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Ishida R, Koga K, Ohbe H, Izumi G, Matsui H, Yasunaga H, Osuga Y. Impact of government-issued financial incentive to medical facilities on management of secondary dysmenorrhea. J Obstet Gynaecol Res 2024. [PMID: 38597093 DOI: 10.1111/jog.15946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/31/2024] [Indexed: 04/11/2024]
Abstract
AIM In April 2020, the Japanese government introduced a Specific Medical Fee for managing secondary dysmenorrhea (SD). This initiative provided financial incentives to medical facilities that provide appropriate management of SD with hormonal therapies. We aimed to assess how this policy affects the management processes and outcomes of patients with SD. METHODS Using a large Japanese administrative claims database, we identified outpatient visits of patients diagnosed with SD from April 2018 to March 2022. We used an interrupted time-series analysis and defined before April 2020 as the pre-introduction period and after April 2020 as the post-introduction period. Outcomes were the monthly proportions of outpatient visits due to SD and hormonal therapy among women in the database and the proportions of outpatient visits for hormonal therapy and continuous outpatient visits among patients with SD. RESULTS We identified 815 477 outpatient visits of patients diagnosed with SD during the pre-introduction period and 920 183 outpatient visits during the post-introduction period. There were significant upward slope changes after the introduction of financial incentives in the outpatient visits due to SD (+0.29% yearly; 95% confidence interval, +0.20% to +0.38%) and hormonal therapies (+0.038% yearly; 95% confidence interval, +0.030% to +0.045%) among the women in the database. Similarly, a significant level change was observed after the introduction of continuous outpatient visits among patients with SD (+2.68% monthly; 95% confidence interval, +0.87% to +4.49%). CONCLUSIONS Government-issued financial incentives were associated with an increase in the number of patients diagnosed with SD, hormonal therapies, and continuous outpatient visits.
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Affiliation(s)
- Risa Ishida
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kaori Koga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Reproductive Medicine, Chiba University, Chiba, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Gentaro Izumi
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Farmer C, Barnish MS, Trigg LA, Hayward S, Shaw N, Crathorne L, Strong T, Groves B, Spoors J, Melendez Torres GJ. An evaluation of managed access agreements in England based on stakeholder experience. Int J Technol Assess Health Care 2023; 39:e55. [PMID: 37497570 DOI: 10.1017/s0266462323000478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVES The objective of this research was to evaluate managed access policy in England, drawing upon the expertise of a range of stakeholders involved in its implementation. METHODS Seven focus groups were conducted with payer and health technology assessment representatives, clinicians, and representatives from industry and patient/carer organizations within England. Transcripts were analyzed using framework analysis to identify stakeholders' views on the successes and challenges of managed access policy. RESULTS Stakeholders discussed the many aims of managed access within the National Health Service in England, and how competing aims had affected decision making. While stakeholders highlighted a number of priorities within eligibility criteria for managed access agreements (MAAs), stakeholders agreed that strict eligibility criteria would be challenging to implement due to the highly variable nature of innovative technologies and their indications. Participants highlighted challenges faced with implementing MAAs, including evidence generation, supporting patients during and after the end of MAAs, and agreeing and reinforcing contractual agreements with industry. CONCLUSIONS Managed access is one strategy that can be used by payers to resolve uncertainty for innovative technologies that present challenges for reimbursement and can also deliver earlier access to promising technologies for patients. However, participants cautioned that managed access is not a "silver bullet," and there is a need for greater clarity about the aims of managed access and how these should be prioritized in decision making. Discussions between key stakeholders involved in managed access identified challenges with implementing MAAs and these experiences should be used to inform future managed access policy.
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Affiliation(s)
- Caroline Farmer
- Peninsula Technology Assessment Group (PenTAG), Department of Public Health and Sport Sciences, University of Exeter Medical School, Exeter, UK
| | - Maxwell S Barnish
- Peninsula Technology Assessment Group (PenTAG), Department of Public Health and Sport Sciences, University of Exeter Medical School, Exeter, UK
| | - Laura A Trigg
- Peninsula Technology Assessment Group (PenTAG), Department of Public Health and Sport Sciences, University of Exeter Medical School, Exeter, UK
| | - Samuel Hayward
- Health and Care Public Health Team, North Somerset Council
| | - Naomi Shaw
- Peninsula Technology Assessment Group (PenTAG), Department of Public Health and Sport Sciences, University of Exeter Medical School, Exeter, UK
| | - Louise Crathorne
- Peninsula Technology Assessment Group (PenTAG), Department of Public Health and Sport Sciences, University of Exeter Medical School, Exeter, UK
| | - Thomas Strong
- Managed Access Team, National Institute for Health and Care Excellence (NICE), London, UK
| | - Brad Groves
- Managed Access Team, National Institute for Health and Care Excellence (NICE), London, UK
| | - John Spoors
- Medicines Value and Access Unit, NHS England, London, UK
| | - G J Melendez Torres
- Peninsula Technology Assessment Group (PenTAG), Department of Public Health and Sport Sciences, University of Exeter Medical School, Exeter, UK
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3
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Keedy C, Bland CM, Woodhouse A. Expansion of services within primary care clinics due to quality initiatives and revenue generation. Am J Health Syst Pharm 2023:7158840. [PMID: 37161760 DOI: 10.1093/ajhp/zxad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Indexed: 05/11/2023] Open
Abstract
In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.
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Affiliation(s)
- Chelsea Keedy
- University of Georgia College of Pharmacy, Savannah, GA, USA
| | - Christopher M Bland
- University of Georgia College of Pharmacy, Savannah, GA, USA
- St. Joseph's/Candler Health System, Savannah, GA, USA
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4
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Rand LZ, Kesselheim AS. Performance-Linked Reimbursement and the Uncertainty of Novel Drugs. Circ Cardiovasc Qual Outcomes 2022; 15:e008642. [PMID: 35041479 DOI: 10.1161/circoutcomes.121.008642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Leah Z Rand
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, and the Harvard Medical School Center for Bioethics, Boston, MA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, and the Harvard Medical School Center for Bioethics, Boston, MA
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5
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Anderson KE, Polsky D, Dy S, Sen AP. Prescribing of low- versus high-cost Part B drugs in Medicare Advantage and traditional Medicare. Health Serv Res 2021; 57:537-547. [PMID: 34806171 DOI: 10.1111/1475-6773.13912] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/18/2021] [Accepted: 11/03/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Examine whether Medicare Advantage (MA) coverage is associated with more efficient prescribing of Part B drugs than traditional Medicare (TM) coverage. DATA SOURCES Twenty percent sample of 2016 outpatient and carrier TM claims and MA encounter records and Master Beneficiary Summary File data. STUDY DESIGN We analyzed whether MA enrollees compared to TM enrollees more often received the low-cost Part B drug in four clinical scenarios where multiple similarly effective drugs exist: (1) anti-VEGF agents to treat macular degeneration, (2) bone resorption inhibitors for osteoporosis, (3) bone resorption inhibitors for malignant neoplasms, and (4) intravenous iron for iron deficiency anemia. We then estimated differences in spending if TM prescribing aligned with MA prescribing. Finally, using linear probability models, we examined whether differences in MA and TM prescribing patterns were attributable to differences in the hospitals and clinician practices who treat MA and TM enrollees or differences in how these hospitals and clinician practices treat their MA versus TM patients. DATA COLLECTION/EXTRACTION METHODS Not applicable. PRINCIPAL FINDINGS In all cases, a larger share of MA enrollees received the low-cost drug compared to TM enrollees, ranging from 8 percentage points higher for anemia to 16 percentage points higher for macular degeneration in the unadjusted analysis. Results were similar in regression analyses controlling for enrollee characteristics and market factors (5-13 percentage points). If TM prescribing matched MA prescribing, we estimated savings ranging from 6% to 20% of TM spending for each scenario. Differences in prescribing patterns were driven both by MA enrollees receiving treatment at more efficient hospitals and clinician practices and hospitals and clinician practices more often prescribing low-cost drugs to their MA patients. CONCLUSIONS Our findings show MA enrollees were more likely than TM enrollees to receive low-cost Part B drugs in four clinical scenarios where multiple similarly or equally effective treatment options exist.
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Affiliation(s)
- Kelly E Anderson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Daniel Polsky
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins Carey Business School, Hopkins Business of Health Initiative, Baltimore, Maryland, USA
| | - Sydney Dy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins School of Medicine, Division of General Internal Medicine, Baltimore, Maryland, USA
| | - Aditi P Sen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Hawes EM, Misita CP, Amerine LB, Francart SJ. A proactive medical necessity review program reduces revenue loss associated with outpatient medical benefit drugs. Am J Health Syst Pharm 2021; 78:1591-1599. [PMID: 33599737 PMCID: PMC7929436 DOI: 10.1093/ajhp/zxab046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE A common denial trend that occurs with "outpatient medical benefit drugs" (ie, medications covered by a medical benefit plan and administered in an outpatient visit) is payers not requiring or permitting prior authorization (PA) proactively, yet denying the drug after administration for medical necessity. In this situation, a preemptive strategy of complying with payer-mandated requirements is critical for revenue protection. To address this need, our institution incorporated a medical necessity review into its existing closed-loop, pharmacy-managed precertification and denials management program. SUMMARY Referrals for targeted payers and high-cost medical benefit drugs not eligible for PA and deemed high risk for denial were incorporated into the review. Payer medical policies were evaluated and clinical documentation assessed to confirm alignment. This descriptive report outlines the medical necessity workflow as a component of the larger precertification process, details the decision-making process when performing the review, and delineates the roles and responsibilities for involved team members. A total of 526 drug orders were evaluated from September 2018 to August 2019, with 146 interventions completed. Of the 761 individual claims affected by proactive medical necessity review, 99.2% resulted in payment and less than 1% resulted in revenue loss, safeguarding more than $5.3 million in annual institutional drug reimbursement. At the time of analysis, there were only 3 cases of revenue loss. CONCLUSION Our institution's pharmacy-managed medical necessity review program for high-cost outpatient drugs safeguards reimbursement for therapies not eligible for payer PA. It is a revenue cycle best practice that can be replicated at other institutions.
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Affiliation(s)
- Emily M Hawes
- University of North Carolina (UNC) School of Medicine, Department of Family Medicine, and UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Caron P Misita
- Medication Assistance Program (Medical Benefit), UNC Health, Durham, NC, USA
| | - Lindsey B Amerine
- UNC Health and UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
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7
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Abstract
Kidney care in the United States is highly regulated, reflecting the dominance of Medicare as the primary payer for dialysis since inclusion of the end-stage renal disease (ESRD) benefit into payment policy in 1973. In the ensuing decades, bundled payments have been introduced for dialysis and quality programs have been adopted for both ESRD and nondialysis chronic kidney disease care. In this installment of the Core Curriculum in Nephrology, we review the key laws and regulations affecting kidney care in the United States, the Medicare ESRD program, quality assessment and pay-for-performance programs including the ESRD Quality Incentive Program, incentives and disincentives for specific kidney failure care modalities, and recent landmark initiatives to promote more coordinated kidney care across the spectrum of kidney disease. Additional discussion covers policies guiding the care of undocumented immigrants and provision of hospice and palliative care to people with kidney failure. Last, we discuss how the kidney community can activate to advocate effectively to promote better kidney care in the United States.
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Affiliation(s)
- Mallika L Mendu
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston MA
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Tufts University School of Medicine, Boston MA.
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8
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Kusaoi M, Murayama G, Tamura N, Yamaji K. Reimbursement for therapeutic apheresis devices and procedures for using the healthcare insurance system in Japan. Ther Apher Dial 2020; 24:530-547. [PMID: 32567164 PMCID: PMC7540553 DOI: 10.1111/1744-9987.13550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/16/2020] [Accepted: 06/19/2020] [Indexed: 11/29/2022]
Abstract
The aim of this paper was to explain the insurance coverage status of therapeutic apheresis (excluding CHDF) in Japan, alongside the social system of medical reimbursement and concerns regarding the future sustainability of the healthcare system. Insurance schemes and premiums differed for individuals at different levels in the society (eg, municipal residents, employees, and public servants). Insurance premiums and their rates varied depending on the total household income, the number of people living together, age, and the place of residence. In addition, the medical expense subsidies for children through public expenditure were also described. Japan's generous insurance system and multiple medical expense subsidies provide financial support for patients. With Japan's history of medical expense subsidies based on the policy of supporting intractable diseases, we have established an environment where all citizens can receive therapeutic apheresis when needed if they are affected by a disease for which insurance coverage is indicated.
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Affiliation(s)
- Makio Kusaoi
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Go Murayama
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ken Yamaji
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
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9
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McClellan MB, Bleser WK, Joynt Maddox KE. Advancing Value-Based Cardiovascular Care: The American Heart Association Value in Healthcare Initiative. Circ Cardiovasc Qual Outcomes 2020; 13:e006610. [PMID: 32393127 DOI: 10.1161/circoutcomes.120.006610] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mark B McClellan
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (M.B.M., W.K.B.)
| | - William K Bleser
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (M.B.M., W.K.B.)
| | - Karen E Joynt Maddox
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO (K.J.M.).,Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO (K.J.M.)
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10
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Bowers BL, Rowe JM, Fox LM, VanDeWege C, Billings S. A novel synchronized visit model as financial justification for clinic-embedded pharmacists. Am J Health Syst Pharm 2019; 76:2080-2086. [PMID: 31789350 DOI: 10.1093/ajhp/zxz244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Brandi L Bowers
- School of Pharmacy, University of Missouri-Kansas City, Springfield, MO
| | - Jordan M Rowe
- School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO
| | - Lauren M Fox
- Department of Pharmacy, University of Kansas Health System, Kansas City, KS
| | | | - Sarah Billings
- School of Pharmacy, University of Missouri-Kansas City, Springfield, MO
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11
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Parmar A, Jiao T, Saluja R, Chan KKW. Value-based pricing: Toward achieving a balance between individual and population gains in health benefits. Cancer Med 2019; 9:94-103. [PMID: 31711274 PMCID: PMC6943176 DOI: 10.1002/cam4.2694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Value-based pricing of oncology drugs provides a best estimate for the price of a drug, as it relates to the benefits it provides for individual patients. To date, the impact of value-based pricing to reference cost-effectiveness thresholds (λ) on individual and population-level health benefits remains uncharacterized. The current study examined the potential benefits of value-based pricing by quantifying the incremental net health benefit (INHB) of publicly funded oncology drugs, if funding occurred at manufacturer-submitted price without value-based pricing. METHODS Pan-Canadian Oncology Drug Review (pCODR) submissions were reviewed to identify eligible drug indications from which final economic guidance panel reports were reviewed for incremental costs (ΔC) and quality-adjusted life-years (ΔQALY) from manufacturer-submitted, pCODR lower-limit (pCODR-LL) and upper-limit (pCODR-UL) re-analyzed estimates. Annual number of cases in Ontario for each drug indication was obtained from population databases. Annual QALY gain per drug indication was determined by (ΔQALY × cases). Population QALY gain/loss in the absence of value-based pricing to reference λ was estimated by the INHB: (INHB = [ΔQALY - (ΔC/λ)] × cases). RESULTS In total, 34 drug indications (4629 cases) were identified. Annual gain in QALYs for the funded drug indications using manufacturer, pCODR-LL, and pCODR-UL estimates was 1851, 1617, and 1301, respectively. At a λ $100 000/QALY, funding in the absence of value-based pricing resulted in loss of 2311, 2519, and 2604 QALYs. This would result in a provincial net annual loss of 460, 902, and 1303 QALYs. CONCLUSIONS Despite an annual gain in QALY per funded drug indication, a net loss in QALY for the province, in the absence of value-based pricing, was demonstrated. Supportive evidence exists for value-based pricing toward the promotion of health benefits for the greater population.
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Affiliation(s)
- Ambica Parmar
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Tina Jiao
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Ronak Saluja
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Kelvin K W Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada
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12
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Arvidsson E, Dijkstra R, Klemenc-Ketiš Z. Measuring Quality in Primary Healthcare - Opportunities and Weaknesses. Zdr Varst 2019; 58:101-3. [PMID: 31275436 DOI: 10.2478/sjph-2019-0013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 05/22/2019] [Indexed: 11/27/2022] Open
Abstract
The easy access to data from electronic patient records has made using this type of data in pay-for-performance systems increasingly common. General practitioners (GPs) throughout Europe oppose this for several reasons. Not all data can be used to derive good quality indicators and quality indicators can’t reflect the broad scope of primary care. Qualities like person-centred care and continuity are particularly difficult to measure. The indicators urge doctors and nurses to spend too much time on the registration and administration of required data. However, quality indicators can be very useful as starting points for discussions about quality in primary care, with the purpose being to initiate, stimulate and support local improvement work. This led to The European Society for Quality and Patient Safety in General Practice (EQuiP) feeling the urge to clarify the different aspects of quality indicators by updating their statement on measuring quality in Primary Care. The statement has been endorsed by the Wonca Europe Council in 2018.
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13
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Lavergne MR, Hedden L, Law MR, McGrail K, Ahuja M, Barer M. The impact of the 2008/2009 financial crisis on specialist physician activity in Canada. Health Econ 2018; 27:1859-1867. [PMID: 29920841 DOI: 10.1002/hec.3786] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 03/13/2018] [Accepted: 05/17/2018] [Indexed: 06/08/2023]
Abstract
Fee-for-service physicians are responsible for planning for their retirements, and there is no mandated retirement age. Changes in financial markets may influence how long they remain in practice and how much they choose to work. The 2008 crisis provides a natural experiment to analyze elasticity in physician service supply in response to dramatic financial market changes. We examined quarterly fee-for-service data for specialist physicians over the period from 1999/2000 to 2013/2014 in Canada. We used segmented regression to estimate changes in the number of physicians receiving payments, per-physician service counts, and per-physician payments following the 2008 financial crisis and explored whether patterns differed by physician age. The number of specialist physicians increased more rapidly in the period since 2008 than in earlier years, but increases were largest within the youngest age group, and we observed no evidence of delayed retirement among older physicians. Where changes in service volume and payments were observed, they occurred across all ages and not immediately following the 2008 financial crisis. We conclude that any response to the financial crisis was small compared with demographic shifts in the physician population and changes in payments per service over the same time period.
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Affiliation(s)
- M Ruth Lavergne
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Lindsay Hedden
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kim McGrail
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Megan Ahuja
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Morris Barer
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
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14
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Hogan TH, Lemak CH, Ivankova N, Hearld LR, Wheeler J, Menachemi N. Hospital Vertical Integration Into Subacute Care as a Strategic Response to Value-Based Payment Incentives, Market Factors, and Organizational Factors: A Multiple-Case Study. Inquiry 2018; 55:46958018781364. [PMID: 29998776 PMCID: PMC6047235 DOI: 10.1177/0046958018781364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study explores the extent to which payment reform and other factors have motivated hospitals to adopt a vertical integration strategy. Using a multiple-case study research design, we completed case studies of 3 US health systems to provide an in-depth perspective into hospital adoption of subacute care vertical integration strategies across multiple types of hospitals and in different health care markets. Three major themes associated with hospital adoption of vertical integration strategies were identified: value-based payment incentives, market factors, and organizational factors. We found evidence that variation in hospital adoption of vertical integration into subacute care strategies occurs in the United States and gained a perspective on the intricacies of how and why hospitals adopt a vertical integration into subacute care strategy.
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15
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Tesar T, Szilberhorn L, Nemeth B, Nagy B, Wawruch M, Kalo Z. Cost-Utility Analysis of Heberprot-P as an Add-on Therapy to Good Wound Care for Patients in Slovakia with Advanced Diabetic Foot Ulcer. Front Pharmacol 2018; 8:946. [PMID: 29311943 PMCID: PMC5743698 DOI: 10.3389/fphar.2017.00946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/13/2017] [Indexed: 11/25/2022] Open
Abstract
Objectives: To explore whether Heberprot-P (an epidermal growth factor) is a cost-effective option for the treatment of advanced diabetic foot ulcer as an add-on therapy to good wound care (GWC) in Slovakia from the perspective of health care payers. Methods: A Markov model was constructed to compare the costs and effects of Heberprot-P plus GWC to those of GWC alone from the perspective of health care payers. The 52-week clinical trial period was extended to 5- and 10-year time horizons. Transition probabilities were calculated based on a previous clinical trial of Heberprot, utility values were derived from the scientific literature, and cost vectors were collected from the General Health Insurance Fund database in Slovakia. A one-way deterministic sensitivity analysis was employed to explore the influence of uncertainty for each input parameter on the incremental cost-effectiveness ratio (ICER). Results: Based on the ICER threshold of €30,030 per quality-adjusted life year (QALY) recommended by the Slovak Ministry of Health, Heberprot-P therapy plus GWC is not a cost-effective alternative to GWC alone over a 10-year time horizon. The ICER increases if a longer time horizon is applied, as the incremental costs are similar, but the aggregated utility gain from avoided amputation is lower. Based on the sensitivity analysis, the utility multiplier for the health state “no ulcer after small amputation” had the most impact on the ICER; however, the model was robust to changes in all input parameters. Conclusions: Heberprot-P, as an add-on therapy to GWC in the treatment of advanced diabetic foot ulcer, is not a cost-effective alternative to GWC alone. However, if the unit cost of Heberprot-P were to be reduced to <€273, its ICER would be <€30,030.
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Affiliation(s)
- Tomas Tesar
- Department of Organisation and Management in Pharmacy, Faculty of Pharmacy in Bratislava, Comenius University, Bratislava, Slovakia
| | - Laszlo Szilberhorn
- Syreon Research Institute, Budapest, Hungary.,Department of Health Policy and Health Economics, Eötvös Loránd University (ELTE), Budapest, Hungary
| | | | - Balazs Nagy
- Syreon Research Institute, Budapest, Hungary.,Department of Health Policy and Health Economics, Eötvös Loránd University (ELTE), Budapest, Hungary
| | - Martin Wawruch
- Faculty of Medicine in Bratislava, Institute of Pharmacology and Clinical Pharmacology, Comenius University, Bratislava, Slovakia
| | - Zoltan Kalo
- Syreon Research Institute, Budapest, Hungary.,Department of Health Policy and Health Economics, Eötvös Loránd University (ELTE), Budapest, Hungary
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16
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Abstract
The commercial development of advanced therapy medicinal products (ATMPs) represents great opportunity for therapeutic innovation but is beset by many challenges for its developers. Although the ATMP field continues to progress at a rapid pace, evidenced by the increasing number of clinical trials conducted over the past few years, several factors continue to complicate the introduction of ATMPs as a curative treatment for multiple disease types, by blocking their translational pathway from research to the patient. While several recent publications (Trounson and McDonald, 2015; Abou-El-Enein et al., 2016a,b) as well as an Innovative Medicines Initiative consultation (IMI, 2016) this year have highlighted the major gaps in ATMP development, with manufacturing, regulatory, and reimbursement issues at the forefront, there remains to be formulated a coherent strategy to address these by bringing the relevant stakeholders to a single forum, whose task it would be to design and execute a delta plan to alleviate the most pressing bottlenecks. This article focuses on two of the most urgent areas in need of attention in ATMP development, namely manufacturing and reimbursement, and promotes the concept of innovation-dedicated research infrastructures to support a multi-sector approach for ensuring the successful development, entry, and ensuing survival of ATMPs in the healthcare market.
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Affiliation(s)
- David Morrow
- EATRIS ERIC, European Infrastructure for Translational Medicine, Amsterdam, Netherlands
| | - Anton Ussi
- EATRIS ERIC, European Infrastructure for Translational Medicine, Amsterdam, Netherlands
| | - Giovanni Migliaccio
- EATRIS ERIC, European Infrastructure for Translational Medicine, Amsterdam, Netherlands
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17
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Shirk JD, Kwan L, Laviana AA, Chu S, Huen KH, Bergman J. Is More Really Better? An Examination of Services and Payment Patterns among Urologists from the Centers for Medicare & Medicaid Services. Urol Pract 2017; 4:302-307. [PMID: 37592671 DOI: 10.1016/j.urpr.2016.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION We examined provider and regional variation in services provided and payments made to urologists by CMS (Centers for Medicare & Medicaid Services) by linking payments to individual beneficiaries and examining the proportion of submitted charges resulting in payments. METHODS We analyzed Medicare Part B Provider Utilization and Payment Data released by CMS for 2012, the last year of the purely fee-for-service reimbursement model. For each provider we determined the ratio of number of services provided to individual beneficiaries as well as the ratio of total submitted charges-to-total Medicare payments. Each provider was stratified into deciles of total Medicare payments and the mean per decile of total Medicare payment was calculated. Finally, to elucidate the potential association between the ratio of services-to-beneficiaries, we conducted multivariate linear regressions. RESULTS The 20th, 40th, 60th and 80th percentiles for the ratio of number of services per individual beneficiary ratios to total Medicare Part B payments are 2.8, 4.0, 5.2 and 7.4, respectively. Urologists with greater payments received provided more services to individual beneficiaries. Submitted charges exceeded payments by 3:1. Finally, female providers had lower ratios (p <0.01) and there was significant regional variation in the ratio of services per unique beneficiary (p <0.001 for each of the 10 Standard Federal Regions). CONCLUSIONS We found significant variation in services and payment in CMS. Reimbursement models replacing fee-for-service should be tailored to ensure appropriate health care resource utilization.
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Affiliation(s)
- Joseph D Shirk
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Lorna Kwan
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Aaron A Laviana
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Stephanie Chu
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Kathy H Huen
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jonathan Bergman
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, California
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18
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Groeneveld EI, Cassel JB, Bausewein C, Csikós Á, Krajnik M, Ryan K, Haugen DF, Eychmueller S, Gudat Keller H, Allan S, Hasselaar J, García-Baquero Merino T, Swetenham K, Piper K, Fürst CJ, Murtagh FE. Funding models in palliative care: Lessons from international experience. Palliat Med 2017; 31:296-305. [PMID: 28156188 PMCID: PMC5405831 DOI: 10.1177/0269216316689015] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Funding models influence provision and development of palliative care services. As palliative care integrates into mainstream health care provision, opportunities to develop funding mechanisms arise. However, little has been reported on what funding models exist or how we can learn from them. AIM To assess national models and methods for financing and reimbursing palliative care. DESIGN Initial literature scoping yielded limited evidence on the subject as national policy documents are difficult to identify, access and interpret. We undertook expert consultations to appraise national models of palliative care financing in England, Germany, Hungary, Republic of Ireland, New Zealand, The Netherlands, Norway, Poland, Spain, Sweden, Switzerland, the United States and Wales. These represent different levels of service development and a variety of funding mechanisms. RESULTS Funding mechanisms reflect country-specific context and local variations in care provision. Patterns emerging include the following: Provider payment is rarely linked to population need and often perpetuates existing inequitable patterns in service provision. Funding is frequently characterised as a mixed system of charitable, public and private payers. The basis on which providers are paid for services rarely reflects individual care input or patient needs. CONCLUSION Funding mechanisms need to be well understood and used with caution to ensure best practice and minimise perverse incentives. Before we can conduct cross-national comparisons of costs and impact of palliative care, we need to understand the funding and policy context for palliative care in each country of interest.
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Affiliation(s)
- E Iris Groeneveld
- 1 Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
| | - J Brian Cassel
- 2 School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Claudia Bausewein
- 3 Department of Palliative Medicine, Munich University Hospital, Ludwigs-Maximilians-University Munich, Munich, Germany
| | - Ágnes Csikós
- 4 PTE ÁOK Családorvostani Intézet, Hospice-Palliativ Tanszék, Pécs, Hungary
| | - Malgorzata Krajnik
- 5 Department of Palliative Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Karen Ryan
- 6 Saint Francis Hospice and Mater Hospital, Dublin, Ireland
| | - Dagny Faksvåg Haugen
- 7 Regional Centre of Excellence for Palliative Care, Haukeland University Hospital, Bergen, Norway.,8 Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
| | | | | | - Simon Allan
- 11 Arohanui Hospice, Palmerston North, New Zealand
| | - Jeroen Hasselaar
- 12 Department of Anesthesiology, Pain and Palliative Care, RadboudUMC, Nijmegen, The Netherlands
| | - Teresa García-Baquero Merino
- 13 Viceconsejería de Asistencia Sanitaria, Consejería de Sanidad de Madrid, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Kate Swetenham
- 14 Southern Adelaide Palliative Services, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Kym Piper
- 15 Finance & Corporate Services, South Australia Health, Adelaide, SA, Australia
| | - Carl Johan Fürst
- 16 Palliativa Utvecklingscentrum, Lund University and Region Skåne, Lund, Sweden
| | - Fliss Em Murtagh
- 1 Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
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19
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Gutiérrez-Ibarluzea I, Chiumente M, Dauben HP. The Life Cycle of Health Technologies. Challenges and Ways Forward. Front Pharmacol 2017; 8:14. [PMID: 28174538 PMCID: PMC5258694 DOI: 10.3389/fphar.2017.00014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 01/09/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Iñaki Gutiérrez-Ibarluzea
- Osteba, Basque Office for Health Technology Assessment (HTA), Ministry for Health, Basque Government Vitoria-Gasteiz, Spain
| | - Marco Chiumente
- Societá Italiana di Farmacia Clinica e Terapia (SIFaCT) - Italian Society of Clinical Pharmacy and Therapeutics Milan, Italy
| | - Hans-Peter Dauben
- German Agency for Health Technology Assessment (DAHTA), Deutsches Institut für Medizinische Dokumentation und Information (DIMDI) Cologne, Germany
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20
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Abstract
Most currently available quality measures reflect point-in-time provider tasks, providing a limited and fragmented assessment of care. The concept of episodes of care could be used to develop quality measurement approaches that reflect longer periods of care. With input from clinical experts, we constructed episode-of-care frameworks for six illustrative conditions and identified potential gaps and measure development priority areas. Episode-based measures could assess changes in health outcomes ("delta measures"), the amount of time during an episode in which a patient has suboptimal health status ("integral measures"), quality contingent upon events occurring previously ("contingent measures"), and composites of measures throughout the episode. This article identifies a number of challenges that will need to be addressed to advance operationalization of episode-based quality measurement.
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Affiliation(s)
| | - Mark W Friedberg
- 1 RAND Corporation, Boston, MA, USA.,5 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA.,6 Harvard Medical School, Boston, MA
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21
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Merlin TL, Hiller JE, Ryan P. Impact of the "Linked Evidence Approach" Method on Policies to Publicly Fund Diagnostic, Staging, and Screening Medical Tests. MDM Policy Pract 2016; 1:2381468316672465. [PMID: 30288408 PMCID: PMC6124925 DOI: 10.1177/2381468316672465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 08/23/2016] [Indexed: 11/16/2022] Open
Abstract
Background: The linked evidence approach (LEA) is used in health
technology assessment (HTA) to evaluate the clinical utility of new medical
tests in the absence of direct trial evidence. Objective: To
determine whether use of LEA affects decisions to publicly fund medical tests.
Methods: Australian HTAs that evaluated medical tests before
and after LEA was mandated (in 2005) were screened for eligibility. Data were
extracted and the impact of LEA and other possible clinical predictors (selected
a priori) on funding decisions was modelled. Regression diagnostics were
performed to estimate model fit, model specification, and to inform model
selection. The unit of analysis was per clinical indication for each new test,
so analyses were adjusted for clustering. Results: 83 HTAs (for 173
clinical indications) were eligible from the 259 screened. When health policy
was compared before and after 2005, there was an 11% reduction in overall
positive funding decisions, including a 25% decrease in “interim” (coverage with
evidence development) funding decisions. The odds of obtaining interim funding
reduced by 98% (odds ratio = 0.02, 95% confidence interval = 0.0005, 0.17), but
there was no change in the direction of funding decisions (odds ratio = 1.36,
95% confidence interval = 0.62, 3.01). Across both time periods, when LEA was
used there was a very strong likelihood that the medical test would not receive
interim funding (χ2 = 12.63, df = 1, P = 0.001). For positive funding
decisions, the strongest predictors were whether or not the new test would
replace an existing test and whether the available evidence was limited.
Conclusions: The use of LEA did not predict the direction of
funding decisions. Application of the method did predict that a “coverage with
evidence development” decision was unlikely. This suggests that LEA may reduce
decision-maker uncertainty.
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Affiliation(s)
- Tracy L Merlin
- Adelaide Health Technology Assessment, School of Public Health, University of Adelaide, Adelaide, South Australia, Australia (TLM).,Faculty of Health Sciences, Swinburne University, Melbourne, Victoria, Australia (JEH).,School of Public Health, University of Adelaide, Adelaide, South Australia, Australia (JEH, PR)
| | - Janet E Hiller
- Adelaide Health Technology Assessment, School of Public Health, University of Adelaide, Adelaide, South Australia, Australia (TLM).,Faculty of Health Sciences, Swinburne University, Melbourne, Victoria, Australia (JEH).,School of Public Health, University of Adelaide, Adelaide, South Australia, Australia (JEH, PR)
| | - Philip Ryan
- Adelaide Health Technology Assessment, School of Public Health, University of Adelaide, Adelaide, South Australia, Australia (TLM).,Faculty of Health Sciences, Swinburne University, Melbourne, Victoria, Australia (JEH).,School of Public Health, University of Adelaide, Adelaide, South Australia, Australia (JEH, PR)
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22
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Abstract
The US healthcare system is rapidly moving toward rewarding value. Recent legislation, such as the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act, solidified the role of value-based payment in Medicare. Many private insurers are following Medicare's lead. Much of the policy attention has been on programs such as accountable care organizations and bundled payments; yet, value-based purchasing (VBP) or pay-for-performance, defined as providers being paid fee-for-service with payment adjustments up or down based on value metrics, remains a core element of value payment in Medicare Access and CHIP Reauthorization Act and will likely remain so for the foreseeable future. This review article summarizes the current state of VBP programs and provides analysis of the strengths, weaknesses, and opportunities for the future. Multiple inpatient and outpatient VBP programs have been implemented and evaluated; the impact of those programs has been marginal. Opportunities to enhance the performance of VBP programs include improving the quality measurement science, strengthening both the size and design of incentives, reducing health disparities, establishing broad outcome measurement, choosing appropriate comparison targets, and determining the optimal role of VBP relative to alternative payment models. VBP programs will play a significant role in healthcare delivery for years to come, and they serve as an opportunity for providers to build the infrastructure needed for value-oriented care.
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Affiliation(s)
- Tingyin T Chee
- From Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (T.T.C., W.B.B.); Department of Health Policy, University of Michigan, Ann Arbor (A.M.R.); and Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (J.H.W.)
| | - Andrew M Ryan
- From Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (T.T.C., W.B.B.); Department of Health Policy, University of Michigan, Ann Arbor (A.M.R.); and Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (J.H.W.)
| | - Jason H Wasfy
- From Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (T.T.C., W.B.B.); Department of Health Policy, University of Michigan, Ann Arbor (A.M.R.); and Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (J.H.W.)
| | - William B Borden
- From Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC (T.T.C., W.B.B.); Department of Health Policy, University of Michigan, Ann Arbor (A.M.R.); and Cardiology Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (J.H.W.)
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23
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Fugel HJ, Nuijten M, Postma M, Redekop K. Economic Evaluation in Stratified Medicine: Methodological Issues and Challenges. Front Pharmacol 2016; 7:113. [PMID: 27242524 PMCID: PMC4861004 DOI: 10.3389/fphar.2016.00113] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 04/14/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Stratified Medicine (SM) is becoming a practical reality with the targeting of medicines by using a biomarker or genetic-based diagnostic to identify the eligible patient sub-population. Like any healthcare intervention, SM interventions have costs and consequences that must be considered by reimbursement authorities with limited resources. Methodological standards and guidelines exist for economic evaluations in clinical pharmacology and are an important component for health technology assessments (HTAs) in many countries. However, these guidelines have initially been developed for traditional pharmaceuticals and not for complex interventions with multiple components. This raises the issue as to whether these guidelines are adequate to SM interventions or whether new specific guidance and methodology is needed to avoid inconsistencies and contradictory findings when assessing economic value in SM. OBJECTIVE This article describes specific methodological challenges when conducting health economic (HE) evaluations for SM interventions and outlines potential modifications necessary to existing evaluation guidelines /principles that would promote consistent economic evaluations for SM. RESULTS/CONCLUSIONS Specific methodological aspects for SM comprise considerations on the choice of comparator, measuring effectiveness and outcomes, appropriate modeling structure and the scope of sensitivity analyses. Although current HE methodology can be applied for SM, greater complexity requires further methodology development and modifications in the guidelines.
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Affiliation(s)
- Hans-Joerg Fugel
- Department of Pharmacy, University of Gronigen Groningen, Netherlands
| | | | - Maarten Postma
- Department of Pharmacy, University of Gronigen Groningen, Netherlands
| | - Ken Redekop
- Institute of Health Policy & Management, Erasmus University Rotterdam Rotterdam, Netherlands
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24
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Grašič K, Mason AR, Street A. Paying for the quantity and quality of hospital care: the foundations and evolution of payment policy in England. Health Econ Rev 2015; 5:50. [PMID: 26062538 PMCID: PMC4468579 DOI: 10.1186/s13561-015-0050-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/08/2015] [Indexed: 05/13/2023]
Abstract
Prospective payment arrangements are now the main form of hospital funding in most developed countries. An essential component of such arrangements is the classification system used to differentiate patients according to their expected resource requirements. In this article we describe the evolution and structure of Healthcare Resource Groups (HRGs) in England and the way in which costs are calculated for patients allocated to each HRG. We then describe how payments are made, how policy has evolved to incentivise improvements in quality, and how prospective payment is being applied outside hospital settings.
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Affiliation(s)
- Katja Grašič
- Centre for Health Economics, University of York, York, YO10 5DD UK
| | - Anne R. Mason
- Centre for Health Economics, University of York, York, YO10 5DD UK
| | - Andrew Street
- Centre for Health Economics, University of York, York, YO10 5DD UK
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25
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Abstract
In 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a provision that denies Medicare payment for hospital-acquired conditions (HACs). This provision brings attention to the quality of patient care and the financial impact associated with "never-events" occurring during a patient's hospitalization. Our review of HACs focuses on the 5 which are most pertinent to the neurohospitalist: stages III and IV pressure ulcers, catheter-associated urinary tract infection, vascular catheter-associated infection, manifestations of poor glycemic control, and falls resulting in fractures, dislocations, and/or intracranial injuries. We address why CMS came up with them, their impact on quality patient care and hospital finances, and how the neurohospitalist can continue to participate in the future of HAC prevention and management as they relate to one's patients, hospital, and community.
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Affiliation(s)
- Heather Sand
- University of California, Irvine, Orange, CA, USA
| | - Mary Owen
- University of California, Irvine, Orange, CA, USA
| | - Alpesh Amin
- University of California, Irvine, Orange, CA, USA
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26
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Hoebert JM, Souverein PC, Mantel-Teeuwisse AK, Leufkens HGM, van Dijk L. Reimbursement restriction and moderate decrease in benzodiazepine use in general practice. Ann Fam Med 2012; 10:42-9. [PMID: 22230829 PMCID: PMC3262472 DOI: 10.1370/afm.1319] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To limit misuse and save costs, on January 1, 2009, benzodiazepines were excluded from the Dutch reimbursement list when used as anxiolytic, hypnotic, or sedative. This study aims to assess the impact of this reimbursement restriction on benzodiazepine use in patients with newly diagnosed anxiety or sleeping disorder in general practice. METHODS Was conducted a retrospective observational database study deriving data on diagnoses and prescriptions from the electronic health records-based Netherlands Information Network of General Practice (LINH). We looked for patients aged 18 years and older with an incident diagnosis of sleeping disturbance (International Classification of Primary Care code: P06) or anxiety (P74, P01) between January 2008 and December 2009. Incidence of these diagnoses, benzodiazepine use, and initiation of selective serotonin reuptake inhibitor (SSRI) treatment was compared between 2008 and 2009. RESULTS In total, we identified 13,596 patients with an incident diagnosis of anxiety (3,769 in 2008 and 3,710 in 2009) or sleeping disorder (3,254 in 2008 and 2,863 in 2009). The proportion of patients being prescribed a benzodiazepine after a diagnosis was lower in 2009 than in 2008 for both anxiety (30.1% vs. 33.7% P < .05) and sleeping disorder (59.1% vs. 67.0%, P < .05), as was the proportion of patients with more than 1 benzodiazepine prescription for both anxiety (36.4% vs. 42.6%, P < .05) and sleeping disorder (35.0% vs. 42.6%, P < .05). We found no increase in the use of alternative treatment for anxiety with SSRIs. CONCLUSIONS The reimbursement restriction has led to a moderate decrease in the number of incident diagnoses and initiation of benzodiazepine use in patients with newly diagnosed anxiety or sleeping disorder. This finding indicates that in settings where no such reimbursement opportunities exist, physicians have room to reduce benzodiazepine prescribing.
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Affiliation(s)
- Joëlle M Hoebert
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, The Netherlands
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27
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Abstract
BACKGROUND Public policy makers and benefit plan managers need to restrain rising pharmaceutical drug costs while preserving access and optimizing health benefits. OBJECTIVES To determine the effects of a pharmaceutical policy restricting the reimbursement of selected medications on drug use, health care utilization, health outcomes and costs (expenditures). SEARCH STRATEGY We searched the 14 major bibliographic databases and websites (to January 2009). SELECTION CRITERIA Included were studies of pharmaceutical policies that restrict coverage and reimbursement of selected drugs or drug classes, often using additional patient specific information related to health status or need. We included randomised controlled trials, non-randomised controlled trials, interrupted time series (ITS) analyses, repeated measures studies and controlled before-after studies set in large care systems or jurisdictions. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed study limitations. Quantitative re-analysis of time series data was undertaken for studies with sufficient data. MAIN RESULTS We included 29 ITS analyses (12 were controlled) investigating policies targeting 11 drug classes for restriction. Participants were most often senior citizens or low income adult populations, or both, in publically subsidized or administered pharmaceutical benefit plans. Impact of policies varied by drug class and whether restrictions were implemented or relaxed. When policies targeted gastric-acid suppressant and non-steroidal anti-inflammatory drug classes, decreased drug use and substantial savings on drugs occurred immediately and for up to two years afterwards, with no increase in the use of other health services (6 studies). Targeting second generation antipsychotic drugs increased treatment discontinuity and the use of other health services without reducing overall drug expenditures (2 studies). Relaxing restrictions for reimbursement of antihypertensives and statins increased appropriate use and decreased overall drug expenditures. Two studies which measured health outcomes directly were inconclusive. AUTHORS' CONCLUSIONS Implementing restrictions to coverage and reimbursement of selected medications can decrease third-party drug spending without increasing the use of other health services (6 studies). Relaxing reimbursement rules for drugs used for secondary prevention can also remove barriers to access. Policy design, however, needs to be based on research quantifying the harm and benefit profiles of target and alternative drugs to avoid unwanted health system and health effects. Health impact evaluation should be conducted where drugs are not interchangeable. Impacts on health equity, relating to the fair and just distribution of health benefits in society (sustainable access to publically financed drug benefits for seniors and low income populations, for example), also require explicit measurement.
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Affiliation(s)
- Carolyn J Green
- University of VictoriaDivision of Medical SciencesPO Box 3040 STN CSCVictoriaCanadaV8W 3N7
| | - Malcolm Maclure
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and TherapeuticsRm 3201 JPPN910 West 10th AvenueVancouverCanadaV5Z 4E3
| | | | - Craig R Ramsay
- University of AberdeenHealth Services Research Unit, Division of Applied Health SciencesPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
| | - Morten Aaserud
- Norwegian Medicines AgencyStatens legemiddelverkSven Oftedals vei 8OsloNorwayNO‐0950
| | - Stan Bardal
- University of VictoriaDivision of Medical SciencesPO Box 3040 STN CSCVictoriaCanadaV8W 3N7
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28
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Abstract
Initial enthusiasm for the potential of pharmacogenomics (PGx) to transform medical practice has been tempered by the reality that the process of biomarker discovery, validation, and clinical qualification has been disappointingly slow, with a limited number of PGx tests entering the marketplace since the initial publication of the human genome sequence. Reasons for the delays include the complexity of the underlying science as well as clinical, economic, and organizational barriers to the effective delivery of personalized health care. Nevertheless, payers are interested in using PGx services to ensure that drug use is safer and more effective, particularly in the settings of medications that are widely used, have significant risks of serious adverse events, have poor or highly variable drug response, or are very expensive. However, public and private payers have specific evidence requirements for new health care technologies that must be met prior to obtaining favorable coverage and reimbursement status. These evaluation criteria are frequently more rigorous than the current level of evidence required for regulatory approval of new PGx tests or PGx-related drug labeling. To support payer decision-making, researchers will need to measure the impact of PGx testing on clinical and economic outcomes and demonstrate the net benefit of PGx testing as compared to usual care. By linking payer information needs with the current PGx research agenda, there is the opportunity to develop the data required for informed decision-making. This strategy will increase the likelihood that PGx services will be both reimbursed and used appropriately in clinical practice.
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Affiliation(s)
- P A Deverka
- Division of Pharmacotherapy, UNC Institute for Pharmacogenomics and Individualized Therapy, University of North Carolina, Chapel Hill, NC 27599-7360, USA.
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29
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Abstract
OBJECTIVE To evaluate the impact of regulatory scenarios on the financial viability of medical device companies. DESIGN We developed a model to calculate the expected net present value of a hypothetical product throughout preclinical development, clinical testing, regulatory approval, and postmarketing. We tested 3 scenarios: (1) the current regulatory environment; (2) a scenario in which medical devices are subject to the same evidence standards required for pharmaceuticals; and (3) a scenario consistent with the Coverage with Evidence Development: Coverage with Study Participation (CSP) policy proposed by the Centers for Medicare and Medicaid Services, whereby Medicare will pay for beneficiaries to receive new devices that are not currently determined to be "reasonable and necessary" if the patients participate in clinical studies or registries. MEASUREMENTS AND MAIN RESULTS When applying assumptions consistent with the implantable cardioverter-defibrillator market, the net present value at the start of development was an estimated $553 million in the current regulatory environment, $322 million in the pharmaceutical scenario, and $403 million in the CSP scenario. Sensitivity analyses showed that the device industry would likely be profitable in all 3 scenarios over a range of assumptions. CONCLUSIONS The environment in which the medical device industry operates is financially attractive. Furthermore, when compared with the alternative of applying the same evidence standards for pharmaceuticals to medical devices, the CSP policy offers improved financial incentives for medical device companies.
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Affiliation(s)
- Shelby D Reed
- Center for Clinical and Genetic Economics, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA
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30
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Marshall DA, McGeer A, Gough J, Grootendorst P, Buitendyk M, Simonyi S, Green K, Jaszewski B, MacLeod SM, Low DE. Impact of antibiotic administrative restrictions on trends in antibiotic resistance. Can J Public Health 2006; 97:126-31. [PMID: 16620000 PMCID: PMC6975704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
CONTEXT In March 2001, in response to concerns about increasing resistance to fluoroquinolone (FQ) antibiotics, the Ontario Drug Benefit (ODB) program limited reimbursement of FQs to ODB beneficiaries defined as high risk or in whom other therapies are not tolerated. OBJECTIVE To analyze the impact of the limited use (LU) policy changes on antibiotic resistance rates in Ontario, focussing on community-acquired pathogens. DESIGN Ontario data submitted to the Canadian Bacterial Surveillance Network (CBSN) between January 1, 1998 and June 30, 2002 were analyzed for rates of resistance in various pathogen-antibiotic combinations. The effect of the LU policy on the level and rate of change of antibiotic resistance was estimated using time series models. RESULTS Resistance rates for S. pneumoniae were 10-12% for penicillin, erythromycin and trimethoprim sulfamethoxazole (TMP/SMX) and less than 3% for amoxicillin and all three FQs tested. There was a statistically significant increasing trend in resistance rates of S. pneumoniae to amoxicillin and levofloxacin throughout the study period. Antibiotic resistance of S. pneumoniae to ciprofloxacin indicated a statistically significant decreasing trend over the study period with a statistically significant increase in the level of antibiotic resistance at the time of the LU policy implementation. No other indication of any statistically significant decrease in resistance rates associated with the LU policy was found. CONCLUSIONS Although no direct cause and effect can be proven with these observational data, there is no evidence that the limited use policy to restrict fluoroquinolones decreased antibiotic resistance in any of the pathogen-antibiotic combinations tested.
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Affiliation(s)
- D A Marshall
- Health Economics and Outcomes Research, Innovus Research Inc., Burlington, ON.
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Green LA, Graham R, Bagley B, Kilo CM, Spann SJ, Bogdewic SP, Swanson J. Task Force 1. Report of the Task Force on Patient Expectations, Core Values, Reintegration, and the New Model of Family Medicine. Ann Fam Med 2004; 2:S33-S50. [PMCID: PMC1466760 DOI: 10.1370/afm.134] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND To lay the groundwork for the development of a comprehensive strategy to transform and renew the specialty of family medicine, this Future of Family Medicine task force was charged with identifying the core values of family medicine, developing proposals to reform family medicine to meet consumer expectations, and determining systems of care to be delivered by family medicine in the future. METHODS A diverse, multidisciplinary task force representing a broad spectrum of perspectives and expertise analyzed and discussed published literature; findings from surveys, interviews, and focus groups compiled by research firms contracted to the Future of Family Medicine project; and analyses from The Robert Graham Center, professional societies in the United States and abroad, and others. Through meetings, conference calls, and writing, and revision of a series of subcommittee reports, the entire task force reached consensus on its conclusions and recommendations. These were reviewed by an external panel of experts and revisions were made accordingly. MAJOR FINDINGS After delivering on its promise to reverse the decline of general practice in the United States, family medicine and the nation face additional challenges to assure all people receive care that is safe, effective, patient-centered, timely, efficient, and equitable. Challenges the discipline needs to address to improve family physicians’ ability to make important further contributions include developing a broader, more accurate understanding of the specialty among the public and other health professionals, addressing the wide scope and variance in practice types within family medicine, winning respect for the specialty in academic circles, making family medicine a more attractive career option, and dealing with the perception that family medicine is not solidly grounded in science and technology. The task force set forth a proposed identity statement for family medicine, a basket of services that should be reliably provided in family medicine practices, and an itemization of key attributes and core values that define the specialty. It also proposed and described a New Model of family medicine for people of all ages and both genders that emphasizes patient-centered, evidence-based, whole-person care provided through a multidisciplinary team approach in settings that reduce barriers to access and use advanced information systems and other new technologies. The task force recommended a time of active experimentation to redesign the work and workplace of family physicians; the development of revised financial models for family medicine, and a national resource to provide assistance to individual practices moving to New Model practice; and cooperation with others pursuing the transformation of frontline medicine to better serve the public. CONCLUSIONS Unless there are changes in the broader health care system and within the specialty, the position of family medicine in the United States will be untenable in a 10- to 20-year time frame. Even within the constraints of today’s flawed health care system, there are major opportunities for family physicians to realize improved results for patients and economic success. A period of aggressive experimentation and redevelopment of family medicine is needed now. The future success of the discipline and its impact on public well-being depends in large measure on family medicine’s ability to rearticulate its vision and competencies in a fashion that has greater resonance with the public while substantially revising the organization and processes by which care is delivered. When accomplished, family physicians will achieve more fully the aspirations articulated by the specialty’s core values and contribute to the solution of the nation’s serious health care problems.
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Affiliation(s)
| | - Larry A. Green
- Chair, Task Force 1, Co-Editor Task Force 1 Report, Denver, Colo, and Washington, DC
| | | | - Bruce Bagley
- Chair, Core Values Writing Group, Task Force 1, Leawood, Kan
| | - Charles M. Kilo
- Chair, Patient Expectations Writing Group, Task Force 1, Portland, Ore
| | | | - Stephen P. Bogdewic
- Chair Essential Interfaces and Reintegration with Patients Writing Group; Vice Chair, Task Force 1, Indianapolis, Ind
| | - John Swanson
- Staff Executive, American Academy of Family Physicians, Leawood, Kan
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