Actual Reimbursement Research Articles

Weekly touch calls with high-risk cohort of patients with commercial Medicare Advantage to reduce avoidable hospital admissions.

282 Background: Patients who have been diagnosed with cancer have an increased risk of complications and potential hospitalization instances. Those in more advanced age groups have an additional risk, especially those of the age group of 65 and higher. Avoidable hospitalizations increase the total cost of care and decrease patient quality of life during treatment. Methods: To reduce potentially avoidable hospital admissions, patients enrolled in a commercial insurance contract were reviewed weekly for a high-risk potential. Criteria for high-risk inclusion included: Any patient >75 years of age receiving treatment; Any patient receiving chemotherapy/radiation combination therapy; Any patient with the following diagnosis: Metastatic lung cancer, Metastatic pancreatic cancer, Multiple myeloma, Breast cancer, Prostate cancer with multiple HCC; Any patient receiving: Cisplatin, Adriamycin, Taxanes, Ifosfimide, Doxorubicin, or Carbo with AUC 4 or greater; Any patient that has had one visit to ER/hospital during the program During the recording period, the high-risk list of patients was reviewed weekly. Before the weekend, each patient identified was contacted by phone by a registered nurse for a weekly “touch call” to address side effects, treatment questions, complications, or concerns. Patients were reminded to contact the practice first when a non-life-threatening concern occurs. Results: The program began on April 1, 2020, with a baseline admission rate of 1.8%. At the conclusion of the program on March 31st, 2023, this cohort of patients had a 53.1% reduction in admission rates from their baseline. Additionally, the reimbursement PPPM was under target yearly, concluding at $65.64, $14.46 below the target amount of $80. The cohort consisted of a range of 36-75 patients per quarter, program total of 185 enrolled patients. Conclusions: Identifying potentially high-risk patients and conducting weekly, personalized calls before the weekend reduced the overall avoidable admission rate. Timely identification and support for high-risk patients reduces the total cost of care and potentially increases patient care quality during treatment. Period Practice Inpatient Admits per 1000 Benchmark Target Target Difference Targeted Reimbursement PPPM Actual Reimbursement PPPM Reimbursement Difference 2020 Q1 1.8% 754 378 $80 2020 Q4 -17.9% 680 233 $80 $75.56 -$4.44 2021 Q4 -31.5% 622 3 $80 $66.66 -$13.34 2022 Q4 -51.3% 602 -235 $80 $65.64 -$14.46

Patient Perception of Physician Reimbursement by Medicare for Artificial Urinary Sphincter Placement.

Patient perceptions of physician reimbursement commonly differ from actual reimbursement. This study aims to improve health care cost transparency and trust between patients, physicians, and the health care system by evaluating patient perceptions of Medicare reimbursement for artificial urinary sphincter (AUS) placement. We identified patients who underwent AUS placement at a single institution from 2014 to 2023. After obtaining informed consent, we administered a telephone survey to ask patients about their perceptions of Medicare reimbursement for AUS surgery and the amount they felt the physician should be compensated. Sixty-four patients were enrolled and completed the survey. On average, patients estimated Medicare physician reimbursement to be $18,920, 25 times the actual average procedure reimbursement. Once informed that the actual amount was $757.52, 97% of respondents felt that the reimbursement was "somewhat lower" (13%) or "much lower" (84%) than what they considered fair. The average amount that patients felt the physician should be paid was $8,844, 12 times the actual average procedure reimbursement. Fifty-four percent of patients estimated their physician's reimbursement to be higher than what they later reported as being "fair," representing a presurvey belief that their physician was overpaid. Patient perceptions of physician reimbursement for AUS are vastly different than the actual amount paid. The discordance between patient perception and actual reimbursement could impact how patients view health care costs and the relationship with their provider.

Antenatal cardiotocography in primary midwife-led care: a budget impact analysis

ObjectivesIn many countries, the healthcare sector is dealing with important challenges such as increased demand for healthcare services, capacity problems in hospitals and rising healthcare costs. Therefore, one of the...

Analysis of affordability differences for rare diseases in China: a comparison across disease types and regions

BackgroundChina has implemented policies to make rare diseases more affordable. While previous studies evaluated overall affordability, few have examined affordability differences across regions and disease types. Given the vastness of China and varying medical policies across cities, this study assesses the affordability of rare diseases based on China’s First List of Rare Diseases (CFLRD), National Reimbursement Drug List (NRDL), and outpatient chronic and special disease policies in each prefecture.MethodSix rare diseases were selected and the average annual treatment cost of all relevant drugs in NRDL was calculated for each disease. Based on the WHO/HAI standardized approach, the study analyzed 289 cities with outpatient chronic and special disease policies, measured the security levels by the actual reimbursement ratio of Basic Medical Insurance (BMI) and affordability by the ratio of individual expenses after reimbursement to the annual disposable income of urban residents in the province. The security levels and affordability differences across disease types and provinces were analyzed using the Mann-Whitney U test and the K-W test.ResultThe affordability of rare diseases varied significantly on the disease types and annual treatment cost. Diseases with an annual treatment cost below 100 000 yuan are affordable to all prefectures even with low reimbursement rates, while those with a higher treatment cost were not affordable in at least 80% of prefectures even though the reimbursement ratio is high. The affordability of the same disease varies significantly across provinces and municipalities. Outpatient chronic and special diseases insurance and critical illness insurance, and the inconsistencies between them, result in regional differences.ConclusionAlthough China has made progress in improving the affordability of rare diseases, significant differences persist between cities and diseases. The study suggests the optimization of the BMI system and explores independent funds and innovative insurance models to enhance the affordability of rare diseases, particularly those with extremely high treatment costs.

The effect of urban-rural resident basic medical insurance on physical health of the rural older adult in China.

Urban-Rural Resident Basic Medical Insurance (URRBMI) is an important system for effectively transferring disease risks to the rural older adult. As China experiences rapid aging, maintaining the physical health of the rural older adult is key to achieving the goal of healthy aging. The study explores the impact of URRBMI on physical health of the rural older adult in China using the Chinese Longitudinal Healthy Longevity Survey (CLHLS) data in 2018. Ordinary least square models were used to analyze the relationship between URRBMI and physical health of the rural older adult, and we used instrumental variable method to address the potential endogenous problem. We find that URRBMI greatly improves physical health of the rural older adult. The heterogeneity analysis indicates that URRBMI contributes more significantly to the rural older adult in eastern areas and the advanced rural older adult. The results also suggested that URRBMI improves physical health of the rural older adult through increasing life satisfaction and enhancing the timeliness of medical services. This study implies that we need to further improve the participation rate, increase the actual reimbursement ratio and increase financial subsidies for URRBMI in central and western areas, and further integrate the distribution of medical resources to promote physical health of the rural older adult.

Analysis of the current status and influencing factors of cross-regional hospitalization services utilization by basic medical insurance participants in China - taking a central province as an example.

The geographically uneven distribution of healthcare resources has resulted in a dramatic increase of cross-regional hospitalization services in China. The over-use of cross-regional hospitalization services may hinder the utilization and improvement of local hospitalization services. It is of great practical significance to study the utilization of cross-regional hospitalization services and its influencing factors in order to effectively allocate medical resources and guide patients to seek medical treatment rationally. Therefore, this study aims to analyze the current situation and influencing factors of the utilization of cross-regional hospitalization services by patients insured by basic medical insurance in China. A total of 3,291 cross-provincial inpatients were randomly selected in a central province of China in 2020. The level of medical institutions, hospitalization expenses and actual reimbursement rate were selected as indicators of hospitalization service utilization. Exploratory factor analysis was used to assess the dimensionality of influencing factors and reduce the number of variables, and binomial logistic regression analysis and multiple linear regression analysis to explore the influencing factors of the utilization of cross-regional hospitalization services. The proportion of cross-provincial inpatients choosing tertiary hospitals was the highest with average hospitalization expenses of 24,662 yuan and an actual reimbursement rate of 51.0% on average. Patients insured by Urban Employees' Basic Medical Insurance (UEBMI) were more frequently (92.9% vs. 88.5%) to choose tertiary hospitals than those insured by Urban and Rural Residents' Basic Medical Insurance (URRBMI), and their average hospitalization expenses (30,727 yuan) and actual reimbursement rate (68.2%) were relatively higher (p < 0.001). The factor "income and security," "convenience of medical treatment" and "disease severity" had significant effects on inpatients' selection of medical institution level, hospitalization expenses and actual reimbursement rate, while the factor "demographic characteristics" only had significant effects on hospitalization expenses and actual reimbursement rate. Cross-provincial inpatients choose tertiary hospitals more frequently, and their financial burdens of medical treatment are heavy. A variety of factors jointly affect the utilization of cross-provincial hospitalization services for insured patients. It is necessary to narrow down the gap of medical treatment between UEBMI and URRBMI patients, and make full use of high-quality medical resources across regions.

Rehabilitation complexity scale and reimbursement of in-hospital pulmonary rehabilitation.

The use of case-based reimbursement for medical rehabilitation is greatly discussed. The investigators explored the relationship between disability and reimbursement opportunities in individuals with respiratory diseases undergoing in-hospital pulmonary rehabilitation (PR), considering the correlation (if any) between the Rehabilitation Complexity Scale (RCS-E v13) scores used at admission and the actual reimbursement. This study is part of a larger prospective multicenter study conducted by eight Pulmonary Rehabilitation Units in Italy. Here, investigators considered only data from the Lombardy Region. On January 30th or February 28th, 2023, participants were allocated according to the main DRG into 4 groups [tracheostomized/ventilated (TX/V), chronic respiratory failure (CRF), COPD, and miscellaneous group]. We recorded anthropometrics, diagnosis, international outcome measures, and calculated admission and discharge RCS-E v13 scores and hospital stay reimbursement according to the healthcare system (HS). Three hundred and sixteen participants were evaluated. Patients were elderly, in the majority of cases with CRF, presenting comorbidities, disability, dyspnea, and reduced effort tolerance. At admission, RCS-E v13 showed an average moderate value of complexity. The median (IQR) HS reimbursement/stay was different among groups. RCSE v13 evaluated at admission was weakly (r=0.3471), but significantly related to the HS reimbursement/stay (p<0.0001) mainly due to TX/V and miscellaneous subgroups, while no relationship was found for COPD and CRF patients. After PR, all outcome measures improved significantly in all groups (p<0.001 for all). Higher RCS-E v13 scores at admission did not correspond to a proper amount of reimbursement, being this latter under- or over-estimated if compared to needs assessed by RCS-E v13. RCS-E v13 at discharge decreased for all subgroups (range from -6 to -11) reaching a low value of complexity. The RCS-E v13 disability score does not fully mirror the HS reimbursement for patients undergoing inhospital PR.

Dental Protraction Versus Surgery for Cleft Lip and Palate: A Budget Impact Analysis.

Class III malocclusion for individuals with cleft lip and palate has historically been managed with surgery. Orthodontic protraction is a noninvasive alternative that may be associated with lower costs. This analysis investigated the budget impact of protraction versus surgery from an institutional perspective. Using a decision tree, analysis was conducted using costs derived from Medicaid reimbursement codes and using actual institutional reimbursement. Probabilities of success, failure, and complications were based on a clinical trial comparing the 2 treatment modalities. One-way and probabilistic sensitivity analyses tested the robustness of results to model parameters. Based on Medicaid fee schedules and failure rates requiring additional surgery, the total cost of protraction was $79,506 versus $172,807 for surgery, resulting in $93,302 cost-savings per patient. The cost and probability of surgery success, as well as the cost of surgery failure and repeat surgery, had the largest impact on these cost-savings. Probabilistic sensitivity analysis showed cost-savings of nearly $92,000 or higher in >50% of simulations. This study showed that protraction is associated with lower costs than surgery and may present a cost-effective alternative to surgery in eligible, appropriate patients.

Healthcare costs for patients with rare diseases: Evidence from China.

Rare diseases cause a huge financial burden to countless patients and families. It is an important public health issue that requires widespread attention. This study analyzes medical expenses composition and the change in trends of out-of-pocket (OOP) expenses for patients with Amyotrophic lateral sclerosis (ALS) and explores the factors influencing these changes. Data were obtained from the Chinese Medical Insurance Department database from 2018 to 2020, including 857 patients with ALS in 60 cities across 30 provinces. We used descriptive methods to analyse the baseline characteristics and medical expenses of outpatients and inpatients with ALS. And we used quantile regression to analyse the differences in patient OOP ratio and the factors influencing them. In China, 80.3% of ALS patients chose tertiary hospitals, with an annual direct medical cost of 11,339.7 RMB per patient and an OOP ratio of 41.6%. The annual medical cost for outpatients was 345.1 RMB per patient, with an OOP ratio of 36.7%. The annual medical cost for inpatients was 28,139.8 RMB per patient, with an OOP ratio of 41.7%. Compared to outpatients, inpatients had higher medical costs but lower actual reimbursement rates. The OOP ratio of ALS patients decreased, then increased over time. And the OOP ratio was influenced by medical institution, medical insurance, and age (p<0.05). Patients who chose tertiary hospitals, those who were covered by the urban resident basic medical insurance and younger patients had relatively higher OOP ratio. In recent years, although China has begun to pay attention to the rights and interests of patients with rare diseases, the government has provided some healthcare security to patients with rare diseases. However, the level of medical insurance coverage was still low, the equity of protection was still insufficient and the financial burden on patients was high. Therefore, the government should further improve the healthcare system to provide full life-cycle and affordable healthcare services to patients with rare diseases.

Comparing Changes in Medicare Reimbursement for Radiation Oncology and Medical Oncology (2010-2020)

A recent study found that radiation oncology (RO) has seen significant declines in Medicare reimbursement (MCR) from 2010-2019. While it is presumed that other cancer subspecialties have seen decreasing MCR, to our knowledge, there are no studies directly comparing changes in MCR between RO and other oncology subspecialties. In this study, we analyze changes in MCR from 2010-2020 for both RO and medical oncology. We hypothesized that the declines in MCR will be similar between the two fields. The publicly available Physician/Supplier Procedure Summary (PSPS) database was used for all years from 2010-2020. All reimbursement for providers with primary provider codes 92 (RO) and 83 and 90 (heme/onc and medical oncology, respectively) were analyzed. For the 150 most highly-reimbursed HCPCS codes for each specialty in 2010, the total allowed charge for each code was corrected for inflation and then divided by the number of submitted claims to calculate average MCR per code for each year. For each code and each specialty, the 2020 billing frequency was multiplied by the calculated average reimbursement per claim in a given year to calculate what the reimbursement would have been in that year using 2020 dollars and utilization rates (projected reimbursement). The projected reimbursement was summed for all HCPCS codes in each year for each specialty to calculate an aggregate MCR for that specialty for that year. This aggregate MCR was then compared with the actual 2020 reimbursement for that basket of codes to calculate the change in MCR over time. Both medical and radiation oncology saw decreases in projected vs. actual MCR from 2010-2020 for this basket of services (Table). Adjusting for inflation and utilization, RO MCR declined by $0.7 billion (B) (-29.0%) from 2010 to 2020 and by $0.2B (-10.5%) from 2015 to 2020 while medical oncology MCR declined by $0.8B (-14.7%) from 2010-2020 and by $0.4B (-6.6%) from 2015-2020. The average decrease per year in projected vs. actual reimbursement for RO was 2.9% (2010 to 2015) and 1.05% (2015 to 2020) and for medical oncology was 1.5% (2010-2015) and 0.7% (2015-2020), respectively. Adjusting for inflation, Medicare reimbursement for a large array of services has declined for both medical oncology and RO from 2010 - 2020. Contrary to our hypothesis, RO reported a 97% greater relative decline in reimbursement compared with medical oncology from 2010 - 2020. Significant decreases in reimbursement to both fields and their potential implications on patient care and access to care should be considered by policymakers while shifting towards an episode-based Alternative Payment Model and when considering further cuts to Medicare reimbursement.

Editor's Spotlight/Take 5: The Price-Quality Mismatch: Are Negotiated Prices for Total Joint Arthroplasty Associated With Hospital Quality in a Large California Health System?

Editor's Spotlight/Take 5: The Price-Quality Mismatch: Are Negotiated Prices for Total Joint Arthroplasty Associated With Hospital Quality in a Large California Health System?

Utilization and performance of long-term care system for older people with disabilities and dementia in Zhejiang Province, China.

To explore changes in performance, weaknesses, and utilization of the long-term care (LTC) system for older people with disabilities and dementia (OPWDD) in Zhejiang Province, China, thereby providing a reference for decision-making amid a progressively aging population. A performance evaluation model of the LTC system for OPWDD was constructed using three dimensions: input, process, and outcome. Performance indicators and trends were calculated based on data collected from statistical yearbooks, documents, and work reports of the Bureau of Statistics and other government departments in Zhejiang Province, China, published in 2015-2021. Significant improvements were observed in most LTC performance indicators for OPWDD, such as input, process, and outcome, with notable enhancements in fairness, accessibility, and affordability of LTC services. By 2021, there were 6.20 nursing and rehabilitation beds in medical institutions and 3.77 general practitioners per 1,000 people aged 65 and above, up 144.14% and 13.73%, respectively, from 2015. The rate of health management for older people was 70.91%, representing a 10.33% increase from 2015. The actual reimbursement ratio of hospitalization expenses covered by basic medical insurance for older people rose 7.05%, from 72.76% in 2015 to 77.89% in 2021. Social security satisfaction rose 12.4%, from 71.3% in 2015 to 83.7% in 2021. Certain indicators, however, showed no significant improvement and tended to decline, such as the number of beds at older care institutions and caregivers per 1,000 people aged 65 and over. It is imperative to further balance the allocation of care resources, using a people-centered and integrated LTC system. The proportion of rehabilitation and nursing beds for older people should be consistently increased to effectively alleviate the shortage of care beds. Furthermore, a talent incentive policy should be improved to train caregivers and provide whole-person and whole-life course care based on OPWDD needs.

Reimbursement Trends in Reduction Mammoplasty: A Single-Center Analysis of Insurance Reimbursements From 2012 to 2021.

Medicare reimbursement for plastic surgery procedures increased by 2% while inflation increased by 19% in the past decade. Given increasing national breast reduction case volume and the negative impact decreased reimbursements have on surgeon well-being, we sought to evaluate actual surgeon reimbursements for bilateral breast reduction over a decade. A retrospective review was performed including all identifiable breast reduction procedures (Current Procedure Terminology 19318) performed at a tertiary academic hospital between October 2011 and September 2021 (fiscal year 2012-2021). The annual number of patients undergoing breast reduction, the payor, and average yearly amounts reimbursed were evaluated and trended over time. Percent change from Medicare average yearly reimbursements was evaluated and trended over time. All values were adjusted to 2021 US dollars. During our study period, there were 486 bilateral breast reduction procedures with 36 outlier payments; therefore, 450 reimbursements were included in the study. There were 5 payors, and the average adjusted reimbursement amount was $2418.74 ± $1123.83. All private payors had significantly higher average reimbursement than Medicare ( P < 0.0001), and Medicare was the only payor with significant decrease in reimbursement over time (-$58.58 per year, 95% confidence interval, -$110.80 to -$6.33, P = 0.033). Our data demonstrate that a difference exists between public and private payors for bilateral breast reduction procedures. Private payor reimbursements outpaced inflation. Medicare is an unreliable benchmark that may indirectly lead to declining reimbursements over time.

Accuracy of Surgeon and Patient Estimated Cost and Reimbursement for Common General Surgical Operations and Benefit of Centers for Medicare and Medicaid Services Price Transparency Rules.

On January 1, 2021, the Centers for Medicare and Medicaid Services implemented a hospital price transparency rule. Consumerism as a means of reducing healthcare expenditure is predicated on informed consumers making discrete choices. For 10 months, immediately after a preoperative clinic visit at an academic medical center, patients and their surgeons were surveyed regarding their estimation of hospital cost and hospital reimbursement for the upcoming operation. Responses were compared to average institutional cost (fiscal year 2019) for Medicare patients undergoing a laparoscopic approach for each operation. We calculated the difference between actual reimbursement and cost with patients' estimates and actual reimbursement and cost with surgeons' estimates. Sixty-six questionnaires were collected from patients who underwent laparoscopic operations, that included cholecystectomy (n = 20), inguinal hernia (n = 17), umbilical hernia repair (n = 6), ventral hernia repair (n = 6), incisional hernia (n = 6), hiatal hernia repair (n = 1), and lipoma or cyst excision (n = 10). Patients' estimates of hospital cost exceeded actual hospital cost by a median of $4,502 and were less than hospital reimbursement by a median of $1,834. Surgeon estimates for direct cost were $825 less than hospital direct cost and $1,659 less than hospital reimbursement. Patients as well as their surgeons do not estimate healthcare cost or remuneration accurately and therefore will be ineffective change agents in reducing surgical spending based on price transparency without further education of both parties. Patients consistently overestimated surgical cost while surgeons consistently underestimated surgical cost and reimbursement. It is likely that better-informed surgeons and patients are necessary prerequisites for Centers for Medicare and Medicaid Services price transparency rules to be effective in reducing Medicare expenditures in surgery.

Medical center reimbursement for vascular procedures has increased over time while professional reimbursement has declined

ObjectiveThe United States healthcare system uses different methods for assigning medical center reimbursement (MCR) and professional reimbursement (PR) for clinical services. We hypothesized that PR has not increased proportionately to MCR for the same vascular services. MethodsMCR and PR were compared for commonly performed inpatient and outpatient vascular procedures between 2012 and 2021. MCR was calculated using the Medicare inpatient prospective payment system and outpatient prospective payment system. MCR is based on the Centers for Medicare and Medicaid Services definition and criteria for comorbidities and the occurrence of complications; thus, changes in MCR were reported as a range based on the degree of comorbidities and complications using the Diagnosis Related Group. PR was calculated using the Medicare physician fee schedule, which assigns a numerical work relative value unit to each surgical service, with final compensation determined by an annually adjusted conversion factor to yield a final dollar amount. The expected reimbursement based on the observed inflation during the study period using the consumer price index was calculated and compared to the actual reimbursement. ResultsFrom 2012 to 2021, MCR for inpatient procedures increased 20% to 26% for carotid endarterectomy, 24% to 27% for femoral endarterectomy, 24% to 27% for femoropopliteal bypass with vein, 14% to 19% for thoracic endovascular aortic repair, and 15% for aortobifemoral bypass. During the same period, PR increased 3.3% for carotid endarterectomy but decreased for femoral endarterectomy (−5.0%), femoropopliteal bypass (−4.6%), thoracic endovascular aortic repair (−4.2%), and aortobifemoral bypass (−5.0%). Comparing the expected reimbursement, adjusted for inflation, to the actual reimbursement, PR experienced a 10% to 17% reduction but MCR outpaced inflation by 3.7% to 10%. For outpatient procedures, MCR increased 117% for tibial angioplasty, 24% for superficial femoral artery (SFA) stenting, 62% for tunneled dialysis catheter (TDC) insertion, and 24% for iliac stenting but decreased 0.43% for arteriovenous fistula (AVF) creation and 7.6% for radiofrequency ablation (RFA). PR increased 0.91% for SFA stenting but decreased for tibial angioplasty (−17%), AVF creation (−6.4%), TDC insertion (−7.1%), iliac stenting (−3.8%), and RFA (−22%). Comparing the expected reimbursement, adjusted for inflation, to the actual reimbursement, PR experienced a 13% to 32% reduction. In contrast, MCR outpaced inflation 7.5% to 88% for tibial angioplasty, SFA stenting, TDC insertion, and iliac stenting but experienced a reduction for AVF (−13%) and RFA (−19%). ConclusionsMCR for commonly performed vascular procedures has increased and outpaced inflation. In contrast, PR for these same services has decreased across all procedure types. This decrease in PR was exacerbated when adjusted for inflation. This inequity in the reimbursement methods between MCR and PR poses a threat to the viability of the physician workforce. Either changes to the reimbursement methods or a reallocation of reimbursement to physicians are imperative to sustain physician practices.

The time and financial ramifications of providing services for retinopathy of prematurity at a single inner-city institution in the United States: a pilot study

Retinopathy of prematurity (ROP) is a sight-threatening disease that requires strict, scheduled screening and timely treatment. Examining infants in the neonatal intensive care unit (NICU) confers an added burden for ophthalmologists whose practices are predominantly outpatient. We sought to evaluate the time required for ROP services and to approximate compensation to better understand the implications of providing this crucial service. The ROP coordinator tracked the time ophthalmologists spent providing ROP services at two NICUs (2018-2020). Estimated revenue was calculated using Medicaid Current Procedural Terminology codes. Total ophthalmologist time was from NICU arrival to departure; travel time was estimated as 45 minutes. The ophthalmologists cumulatively spent on average 98 and 108 hours yearly for screening only (SO) and screening plus treatment (ST), respectively; this increased to 164 and 181 hours yearly with travel time, respectively. Estimated annual Medicaid physician reimbursements were $15,246 ($156/hour) for SO and $19,184 for ST ($177/hour). Actual annual physician reimbursements were $39,655 ($405/hour) for SO and $53,385 for ST ($492/hour). With travel time, reimbursements decreased by about 40%. A hypothetical full-time ROP practice would generate annual physician salaries of $204,732 for SO and $232,807 for ST. With travel time, this decreases to $122,452 and $139,379, respectively. Performing ROP services requires substantial time, especially when including travel among facilities. This study highlights the extensive requirements for the critical task of decreasing ROP blindness.

The monetary costs of pediatric upper urinary tract stone disease: Analysis in a contemporary United States cohort

The prevalence of upper urinary tract stone disease (USD) in the United States is rising among both adults and children. Studies on the contemporary economic burden of USD management in the pediatric population are lacking. To comprehensively analyze the economic impact of USD in a contemporary United States pediatric cohort, and to evaluate drivers of cost. A retrospective cohort study of pediatric patients (aged 0-17), diagnosed with USD between 2011 and 2018 were identified from PearlDiver-Mariner, an all-payer claims database containing diagnostic, treatment and prescription data provided in all treatment settings. Relevant International Classification of Disease (ICD-9 and ICD-10) and Current Procedural Terminology (CPT) codes were used for identification, and only patients with claims recorded for at least one year before and after entry of a diagnosis code for USD were selected (N=10,045). Patients were stratified into those undergoing operative vs. non-operative management and for each patient, total 1-year healthcare costs following USD diagnosis, including same day and non-same day encounters, were analyzed. Factors associated with increased spending, as well as economic trends were analyzed. Overall, 8498 (85%) patients were managed non-operatively, while 1547 (15%) underwent a total of 1880 procedural interventions. Total overall cost was $117.1 million, while median annual expenditure was $15.8 million. Proportion of spending for outpatient, inpatient and prescription services was 52%, 32% and 16%, respectively (Table). Outpatient management accounted for 67% of overall spending. The proportion of patients managed non-operatively increased significantly over time, in parallel with spending for non-operative care. Comorbidity burden, treatment year and geographic region were among predictors of costs. Our study is the first to report actual insurance reimbursements for pediatric USD management using actual reimbursement data, examined across all treatment settings. We found that majority of the costs were for outpatient services and for non-operative management, with a rising tendency toward non-operative management over time. Regional variation in expenditures was evident. Specific reasons underlying these observed patterns could not directly be discerned from our dataset, but merit further investigation. Non-operative and outpatient management for pediatric USD are increasingly common, resulting in parallel shifts in spending. Notably, 52% of overall spending was for outpatient care. These insights into the contemporary economic burden of pediatric USD could provide value in shaping future healthcare policy.

Actual management costs of patients with non-valvular atrial fibrillation treated with percutaneous left atrial appendage closure or oral anticoagulation

AimsComparing actual management costs in patients with non-valvular atrial fibrillation (AF) treated with percutaneous left atrial appendage closure (LAAC) or OAC only. Methods and resultsPatients undergoing percutaneous LAAC and AF patients treated with OAC only were matched for gender, age, and diagnosis related groups (DRG) clinical complexity level (CCL). Costs for cardiovascular outpatient clinic visits and hospitalizations were derived from the actual reimbursement records.Between 1/2012 and 12/2016, 8478 patients were referred: 7801 (92%) managed with OAC and 677 (8%) with percutaneous LAAC. Matching resulted in 558 patients (279 per group) for final analysis. Age was 74.9 ± 7.5 years, 244 were female (43.7%), and DRG CCL was 1.8 ± 1.1.Annualized management cost before percutaneous LAAC was € 3110 (IQR: € 1281–8127). After 4.5 ± 1.4 years follow-up, annualized management cost was € 1297 (IQR: € 607–2735) in OAC patients and € 1013 (IQR: € 0–4770) in patients after percutaneous LAAC (p = 0.003). Percutaneous LAAC was the strongest independent determinant to reduce follow-up costs (B = −0.8; CI: −1.09 ̶̶̶̶̶ -0.6; p < 0.0001). Estimated 3-year survival was 92% in percutaneous LAAC and 90% in OAC patients (p = 0.7). ConclusionPercutaneous LAAC significantly reduces management costs. Management costs are significantly higher for patients treated with only OAC compared to patients after percutaneous LAAC. In spite of their complex comorbid profile, percutaneous LAAC patients show a follow-up survival rate similar to patients solely treated with OAC. Future studies are necessary to investigate the potential net economic and clinical benefit of percutaneous LAAC in patients treated with OAC only.

Hospital response to a case-based payment scheme under regional global budget: The case of Guangzhou in China

Both developed and developing countries have been searching for effective provider payment methods to control health expenditure inflation. In January 2018, Guangzhou city in Southern China initiated an innovative case-based payment method for inpatient care under the framework of the regional global budget, called the Diagnosis-Intervention Packet (DIP). Contrary to the usual practice of the case-based payment, the DIP payment scheme includes a price adjustment mechanism through which the actual reimbursement for each case is determined ex post. By employing the difference-in-difference method and data from Beijing and Guangzhou, we evaluate the effects of the DIP payment on medical expenditures and provider behaviors. We find that total health expenditures per case have decreased by 3.5%, which is mainly driven by a substantial decrease in drug expenditures. It suggests that the DIP payment reform achieved a short-term success in slowing down the growth of health expenditures. However, the average point volume per case for local inpatients with social health insurance coverage has increased by more than 3%, primarily due to an increasing likelihood of performing at least one procedure. We also find suggestive evidence of up-coding. All these results suggest that healthcare providers have taken strategic behaviors in response to the DIP payment. These findings hold lessons for the ongoing payment reforms in China and other countries.

Actual management costs of patients with non-valvular atrial fibrillation treated with percutaneous left atrial appendage closure or oral anticoagulation

Abstract Background Left atrial appendage closure (LAAC) is a safe and efficacious alternative to oral anticoagulation (OAC) therapy in patients with non-valvular atrial fibrillation (AF) who are at high risk for both stroke and bleeding. Data on cost-effectiveness of LAAO are limited and existing studies on the topic are based on simulation model approaches rather than on real-world costs. Purpose To compare actual management costs in patients with non-valvular AF treated with LAAC or OAC only. Methods Percutaneous LAAC was performed only in patients with at least one cerebral thromboembolic event, one major bleeding episode while under OAC, and with absolute contraindication to prolonged OAC. AF patients undergoing percutaneous LAAC were matched with AF patients treated with OAC only. Matching variables were gender, age, and Diagnosis Related Groups (DRG) clinical complexity level. Costs for cardiovascular outpatient clinic visits and hospitalizations were derived from the actual medical claims and reimbursement records. Data were prospectively collected and retrospectively analyzed. Results Between 1/2012 and 12/2016, 8478 patients with non-Valvular AF were referred to our institution: 7801 (92%) were managed with OAC only and 677 (8%) with LAAC. A total of 559 patients (279 per group) were matched. Mean age was 74.9±7.5 years, 244 were female (43.7%), and mean DRG clinical complexity level was 1.8±1.1. Median annualized management cost before LAAC was €3110 (IQR €1281–8127). Median hospitalization cost for LAAC was €9601 (IQR: €9393–10007). After a mean follow-up of 4.5±1.4 years, median annualized management cost was €1297 (€607–2735) in patients with sole OAC and €1013 (IQR €0–4770) in patients after LAAC (p=0.003). Undergoing LAAC was the strongest independent determinant to reduce follow-up management costs (linear regression: beta = −0.335; CI: −1.09 to −0.682; p&amp;lt;0.0001). Estimated 3-year survival was similar in the LAAC (92%) and OAC patients (90%) (p=0.7). Conclusion LAAC significantly reduces management costs of patients with non-valvular AF. In patients referred for percutaneous LAAC, the drastic reduction in management costs following LAAC justifies the procedural costs. In spite of their complex comorbid profile, LAAC patients show a follow-up survival rate similar to those of patients solely treated with OAC. Management costs of patients solely on OAC are significantly higher than management costs of patients after LAAC. Future studies are necessary to investigate the potential net economic and clinical benefit of LAAC in patients that are treated with OAC only. Funding Acknowledgement Type of funding sources: None.