Current Reimbursement Policies Research Articles

A Relative Value Unit–Based Model for Targeted Nipple–Areola Complex Neurotization in Gender-Affirming Mastectomy

Background: For transmasculine individuals, double-incision mastectomy with free nipple grafts is the most common procedure for gender-affirming chest masculinization. However, patients report decreased sensation postoperatively. Direct coaptation of intercostal nerves to the nipple–areolar complex (NAC) is an experimental technique that may preserve postoperative sensation, yet whether reimbursements and billing codes incentivize hospital systems and surgeons to offer this procedure lacks clarity. Methods: A retrospective cross-sectional analysis of fiscal year 2023 Medicare physician fee schedule values was performed for neurotization procedures employing Current Procedural Terminology codes specified by prior studies for neurotization of the NAC. Additionally, operative times for gender-affirming mastectomy at a single center were examined to compare efficiency between procedures with and without neurotization included. Results: A total of 29 encounters were included in the study, with 11 (37.9%) receiving neurotization. The mean operating time was 100.3 minutes (95% CI, 89.2–111.5) without neurotization and 154.2 minutes (95% CI, 139.9–168.4) with neurotization. In 2023, the average work relative value units (wRVUs) for neurotization procedures was 13.38. Efficiency for gender-affirming mastectomy was 0.23 wRVUs per minute without neurotization and 0.24 wRVUs per minute with neurotization, yielding a difference of 0.01 wRVUs per minute. Conclusions: Neurotization of the NAC during double-incision mastectomy with free nipple grafts is an experimental technique that may improve patient sensation after surgery. Current reimbursement policy appropriately values the additional operative time associated with neurotization relative to gender-affirming mastectomy alone.

Safety considerations for withdrawal of nucleos(t)ide analogues in patients with chronic hepatitis B: First, do no harm.

Nucleos(t)ide analogues (NA) are widely used to treat hepatitis B virus (HBV) infection, but they cannot eradicate the virus and treatment duration can be lifelong if the endpoint is set at seroclearance of the hepatitis B surface antigen (HBsAg). As an alternative strategy, finite NA therapy without the prerequisite of HBsAg seroclearance has been proposed to allow treatment cessation in patients with sustained undetectable HBV viremia for two to three years. However, reactivation of viral replication almost always follows NA withdrawal. Whereas HBV reactivation might facilitate HBsAg seroclearance in some, it could lead to serious acute flare-ups in a certain proportion of patients. Occurrence and consequences of NA withdrawal flares are complicated with various factors involving the virus, host, and treatment. Accurate risk prediction for severe flares following NA cessation is essential to ensure patient safety. The risks of life-threatening flares in patients who discontinued NA according to the stopping rules of current guidelines or local reimbursement policies have recently been quantitatively estimated in large-scale studies, which also provided empirical evidence to help identify vulnerable patients at risk of devastating outcomes. Moreover, risk predictors were further explored and validated to hopefully aid in patient selection and management. In this narrative review with a focus on patient safety, we summarize and discuss current literature on the incidence of severe flares following NA cessation, risk stratification for candidate selection, rules of posttreatment monitoring, and indications for treatment resumption. We also share our thoughts on the limitations of existing knowledge and suggestions for future research.

Launch sequencing of pharmaceuticals with multiple therapeutic indications: evidence from seven countries

BackgroundNew medicines are increasingly being identified as efficacious across multiple indications. The impact of current pricing and reimbursement policies on launch decisions across these indications remains unclear.ObjectiveThis paper, first, maps marketing authorisation and HTA coverage recommendation sequences of multi-indication medicines across Germany, France, England, Scotland, Canada, Australia, and the USA, and, second, evaluates the clinical characteristics, clinical development time and coverage recommendation time of multi-indication medicines, drawing comparisons between the first and subsequent indications of an approved molecule.MethodsMedicine approvals by the Food and Drug Administration between 2009–2019 were screened to identify multi-indication products with approved oncology indications. Data on clinical trial characteristics, clinical performance and HTA outcomes were extracted from publicly available regulatory approval and HTA reports.ResultsRelative to subsequent indications, first indications were more likely to receive conditional marketing authorisation, have an orphan designation, have a single arm phase II pivotal trial and lower MCBS score. Subsequent indications had faster HTA coverage recommendation times in England and Canada. While the majority of first indications received HTA coverage recommendations across all settings, the proportion of subsequent indications with HTA coverage recommendations was lower and uptake varied considerably across settings.ConclusionsDiscordance in the value of first versus subsequent indications can pose major challenges in systems that define price based on the initial indication. Current pricing and reimbursement systems generate significant fragmentation in the approval and availability of multi-indication products across settings.

국내 인슐린 주입기기 요양비 지원 정책 현황 및 개선 방안

Intensive insulin therapy is the primary treatment option for patients with type 1 and uncontrolled type 2 diabetes. Insulin pump therapy and multiple daily insulin injections (MDI) are the principal methods of intensive insulin therapy. The clinical utility of an insulin pump is generally greater than an MDI regimen. An artificial pancreas, which is an insulin pump with an integrated continuous glucose monitor (CGM), has recently been introduced on the market with emerging clinical evidence. Although it may offer clinical benefits and reduce the self-management burden among patients with diabetes, its potential for inappropriate use and unaffordability are the major barriers to its universal utilization. Despite the medical assistance program offered by the Korean National Healthcare System, which provides coverage for consumables and devices for diabetes treatment, some patients cannot afford to use an advanced insulin delivery system (i.e., the artificial pancreas). Under the current reimbursement policy, the healthcare system considers an insulin pump and a CGM as separate items for regulatory and reimbursement purposes. In other words, the artificial pancreas is categorized as an insulin pump and reimbursed at the same amount as a traditional insulin pump. The fundamental operating function may be the same between the artificial pancreas and a traditional insulin pump; however, there should be a different reimbursement pathway to make a novel category for the artificial pancreas instead of categorizing it under insulin pumps and to differentiate pricing based on the comparative (cost-) effectiveness among insulin delivery devices. Other countries such as the United States, the United Kingdom, Germany, and France are moving toward rapid and universal adoption of the artificial pancreas supported by their clinical governance and regulatory affairs. In this review, we highlight the need to improve the accessibility and affordability of advanced diabetes technology by discussing the current issues in the reimbursement policy that limit the universal use of advanced insulin delivery devices in Korea.

Pharmaceutical regulation and policies in Austria

Austria is a middle-sized, high-income country in Central Europe with universal health coverage and a highly fragmented health care system. Medicines for outpatient use that are reimbursed by the social health insurance are price-regulated, whereas medicines for inpatient use are neither subject to price regulation nor to health technology assessment (HTA). These medicines are procured by hospitals, hospital groups and provinces which are the main owner of public hospitals. The major pricing policy for new medicines in the outpatient sector is external price referencing. Austria refers to all other 26 European Union (EU) Member States; the determined benchmark price must not exceed the EU average price. External price referencing is based on list prices, but the statutory manufacturer discounts applicable in some reference countries are considered. Regular price reviews with subsequent price adjustments are in place. For generic and biosimilar medicines to be included in the outpatient positive list, a price link policy is applied with different reduction rates for generics and biosimilars. In the supply chain, prices of all medicines are regulated through regressive mark-up schemes for wholesale and community pharmacies. The inclusion in the outpatient positive list is based on an HTA process which comprises pharmacological, medical-therapeutic and economic evaluations, followed by price negotiations about the reimbursement price. For medicines with high financial burden for the public payers, the Austrian Social Insurance (for the outpatient sector) and procurers for hospitals tend to conclude managed-entry agreements with confidential discounts. For outpatient medicines, patients are charged a fixed prescription fee per prescribed item; no further co-payments apply for outpatient or inpatient medicines. Studies have shown that the current pricing and reimbursement policies in Austria have contributed to keep prices of outpatient medicines stable (high-cost medicines tend to range above EU average), whereas the unregulated prices of medicines used in hospitals are frequently the highest in European comparison. Pharmacy mark-ups are also high in comparison to other European countries.

Strategies for Improving Access to Cancer Services in Rural Communities: A Pre-implementation Study.

Implementation science is defined as the scientific study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners. Failure of implementation is more common in resource-limited settings and may contribute to health disparities between rural and urban communities. In this pre-implementation study, we aimed to (1) evaluate barriers and facilitators for implementation of guideline-concordant healthcare services for cancer patients in rural communities in Upstate New York and (2) identify key strategies for successful implementation of cancer services and supportive programs in resource-poor settings. The mixed methods study was guided by the Consolidated Framework for Implementation Research (CFIR). Using engagement approaches from Community-Based Participatory Research, we collected qualitative and quantitative data to assess barriers and facilitators to implementation of rural cancer survivorship services (three focus groups, n = 43, survey n = 120). Information was collected using both in-person and web-based approaches and assessed attitude and preferences for various models of cancer care organization and delivery in rural communities. Stakeholders included cancer survivors, their families and caregivers, local public services administrators, health providers, and allied health-care professionals from rural and remote communities in Upstate New York. Data was analyzed using grounded theory. Responders reported preferences for cross-region team-based cancer care delivery and emphasized the importance of connecting local providers with cancer care networks and multidisciplinary teams at large urban cancer centers. The main reported barriers to rural cancer program implementation included regional variation in infrastructure and services delivery practices, inadequate number of providers/specialists, lack of integration among oncology, primary care and supportive services within the regions, and misalignment between clinical guideline recommendations and current reimbursement policies. Our findings revealed a unique combination of community, socio-economic, financial, and workforce barriers to implementation of guideline-concordant healthcare services for cancer patients in rural communities. One strategy to overcome these barriers is to improve provider cross-region collaboration and care coordination by means of teamwork and facilitation. Augmenting implementation framework with provider team-building strategies across and within regions could improve rural provider confidence and performance, minimize chances of implementation failure, and improve continuity of care for cancer patients living in rural areas.

Moving the Needle Toward Fair Compensation in Pediatric Nephrology.

Remuneration issues are a substantial threat to the long-term stability of the pediatric nephrology workforce. It is uncertain whether the pediatric nephrology workforce will meet the growing needs of children with kidney disease without a substantial overhaul of the current reimbursement policies. In contrast to adult nephrology, the majority of pediatric nephrologists practice in an academic setting affiliated with a university and/or children's hospital. The pediatric nephrology service line is crucial to maintaining the financial health and wellness of a comprehensive children's hospital. However, in the current fee-for-service system, the clinical care for children with kidney disease is neither sufficiently valued, nor appropriately compensated. Current compensation models derived from the relative value unit (RVU) system contribute to the structural biases inherent in the current inequitable payment system. The perceived negative financial compensation is a significant driver of waning trainee interest in the field which is one of the least attractive specialties for students, with a significant proportion of training spots going unfilled each year and relatively stagnant growth rate as compared to the other pediatric subspecialties. This article reviews the current state of financial compensation issues plaguing the pediatric nephrology subspecialty. We further outline strategies for pediatric nephrologists, hospital administrators, and policy-makers to improve the landscape of financial reimbursement to pediatric subspecialists. A physician compensation model is proposed which aligns clinical activity with alternate metrics for current non-RVU producing activities that harmonizes hospital and personal mission statements.

Italian guidelines for the treatment of type 2 diabetes

•This guideline is aimed at providing a reference for pharmacological and non-pharmacological treatment of type 2 diabetes in adults.•Recommendations are designed as indications for healthcare professionals in charge of diabetes treatment.•These recommendations apply to outpatients, either in primary care or at specialist referral.•Recommendations have been formulated on the basis of available evidence, independent of current reimbursement policies.

Lifestyle Medicine Reimbursement: A Proposal for Policy Priorities Informed by a Cross-Sectional Survey of Lifestyle Medicine Practitioners.

Lifestyle medicine (LM) is a rapidly emerging clinical discipline that focuses on intensive therapeutic lifestyle changes to treat chronic disease, often producing dramatic health benefits. In spite of these well-documented benefits of LM approaches to provide evidence-based care that follows current clinical guidelines, LM practitioners have found reimbursement challenging. The objectives of this paper are to present the results of a cross-sectional survey of LM practitioners regarding lifestyle medicine reimbursement and to propose policy priorities related to the ability of practitioners to implement and achieve reimbursement for these necessary services. Results from a closed, online survey in 2019 were analyzed, with a total of n = 857 included in this analysis. Results were descriptively analyzed. This manuscript articulates policy proposals informed by the survey results. The study sample was 58% female, with median age of 51. A minority of the sample (17%) reported that all their practice was LM, while 56% reported that some of their practice was LM. A total of 55% of practitioners reported not being able to receive reimbursement for LM practice. Of those survey respondents who provided an answer to the question of what would make the practice of LM easier (n = 471), the following suggestions were offered: reimbursement overall (18%), reimbursement for more time spent with patients (17%), more support from leadership (16%), policy measures to incentivize health (13%), education in LM for practitioners (11%), LM-specific billing codes and billing knowledge along with better electronic medical record (EMR) capabilities and streamlined reporting/paperwork (11%), and reimbursement for the extended care team (10%). Proposed policy changes focus on three areas of focus: (1) support for the care process using a LM approach, (2) reimbursement emphasizing outcomes of health, patient experience, and delivering person-centered care, and (3) incentivizing treatment that produces disease remission/reversal. Rectifying reimbursement barriers to lifestyle medicine practice will require a sustained effort from health systems and policy makers. The urgency of this transition towards lifestyle medicine interventions to effectively address the epidemic of chronic diseases in a way that can significantly improve outcomes is being hindered by current reimbursement policies and models.

PNS51 Global Survey of Genetic Testing Reimbursement Policies

Genetic testing is critical to optimizing the outcomes of targeted therapies since testing identifies patients who are most likely to benefit from these treatments. Further, product labels may require genetic testing. Thus, it is important to understand current genetic testing reimbursement policies. This study characterized the global reimbursement landscape of genetic testing across thirteen markets. Secondary research through various sources (e.g., insurance policies, fee schedules, laboratory catalogues, government websites, etc.) was conducted to understand current reimbursement mechanisms for genetic testing. Thirteen markets across five continents were surveyed: US, Canada, EU4, UK, Switzerland, Sweden, Japan, China, Brazil, and Australia. Findings on current reimbursement policies and coding infrastructure were synthesized. The presence of manufacturer-sponsored genetic testing was also researched. Several trends in genetic testing reimbursement were identified. While genetic testing is often reimbursed in the majority (10/13, 77%) of surveyed markets, 3/13 (23%) do not provide routine public reimbursement for genetic testing (Australia, Brazil, and China). The coding infrastructure utilized for genetic testing reimbursement varies across the 10/13 (77%) markets with coverage. 6/13 (46%) of markets (USA, France, Germany, Switzerland, Sweden, and Japan) often utilize general genetic testing codes, which are independent of any gene or disease. Codes specific to genes or diseases were found in 3/13 (23%) of markets (UK, Spain, and Canada). In 1/13 (8%) markets (Italy), both general and specific codes were identified. Manufacturer-sponsored genetic testing programs were identified in all markets across various diseases. These programs encompassed both direct patient sponsorship and more indirect avenues such as grants to research or patient advocacy organizations. Reimbursement of genetic testing varies globally across markets. Since securing reimbursement can be a complex process which differs across markets, sponsors should carefully assess any reimbursement barriers and consider mitigation tactics in order to increase access and uptake for products that require genetic testing.

PNS163 The Definition of Innovation in Health Technology Assessments (HTA): A Systematic Literature Review

A major goal of current pharmaceutical pricing and reimbursement policies is to maintain affordability and access to medicines, yet at the same time provide incentives for continued innovation. While the term “innovation” is widely used, it often remains undefined or is defined differently depending upon the perspective. Accordingly, establishing a link between the level of innovativeness and price premiums poses a major challenge. In this study, we systematically review current literature and discuss how pharmaceutical innovation is defined in health technology assessments (HTA) of different countries and how it is incentivized and rewarded through pricing and reimbursement schemes. We conducted a systematic literature review using PubMed and the Social Science Citation Index (SSCI) and covering articles published from 2010 to 2019. Our review shows that innovation beyond the added therapeutic value is rarely considered in HTAs. While other elements such as nature of treatment or ease and convenience of administering the drug are occasionally considered, only the added therapeutic value is crucial when it comes to pricing and reimbursement decisions. Regarding changes to the current approaches, our review shows that most studies do not advocate drastic changes to the current methods of capturing innovation in pricing policies. Suggestions focus on how added therapeutic benefits, given they exist, are considered in HTAs rather than how innovation should be defined in the first place. Innovation is a widely but variously used term. Generally, a drug that is considered innovative implies that it has properties that are worthy of recognition and reward and that the product has a unique value. However, notions of value are a matter of perspective and valuing innovation is a complex and difficult task. Since the value of innovation could be derived from more unobvious benefits, changes in the current assessment process may be warranted.

HTA4 Clinical Development and HTA Approval of MULTI-Indication Oncology Products: Evidence from Germany, France, England, Scotland, the US, Canada, and Australia

It is unclear if current pricing and reimbursement policies adequately capture the incremental value of individual indications for multi-indication products. This study aims to map the launch sequence of multi-indication products across seven countries and compares indications in terms of quality of clinical evidence, regulatory approval timelines and HTA approval timelines.

Going the distance for procurement of donation after circulatory death livers for transplantation-Does reimbursement reflect reality?

Donation after circulatory death (DCD) liver transplantation (LT) has increased slowly over the past decade. Given that transplant surgeons generally determine liver offer acceptance, understanding surgeon incentives and disincentives is paramount. The purpose of this study was to assess aggregate travel distance per successful DCD versus deceased after brain death (DBD) liver procurement as a surrogate for surgeon time expenditure and opportunity cost. All consecutive liver offers made to Michigan Medicine from 2006 to 2017 were analyzed. Primary outcome was the summative travel distance (spent on all attempted procurements) per successful liver procurement that resulted in LT. Donation after circulatory death liver offer acceptance was lower than DBD liver offers, as was proportion ofsuccessful procurements among accepted offers. Overall, 10275 miles were travelled for accepted DCD liver offers, resulting in 23 successful procurements (mean 447 miles per successful DCD liver procurement). For accepted DBD liver offers, 197299 miles were travelled, resulting in 863 successful procurements (mean 229 miles per successful DBD liver procurement). On average, each successful DCD liver procurement required 218 more miles of travel than each successful DBD liver procurement. Current reimbursement policies poorly reflect increased surgeon travel (and time) expenditures between DCD and DBD liver offers.

Analysis of Outpatient Telemedicine Reimbursement in an Integrated Healthcare System

Current reimbursement policy surrounding telemedicine has been cited as a barrier for the adaptation of this care model. The objective of this study is to analyze the reimbursement figures for outpatient telemedicine consultation in vascular surgery. Patients first underwent synchronous telemedicine visits after receiving point-of-care ultrasound at one of 3 satellite locations of Henry Ford Health System in Michigan. Visit types included new, return, and postoperative patients. Reimbursement information related to payor, adjustment, denial, paid and outstanding balances were recorded for each telemedicine visit. Then, using an enterprise data warehouse, a retrospective analysis was performed for the aforementioned telemedicine visits. The data were analyzed to determine the outcome of total billed charges, number of denied claims, reimbursement per payor, reimbursement per patient, and out-of-pocket costs to the patients. Among 184 virtual clinical encounters, the payors included Aetna US Healthcare, Blue Advantage, Blue Cross Blue Shield, Cofinity Plan, Health Alliance Plan, HAP Medicare Advantage, Humana Medicare Advantage, Medicaid, Medicare, Molina Medicaid HMO, United Healthcare, Blue Care Network, Aetna Better Health of Michigan, Priority Health, and self-pay. Among the 15 payors, reimbursement ranged from 0% to 67% of the total charges billed. Among the 184 virtual visits, a grand total of $22,145 was collected or an average of $120.35 per virtual encounter. The breakdown of charges billed was 40% adjusted, 41% paid by insurance, 10% paid by patient, and 13% denied. There were 27 total denials (15%). Denial of payment included telehealth and nontelehealth reasons, citing noncovered charges, payment included for other prior services, new patient quality not met, and not covered by payor. The average out-of-pocket cost to patients was $12.59 per visit. These reimbursement data validate the economic potential within this new platform of healthcare delivery. As our experience with the business model grows, we expect to see an increase in reimbursement from private payors and acceptance from patients. Within a tertiary care system, telemedicine for chronic vascular disease has proven to be a viable means to reach a broader population base, and without significant cost to the patients.

An International Analysis of Dialysis Services Reimbursement.

The prevalence of patients with ESKD who receive extracorporeal kidney replacement therapy is rising worldwide. We compared government reimbursement for hemodialysis and peritoneal dialysis worldwide, assessed the effect on the government health care budget, and discussed strategies to reduce the cost of kidney replacement therapy. Cross-sectional global survey of nephrologists in 90 countries to assess reimbursement for dialysis, number of patients receiving hemodialysis and peritoneal dialysis, and measures to prevent development or progression of CKD, conducted online July to December of 2016. Of the 90 survey respondents, governments from 81 countries (90%) provided reimbursement for maintenance dialysis. The prevalence of patients per million population being treated with long-term dialysis in low- and middle-income countries increased linearly with Gross Domestic Product per capita (GDP per capita), but was substantially lower in these countries compared with high-income countries where we did not observe an higher prevalence with higher GDP per capita. The absolute expenditure for dialysis by national governments showed a positive association with GDP per capita, but the percent of total health care budget spent on dialysis showed a negative association. The percentage of patients on peritoneal dialysis was low, even in countries where peritoneal dialysis is better reimbursed than hemodialysis. The so-called peritoneal dialysis-first policy without financial incentive seems to be effective in increasing the utilization of peritoneal dialysis. Few countries actively provide CKD prevention. In low- and middle-income countries, reimbursement of dialysis is insufficient to treat all patients with ESKD and has a disproportionately high effect on public health expenditure. Current reimbursement policies favor conventional in-center hemodialysis.

USE OF ELECTRONIC PATIENT REPORTED OUTCOMES AND AUTOMATED DEVICES FOR HEART FAILURE DISEASE MANAGEMENT

Congestive Heart failure (CHF) is a major health issue affecting 6.5 million people in the U.S. alone. Current reimbursement policies use readmission rates and length of hospital stays as indicators of quality of care. This project aimed to improve patients’ self-monitoring practices post-hospital

Financing the Primary Care Behavioral Health Model.

The PCBH model of integrated care blends behavioral health professionals into the primary care team, thereby enhancing the scope of primary care and expanding the range of services provided to the patient. Despite promising evidence in support of the model and a growing number of advocates and practitioners of PCBH integration, current reimbursement policies are not always favorable. As the nation's healthcare system transitions to value-based payment models, new financing strategies are emerging which will further support the viability of PCBH integration. This article provides an overview of the infrastructure necessary to support PCBH practice; reviews the current PCBH funding landscape; discusses how emerging trends in healthcare financing are impacting the model; and provides a vision for the viability of the PCBH model within the value-based financing of our healthcare system in the future.

Use of Electronic Patient Reported Outcomes and Automated Devices for Heart Failure Disease Management

Background: Congestive heart failure (CHF) is a major public health issue. Today, CHF affects 6.5 million people in the U.S. and the incidence rate is projected to rise by 46% to more than 8 million cases by 2030. Current reimbursement policies use readmission rates and length of hospital stays as indicators of quality of care, and incentivize providers to meet these quality measures as the cost of hospitalization alone significantly contributes to the overall burden of CHF on patients and health systems. Symptoms of CHF can be unpredictable and presently there are no reliable solutions to track disease control for discharged patients.

Evaluation of Delivery Costs for External Beam Radiation Therapy and Brachytherapy for Locally Advanced Cervical Cancer Using Time-Driven Activity-Based Costing

To evaluate the delivery costs, using time-driven activity-based costing, and reimbursement for definitive radiation therapy for locally advanced cervical cancer. Process maps were created to represent each step of the radiation treatment process and included personnel, equipment, and consumable supplies used to deliver care. Personnel were interviewed to estimate time involved to deliver care. Salary data, equipment purchasing information, and facilities costs were also obtained. We defined the capacity cost rate (CCR) for each resource and then calculated the total cost of patient care according to CCR and time for each resource. Costs were compared with 2016 Medicare reimbursement and relative value units (RVUs). The total cost of radiation therapy for cervical cancer was $12,861.68, with personnel costs constituting 49.8%. Brachytherapy cost $8610.68 (66.9% of total) and consumed 423minutes of attending radiation oncologist time (80.0% of total). External beam radiation therapy cost $4055.01 (31.5% of total). Personnel costs were higher for brachytherapy than for the sum of simulation and external beam radiation therapy delivery ($4798.73 vs $1404.72). A full radiation therapy course provides radiation oncologists 149.77 RVUs with intensity modulated radiation therapy or 135.90 RVUs with 3-dimensional conformal radiation therapy, with total reimbursement of $23,321.71 and $16,071.90, respectively. Attending time per RVU is approximately 4-fold higher for brachytherapy (5.68minutes) than 3-dimensional conformal radiation therapy (1.63minutes) or intensity modulated radiation therapy (1.32 minutes). Time-driven activity-based costing was used to calculate the total cost of definitive radiation therapy for cervical cancer, revealing that brachytherapy delivery and personnel resources constituted the majority of costs. However, current reimbursement policy does not reflect the increased attending physician effort and delivery costs of brachytherapy. We hypothesize that the significant discrepancy between treatment costs and physician effort versus reimbursement may be a potential driver of reported national trends toward poor compliance with brachytherapy, and we suggest re-evaluation of payment policies to incentivize quality care.

Rural Family Physicians Are Twice as Likely to Use Telehealth as Urban Family Physicians.

Telehealth has the potential to reduce health inequities and improve health outcomes among rural populations through increased access to physicians, specialists, and reduced travel time for patients. Although rural telehealth services have expanded in several specialized areas, little is known about the attitudes, beliefs, and uptake of telehealth use in rural American primary care. This study characterizes the differences between rural and urban family physicians (FPs), their perceptions of telehealth use, and barriers to further adoption. Nationally representative randomly sampled survey of 5,000 FPs. Among the 31.3% of survey recipients who completed the survey, 83% practiced in urban areas and 17% in rural locations. Rural FPs were twice as likely to use telehealth as urban FPs (22% vs. 10%). Logistic regressions showed rural FPs had greater odds of reporting telehealth use to connect their patients to specialists and to care for their patients. Rural FPs were less likely to identify liability concerns as a barrier to using telehealth. Telemedicine allows rural patients to see specialists without leaving their communities and permits rural FPs to take advantage of specialist expertise, expand their scope of practice, and reduce the feeling of isolation experienced by rural physicians. Efforts to raise awareness of current payment policies for telehealth services, addressing the limitations of current reimbursement policies and state regulations, and creating new avenues for telehealth reimbursement and technological investments are critical to increasing primary care physician use of telehealth services.