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McCullough MC, Wlodarczyk J, Jacob L, Hershenhouse K, Seruya M. Surgical Complexity and Physician Compensation: An Analysis of Relative Under-Valuation for Pediatric Brachial Plexus Surgery. Hand (N Y) 2024; 19:374-381. [PMID: 36168295 PMCID: PMC11067842 DOI: 10.1177/15589447221120845] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Brachial plexus reconstruction (BPR) is a rapidly advancing field within hand surgery. BPR procedures are complex, time-intensive, and require microsurgical expertise. As physician reimbursement rates for BPR are poorly defined, relative to more common hand procedures, we sought to analyze compensation for BPR across different payor groups and understand the factors contributing to their reimbursement. METHODS A retrospective review was performed of surgeries by a single senior staff member in a 4-year period to evaluate Current Procedural Terminology (CPT) codes from BPR cases. For comparison, all finger fracture fixations and skin graft reconstructions performed by the same surgeon over the same time period were analyzed as well. RESULTS A total of 57 BPR cases, 94 finger fracture fixation cases, and 69 skin grafting cases met inclusion criteria. Among the top 5 insurance providers, average work relative value unit (wRVU)/hour was 6.55, 3.49, and 12.67 for BPR, fracture fixation, and skin grafts, respectively. Reimbursements were an average $685.76/hour for BPR, compared to $590.10/hour for fracture fixation and $1,197.94/hour for skin grafts. CONCLUSIONS BPR demonstrates a relative undervaluation, in terms of reimbursement per hour, given the time and surgical skill required for such cases, particularly compared to shorter, less complex cases such as skin grafting and fracture fixation. We find that this discrepancy is amplified across multiple levels of coding, billing, and reimbursement. We suggest specific strategies for physician leadership to more directly participate in the financial decisions that affect themselves, their patients, and their specialty.
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Affiliation(s)
- Meghan C. McCullough
- University of Southern California, Los Angeles, USA
- Children’s Hospital of Los Angeles, CA, USA
| | - Jordan Wlodarczyk
- University of Southern California, Los Angeles, USA
- Children’s Hospital of Los Angeles, CA, USA
| | - Laya Jacob
- University of Southern California, Los Angeles, USA
- Children’s Hospital of Los Angeles, CA, USA
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Cordero JJ, Alaniz L, Kalavacherla S, Tholpady SS, Chu MW. Trends of Medicare Reimbursement Rates for Gender-Affirming Surgery Procedures. Ann Plast Surg 2024; 92:S366-S370. [PMID: 38689421 DOI: 10.1097/sap.0000000000003799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Awareness of Medicare reimbursement is important for gender-affirming surgeons who treat transgender patients with Medicare. In 2014, Medicare began to provide coverage for medically necessary transition-related surgery. The purpose of this study was to analyze trends in Medicare reimbursement rates for gender-affirming surgery procedures from 2014 to 2022. METHODS The Medicare Physician Fee Schedule Look-Up Tool provided by the Centers for Medicare and Medicaid Services was used, and the Current Procedural Terminology codes for 43 gender-affirming surgery services were obtained. Monetary units, conversion factors, relative value units (RVUs) for work, facility, and malpractice costs for 30 transmasculine and 13 transfeminine procedures were analyzed. Descriptive statistics were performed to account for inflation and to determine the relative differences between 2014 and 2022. RESULTS For all gender-affirming surgery procedures covered by Medicare, the average relative difference of monetary units decreased by 2.99% between 2014 and 2022. On average, there was a 3.97% decrease of work-based RVU charges for transmasculine procedures and a 1.73% decrease of work-based RVU charges for transfeminine procedures. After adjusting for inflation, the average relative difference of monetary units for all gender-affirming surgery procedures decreased by 23.42% between 2014 and 2022. CONCLUSIONS Reimbursement rates for gender-affirming surgery procedures covered under Medicare have decreased over the observed period, and trends in reimbursement rates have not kept up with consumer price index inflation. Gender-affirming surgeons should be conscious of these changes in reimbursement rates and advocate for fairer compensation to promote medical care among an underserved population.
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Affiliation(s)
- Justin J Cordero
- From the School of Medicine, University of California Riverside, Riverside
| | | | | | - Sunil S Tholpady
- Division of Plastic and Reconstructive Surgery, Indiana University, Indianapolis, IN
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Stoffel V, Camacho JM, Heeb C, Cui S, Shim JY, Pacella SJ, Gosman AA, Reid CM. Unveiling the Hidden Discrepancies Between Medicare Physician Reimbursement Rates and Inflation Across Different Surgical Specialties. Ann Plast Surg 2024; 92:S340-S344. [PMID: 38689416 DOI: 10.1097/sap.0000000000003806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
OBJECTIVE This study aimed to analyze the trends of Medicare physician reimbursement from 2011 to 2021 and compare the rates across different surgical specialties. BACKGROUND Knowledge of Medicare is essential because of its significant contribution in physician reimbursements. Previous studies across surgical specialties have demonstrated that Medicare, despite keeping up with inflation in some areas, has remained flat when accounting for physician reimbursement. STUDY DESIGN The Physician/Supplier Procedure Summary data for the calendar year 2021 were queried to extract the top 50% of Current Procedural Terminology codes based on case volume. The Physician Fee Schedule look-up tool was accessed, and the physician reimbursement fee was abstracted. Weighted mean reimbursement was adjusted for inflation. Growth rate and compound annual growth rate were calculated. Projection of future inflation and reimbursement rates were also calculated using the US Bureau of Labor Statistics. RESULTS After adjusting for inflation, the weighted mean reimbursement across surgical specialties decreased by -22.5%. The largest reimbursement decrease was within the field of general surgery (-33.3%), followed by otolaryngology (-31.5%), vascular surgery (-23.3%), and plastic surgery (-22.8%). There was a significant decrease in median case volume across all specialties between 2011 and 2021 (P < 0.001). CONCLUSIONS This study demonstrated that, when adjusted for inflation, over the study period, there has been a consistent decrease in reimbursement for all specialties analyzed. Awareness of the current downward trends in Medicare physician reimbursement should be a priority for all surgeons, as means of advocating for compensation and to maintain surgical care feasible and accessible to all patients.
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Affiliation(s)
- Victoria Stoffel
- From the Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Justin M Camacho
- From the Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Connor Heeb
- Department of Economics, Columbia University, New York, New York
| | - Saishi Cui
- From the Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jalene Y Shim
- Department of Surgery, Division of Plastic Surgery, UC San Diego School of Medicine, San Diego, CA
| | - Salvatore J Pacella
- Division of Plastic Surgery, Scripps MD Anderson Cancer Center, Scripps Clinic Green Hospital, La Jolla, CA
| | - Amanda A Gosman
- Department of Economics, Columbia University, New York, New York
| | - Chris M Reid
- Department of Surgery, Division of Plastic Surgery, UC San Diego School of Medicine, San Diego, CA
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Liu BY, Rome BN. State Coverage and Reimbursement of Antiobesity Medications in Medicaid. JAMA 2024; 331:1230-1232. [PMID: 38483403 PMCID: PMC10941017 DOI: 10.1001/jama.2024.3073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/21/2024] [Indexed: 03/17/2024]
Abstract
This study examines state Medicaid coverage policies for antiobesity medications and their trends in Medicaid reimbursement from 2011 to 2022.
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Affiliation(s)
- Benjamin Y. Liu
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Benjamin N. Rome
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, Massachusetts
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Gaddis G. The Generous Reimbursement of Non-Physician Clinical Services: Part I: A Deep Dive into the Resource-Based Relative Value Scale. Mo Med 2024; 121:105-112. [PMID: 38694606 PMCID: PMC11057855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Affiliation(s)
- Gary Gaddis
- Teaching Professor of Biomedical and Health Informatics, at the University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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Hernandez I, Gabriel N, Kaltenboeck A, Boccuti C, Hansen RN, Sullivan SD. Reimbursement to Pharmacies for Generic Drugs by Medicare Part D Sponsors. JAMA 2023; 330:2390-2392. [PMID: 38051277 PMCID: PMC10698681 DOI: 10.1001/jama.2023.21481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/02/2023] [Indexed: 12/07/2023]
Abstract
This study evaluates whether organizations that offer Medicare Part D plans (referred to as Part D sponsors) overpay pharmacies for generic drugs.
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Affiliation(s)
- Inmaculada Hernandez
- Division of Clinical Pharmacy, University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla
| | - Nico Gabriel
- Division of Clinical Pharmacy, University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla
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Palacios A, Rodriguez-Cairoli F, Balan D, Rojas-Roque C, Moreno-López C, Braun B, Augustovski F, Pichon-Riviere A, Bardach A. Budget Impact Analysis of the FreeStyle Libre Flash Continuous Glucose Monitoring System ® in Patients with Type 1 Diabetes Mellitus and Type 2 Diabetes Mellitus with Multiple Daily Insulin Injections in Argentina. Appl Health Econ Health Policy 2023; 21:637-650. [PMID: 37062046 DOI: 10.1007/s40258-023-00800-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To estimate the budget impact of the potential coverage of FreeStyle Libre Flash Continuous Glucose Monitoring System (FSL) for glycemia monitoring in all type 1 diabetes mellitus (T1DM) patients and in those with type 2 diabetes mellitus (T2DM) with multiple daily insulin injections, from the social security and the private third-party payer's perspective in Argentina. METHODS A budget impact model was developed to estimate the cost difference between the self-monitoring of blood glucose (standard of care) and FSL over 5 years. Input parameters were retrieved from local literature complemented by expert opinion. Health care costs were estimated by a micro-costing approach and reported in USD as of April 2022 (1 USD = 113.34 Argentine pesos). One-way sensitivity and scenario analyses were conducted. RESULTS From a social security third-party payer perspective, the incorporation of FSL was associated with net savings per member per month (PMPM) of $0.026 (Year 1) to $0.097 (Year 5) and net savings PMPM of $0.002 (Year 1) to $0.008 (Year 5) for T1DM and T2DM patients, respectively. Similar findings are reported from the private third-party payer perspective. The budget impact results were more sensitive to the acquisition costs of the FSL and test strips. CONCLUSION The potential coverage of FSL in patients with T1DM and T2DM with multiple daily insulin injections could be associated with small financial savings considering current technology acquisition costs (FSL and test strips) for social security and the private sector third-party payers in Argentina.
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Affiliation(s)
- Alfredo Palacios
- Department of Health Technology Assessment and Health Economics, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.
- Department of Economics, Universidad de Buenos Aires, Buenos Aires, Argentina.
- Centre for Health Economics (CHE), University of York, York, UK.
| | - Federico Rodriguez-Cairoli
- Department of Health Technology Assessment and Health Economics, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Dario Balan
- Department of Health Technology Assessment and Health Economics, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Carlos Rojas-Roque
- Department of Health Technology Assessment and Health Economics, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Carolina Moreno-López
- Department of Health Technology Assessment and Health Economics, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Barbara Braun
- Departamento de Clínica Médica y Diabetología, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
| | - Federico Augustovski
- Department of Health Technology Assessment and Health Economics, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Andrés Pichon-Riviere
- Department of Health Technology Assessment and Health Economics, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Ariel Bardach
- Department of Health Technology Assessment and Health Economics, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
- Center for Research in Epidemiology and Public Health (CIESP), Buenos Aires, Argentina
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Harris E. CMS Rule Cracks Down on Medicare Advantage Overpayments. JAMA 2023; 329:704. [PMID: 36790828 DOI: 10.1001/jama.2023.1557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Affiliation(s)
- Ateev Mehrotra
- From Harvard Medical School and Beth Israel Deaconess Medical Center - both in Boston (A.M.); and the RAND Corporation, Arlington, VA (L.U.-P.)
| | - Lori Uscher-Pines
- From Harvard Medical School and Beth Israel Deaconess Medical Center - both in Boston (A.M.); and the RAND Corporation, Arlington, VA (L.U.-P.)
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Affiliation(s)
| | - Huseyin Naci
- Department of Health Policy, London School of Economics, UK
| | | | - Harald Schmidt
- Department of Medical Ethics and Health Policy, University of Pennsylvania, USA
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Ten Ham RMT, Frederix GWJ, Wu O, Goettsch W, Leufkens HGM, Klungel OH, Hoekman J. Key Considerations in the Health Technology Assessment of Advanced Therapy Medicinal Products in Scotland, The Netherlands, and England. Value Health 2022; 25:390-399. [PMID: 35227451 DOI: 10.1016/j.jval.2021.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 09/13/2021] [Accepted: 09/23/2021] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Advanced therapy medicinal products (ATMPs) are highly innovative therapies. Their costs and uncertain value claims have raised concerns among health technology assessment (HTA) bodies and payers. Little is known about how underlying considerations in HTA of ATMPs shape assessment and reimbursement recommendations. We aim to identify and assess key considerations that played a role in HTA of ATMPs underlying reimbursement recommendations. METHODS A review of HTA reports was conducted of all authorized ATMPs in Scotland, The Netherlands, and England. Considerations were extracted and categorized into EUnetHTA Core Model domains. Per jurisdiction, considerations were aggregated and key considerations identified (defined as occurring in >1/assessment per jurisdiction). A narrative analysis was conducted comparing key considerations between jurisdictions and different reimbursement recommendations. RESULTS We identified 15 ATMPs and 18 HTA reports. In The Netherlands and England most key considerations were identified in clinical effectiveness (EFF) and cost- and economic effectiveness (ECO) domains. In Scotland, the social aspects domain yielded most key considerations, followed by ECO and EFF. More uncertainty in evidence and assessment outcomes was accepted when orphan or end-of-life criteria were applied. A higher percentage of considerations supporting recommendations were identified for products with positive recommendations compared with restricted and negative recommendations. CONCLUSIONS This is the first empirical review of HTA's using the EUnetHTA Core Model to identify and structure key considerations retrospectively. It provides insights in supporting and opposing considerations for reimbursement of individual products and differences between jurisdictions. Besides the EFF and ECO domain, the social, ethical, and legal domains seem to bear considerable weight in assessment of ATMPs.
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Affiliation(s)
- Renske M T Ten Ham
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands; Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, UK.
| | - Geert W J Frederix
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands; Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Olivia Wu
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, UK
| | - Wim Goettsch
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands; National Health Care Institute, Diemen, The Netherlands
| | - Hubert G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands; Lygature, Utrecht, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - Jarno Hoekman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands; Innovation Studies, Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
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Horný M, Shafer PR, Dusetzina SB. Concordance of Disclosed Hospital Prices With Total Reimbursements for Hospital-Based Care Among Commercially Insured Patients in the US. JAMA Netw Open 2021; 4:e2137390. [PMID: 34902037 PMCID: PMC8669520 DOI: 10.1001/jamanetworkopen.2021.37390] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/08/2021] [Indexed: 12/12/2022] Open
Abstract
Importance To improve health care price transparency and promote cost-conscious selection of health care organizations and practitioners, the Centers for Medicare & Medicaid Services (CMS) required that hospitals share payer-specific negotiated prices for selected shoppable health services by January 2021. While this regulation improves price transparency, it is unclear whether disclosed prices reflect total costs of care, since many hospital-based services are delivered and billed separately by independent practitioners or other health care entities. Objective To assess the extent to which prices disclosed under the new hospital price transparency regulation are correlated with total costs of care among commercially insured individuals. Design, Setting, and Participants This cross-sectional study used a large database of commercial claims from 2018 to analyze encounters at US hospitals for shoppable health care services for which price disclosure is required by CMS. Data were analyzed from November 2020 to February 2021. Exposures Whether the service was billed by the hospital or another entity. Main Outcomes and Measures Outcomes of interest were the percentage of encounters with at least 1 service billed by an entity other than the hospital providing care, number of billing entities, amounts billed by nonhospital entities, and the correlation between hospital and nonhospital reimbursements. Results The study analyzed 4 545 809 encounters for shoppable care. Independent health care entities were involved in 7.6% (95% CI, 6.7% to 8.4%) to 42.4% (95% CI, 39.1% to 45.6%) of evaluation and management encounters, 15.9% (95% CI, 15.8% to 16%) to 22.2% (95% CI, 22% to 22.4%) of laboratory and pathology services, 64.9% (95% CI, 64.2% to 65.7%) to 87.2% (95% CI, 87.1% to 87.3%) of radiology services, and more than 80% of most medicine and surgery services. The median (IQR) reimbursement of independent practitioners ranged from $61 ($52-$102) to $412 ($331-$466) for evaluation and management, $5 ($4-$6) to $7 ($4-$12) for laboratory and pathology, $26 ($20-$32) to $210 ($170-$268) for radiology, and $47 ($21-$103) to $9545 ($7750-$18 277) for medicine and surgery. The reimbursement for services billed by the hospital was not strongly correlated with the reimbursement of independent clinicians, ranging from r = -0.11 (95% CI, -0.69 to 0.56) to r = 0.53 (95% CI, 0.13 to 0.78). Conclusions and Relevance This cross-sectional study found that independent practitioners were frequently involved in the delivery of shoppable hospital-based care, and their reimbursement may have represented a substantial portion of total costs of care. These findings suggest that disclosed hospital reimbursement was usually not correlated with total cost of care, limiting the potential benefits of the hospital price transparency rule for improving consumer decision-making.
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Affiliation(s)
- Michal Horný
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
- Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Paul R. Shafer
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Stacie B. Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
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Itoga NK, Martinez-Singh K, Lee JT, John Harris E, Baker LC, Garcia-Toca M. Analysis of Medicare Payments and Patient Outcomes With Pre-Operative Imaging for Carotid Endarterectomy. Ann Vasc Surg 2021; 76:179-184. [PMID: 34153493 DOI: 10.1016/j.avsg.2021.06.001] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/18/2021] [Accepted: 06/06/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The use of radiographic evaluation of carotid disease may vary, and current guidelines do not strongly recommend the use of cross-sectional imaging (CSI) prior to surgical intervention. We sought to describe the trends in preoperative carotid imaging and evaluate the associated clinical outcomes and Medicare payments for patients undergoing carotid endarterectomy (CEA) for asymptomatic carotid disease. METHODS We used a 20% Medicare sample from 2006 to 2014 identifying patients undergoing CEA for asymptomatic disease. We evaluated preoperative carotid ultrasound and CSI use: CT or MRI of the neck prior to CEA. We calculated average payments of each study from the carrier file and revenue center file. Imaging payments included both the professional component (PC) and the technical component (TC). Claims with a reimbursement of $0 and studies where payment for both the TC and PC could not be identified were excluded from the overall calculation to determine average payment per study. Inpatient reimbursements according to DRG 37-39 were calculated. We compared hospital length of stay (LOS), in hospital stroke, carotid re-exploration, and mortality according to CSI use. RESULTS A total of 58,993 CEAs were identified with pre-operative carotid imaging. The average age was 74.8 ± 7.5 years, and 56.0% were men. A total of 19,678 (33%) patients had ultrasound alone with an average of (2.4 ± 1.9) exams prior to CEA. A total of 39,315 patients underwent CSI prior to CEA with 2.5 ± 2.1 ultrasounds, 0.95 ± 0.86 neck CTs and 0.47 ± 0.7 MRIs per patient. The average payment for ultrasound was $140 ± 40, $282 ± 94 for CT and $410 ± 146 for MRI. The average inpatient reimbursements were $7,413 ± 4,215 for patients without CSI compared with $7,792 ± 3,921 for patients with CSI, P < 0.001. The average LOS during CEA admission was 2.5 ± 3.7days. Patients with CSI had a slightly lower percentage of patients being discharged by postoperative day 2 compared with ultrasound alone (88.9% vs. 91.5%, respectively, P < 0.001). The overall in-hospital stroke rate was 0.38% and carotid re-exploration rate was 1.0% and there was no statistical significant difference between groups. Median follow-up was 3.9 years, and mortality at 8 years was 50% and did not statistically differ between groups. CONCLUSIONS Our analysis found preoperative imaging to include CSI in nearly two-thirds of patients prior to CEA for asymptomatic disease. As imaging and inpatient payments were higher with patients with CSI further work is needed to understand when CSI is appropriate prior to surgical intervention to appropriately allocate healthcare resources.
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Affiliation(s)
- Nathan K Itoga
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA; Department of Health Research and Policy, Stanford University, Stanford, CA; Department of Surgery, University of Hawaii, Honolulu, Hawaii.
| | | | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Edmund John Harris
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA
| | - Laurence C Baker
- Department of Health Research and Policy, Stanford University, Stanford, CA
| | - Manuel Garcia-Toca
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA
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Abstract
OBJECTIVE Excess administrative costs in the US health care system are routinely referenced as a justification for comprehensive reform. While there is agreement that these costs are too high, there is little understanding of what generates administrative costs and what policy options might mitigate them. DATA SOURCES Literature review and national utilization and expenditure data. STUDY DESIGN We developed a simulation model of physician billing and insurance-related (BIR) costs to estimate how certain policy reforms would generate savings. Our model is based on structural elements of the payment process in the United States and considers each provider's number of health plan contracts, the number of features in each health plan, the clinical and nonclinical processes required to submit a bill for payment, and the compliance costs associated with medical billing. DATA EXTRACTION For several types of visits, we estimated fixed and variable costs of the billing process. We used the model to estimate the BIR costs at a national level under a variety of policy scenarios, including variations of a single payer "Medicare-for-All" model that extends fee-for-service Medicare to the entire population and policy efforts to reduce administrative costs in a multi-payer model. We conducted sensitivity analyses of a wide variety of model parameters. PRINCIPAL FINDINGS Our model estimates that national BIR costs are reduced between 33% and 53% in Medicare-for-All style single-payer models and between 27% and 63% in various multi-payer models. Under a wide range of assumptions and sensitivity analyses, standardizing contracts generates larger savings with less variance than savings from single-payer strategies. CONCLUSION Although moving toward a single-payer system will reduce BIR costs, certain reforms to payer-provider contracts could generate at least as many administrative cost savings without radically reforming the entire health system. BIR costs can be meaningfully reduced without abandoning a multi-payer system.
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Affiliation(s)
- David Scheinker
- Systems Utilization Research for Stanford MedicineStanford UniversityStanfordCaliforniaUSA
- Clinical Excellence Research CenterSchool of MedicineStanford UniversityStanfordCaliforniaUSA
| | - Barak D. Richman
- Clinical Excellence Research CenterSchool of MedicineStanford UniversityStanfordCaliforniaUSA
- Duke University School of LawDurhamNorth CarolinaUSA
| | - Arnold Milstein
- Clinical Excellence Research CenterSchool of MedicineStanford UniversityStanfordCaliforniaUSA
| | - Kevin A. Schulman
- Clinical Excellence Research CenterSchool of MedicineStanford UniversityStanfordCaliforniaUSA
- Graduate School of BusinessStanford UniversityStanfordCaliforniaUSA
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Rayzah M, Ryu JM, Lee JH, Nam SJ, Kim SW, Lee SK, Yu J, Lee KT, Bang SI, Mun GH, Pyon JK, Jeon BJ, Lee JE. Changes in Korean National Healthcare Insurance Policy and Breast Cancer Surgery Trend in Korea. J Korean Med Sci 2021; 36:e194. [PMID: 34313035 PMCID: PMC8313396 DOI: 10.3346/jkms.2021.36.e194] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/20/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Since April 2015, the Korean National Health Insurance (NHI) has reimbursed breast cancer patients, approximately 50% of the cost of the breast reconstruction (BR) procedure. We aimed to investigate NHI reimbursement policy influence on the rate of immediate BR (IBR) following total mastectomy (TM). METHODS We retrospectively analyzed breast cancer data between April 2011 and June 2016. We divided patients who underwent IBR following TM for primary breast cancer into "uninsured" and "insured" groups using their NHI statuses at the time of surgery. Univariate analyses determined the insurance influence on the decision to undergo IBR. RESULTS Of 2,897 breast cancer patients, fewer uninsured patients (n = 625) underwent IBR compared with those insured (n = 325) (30.0% vs. 39.8%, P < 0.001). Uninsured patients were younger than those insured (median age [range], 43 [38-48] vs. 45 [40-50] years; P < 0.001). Pathologic breast cancer stage did not differ between the groups (P = 0.383). More insured patients underwent neoadjuvant chemotherapy (P = 0.011), adjuvant radiotherapy (P < 0.001), and IBR with tissue expander insertion (P = 0.005) compared with those uninsured. CONCLUSION IBR rate in patients undergoing TM increased after NHI reimbursement.
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Affiliation(s)
- Musaed Rayzah
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Surgery, College of Medicine, Majmaah University, Ministry of Education, Riyadh, Saudi Arabia
| | - Jai Min Ryu
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Hee Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Jin Nam
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Won Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se Kyung Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jonghan Yu
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeong Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sa Ik Bang
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Goo Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jai Kyong Pyon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung Joon Jeon
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Eon Lee
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Nayar SK, Aziz KT, Best MJ, Giladi AM, LaPorte DM, Srikumaran U, Ingari JV. Relative Value Unit Compensation Rates for Hospital-Based Shoulder/Elbow Surgery Versus Hand Surgery. Orthopedics 2021; 44:e373-e377. [PMID: 33238011 DOI: 10.3928/01477447-20201119-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Upper extremity surgeons perform diverse operations, including hand surgery, microsurgery, and shoulder/elbow arthroscopy and arthroplasty. Declining orthopedic reimbursement rates may encourage surgeons to adjust their case mix, favoring a shift toward procedures with higher compensation. To determine whether upper extremity surgeons and hand-fellowship trainees may be financially incentivized to perform more shoulder/elbow procedures than hand procedures in a hospital-based setting, relative value unit (RVU) compensation rates were compared for these 2 fields. Using Centers for Medicare & Medicaid Services-assigned work RVUs (wRVU) and National Surgical Quality Improvement Program operative time data, wRVU compensation rates per minute of operative time were determined for common shoulder/elbow surgeries. Overall nonweighted and weighted wRVU/min averages were calculated for hospital-based shoulder/elbow and hand surgery. A total of 27 shoulder/elbow procedures and 53 hand surgery procedures were analyzed. Nonweighted comparison showed shoulder/elbow surgery had a higher wRVU/min (0.19±0.03 vs 0.14±0.05, P<.0001) vs hand surgery. When weighted by procedure frequency, shoulder/elbow surgery also had higher wRVU/min (0.19±0.02 vs 0.15±0.05, P<.0001). Fourteen of the 27 shoulder/elbow procedures were compensated either the same wRVU/min or more than all hand procedures except for epicondyle debridement and flexor tendon bursectomy. Almost half of commonly performed shoulder/elbow procedures were compensated at greater rates than most hand procedures in a hospital-based setting. This disproportionate compensation may affect upper extremity surgeons' case mix and motivate providers and hand-fellowship trainees to seek additional training in shoulder arthroplasty and arthroscopy to supplement their practice. [Orthopedics. 2021;44(3):e373-e377.].
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Harrison RF, Fu S, Sun CC, Zhao H, Lu KH, Giordano SH, Meyer LA. Patient cost sharing during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment in ovarian cancer. Am J Obstet Gynecol 2021; 225:68.e1-68.e11. [PMID: 33549538 DOI: 10.1016/j.ajog.2021.01.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/26/2021] [Accepted: 01/30/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND More patients with ovarian cancer are being treated with poly(adenosine diphosphate-ribose) polymerase inhibitors because regulatory agencies have granted these drugs new approvals for a variety of treatment indications. However, poly(adenosine diphosphate-ribose) polymerase inhibitors are expensive. When administered as a maintenance therapy, these drugs may be administered for months or years. How much of this cost patients experience as out-of-pocket spending is unknown. OBJECTIVE This study aimed to estimate the out-of-pocket spending that patients experience during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment and to characterize which healthcare services account for that spending. STUDY DESIGN A retrospective cohort study was performed with a sample of patients with ovarian cancer treated between 2014 and 2017 with olaparib, niraparib, or rucaparib. Patients were identified using MarketScan, a health insurance claims database. All insurance claims during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment were collected. The primary outcome variable was the patients' out-of-pocket spending (copayment, coinsurance, and deductibles) during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment for the medication itself. Other outcomes of interest included out-of-pocket spending for other healthcare services, the types and frequency of other healthcare services used, health plan spending, the estimated proportion of patients' household income used each month for healthcare, and patients' out-of-pocket spending immediately before poly(adenosine diphosphate-ribose) polymerase inhibitor treatment. RESULTS We identified 503 patients with ovarian cancer with a median age of 55 years (interquartile range, 50-62 years); 83% of those had out-of-pocket spendings during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment. The median treatment duration was 124 days (interquartile range, 66-240 days). The mean out-of-pocket spending for poly(adenosine diphosphate-ribose) polymerase inhibitors was $305 (standard deviation, $2275) per month. On average, this accounted for 44.8% (standard deviation, 34.8%) of the patients' overall monthly out-of-pocket spending. The mean out-of-pocket spending for other healthcare services was $165 (standard deviation, $769) per month. Health plans spent, on average, $12,661 (standard deviation, $15,668) per month for poly(adenosine diphosphate-ribose) polymerase inhibitors and $7108 (standard deviation, $15,254) per month for all other healthcare services. The cost sharing for office visits, laboratory tests, and imaging studies represented the majority of non-poly(adenosine diphosphate-ribose) polymerase inhibitor treatment out-of-pocket spending. The average amount patients paid for all healthcare services per month during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment was $470 (standard deviation, $2407), which was estimated to be 8.7% of the patients' monthly household income. The mean out-of-pocket spending in the 12 months before poly(adenosine diphosphate-ribose) polymerase inhibitor treatment was $3110 (standard deviation, $6987). CONCLUSION Patients can face high out-of-pocket costs for poly(adenosine diphosphate-ribose) polymerase inhibitors, although the sum of cost sharing for other healthcare services used during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment is often higher. The spending on healthcare costs consumes a large proportion of these patients' household income. Patients with ovarian cancer experience high out-of-pocket costs for healthcare, both before and during poly(adenosine diphosphate-ribose) polymerase inhibitor treatment.
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Affiliation(s)
- Ross F Harrison
- Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shuangshuang Fu
- Cancer Prevention and Population Sciences Division, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charlotte C Sun
- Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hui Zhao
- Cancer Prevention and Population Sciences Division, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Karen H Lu
- Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sharon H Giordano
- Cancer Prevention and Population Sciences Division, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Larissa A Meyer
- Division of Surgery, Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Cancer Prevention and Population Sciences Division, Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Schultz BG, Tilton J, Jun J, Scott-Horton T, Quach D, Touchette DR. Cost-Effectiveness Analysis of a Pharmacist-Led Medication Therapy Management Program: Hypertension Management. Value Health 2021; 24:522-529. [PMID: 33840430 DOI: 10.1016/j.jval.2020.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/30/2020] [Accepted: 10/13/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Uncontrolled hypertension is a common cause of cardiovascular disease, which is the deadliest and costliest chronic disease in the United States. Pharmacists are an accessible community healthcare resource and are equipped with clinical skills to improve the management of hypertension through medication therapy management (MTM). Nevertheless, current reimbursement models do not incentivize pharmacists to provide clinical services. We aim to investigate the cost-effectiveness of a pharmacist-led comprehensive MTM clinic compared with no clinic for 10-year primary prevention of stroke and cardiovascular disease events in patients with hypertension. METHODS We built a semi-Markov model to evaluate the clinical and economic consequences of an MTM clinic compared with no MTM clinic, from the payer perspective. The model was populated with data from a recently published controlled observational study investigating the effectiveness of an MTM clinic. Methodology was guided using recommendations from the Second Panel on Cost-Effectiveness in Health and Medicine, including appropriate sensitivity analyses. RESULTS Compared with no MTM clinic, the MTM clinic was cost-effective with an incremental cost-effectiveness ratio of $38 798 per quality-adjusted life year (QALY) gained. The incremental net monetary benefit was $993 294 considering a willingness-to-pay threshold of $100 000 per QALY. Health-benefit benchmarks at $100 000 per QALY and $150 000 per QALY translate to a 95% and 170% increase from current reimbursement rates for MTM services. CONCLUSIONS Our model shows current reimbursement rates for pharmacist-led MTM services may undervalue the benefit realized by US payers. New reimbursement models are needed to allow pharmacists to offer cost-effective clinical services.
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Affiliation(s)
- Bob G Schultz
- Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA
| | - Jessica Tilton
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA
| | - Julie Jun
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA
| | - Tiffany Scott-Horton
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA
| | - Danny Quach
- Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA
| | - Daniel R Touchette
- Pharmacy Systems, Outcomes, and Policy, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA.
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21
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Tai TA, Latimer NR, Benedict Á, Kiss Z, Nikolaou A. Prevalence of Immature Survival Data for Anti-Cancer Drugs Presented to the National Institute for Health and Care Excellence and Impact on Decision Making. Value Health 2021; 24:505-512. [PMID: 33840428 DOI: 10.1016/j.jval.2020.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 09/18/2020] [Accepted: 10/18/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES This research aims to explore how often the National Institute for Health and Care Excellence (NICE) uses immature overall survival data to inform reimbursement decisions on cancer treatments, and the implications of this for resource allocation decisions. METHODS NICE cancer technology appraisals published between 2015 and 2017 were reviewed to determine the prevalence of using immature survival data. A case study was used to demonstrate the potential impact of basing decisions on immature data. The economic model submitted by the company was reconstructed and was populated first using survival data available at the time of the appraisal, and then using data from an updated data cut published after the appraisal concluded. The incremental cost-effectiveness ratios (ICERs) obtained using the different data cuts were compared. Probabilistic sensitivity analysis was undertaken and expected value of perfect information estimated. RESULTS Forty-one percent of NICE cancer technology appraisals used immature data to inform reimbursement decisions. In the case study, NICE gave a positive recommendation for a limited patient subgroup, with ICERs too high in the complete patient population. ICERs were dramatically lower when the final data cut was used, irrespective of the parametric model used to model survival. Probabilistic sensitivity analysis and expected value of perfect information may not have fully characterized uncertainty, because as they did not account for structural uncertainty. CONCLUSION Analyses of cancer treatments using immature survival data may result in incorrect estimates of survival benefit and cost-effectiveness, potentially leading to inappropriate funding decisions. This research highlights the importance of revisiting past decisions when updated data cuts become available.
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Affiliation(s)
- Ting-An Tai
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK.
| | - Nicholas R Latimer
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | | | - Zsofia Kiss
- Modelling and Simulation, Evidera, London, England, UK
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22
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Schartz D, Young E. Medicare Reimbursement Trends for Interventional Radiology Procedures: 2012 to 2020. J Vasc Interv Radiol 2021; 32:447-452. [PMID: 33454179 DOI: 10.1016/j.jvir.2020.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/02/2020] [Accepted: 12/05/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To investigate the reimbursement trends for interventional radiology (IR) procedures from 2012 to 2020. MATERIALS AND METHODS Reimbursement data from the Physician Fee Schedule look-up tool from the Centers for Medicare and Medicaid Services was compiled for 20 common IR procedures. The authors then investigated compensation trends after adjusting for inflation and from the unadjusted data between 2012 and 2020. RESULTS From 2012 to 2020, the mean unadjusted reimbursement for procedures decreased by -6.9% (95% confidence interval [CI], -13.5% to -0.34%). This trend was even more profound after inflation was taken into account, with a mean decline in adjusted reimbursement of -18.7% (95% CI, -24.4% to -12.9%) during the study period, with a mean yearly decline of -2.8%. The difference between the mean unadjusted and adjusted payment amounts was significant (P = .012). Similarly, linear regression analysis of the adjusted average reimbursement across all procedures revealed an overall decline from 2012 to 2020 (R2 = 0.97), indicating a steady decline in reimbursement over time. CONCLUSIONS In just under a decade, IR has experienced significant reimbursement cuts by Medicare, as demonstrated by both the unadjusted and inflation-adjusted payment trends. Knowledge of these trends is critically important for practicing interventional radiologists, leaders within the field, and legislators, who may play a role in formulating future reimbursement schedules for IR. These data may be used to help support more amenable reimbursement plans to sustain and facilitate the growth of the specialty.
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Affiliation(s)
- Derrek Schartz
- University of Rochester Medical Center, Department of Imaging Sciences, 601 Elmwood Avenue, Rochester, NY, 14642.
| | - Emily Young
- University of Rochester Medical Center, Department of Imaging Sciences, 601 Elmwood Avenue, Rochester, NY, 14642
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Affiliation(s)
- James M Perrin
- From the MassGeneral Hospital for Children and Harvard Medical School, Boston (J.M.P.); and the Urban Institute (G.M.K.) and the Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University (S.R.) - both in Washington, DC
| | - Genevieve M Kenney
- From the MassGeneral Hospital for Children and Harvard Medical School, Boston (J.M.P.); and the Urban Institute (G.M.K.) and the Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University (S.R.) - both in Washington, DC
| | - Sara Rosenbaum
- From the MassGeneral Hospital for Children and Harvard Medical School, Boston (J.M.P.); and the Urban Institute (G.M.K.) and the Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University (S.R.) - both in Washington, DC
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Li M, Schulz R, Chisholm-Burns M, Wang J, Lu ZK. Racial/ethnic and gender disparities in the use of erythropoiesis-stimulating agents and blood transfusions: cancer management under Medicare's reimbursement policy. J Manag Care Spec Pharm 2020; 26:1477-1486. [PMID: 33119441 PMCID: PMC10390950 DOI: 10.18553/jmcp.2020.26.11.1477] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Because of increasing safety concerns related to erythropoiesisstimulating agents (ESAs), the Centers for Medicare & Medicaid Services issued a Medicare reimbursement policy change regarding these medications in cancer patients. However, the policy established an absolute hemoglobin or hematocrit threshold to qualify for reasonable use but did not take the effect of gender and racial/ethnic differences in hemoglobin levels into consideration. OBJECTIVE: To examine disparities in the use of ESAs and blood transfusions after the Medicare policy change. METHODS: This study was an exploratory treatment effectiveness study and used the SEER-Medicare linked database. The treatment group was composed of cancer patients, whereas the control group was composed of chronic kidney disease patients. An interrupted time series design was used to examine the effect of the Medicare policy change on the use of ESAs and blood transfusions in different gender and racial/ethnic groups. RESULTS: The Medicare reimbursement policy change had an immediate effect on reducing the use of ESAs by 50% and increasing the use of blood transfusions by 10%. The immediate effect of the policy change on the monthly utilization of ESAs was 2 times greater in females (60% reduction) than males (30% reduction). Females had a 10% immediate increase in the monthly utilization of blood transfusions after the policy change. The policy change had the same immediate effect of a 50% reduction on the use of ESAs for Whites, African Americans/Blacks, and Latinos. African Americans/Blacks had a 50% immediate increase in the monthly utilization of blood transfusions after the policy change. CONCLUSIONS: Gender and racial/ethnic disparities were associated with the Medicare reimbursement policy change in the use of ESAs and blood transfusions. Thus, future policy considerations should keep biologic differences across gender and racial/ethnic groups in mind. DISCLOSURES: This study was funded by the SPARC Research Grant. The funder had no role in any part of this study. The authors have nothing to disclose.
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Affiliation(s)
- Minghui Li
- University of Tennessee Health Science Center College of Pharmacy, Memphis
| | - Richard Schulz
- University of South Carolina College of Pharmacy, Columbia
| | | | - Junling Wang
- University of Tennessee Health Science Center College of Pharmacy, Memphis
| | - Z. Kevin Lu
- University of South Carolina College of Pharmacy, Columbia
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Elliott J, DeJean D, Potter BK, Coyle D, Clifford T, McCoy B, Wells GA. Barriers in accessing medical cannabis for children with drug-resistant epilepsy in Canada: A qualitative study. Epilepsy Behav 2020; 111:107120. [PMID: 32570201 DOI: 10.1016/j.yebeh.2020.107120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/11/2020] [Accepted: 04/11/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The use of medical cannabis to treat drug-resistant epilepsy in children is increasing; however, there has been limited study of the experiences of parents with the current system of accessing medical cannabis for their children. METHODS In this qualitative study, we used a patient-centered access to care framework to explore the barriers faced by parents of children with drug-resistant epilepsy when trying to access medical cannabis in Canada. We conducted semistructured interviews with 19 parents to elicit their experiences with medical cannabis. We analyzed the data according to five dimensions of access, namely approachability, acceptability, availability, affordability, and appropriateness. RESULTS Parents sought medical cannabis as a treatment because of a perceived unmet need stemming from the failure of antiepileptic drugs to control their children's seizures. Medical cannabis was viewed as an acceptable treatment, especially compared with adding additional antiepileptic drugs. After learning about medical cannabis from the media, friends and family, or other parents, participants sought authorization for medical use. However, most encountered resistance from their child's neurologist to discuss and/or authorize medical cannabis, and many parents experienced difficulty in obtaining authorization from a member of the child's existing care team, leading them to seek authorization from a cannabis clinic. Participants described spending up to $2000 per month on medical cannabis, and most were frustrated that it was not eligible for reimbursement through public or private insurance programs. CONCLUSIONS Parents pursue medical cannabis as a treatment for their children's drug-resistant epilepsy because of a perceived unmet need. However, parents encounter barriers in accessing medical cannabis in Canada, and strategies are needed to ensure that children using medical cannabis receive proper care from healthcare professionals with training in epilepsy care, antiepileptic drugs, and medical cannabis.
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Affiliation(s)
- Jesse Elliott
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada.
| | | | - Beth K Potter
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Tammy Clifford
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Bláthnaid McCoy
- Department of Paediatrics, University of Toronto, Ontario, Canada; Division of Neurology, The Hospital for Sick Children Toronto, Toronto, Ontario, Canada
| | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
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Miller AL, Rathi VK, Burks CA, DeVore EK, Bergmark RW, Gray ST. Assessment of Gender Differences in Clinical Productivity and Medicare Payments Among Otolaryngologists in 2017. JAMA Otolaryngol Head Neck Surg 2020; 146:1-10. [PMID: 32745204 PMCID: PMC7393586 DOI: 10.1001/jamaoto.2020.1928] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/03/2020] [Indexed: 01/21/2023]
Abstract
Importance Women comprise an increasing proportion of the otolaryngology workforce. Prior studies have demonstrated gender-based disparity in physician practice and income in other clinical specialties; however, research has not comprehensively examined whether gender-based income disparities exist within the field of otolaryngology. Objective To determine whether diversity of practice, clinical productivity, and Medicare payment differ between male and female otolaryngologists and whether any identified variation is associated with practice setting. Design, Setting, and Participants Retrospective cross-sectional analysis of publicly available Medicare data summarizing payments to otolaryngologists from January 1 through December 31, 2017. Male and female otolaryngologists participating in Medicare in facility-based (FB; hospital-based) and non-facility-based settings (NFB; eg, physician office) for outpatient otolaryngologic care were included. Main Outcomes and Measures Number of unique billing codes (diversity of practice) per physician, number of services provided per physician (physician productivity), and Medicare payment per physician. Outcomes were stratified by practice setting (FB vs NFB). Results A total of 8456 otolaryngologists (1289 [15.2%] women; 7167 [84.8%] men) received Medicare payments in 2017. Per physician, women billed fewer unique codes (mean difference, -2.10; 95% CI, -2.46 to -1.75; P < .001), provided fewer services (mean difference, -640; 95% CI, -784 to -496; P < .001), and received less Medicare payment than men (mean difference, -$30 246 (95% CI, -$35 738 to -$24 756; P < .001). When stratified by practice setting, women in NFB settings billed 1.65 fewer unique codes (95% CI, -2.01 to -1.29; P < .001) and provided 633 fewer services (95% CI, -791 to -475; P < .001). In contrast, there was no significant gender-based difference in number of unique codes billed (mean difference, 0.04; 95% CI, -0.217 to 0.347; P = .81) or number of services provided (mean difference, 5.1; 95% CI, -55.8 to 45.6; P = .85) in the FB setting. Women received less Medicare payment in both settings compared with men (NFB: mean difference, -$27 746; 95% CI, -$33 502 to -$21 989; P < .001; vs FB: mean difference, -$4002; 95% CI, -$7393 to -$612; P = .02), although the absolute difference was lower in the FB setting. Conclusions and Relevance Female sex is associated with decreased diversity of practice, lower clinical productivity, and decreased Medicare payment among otolaryngologists. Gender-based inequity is more pronounced in NFB settings compared with FB settings. Further efforts are necessary to better evaluate and address gender disparities within otolaryngology.
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Affiliation(s)
- Ashley L. Miller
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Boston
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Vinay K. Rathi
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Boston
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Business School, Boston, Massachusetts
| | - Ciersten A. Burks
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Boston
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Elliana Kirsh DeVore
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Boston
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Regan W. Bergmark
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
- Patient-Reported Outcomes, Value and Experience (PROVE) Center, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Stacey T. Gray
- Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Boston
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
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Kasahara-Kiritani M, Chaturvedi A, Inagaki A, Wakamatsu A, Jung W. Budget impact analysis of long acting injection for schizophrenia in Japan. J Med Econ 2020; 23:848-855. [PMID: 32271640 DOI: 10.1080/13696998.2020.1754229] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Aims: To estimate the budgetary impact of providing additional reimbursement for long acting injections for schizophrenia patients in psychiatric hospital settings in Japan to improve patient outcomes in schizophrenia.Methods: Budget impact analysis of change in reimbursement policy using a prevalence-based model over a five-year time horizon. The results are reported as net change in expenditure and consequent cost/savings in Japanese yen at the time of analysis.Results: The budget impact analysis shows that an increase in reimbursement for LAIs could lead to cumulative savings of an estimated 36.6 billion JPY over five years. These savings result from a decrease in hospitalization costs and an increased usage of LAI (assumed to be 10%). Based on the sensitivity analysis, the saving estimates are most sensitive to change in market share of generic and branded oral antipsychotics.Limitations: Historical data were used to estimate the future costs of drug and hospitalization; however, it is not the best predictor of future, hence a source of potential bias. A good level of treatment adherence with oral antipsychotics was assumed, which is generally not the case; therefore, we might have overestimated the effectiveness of oral atypical antipsychotics. Additionally, the drug cost due to reimbursement might have also been overestimated because in clinical setting, the increase of LAI use may not have reached 10% of the market share. Lastly, patients' behavior was derived from models, which may have loosely approximated the reality.Conclusions: An additional reimbursement for the use of LAI in schizophrenia patients is likely to be cost neutral/cost saving and should be considered as a policy option to improve patient outcomes and budget sustainability.
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Affiliation(s)
| | - Amish Chaturvedi
- Health Economics & Price, Janssen Asia Pacific, Singapore, Singapore
| | - Ataru Inagaki
- Department of Education, College of Education, Psychology and Human Studies, Aoyama Gakuin University, Shibuya City, Japan
| | | | - Wonjoo Jung
- Integrated Market Access, Janssen Pharmaceutical K.K., Tokyo, Japan
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Ahmad S, Ramulu P, Akpek E, Deobhakta A, Klawe J. Gender-Specific Trends in Ophthalmologist Medicare Collections. Am J Ophthalmol 2020; 214:32-39. [PMID: 31926887 DOI: 10.1016/j.ajo.2019.12.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the factors influencing the Medicare collections disparity between male and female ophthalmologists. DESIGN Retrospective cohort study. METHODS The Medicare Provider Utilization and Payment Data from 2012-2015 were combined with the 2015 Physician Compare National Downloadable file and US Census data. Three complementary regression models were generated for number of patients seen, number of services performed per patient, and the amount collected per service. Predictor variables included gender, calendar year, geography, years since medical school graduation, and subspecialty. RESULTS After adjusting for age, geography, and subspecialty, women ophthalmologists collected 42% less as compared to male ophthalmologists, with the median male ophthalmologist out-earning the 75th-percentile female ophthalmologist across almost all age groups, practice categories, and geographic regions. Although women are entering more lucrative subspecialties (cataract and retina) at a higher rate than before, the percentage of women pursuing these subspecialties remains lower than that of men. CONCLUSIONS Compared with men, women ophthalmologists see fewer patients and have lower Medicare collections. The observed gender gap in collections was highly persistent across years in practice, subspecialty, and geographic region. Future studies are warranted to examine whether the observed gender collections gap results from structural inequities, social circumstances, or personal choices.
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Affiliation(s)
- Sumayya Ahmad
- Icahn School of Medicine of Mount Sinai, New York, New York, USA.
| | - Pradeep Ramulu
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Esen Akpek
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Avnish Deobhakta
- Icahn School of Medicine of Mount Sinai, New York, New York, USA
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Govaerts L, Simoens S, Van Dyck W, Huys I. Shedding Light on Reimbursement Policies of Companion Diagnostics in European Countries. Value Health 2020; 23:606-615. [PMID: 32389226 DOI: 10.1016/j.jval.2020.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 01/12/2020] [Accepted: 01/24/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Ensuring access to precision medicine has been an issue because in some European countries, desynchronized reimbursement decision-making occurs between the medicine and the companion diagnostic (CDx). This has resulted in cases in which precision medicine is reimbursed but not the CDx. In overcoming this issue, an alignment of the decision-making process for reimbursement between the 2 entities should be considered. As pharmaceutical reimbursement procedures are meticulously covered in the literature, we set out to systematically map in vitro diagnostic (IVD) reimbursement procedures and identify policies for aligning these procedures with the pharmaceutical reimbursement procedures. METHODS We selected 8 European countries for this analysis. For each country, we characterized the national benefit basket entailing the IVD medical acts in outpatient care, evaluated the procedure for inclusion, and identified alternative reimbursement practices for CDx. Targeted searches, using publicly accessible sources, were conducted to identify relevant reimbursement policies and laws. RESULTS We systematically describe the reimbursement process in 8 European countries. Alternative procedures for CDx reimbursement were identified in Belgium and Germany. Alternative policies attributed to the practice of precision medicine were identified in England and Italy. In France, some CDx are included in the "coverage with evidence" development program. Specifically, the health technology assessment agencies of France and England commented on the assessment of companion diagnostics and their clinical utility. CONCLUSION CDx reimbursement procedures have recently been implemented in some countries. This was seemingly done primarily to ensure access to the precision medicine and only secondary to the value they would provide.
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Affiliation(s)
- Laurenz Govaerts
- Department of Pharmaceutical and Pharmacological Sciences, Catholic University of Leuven, Leuven, Belgium; Healthcare Management Centre, Vlerick Business School, Ghent, Belgium.
| | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, Catholic University of Leuven, Leuven, Belgium
| | - Walter Van Dyck
- Healthcare Management Centre, Vlerick Business School, Ghent, Belgium
| | - Isabelle Huys
- Department of Pharmaceutical and Pharmacological Sciences, Catholic University of Leuven, Leuven, Belgium
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Deverka PA, Douglas MP, Phillips KA. Use of Real-World Evidence in US Payer Coverage Decision-Making for Next-Generation Sequencing-Based Tests: Challenges, Opportunities, and Potential Solutions. Value Health 2020; 23:540-550. [PMID: 32389218 PMCID: PMC7219085 DOI: 10.1016/j.jval.2020.02.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 08/05/2019] [Revised: 01/26/2020] [Accepted: 02/02/2020] [Indexed: 05/05/2023]
Abstract
OBJECTIVES Given the potential of real-world evidence (RWE) to inform understanding of the risk-benefit profile of next-generation sequencing (NGS)-based testing, we undertook a study to describe the current landscape of whether and how payers use RWE as part of their coverage decision making and potential solutions for overcoming barriers. METHODS We performed a scoping literature review of existing RWE evidentiary frameworks for evaluating new technologies and identified barriers to clinical integration and evidence gaps for NGS. We synthesized findings as potential solutions for improving the relevance and utility of RWE for payer decision-making. RESULTS Payers require evidence of clinical utility to inform coverage decisions, yet we found a relatively small number of published RWE studies, and these are predominately focused on oncology, pharmacogenomics, and perinatal/pediatric testing. We identified 3 categories of innovation that may help address the current undersupply of RWE studies for NGS: (1) increasing use of RWE to inform outcomes-based contracting for new technologies, (2) precision medicine initiatives that integrate clinical and genomic data and enable data sharing, and (3) Food and Drug Administration reforms to encourage the use of RWE. Potential solutions include development of data and evidence review standards, payer engagement in RWE study design, use of incentives and partnerships to lower the barriers to RWE generation, education of payers and providers concerning the use of RWE and NGS, and frameworks for conducting outcomes-based contracting for NGS. CONCLUSIONS We provide numerous suggestions to overcome the data, methodologic, infrastructure, and policy challenges constraining greater integration of RWE in assessments of NGS.
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Affiliation(s)
| | - Michael P Douglas
- Center for Translational and Policy Research on Personalized Medicine, Department of Clinical Pharmacy, University of California at San Francisco, San Francisco, CA, USA
| | - Kathryn A Phillips
- Center for Translational and Policy Research on Personalized Medicine, Department of Clinical Pharmacy, University of California at San Francisco, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy, University of California, San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer, University of California at San Francisco, San Francisco, CA, USA
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31
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Dhanda DS, Veenstra DL, Regier DA, Basu A, Carlson JJ. Payer Preferences and Willingness to Pay for Genomic Precision Medicine: A Discrete Choice Experiment. J Manag Care Spec Pharm 2020; 26:529-537. [PMID: 32223606 PMCID: PMC10390910 DOI: 10.18553/jmcp.2020.26.4.529] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although precision medicine using genetic information offers significant promise, its uptake and eventual clinical and economic impacts are uncertain. Health care payers will play an important role in evaluating evidence and costs to develop coverage and reimbursement policies. OBJECTIVE To elicit U.S. health care payer preference for genomic precision medicine to better understand trade-offs among clinical benefits, uncertainty, and cost. METHODS Using key informant interviewer discussions (N = 6 payers), we identified 6 key attributes of genetic tests important to payers: type of information the test provides (screening vs. treatment prediction), probability that the member has an informative genetic marker, expert agreement on changing medical care based on the marker, quality-of-life gains, life expectancy gains (with statistical uncertainty), and cost to the plan. We designed a stated preference discrete choice experiment using these attributes and administered a web survey to a sample of U.S. health care payers. We used effects coding and analyzed the data using an error component mixed logit modeling approach. RESULTS The survey response rate was 58% (150 participants completed the survey). Approximately 53% of respondents had previous experience evaluating genetic tests for reimbursement, and 85% had more than 5 years of health care decision-making experience. Payers valued improvements in quality of life the most (marginal willingness to pay [mWTP] of $1,513-$6,076), followed by medical expert agreement on the treatment change (mWTP of $2,881-$3,489). Payers placed a relatively lower value for genetic tests with lower marker probability (mWTP of $2,776 for highest marker probability to $423 for lowest marker probability). Payers mWTP was lowest for resolving uncertainty in quality of life (mWTP of $1,513-$2,031) and life expectancy gains ($536-$1,537). CONCLUSIONS Payers exhibited a strong preference for genetic tests that improved quality of life, had high expert agreement on changing medical care, and increased life expectancy. These findings suggest that payers will need evidence of clinical utility to support coverage and reimbursement of genomic precision medicine. DISCLOSURES This study was supported by a grant from the NIH Common Fund and NIA (1U01AG047109-01) via the Personalized Medicine Economics Research (PriMER) project. Unrelated to this study, Veenstra reports consulting fees from Bayer and Halozyme; Basu reports consulting fees from Salutis Consulting; and Reiger reports consulting fees from Roche. Carlson reports grants from Institute for Clinical and Economic Review, during the conduct of this study, and consulting fees from Bayer, Adaptive Biotechnologies, Allergan, Galderma, and Vifor Pharma, unrelated to this study.
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Affiliation(s)
- Devender S. Dhanda
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - David L. Veenstra
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - Dean A. Regier
- School of Population and Public Health, University of British Columbia, and Canadian Centre for Applied Research in Cancer Control (ARCC), BC Cancer, Vancouver, BC, Canada
| | - Anirban Basu
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - Josh J. Carlson
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
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Schell RC, Just DR, Levitsky DA. Predicted Lifetime Third-Party Costs of Obesity for Black and White Adolescents with Race-Specific Age-Related Weight Gain. Obesity (Silver Spring) 2020; 28:397-403. [PMID: 31970905 DOI: 10.1002/oby.22690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/24/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE There exists enormous variation in estimates of the lifetime cost of adolescent obesity by race. To justify policy measures to reduce obesity rates nationally in this demographic, the costs of obesity in late adolescence must first be discerned. Although several researchers have sought to quantify obesity's true cost, none has accounted for race-specific age-related weight gain, a vital component in producing an accurate estimate. METHODS This paper employs a Markov model of BMI category state changes separately for black and white males and females from age 18 to 75 applied to updated estimates of obesity's costs and effect on mortality to quantify the median lifetime cost of obesity at age 18. RESULTS This study found lower lifetime costs than previously, largely because of the dramatic gain in weight among normal-weight individuals, particularly black males, that occurs in early adulthood. CONCLUSIONS A substantial portion of obesity's prevalence, and therefore cost, for black males and females comes from age-related weight gain in early adulthood. This speaks to the persistent threat of obesity beyond adolescence for this demographic, and further research should focus on whether policy can modify the behaviors and environment through which and in which this sharp increase in weight occurs.
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Affiliation(s)
- Robert C Schell
- Charles H. Dyson School of Applied Economics and Management, Cornell University, Ithaca, New York, USA
| | - David R Just
- Charles H. Dyson School of Applied Economics and Management, Cornell University, Ithaca, New York, USA
| | - David A Levitsky
- College of Human Ecology, Cornell University, Ithaca, New York, USA
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Fenwick E, Steuten L, Knies S, Ghabri S, Basu A, Murray JF, Koffijberg HE, Strong M, Sanders Schmidler GD, Rothery C. Value of Information Analysis for Research Decisions-An Introduction: Report 1 of the ISPOR Value of Information Analysis Emerging Good Practices Task Force. Value Health 2020; 23:139-150. [PMID: 32113617 DOI: 10.1016/j.jval.2020.01.001] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [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: 01/03/2020] [Accepted: 01/05/2020] [Indexed: 05/22/2023]
Abstract
Healthcare resource allocation decisions made under conditions of uncertainty may turn out to be suboptimal. In a resource constrained system in which there is a fixed budget, these suboptimal decisions will result in health loss. Consequently, there may be value in reducing uncertainty, through the collection of new evidence, to make better resource allocation decisions. This value can be quantified using a value of information (VOI) analysis. This report, from the ISPOR VOI Task Force, introduces VOI analysis, defines key concepts and terminology, and outlines the role of VOI for supporting decision making, including the steps involved in undertaking and interpreting VOI analyses. The report is specifically aimed at those tasked with making decisions about the adoption of healthcare or the funding of healthcare research. The report provides a number of recommendations for good practice when planning, undertaking, or reviewing the results of VOI analyses.
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Affiliation(s)
| | | | - Saskia Knies
- National Health Care Institute (Zorginstituut Nederland), Diemen, The Netherlands
| | - Salah Ghabri
- French National Authority for Health, Paris, France
| | - Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - James F Murray
- Global Patient Outcomes and Real World Evidence, Eli Lilly and Company, Indianapolis, IN, USA
| | - Hendrik Erik Koffijberg
- Department of Health Technology & Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Mark Strong
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Gillian D Sanders Schmidler
- Duke-Margolis Center for Health Policy, Duke Clinical Research Institute and Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Claire Rothery
- Centre for Health Economics, University of York, York, England, UK
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Kannarkat JT, Good CB, Parekh N. Value-Based Pharmaceutical Contracts: Value for Whom? Value Health 2020; 23:154-156. [PMID: 32113619 DOI: 10.1016/j.jval.2019.10.009] [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] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/11/2019] [Accepted: 10/17/2019] [Indexed: 06/10/2023]
Abstract
Value-based pharmaceutical contracts (VBPCs) are performance-based reimbursement agreements between healthcare payers and pharmaceutical manufacturers in which the price, amount, or nature of reimbursement is tied to value-based outcomes. VBPCs are often complex, and the nature of who benefits and in what ways can be unclear. We discuss how VBPCs compare with value-based payer-provider arrangements in terms of performance-based reimbursements and alignment of incentives. In addition, we examine how VBPCs can affect costs, clinical outcomes, and access to medications. Because these contracts are unlikely to reduce costs in isolation, we recommend taking a patient-centered approach when developing VBPCs and tying VBPCs to more overarching payer drug cost reduction strategies.
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Affiliation(s)
- Joseph T Kannarkat
- Department of Politics and International Studies, University of Cambridge, Cambridge, England, UK.
| | - Chester B Good
- UPMC Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Insurance Services Division, Pittsburgh, PA, USA; University of Pittsburgh Division of General Internal Medicine, Pittsburgh, PA, USA
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Salm M, Wübker A. Do hospitals respond to decreasing prices by supplying more services? Health Econ 2020; 29:209-222. [PMID: 31755206 PMCID: PMC7004180 DOI: 10.1002/hec.3973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 10/19/2018] [Revised: 10/07/2019] [Accepted: 10/11/2019] [Indexed: 05/31/2023]
Abstract
Regulated prices are common in markets for medical care. We estimate the effect of changes in regulated reimbursement prices on volume of hospital care based on a reform of hospital financing in Germany. Uniquely, this reform changed the overall level of reimbursement-with increasing prices for some hospitals and decreasing prices for others-without directly affecting the relative prices for different groups of patients or types of treatment. Based on administrative data, we find that hospitals react to increasing prices by decreasing the service supply and to decreasing prices by increasing the service supply. Moreover, we find some evidence that volume changes for hospitals with different price changes are nonlinear. We interpret our findings as evidence for a negative income effect of prices on volume of care.
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Affiliation(s)
- Martin Salm
- Department of Econometrics and Operations ResearchTilburg UniversityThe Netherlands
| | - Ansgar Wübker
- Health DepartmentRWI – Leibniz‐Institute for Economics ResearchEssenGermany
- LSCR ‐ Leibniz Science Campus RuhrGermany
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Levi S, Alberto E, Urban D, Petrelli N, Tiesi G. Health-Care Workers' Perception of Reimbursement for Complex Surgical Oncology Procedures. Am Surg 2020; 86:140-145. [PMID: 32167057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Perception of physician reimbursement for surgical procedures is not well studied. The few existing studies illustrate that patients believe compensation to be higher than in reality. These studies focus on patient perceptions and have not assessed health-care workers' views. Our study examined health-care workers' perception of reimbursement for complex surgical oncology procedures. An anonymous online survey was distributed to employees at our cancer center with descriptions and illustrations of three oncology procedures-hepatectomy, gastrectomy, and pancreaticoduodenectomy. Participants estimated the Medicare fee and gave their perceived value of each procedure. Participants recorded their perception of surgeon compensation overall, both before and after revealing the Medicare fee schedule. Most of the 113 participants were physicians (33.6%) and nurses (28.3%). When blinded to the Medicare fee schedules, most felt that reimbursements were too low for all procedures (60-64%) and that surgeons were overall undercompensated (57%). Value predictions for each procedure were discordant from actual Medicare fee schedules, with overestimates up to 374 per cent. After revealing the Medicare fee schedules, 55 per cent of respondents felt that surgeons were undercompensated. Even among health-care workers, a large discrepancy exists between perceived and actual reimbursement. Revealing actual reimbursements did not alter perception on overall surgeon compensation.
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Bijlmakers L, Jansen M, Boer B, van Dijk W, Groenewoud S, Zwaap J, Helderman JK, van Exel J, Baltussen R. Increasing the Legitimacy of Tough Choices in Healthcare Reimbursement: Approach and Results of a Citizen Forum in The Netherlands. Value Health 2020; 23:32-38. [PMID: 31952671 DOI: 10.1016/j.jval.2019.07.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 04/25/2019] [Accepted: 07/08/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Some studies in the Netherlands have gauged public views on principles for healthcare priority setting, but they fall short of comprehensively explaining the public disapproval of several recent reimbursement decisions. OBJECTIVE To obtain insight into citizens' preferences and identify the criteria they would propose for decisions pertaining to the benefits package of basic health insurance. METHODS Twenty-four Dutch citizens were selected for participation in a Citizen Forum, which involved 3 weekends. Deliberations took place in small groups and in plenary, guided by 2 moderators, on the basis of 8 preselected case studies, which participants later compared and prioritized under the premise that not all treatments can or need to be reimbursed. Participants received opportunities to inform themselves through written brochures and live interactions with 3 experts. RESULTS The Citizen Forum identified 16 criteria for inclusion or exclusion of treatments in the benefits package; they relate to the condition (2 criteria), treatment (11 criteria), and individual characteristics of those affected by the condition (3 criteria). In most case studies, it was a combination of criteria that determined whether or not participants favored inclusion of the treatment under consideration in the benefits package. Participants differed in their opinion about the relative importance of criteria, and they had difficulty in operationalizing and trading off criteria to provide a recommendation. CONCLUSIONS Informed citizens are prepared to make and, to a certain extent, capable of making reasoned choices about the reimbursement of health services. They realize that choices are both necessary and possible. Broad public support and understanding for making tough choices regarding the benefits package of basic health insurance is not automatic: it requires an investment.
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Affiliation(s)
- Leon Bijlmakers
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Maarten Jansen
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bert Boer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Wieteke van Dijk
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stef Groenewoud
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jan-Kees Helderman
- Institute for Management Research, Radboud University, Nijmegen, The Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Rob Baltussen
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Hasegawa M, Komoto S, Shiroiwa T, Fukuda T. Formal Implementation of Cost-Effectiveness Evaluations in Japan: A Unique Health Technology Assessment System. Value Health 2020; 23:43-51. [PMID: 31952673 DOI: 10.1016/j.jval.2019.10.005] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 10/27/2019] [Accepted: 10/31/2019] [Indexed: 05/22/2023]
Abstract
In April 2019, Japan formally introduced health technology assessment (HTA) and, more specifically, a cost-effectiveness analysis, to inform healthcare decision making, mainly when it comes to the pricing of new technologies. This article provides an overview of this new policy, which was implemented formally after a pilot program. In the fiscal year (FY) 2012, discussions on cost-effectiveness assessments were initiated in Japan. After 7 years of deliberations, a cost-effectiveness assessment was implemented formally in April 2019. In Japan, the cost-effectiveness analysis has been used to inform price adjustments of healthcare technologies, although it has not yet been used for decision making on insurance coverage. Selection criteria were established because not all drugs and medical devices could be evaluated owing to a shortage of experts. Exclusion criteria have also been applied to prevent access restriction. The scope of the evaluation's price adjustment target is limited to part of the product price. If the cost per quality-adjusted life-year (QALY) threshold falls below ¥5 million per QALY, the price adjustment rate changes stepwise according to the cost per QALY. In addition to price reduction, a price-raising scheme has also been implemented for scenarios where products are evaluated to be highly cost-effective and innovative. This article describes the first formally implemented HTA system in Japan. Although it is too early to make any conclusions about its effect, the Japan-specific context makes this system unique. To fully understand the opportunities and challenges of the new system, it is vital that Japan accumulates experience with this system and develops human resources in health economic evaluation.
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Affiliation(s)
- Masataka Hasegawa
- Medical Economic Division, Health Insurance Bureau, Ministry of Health, Labour and Welfare, Tokyo, Japan.
| | - Shigekazu Komoto
- Medical Economic Division, Health Insurance Bureau, Ministry of Health, Labour and Welfare, Tokyo, Japan
| | - Takeru Shiroiwa
- Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, Saitama, Japan
| | - Takashi Fukuda
- Center for Outcomes Research and Economic Evaluation for Health, National Institute of Public Health, Saitama, Japan
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Hodgkin D, Garnick DW, Horgan CM, Busch AB, Stewart MT, Reif S. Is it feasible to pay specialty substance use disorder treatment programs based on patient outcomes? Drug Alcohol Depend 2020; 206:107735. [PMID: 31790980 PMCID: PMC6941579 DOI: 10.1016/j.drugalcdep.2019.107735] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 11/06/2019] [Accepted: 11/09/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Some US payers are starting to vary payment to providers depending on patient outcomes, but this approach is rarely used in substance use disorder (SUD) treatment. PURPOSE We examine the feasibility of applying a pay-for-outcomes approach to SUD treatment. METHODS We reviewed several relevant literatures: (1) economic theory papers that describe the conditions under which pay-for-outcomes is feasible in principle; (2) description of the key outcomes expected from SUD treatment, and the measures of these outcomes that are available in administrative data systems; and (3) reports on actual experiences of paying SUD treatment providers based on patient outcomes. RESULTS The economics literature notes that when patient outcomes are strongly influenced by factors beyond provider control and when risk adjustment performs poorly, pay-for-outcomes will increase provider financial risk. This is relevant to SUD treatment. The literature on SUD outcome measurement shows disagreement on whether to include broader outcomes beyond abstinence from substance use. Good measures are available for some of these broader constructs, but the need for risk adjustment still brings many challenges. Results from two past payment experiments in SUD treatment reinforce some of the concerns raised in the more conceptual literature. CONCLUSION There are special challenges in applying pay-for-outcomes to SUD treatment, not all of which could be overcome by developing better measures. For SUD treatment it may be necessary to define outcomes more broadly than for general medical care, and to continue conditioning a sizeable portion of payment on process measures.
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Affiliation(s)
- Dominic Hodgkin
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, USA.
| | - Deborah W Garnick
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, USA
| | - Constance M Horgan
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, USA
| | - Alisa B Busch
- McLean Hospital, and the Department of Health Care Policy, Harvard Medical School, USA
| | - Maureen T Stewart
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, USA
| | - Sharon Reif
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, USA
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Oliva-Moreno J, Puig-Junoy J, Trapero-Bertran M, Epstein D, Pinyol C, Sacristán JA. Economic Evaluation for Pricing and Reimbursement of New Drugs in Spain: Fable or Desideratum? Value Health 2020; 23:25-31. [PMID: 31952669 DOI: 10.1016/j.jval.2019.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 05/23/2019] [Accepted: 06/21/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND The economic evaluation of healthcare technologies has become in many countries a basic tool for reimbursement, pricing and purchasing decisions. OBJECTIVE The objective of this article is to examine the institutional, legal, and political factors that have impeded the application of economic evaluation and the criterion of efficiency in the process of pricing and reimbursement of new medicines in Spain. METHODS Narrative description of the current institutional framework for the use of economic evaluation in pricing and reimbursement in Spain, legal and policy framework in the field of evaluation of new medicines, and stakeholder initiatives and policies related to the use of economic evaluation outside of the pricing and reimbursement process. RESULTS Spain has an institutional framework created and established over the last years that could have facilitated a formal use of economic evaluation in the process of pricing and reimbursement. Nevertheless, the real use of economic evaluation at the central or regional level is still unknown, although application of the efficiency criterion, linking to cost-effectiveness, has been clearly required by Spanish laws and regulations at the national level. We highlight a certain degree of moral hazard from the central government that is not directly responsible for the budget impact of reimbursement and pricing decisions. There are currently a number of ongoing initiatives in the field of economic evaluation by various agents, but they remain uncoordinated. CONCLUSIONS Poor governance at the highest level of decision making is the main reason for the lack of interest in economic evaluation. A profound political change, supported by transparency and accountability, is required before the criterion of efficiency can be fully considered in the process of pricing and reimbursement of new medicines in Spain.
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Affiliation(s)
- Juan Oliva-Moreno
- Department of Economic Analysis and Finance, Universidad de Castilla La-Mancha, Toledo, Spain.
| | - Jaume Puig-Junoy
- Barcelona School of Management, Universitat Pompeu Fabra, Barcelona, Spain
| | - Marta Trapero-Bertran
- Institut de Recerca en Avaluació i Polítiques Públiques, Universitat Internacional de Catalunya, Barcelona, Spain
| | - David Epstein
- Department of Applied Economics, University of Granada, Granada, Spain
| | - Carme Pinyol
- Market Access Department, Pierre Fabre Ibérica, Barcelona, Spain; ISPOR Spain Chapter, Barcelona, Spain
| | - José Antonio Sacristán
- Department of Epidemiology and Public Health, Universidad Autonoma de Madrid, Madrid, Spain; Medical Department, Lilly, Madrid, Spain
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Berkemeier F, Whaley C, Robinson JC. Increasing Divergence in Drug Prices Between the United States and Germany After Implementation of Comparative Effectiveness Analysis and Collective Price Negotiations. J Manag Care Spec Pharm 2019; 25:1310-1317. [PMID: 31778624 PMCID: PMC10397913 DOI: 10.18553/jmcp.2019.25.12.1310] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Payers and purchasers in the United States seek to moderate drug prices and align them with the incremental clinical benefit offered by individual medications; some policymakers have proposed linking U.S. prices to an index of prices paid in other nations. The German health care system resembles that of the United States in featuring multiple private payers but differs in featuring a highly coordinated process of comparative clinical assessment and price negotiations for drugs. OBJECTIVES To (a) measure trends in prices paid for physician-administered drugs in Germany before and after the mandate for comparative effectiveness assessment and price negotiations in 2011 and (b) compare them with price trends for the same drugs in the United States. METHODS This study observed trends in the prices paid for 80 physician-administered drugs, which account for approximately half of Medicare Part B drug spending. Quarterly data covering 2004-2018 were obtained for Germany from the Lauer-Taxe database, which contains net prices paid by all German payers. U.S. data were obtained from the Centers for Medicare & Medicaid Services, which publishes net prices paid by private U.S. payers and the Medicare Part B program. These data contain the net prices actually paid after accounting for all discounts and rebates, not merely the manufacturer's list price. Statistical analyses were conducted with multivariable difference-in-differences regression methods. RESULTS Before implementation in Germany of comparative effectiveness analysis and collective price negotiations, net U.S. prices for physician-administered drugs averaged 29.2% higher (95% CI = 26.6%-31.7) than those in Germany. After implementation of comparative effectiveness assessments and price negotiations in 2011, the divergence between U.S. and German prices increased another 28.9% (95% CI = 23.7%-34.3%). CONCLUSIONS Commercial health insurers and Medicare pay significantly higher net prices for physician-administered drugs than do insurers in Germany, with the divergence growing after the mandate in Germany that new drugs be subject to comparative effectiveness assessment and collective price negotiations. The experience of Germany may be of special value for the current U.S. debate over pharmaceutical pricing reform, given the demographic, economic, and health system similarities between the 2 nations. DISCLOSURES This study was supported by the Commonwealth Fund, New York. The sponsor had no role in the study design, conduct, interpretation, or writing up of results. Whaley reports a grant from the National Institute on Aging, unrelated to this work. The other authors have no potential conflicts of interest to report.
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Abstract
BACKGROUND Pharmaceuticals make an important contribution to people's health. Medicines, however, are frequently not used appropriately. Improving the use of medicines can improve health outcomes and save resources. On the other hand, regulatory and educational policies may have unintended effects on health and costs. OBJECTIVES To assess the effects of pharmaceutical educational and regulatory policies targeting prescribers on medicine use, healthcare utilisation, health outcomes and costs (expenditures). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two trial registries in March 2018 and several other databases between 2014 and 2018. We reviewed the reference lists of included studies and other relevant reviews, contacted authors of relevant reviews and studies to identify additional studies, and did a citation search for all included studies using ISI Web of Science (searched 05 January 2016). SELECTION CRITERIA Randomised trials, non-randomised trials, interrupted time series studies, repeated measures studies and controlled before‒after studies of policies regulating who can prescribe medicines and other policies targeted at prescribers. We included in this category monitoring and enforcement of restrictions, generic prescribing, programmes to implement treatment guidelines, system-wide policies regarding monitoring medicine safety, and legislated or mandatory continuing education or quality improvement specifically targeted at prescribing. We defined 'policies' in this review as laws, rules, financial and administrative orders made by governments, non-governmental organisations or private insurers. We excluded interventions applied at the level of a single facility. For us to include a study, it had to include an objective measure of at least one of the following outcomes: medicine use, healthcare utilization, health outcomes, or costs. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts and reference lists of relevant reports, assessed full-text studies for inclusion, extracted data, and assessed risk of bias and certainty of the evidence (GRADE). For all the steps in the above process we resolved disagreements by discussion. MAIN RESULTS We identified two studies that met our selection criteria: a controlled interrupted time series study evaluating a regulatory policy involving the monitoring of prescribing of benzodiazepines; and a controlled before‒after study of an educational policing involving mailed educational materials on prescribing for physicians and Health Maintenance Organization (HMO) members as well as an intervention to regulate drug reimbursement. We are uncertain about the effects on medicine use of a regulatory policy involving the monitoring of prescribing with triplicate prescriptions, compared with no regulatory intervention (very low certainty evidence). We are also uncertain about the effects on medicine use, assessed through doctors' prescribing, and costs of an educational policy involving mailed educational materials on prescribing for physicians and HMO members, compared to no educational intervention or an intervention to regulate drug reimbursement (very low certainty evidence). Neither of the included studies measured healthcare utilization, health outcomes, or additional costs, if any, to patients. AUTHORS' CONCLUSIONS We are uncertain of the effects of educational or regulatory policies targeting prescribers due to very limited evidence of very low certainty. The impacts of these policies therefore need to be evaluated rigorously using appropriate study designs. Evaluations are needed across a range of settings, including low- and middle-income countries, and across different types of prescribers and medicines.
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Affiliation(s)
- Fatima Suleman
- University of KwaZulu‐NatalDiscipline of Pharmaceutical Sciences, School of Health SciencesPrivate Bag X54001DurbanKZNSouth Africa4000
| | - Espen Movik
- Norwegian Institute of Public HealthOsloNorway
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Goupil B, Balusson F, Naudet F, Esvan M, Bastian B, Chapron A, Frouard P. Association between gifts from pharmaceutical companies to French general practitioners and their drug prescribing patterns in 2016: retrospective study using the French Transparency in Healthcare and National Health Data System databases. BMJ 2019; 367:l6015. [PMID: 31690553 PMCID: PMC6830500 DOI: 10.1136/bmj.l6015] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the association between gifts from pharmaceutical companies to French general practitioners (GPs) and their drug prescribing patterns. DESIGN Retrospective study using data from two French databases (National Health Data System, managed by the French National Health Insurance system, and Transparency in Healthcare). SETTING Primary care, France. PARTICIPANTS 41 257 GPs who in 2016 worked exclusively in the private sector and had at least five registered patients. The GPs were divided into six groups according to the monetary value of the received gifts reported by pharmaceutical, medical device, and other health related companies in the Transparency in Healthcare database. MAIN OUTCOME MEASURES The main outcome measures were the amount reimbursed by the French National Health Insurance for drug prescriptions per visit (to the practice or at home) and 11 drug prescription efficiency indicators used by the National Health Insurance to calculate the performance related financial incentives of the doctors. Doctor and patient characteristics were used as adjustment variables. The significance threshold was 0.001 for statistical analyses. RESULTS The amount reimbursed by the National Health Insurance for drug prescriptions per visit was lower in the GP group with no gifts reported in the Transparency in Healthcare database in 2016 and since its launch in 2013 (no gift group) compared with the GP groups with at least one gift in 2016 (-€5.33 (99.9% confidence interval -€6.99 to -€3.66) compared with the GP group with gifts valued at €1000 or more reported in 2016) (P<0.001). The no gift group also more frequently prescribed generic antibiotics (2.17%, 1.47% to 2.88% compared with the ≥€1000 group), antihypertensives (4.24%, 3.72% to 4.77% compared with the ≥€1000 group), and statins (12.14%, 11.03% to 13.26% compared with the ≥€1000 group) than GPs with at least one gift between 2013 and 2016 (P<0.001). The no gift group also prescribed fewer benzodiazepines for more than 12 weeks (-0.68%, -1.13% to -0.23% compared with the €240-€999 group) and vasodilators (-0.15%, -0.28% to -0.03% compared with the ≥€1000 group) than GPs with gifts valued at €240 or more reported in 2016, and more angiotensin converting enzyme (ACE) inhibitors compared with all ACE and sartan prescriptions (1.67%, 0.62% to 2.71%) compared with GPs with gifts valued at €1000 or more reported in 2016 (P<0.001). Differences were not significant for the prescription of aspirin and generic antidepressants and generic proton pump inhibitors. CONCLUSION The findings suggest that French GPs who do not receive gifts from pharmaceutical companies have better drug prescription efficiency indicators and less costly drug prescriptions than GPs who receive gifts. This observational study is susceptible to residual confounding and therefore no causal relation can be concluded. TRIAL REGISTRATION OSF register OSF.IO/8M3QR.
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Affiliation(s)
- Bruno Goupil
- Department of General Medicine, University of Rennes 1, Rennes, France
| | - Frédéric Balusson
- EA 7449 (Pharmaco-epidemiology and Health Services Research) REPERES, Univ Rennes, Rennes University Hospital, Rennes, France
| | - Florian Naudet
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), F-35000 Rennes, France
- Department of Adult Psychiatry, Rennes University Hospital, Rennes, France
| | - Maxime Esvan
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), F-35000 Rennes, France
| | - Benjamin Bastian
- Department of General Medicine, University of Rennes 1, Rennes, France
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), F-35000 Rennes, France
| | - Anthony Chapron
- Department of General Medicine, University of Rennes 1, Rennes, France
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), F-35000 Rennes, France
| | - Pierre Frouard
- Department of General Medicine, University of Rennes 1, Rennes, France
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Geenen JW, Boersma C, Klungel OH, Hövels AM. Accuracy of budget impact estimations and impact on patient access: a hepatitis C case study. Eur J Health Econ 2019; 20:857-867. [PMID: 30953216 PMCID: PMC6652171 DOI: 10.1007/s10198-019-01048-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/28/2019] [Indexed: 05/08/2023]
Abstract
BACKGROUND High budget impact (BI) estimates of new drugs limit access to patients due to concerns regarding affordability and displacement effects. The accuracy and methodological quality of BI analyses are often low, potentially mis-informing reimbursement decision making. Using hepatitis C as a case study, we aim to quantify the accuracy of the BI predictions used in Dutch reimbursement decision-making and to characterize the influence of market-dynamics on actual BI. METHODS We selected hepatitis C direct-acting antivirals (DAAs) that were introduced in the Netherlands between January 2014 and March 2018. Dutch National Health Care Institute (ZIN) BI estimates were derived from the reimbursement dossiers. Actual Dutch BI data were provided by FarmInform. BI prediction accuracy was assessed by comparing the ZIN BI estimates with the actual BI data. RESULTS Actual BI, from 1 Jan 2014 to 1 March 2018, was €248 million whilst the BI estimates ranged from €388-€510 million. The latter figure represents the estimated BI for the reimbursement scenario that was adopted, implying a €275 million overestimation. Absent incorporation of timing of regulatory decisions and inadequate correction for the introduction of new products were main drivers of BI overestimation, as well as uncertainty regarding the patient population size and the impact of the final reimbursement decision. DISCUSSION BI in reimbursement dossiers largely overestimated actual BI of hepatitis C DAAs. When BI analysis is performed according to existing guidelines, the resulting more accurate BI estimates may lead to better informed reimbursement decisions.
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Affiliation(s)
- Joost W Geenen
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584CG, Utrecht, The Netherlands
| | - Cornelis Boersma
- Division of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
- Health-Ecore, 1e Hogeweg 196, 3701 HL, Zeist, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584CG, Utrecht, The Netherlands.
| | - Anke M Hövels
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584CG, Utrecht, The Netherlands
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Saing S, van der Linden N, Hayward C, Goodall S. Why is There Discordance between the Reimbursement of High-Cost 'Life-Extending' Pharmaceuticals and Medical Devices? The Funding of Ventricular Assist Devices in Australia. Appl Health Econ Health Policy 2019; 17:421-431. [PMID: 30906972 DOI: 10.1007/s40258-019-00470-x] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
New health technologies often yield health benefits, but often at a high cost. In Australia, the processes for public reimbursement of high-cost pharmaceuticals and medical devices are different, potentially resulting in inequity in support for new therapies. We explore how reimbursement is different for medical devices compared with pharmaceuticals, including whether higher cost-effectiveness thresholds are accepted for pharmaceuticals. A literature review identified the challenges of economic evaluations for medical devices compared with pharmaceuticals. We used the ventricular assist device as a case study to highlight specific features of medical device funding in Australia. We used existing guidelines to evaluate whether ventricular assist devices would fulfil the requirements for the "Life-Saving Drugs Program", which is usually reserved for expensive life-extending pharmaceutical treatments of serious and rare medical conditions. The challenges in conducting economic evaluations of medical devices include limited data to support effectiveness, device-operator interaction (surgical experience) and incremental innovations (miniaturisation). However, whilst high-cost pharmaceuticals may be funded by a single source (federal government), the funding of high-cost devices is complex and may be funded via a combination of federal, state and private health insurance. Based on the Life-Saving Drugs Program criteria, we found that ventricular assist devices could be funded by a similar mechanism to that which funds high-cost life-extending pharmaceuticals. This article highlights the complexities of medical device reimbursement. Whilst differences in available evidence affect the evaluation process, differences in funding methods contribute to inequitable reimbursement decisions between medical devices and pharmaceuticals.
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Affiliation(s)
- Sopany Saing
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia.
| | - Naomi van der Linden
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Christopher Hayward
- Heart Failure and Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia
- Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - Stephen Goodall
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia
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Dankó D, Blay JY, Garrison LP. Challenges in the value assessment, pricing and funding of targeted combination therapies in oncology. Health Policy 2019; 123:1230-1236. [PMID: 31337514 DOI: 10.1016/j.healthpol.2019.07.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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] [Received: 09/06/2018] [Revised: 04/24/2019] [Accepted: 07/10/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND The use of targeted combination therapy (TCT) is becoming the standard of care in oncology as cancers are attacked through multiple inhibition mechanisms. TCTs pose a budget challenge to health systems and an economic return challenge for companies developing them. METHODS We conducted a systematic literature review to identify challenges specific to TCTs and reviewed publicly available reports by health technology assessment and pricing and reimbursement bodies. We synthesized our findings into a problem map. RESULTS AND DISCUSSION Challenges and policy solutions linked to TCTs remain almost fully unexplored; we identified few resources that explicitly addressed TCTs. Contributors to the budget challenge are found at different layers; they and include static willingness-to-pay (WTP) for TCTs and inefficiencies in managing prices of backbone therapies. Economic return challenges are related to payer-imposed restrictions, peculiarities of TCT development, and conflicting incentives of pharmaceutical companies that own constituent therapies. Consequences are delayed or restricted patient access to TCTs, disincentives for research and development, and fewer life years gained. CONCLUSIONS Multiple issues will lead to the unsustainability of funding systems and possible conflict between stakeholders around access to TCTs. To manage these, new value assessment and attribution methodologies, modified trial designs and differentiated WTP thresholds can be considered in ways that are customized to the characteristics of different health systems.
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Affiliation(s)
- D Dankó
- Ideas & Solutions, Kelenhegyi út 16B, 1118 Budapest, Hungary.
| | - J-Y Blay
- Centre Léon Bérard, Lyon, France
| | - L P Garrison
- University of Washington, Department of Pharmacy, Seattle (WA), United States
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Espinosa-González AB, Delaney BC, Marti J, Darzi A. The impact of governance in primary health care delivery: a systems thinking approach with a European panel. Health Res Policy Syst 2019; 17:65. [PMID: 31272472 PMCID: PMC6609383 DOI: 10.1186/s12961-019-0456-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 04/23/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Enhancing primary health care (PHC) is considered a policy priority for health systems strengthening due to PHC's ability to provide accessible and continuous care and manage multimorbidity. Research in PHC often focuses on the effects of specific interventions (e.g. physicians' contracts) in health care outcomes. This informs narrowly designed policies that disregard the interactions between the health functions (e.g. financing and regulation) and actors involved (i.e. public, professional, private), and their impact in care delivery and outcomes. The purpose of this study is to analyse the interactions between PHC functions and their impact in PHC delivery, particularly in providers' behaviour and practice organisation. METHODS Following a systems thinking approach with data obtained through a three-round European Delphi process, we developed a framework that captures (1) the interactions between PHC functions by analysing correlations between PHC characteristics of participating countries, (2) how actors involved shaped these interactions by identifying the actor and level of devolution (or fragmentation) in the analysis, and (3) their potential effect on care delivery by exploring panellists' opinions. RESULTS A total of 59 panellists from 24 countries participated in the first round and 76% of the initial panellists (22 countries) completed the last round. Findings show correlations between governance, financing and regulation based on their degree of decentralisation. This is supported by panellists, who agreed that the actors involved in health system governance determine the type of PHC financing (e.g. ownership or payment mechanisms) and regulation (e.g. competences or gatekeeping), and this may impact care delivery and outcomes. Governance in our framework is an overarching function whose impact in PHC delivery is mediated through the degree of decentralisation (both delegation and devolution) of PHC financing and regulation. CONCLUSIONS The application of this approach in policy implementation assessment intends to uncover limitations due to poor accountability and commitment to shared objectives. Its application in the design of health strategies helps foresee (and prevent) undesired or unexpected effects of narrow interventions. This approach will assist in the development of the realistic and long-term policies required for health systems strengthening.
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Affiliation(s)
- Ana Belén Espinosa-González
- Centre for Health Policy, IGHI, Department of Surgery and Cancer, Imperial College London, Room 1035, 10th Floor Queen Elizabeth Queen Mother Wing, St Mary’s Hospital South Wharf Road, London, W2 1NY United Kingdom
| | - Brendan C. Delaney
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Joachim Marti
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Waitzberg R, Quentin W, Daniels E, Perman V, Brammli-Greenberg S, Busse R, Greenberg D. The 2010 expansion of activity-based hospital payment in Israel: an evaluation of effects at the ward level. BMC Health Serv Res 2019; 19:292. [PMID: 31068156 PMCID: PMC6505257 DOI: 10.1186/s12913-019-4083-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 04/09/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In 2010, Israel intensified its adoption of Procedure-Related Group (PRG) based hospital payments, a local version of DRG (Diagnosis-related group). PRGs were created for certain procedures by clinical fields such as urology, orthopedics, and ophthalmology. Non-procedural hospitalizations and other specific procedures continued to be paid for as per-diems (PD). Whether this payment reform affected inpatient activities, measured by the number of discharges and average length of stay (ALoS), is unclear. METHODS We analyzed inpatient data provided by the Ministry of Health from all 29 public hospitals in Israel. Our observations were hospital wards for the years 2008-2015, as proxies to clinical fields. We investigated the impact of this reform at the ward level using difference-in-differences analyses among procedural wards. Those for which PRG codes were created were treatment wards, other procedural wards served as controls. We further refined the analysis of effects on each ward separately. RESULTS Discharges increased more in the wards that were part of the control group than in the treatment wards as a group. However, a refined analysis of each treated ward separately reveals that discharges increased in some, but decreased in other wards. ALoS decreased more in treatment wards. Difference-in-differences results could not suggest causality between the PRG payment reform and changes in inpatient activity. CONCLUSIONS Factors that may have hampered the effects of the reform are inadequate pricing of procedures, conflicting incentives created by other co-existing hospital-payment components, such as caps and retrospective subsidies, and the lack of resources to increase productivity. Payment reforms for health providers such as hospitals need to take into consideration the entire provider market, available resources, other - potentially conflicting - payment components, and the various parties involved and their interests.
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Affiliation(s)
- Ruth Waitzberg
- The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, JDC Hill, P.O.B. 3886, 91037 Jerusalem, Israel
- Department of Health Systems Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
| | - Wilm Quentin
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Elad Daniels
- The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, JDC Hill, P.O.B. 3886, 91037 Jerusalem, Israel
| | - Vadim Perman
- Planning, Budgeting and Pricing division, Ministry of Health, Jerusalem, Israel
| | - Shuli Brammli-Greenberg
- The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, JDC Hill, P.O.B. 3886, 91037 Jerusalem, Israel
- School of Public Health, University of Haifa, Haifa, Israel
| | - Reinhard Busse
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Dan Greenberg
- Department of Health Systems Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Diaz-Perez MDJ, Hanover R, Sites E, Rupp D, Courtemanche J, Levi E. Producing comparable cost and quality results from all-payer claims databases. Am J Manag Care 2019; 25:e138-e144. [PMID: 31120710 PMCID: PMC6613782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To describe how all-payer claims databases (APCDs) can be used for multistate analysis, evaluating the feasibility of overcoming the common barrier of a lack of standardization across data sets to produce comparable cost and quality results for 4 states. This study is part of a larger project to better understand the cost and quality of healthcare services across delivery organizations. STUDY DESIGN Descriptive account of the process followed to produce healthcare quality and cost measures across and within 4 regional APCDs. METHODS Partners from Colorado, Massachusetts, Oregon, and Utah standardized the calculations for a set of cost and quality measures using 2014 commercial claims data collected in each state. This work required a detailed understanding of the data sets, collaborative relationships with each other and local partners, and broad standardization. Partners standardized rules for including payers, data set elements, measure specifications, SAS code, and adjustments for population differences in age and gender. RESULTS This study resulted in the development of a Uniform Data Structure file format that can be scaled across populations, measures, and research dimensions to provide a consistent method to produce comparable findings. CONCLUSIONS This study demonstrates the feasibility of using state-based claims data sets and standardized processes to develop comparable healthcare performance measures that inform state, regional, and organizational healthcare policy.
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Affiliation(s)
| | | | | | | | | | - Emily Levi
- Network for Regional Healthcare Improvement, 500 Southborough Dr, Ste 106, South Portland, ME 04106.
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