence, no heuristics referring to them were derivable.

CONCLUSIONS

There is some evidence for a quasi-algorithmic approach of the arbitration board, even though it is legally determined that it has to decide while taking the peculiar conditions of each case into due consideration, including the characteristics of the respective therapeutic area. The balance of interests proved to be within a very narrow space albeit it concerns in principle discretionary decisions. Thus, the purpose of arbitration seems not to be achieved sufficiently.

Reimbursement as a Legitimizing Strategy for Health Education

The health education profession has made significant advances throughout the past few decades. However, health education is still described as an emerging profession. This article suggests strategies to move health education from its status as an emerging profession into that of an acknowledged profession. The authors assert that actively seeking direct third-party reimbursement will advance health education's emergence as a profession as well as increase its legitimacy in the eyes of other professions. The benefits of direct third-party reimbursement, experiences of the nursing profession's pursuit of direct third-party reimbursement, and the current status of health education are discussed. The article concludes by offering strategies for pursuing direct third-party reimbursement.