Reimbursement Mechanisms Research Articles

The reimbursement of new medical technologies in German inpatient care: What factors explain which hospitals receive innovation payments?

Most hospital payment systems based on diagnosis-related groups (DRGs) provide payments for newly approved technologies. In Germany, they are negotiated between individual hospitals and health insurances. The aim of our study is to assess the functioning of temporary reimbursement mechanisms. We used multilevel logistic regression to examine factors at the hospital and state levels that are associated with agreeing innovation payments. Dependent variable was whether or not a hospital had successfully negotiated innovation payments in 2013 (n = 1532). Using agreement data of the yearly budget negotiations between each German hospital and representatives of the health insurances, the study comprises all German acute hospitals and innovation payments on all diagnoses. In total, 32.9% of the hospitals successfully negotiated innovation payments in 2013. We found that the chance of receiving innovation payments increased if the hospital was located in areas with a high degree of competition and if they were large, had university status and were private for-profit entities. Our study shows an implicit self-controlled selection of hospitals receiving innovation payments. While implicitly encouraging safety of patient care, policy makers should favour a more direct and transparent process of distributing innovation payments in prospective payment systems.

Credit support for the animal breeding through the mechanism ofthe interest rate reimbursement

Subject of research-a set of theoretical and practical outlines of the creditsupport improving for the animal breeding enterprises. The purpose of the article.The purpose of the article is to improve the mechanism of credit support to animalbreeding business entities with the involvement of the state agrarian bank. Identify the advantages and prospects of the proposed algorithm. The methodology ofthe work. The methodological basis of the research is economic-statistical, abstractlogical, calculation-constructive and systematic methods of scientific knowledge.On the basis of the modeling method, a scheme for the credit support with theinvolvement of the state agrarian bank was developed, and the method of generalization revealed positive results of the expansion of the feed base for enterprises. The results of the work. It is proposed to involve the state agrarian bankin the process of credit support, which will act as the guarantor of the return ofthe attracted resources. It is proved, that the proposed scheme of the credit support to expand the feed base will contribute to an increase in output and raise theefficiency of the enterprise. Conclusions. Animal breeding business entities requireadditional financial resources. Credit support through the mechanism of the interest rate reimbursement with the involvement of the state agrarian bank minimizes the risks for creditors and creates favorable conditions for borrowers.

Financial compensation for organ donors.

With an increasing demand for donor organs, strategies to increase the number of available donor organs have become more focused. Compensating donors for donation is one strategy proposed to increase the availability of organs for transplant. This has been implemented in several systems internationally, but debate continues in the United States with respect to appropriate strategies. The National Organ Transplant Act (NOTA) currently prohibits the transfer of any human organ 'for valuable consideration' for transplantation, but allows for the removal of financial disincentives. Several proposals currently exist for compensating patients for living donation. Recent data have focused on studying and creating mechanisms for reimbursement of costs incurred as part of the donation process, which is related to the removal of disincentives to living donation. Others have advocated for the provision of actual incentives to patients for the act of donating, in an attempt to further expand living donation. The current debate focuses on what measures can reasonably be taken to increase donation, and whether additional incentives will encourage more donation or reduce the motivation for altruistic donation. Currently, the transplant community broadly supports the removal of disincentives for living donors, including reimbursement of expenses for travel, housing and lost wages incurred during evaluation, surgery and after care. Others have advocated for financial incentives to further increase the number of donor organs available for transplant. Although the removal of disincentives is currently allowed under the existing legal structure of NOTA, providing financial incentives for living donation would require further evaluation of the economics, law, ethics and public readiness for a significant policy shift.

Evidenced Based Policy Decisions & Population Health: Policies, Disparities, and Data Integrity

The surfeit of health policy research in the health care literature is concomitant with the dearth in the public administration literature, although billions of public dollars are spent annually on healthcare. The purpose of this paper is to shed light on a critical flaw in our ability to accurately analyze the contributions of efficient and effective healthcare practitioners who hold the potential to substantially improve health care equity in the United States. Developing adequate primary care workforce capacity may depend on modernizing state regulatory policies. However, this decision must be based on clear evidence. Evidence related to service delivery and health outcomes for the US’ most vulnerable groups relies on the availability of valid, reliable, quality data. The Centers for Medicare and Medicaid database is the most logical and comprehensive data source. Yet, this intergovernmental and privatized program presents significant data obstacles. In seeking to analyze health policies using Medicaid data, significant data quality concerns emerged. Specifically, nurse practitioner and physician assistant services were under-represented in the datasets analyzed. This underestimates their true contributions to primary care and subsequently impairs our ability to analyze the true cost of primary care service delivery. Why is this important? In an era of healthcare transitions and changing reimbursement mechanisms, the ability to conduct valid investigations into Medicaid services is necessary to accurately inform regulatory and programmatic policy analysis and reform. Improvements in Medicaid data collection will contribute to improving data integrity, thus enabling better evidence based solutions for addressing crippling healthcare fiscal challenges. This study contributes three key findings, the adaptation of a model for data integrity in public administration, and concludes with making three recommendations for improving the utilization and reporting of critical evidence on which to base future health policy.

The medical arms race and its impact in Chinese hospitals: implications for health regulation and planning.

The rapid diffusion of medical technologies is widely recognized as a key driver of healthcare cost escalation. The excessive duplication of technologies gives rise to the so-called medical arms race. Conventional wisdom tends to explain this phenomenon by external reimbursement mechanisms and hospitals' competitive strategies, but has largely neglected the role played by health regulations that may also affect hospitals' technology adoption decisions. This study sheds new light on the medical arms race with evidence from China, which has witnessed an unprecedented expansion of big tertiary hospitals and a keen pursuit of expensive medical technologies. Chinese hospitals aggressively pursue high-tech medical equipment as an opportunistic reaction to the peculiar health regulatory environment. By analysing a panel dataset collected from Shenzhen City, this study reveals a series of important impacts of the medical arms race in Chinese public hospitals. High-tech medical equipment is found to lead to an increase in hospital revenues and patient volumes, but no significant impact is noted on unit costs. While high-tech medical equipment is associated with a discernible improvement in clinical outcomes, no contribution to hospitals' operational efficiency is noted. These findings are interpreted in the context of the broader health regulatory framework and China's public hospital reforms.

PHARMACEUTICAL QUALITY AUDITS: A REVIEW

Auditing is a vital function within a pharmaceutical company nowadays. Quality audit is a review and evaluation of all or part of a quality system with the specific purpose of improving it. It is one of the means to examine pharmacy programs and ensures that the procedures and reimbursement mechanisms comply with the contractual and regulatory requirements. A quality audit is usually conducted by external or independent experts or by a team designated by management for this purpose. These audits can be extended to suppliers and contractors as well. An audit will assess the strengths and weaknesses of quality assurance and quality assurance processes, the results of which assists in improving processes and building a better system for company benefits. This article focuses on various aspects of quality auditing in the pharmaceutical industry including its principles, objectives, importance and benefits and planning along with the deficiencies that are likely to occur during the process. This review comprises a well-organized summary of various guidelines available till date using the Google Scholar search engine and the keywords listed below.

Factors contributing to rapidly increasing rates of cesarean section in Armenia: a partially mixed concurrent quantitative-qualitative equal status study

BackgroundArmenia has an upward trend in cesarean sections (CS); the CS rate increased from 7.2% in 2000 to 31.0% in 2017. The purpose of this study was to investigate potential factors contributing to the rapidly increasing rates of CS in Armenia and identify the actual costs of CS and vaginal birth (VB), which are different from the reimbursement rates by the Obstetric Care State Certificate Program of the Ministry of Health.MethodsThis was a partially mixed concurrent quantitative-qualitative equal status study. The research team collected qualitative data via in-depth interviews (IDI) with obstetrician-gynecologists (OBGYN) and policymakers and focus group discussions (FGD) with women. The quantitative phase of the study utilized the bottom-up cost accounting (considering only direct variable costs) from the perspective of providers, and it included self-administered provider surveys and retrospective review of mother and child hospital records. The survey questionnaire was developed based on IDIs with providers of different medical services.ResultsThe mean estimated direct variable cost per case was 35,219 AMD (94.72 USD) for VB and 80,385 AMD (216.19 USD) for CS. The ratio of mean direct variable costs for CS vs. VB was 2.28, which is higher than the government’s reimbursement ratio of 1.64. The amount of bonus payments to OBGYNs was 11 fold higher for CS than for VB indicating that OBGYNs may have significant financial motivation to perform CS without a medical necessity. The qualitative study analysis revealed that financial incentives, maternal request and lack of regulations could be contributing to increasing the CS rates. While OBGYNs did not report that higher reimbursement for CS could lead to increasing CS rates, the policymakers suggested a relationship between the high CS rate and the reimbursement mechanism. The quantitative phase of the study confirmed the policymakers’ concern.ConclusionThe study suggested an important relationship between the increasing CS rates and the current health care reimbursement system.

The Main Factors of Induced Demand for Medicine Prescription: A Qualitative Study.

Inappropriate request for health care services which are considered to be unnecessary for the patients has long been addressed by several writers. The hypothesis supplier induced demand refers to the induced demand initiated by the supplier who acts in his own economic self-interest rather than patient best interest. The purpose of the present qualitative study was to explore about induced demand and the relevant motivating factors associated with unnecessary prescriptions of medicine. In-depth interviews were used for data generation with a purposive sample of 20 participants who were selected according to their experience. The interviews were transcribed and analyzed. The key themes were identified, named and coded with a sample of quotation. In general, 24 sub-themes or factors were identified and classified into personal, community and institutional themes. Some important factors are asymmetric information, patient expectation, patient poor health literacy, physician›s inadequate knowledge in medicine, neglecting patient rights, financial incentives, barriers in health insurance companies, reimbursement mechanism, marketing and advertising by pharmaceutical companies, Poor financial condition of pharmacies and social interactions. Our results showed that the induced demand for medicine is multifactorial in a health system. Addressing these factors could lead to decrease unnecessary prescription of medicine by a multi-faceted strategy, including curriculum revision, health promotion, and policy making.

Health-Care Administrator Perspectives on Prevention Guidelines and Healthy Lifestyle Counseling in a Primary Care Setting in New York State.

Introduction:The incidence of chronic disease and treatment costs have been steadily increasing in the United States over the past few decades. Primary prevention and healthy lifestyle counseling have been identified as important strategies for reducing health-care costs and chronic disease prevalence. This article seeks to examine decision-makers’ experiences and self-perceived roles in guideline and lifestyle counseling implementation in a primary care setting in the United States.Methods:Qualitative interviews were conducted with administrators at a health-care network in Upstate New York and with state-level administrators, such as insurers. Decision-makers were asked to discuss prevention guidelines and healthy lifestyle counseling, as well as how they support implementation of these initiatives. Interviews were analyzed using a thematic analysis framework and relevant sections of text were sorted using a priori codes.Results:Interviews identified numerous barriers to guideline implementation. These included the complexity and profusion of guidelines, the highly politicized nature of health-care provision, and resistance from providers who sometimes prefer to make decisions autonomously. Barriers to supporting prevention counseling included relatively time-limited patient encounters, the lack of reimbursement mechanisms for counseling, lack of patient resources, and regulatory complexities.Conclusions:Our research indicates that administrators and administrative structures face barriers to supporting prevention activities such as guideline implementation and healthy lifestyle counseling in primary care settings. They also identified several solutions for addressing existing primary prevention barriers, such as relying on nurses to provide healthy lifestyle support to patients. This article provides an important assessment of institutional readiness to support primary prevention efforts.

VP74 Orphan Black Box: Explanatory Principles

IntroductionOrphan legislations over the past thirty years have successfully increased the number of drugs receiving marketing authorization for rare diseases. However, for a therapy to be accessible to most patients, it requires not only marketing authorization, but market access via public reimbursement. In many major markets, the pricing and reimbursement of new therapies is based on an assessment by a national Health Technology Assessment (HTA) body, for which economic value is typically a key consideration. This research evaluates the outcome of HTAs of orphan drugs in Europe.MethodsHTA decision data (to 31/08/2017) was extracted from Gemeinsame Bundesausschuss (G-BA), Haute Autorité de Santé (HAS), National Institute for Health and Care Excellence (NICE), Pharmaceutical Benefits Advisory Committee (PBAC), and Scottish Medicines Consortium (SMC) websites. EC-approval data was extracted from the European Medicines Agency (to 31/08/2017).ResultsOnly a small minority of drugs for orphan diseases received full recommendations for their licensed indication(s) by NICE (3/35, 9%), SMC (8/66, 12%) and PBAC (1/44, 2%). 37% (26/70) of drugs assessed received positive HTA outcome by HAS (ASMR I-III). In Germany, all approved orphan drugs (100/100) received automatic additional benefit post regulatory approval by G-BA.ConclusionsThere have been significant challenges for manufacturers in converting regulatory approval of orphan drugs into commercial success and optimised market access. Attaining positive HTA appraisals for these drugs, which have been approved under expedited regulatory pathways on a less than fully mature dataset, whilst also having high prices, due to small patient populations, limiting commercial returns, may necessitate increased utilisation of alternative reimbursement mechanisms.

Assessment of Public Hospital Governance in Romania: Lessons From 10 Case Studies.

Background: The Government of Romania commissioned international technical assistance to help unpacking the causes of arrears in selected public hospitals. Emphases were placed on the governance-related determinants of the hospital performance in the context of the Romanian health system. Methods: The assessment was structured around a public hospital governance framework examining 4 dimensions: institutional arrangements, financing arrangements, accountability arrangements and correspondence between responsibility and decision-making capacity. The framework was operationalized using a 2-pronged approach: (i) a policy review of broader health system governance arrangements influencing hospital performance; and (ii) a series of 10 casestudies of public hospitals experiencing financial hardship. Data were collected during 2016-2017 through key informant interviews with central authorities and hospital management teams, exhaustive semi-structured questionnaires filled in by hospitals, as well as the review of documentary sources where feasible. Results: Overall, the governance landscape of Romanian public hospitals includes a large number of seemingly modern legislative provisions and management instruments. Over the past 30 years substantial efforts have been made to put in place standardised hospital classification, hospital governance structures, management and service purchasing contracts with key performance indicators, modern reimbursement mechanisms based on diagnosis-related groups (DRGs), and regulatory requirements for accountability, including internal and external audit. Nevertheless, their application appears to have been challenging for a range of reasons, pointing to the misalignment between the responsibility and decisionmaking capacity given to hospitals in a questionably conducive context. Incoherent policy design, outdated and often disjointed regulatory frameworks, and cumbersome administrative procedures limit managerial autonomy and obstruct efficiency gains. In a context of chronic insufficient funding, misaligned incentives, and overly rigid service procurement processes, hospitals seem to struggle to adjust service baskets to the population’s health needs or to overcoming financial hardship. External challenges, combined with the limited strategic, operational, and financial management capacity within hospitals, make it difficult to exhibit good financial and general performance. Conclusion: Existing governance arrangements for Romanian public hospitals appear conducive to poor financial performance. The suggested framework for hospital governance assessment has proved a powerful tool for identifying system and hospital-specific challenges contributing to sub-optimal hospital performance.

Interprofessional education at the meso level: taking the next step in IPE

ABSTRACTThe downstream demand for professionals with competence in Interprofessional Collaboration (IPC) has contributed to the substantial growth in the upstream demand for interprofessional education (IPE). The majority of IPE programs focuses exclusively on direct care practitioners and seldom include those responsible for the administration and management of care. Unfortunately, complex reimbursement mechanisms along with the multiple agencies and departments regulating the delivery, evaluation, and reimbursement of care can result in unintended barriers to IPC and eventually IPE. The Healthcare Services Planning and Management Program (HSPMP) is an innovative model of IPE that was designed to improve system wide collaboration among those responsible for the reimbursement, management and administration of the delivery of care. Although HSPMP was not developed in the US, this innovative model has the potential to develop the systemic integration needed to break down the barriers to the delivery and evaluation of IPE and IPC. The aim of this article is to introduce HSPMP to the US as a model of IPE that could help facilitate better integration of the US health care system and help to reduce some of the consequences resulting from the current fragmented system of care.

Potential utility of an independent decision-making board for seriously ill patients lacking decisional capacity

Summary Physicians acknowledge that they are providing unnecessary medical care at the end of life for a variety of reasons, including fear of malpractice litigation, Medicare's fee-for-service reimbursement mechanism, patient and family requests for care, a culture of denial of mortality, and a physician culture which views a patient's death as a professional failure. Recent data suggest that more than one-fifth of medical care provided at the end of life is unnecessary. Although the problem of over-provision of medical care is now well recognized in the legal and medical literatures, private-ordering solutions, such as better communication training for physicians or improved patient decision aids, will have only marginally ameliorating effects. The inherent challenges in making medical decisions during terminal illness become even more complex when patients are unable to make these choices for themselves. Although patient autonomy, implemented via informed consent, is the primary principle that governs medical decision-making, including on behalf of patients who have lost decisional capacity, insufficient evidence of the patient's wishes coupled with uncertainty about prognosis often leaves physicians and family members in a quandary as to whether to implement or to continue providing therapeutic treatment or life-prolonging care. The default operation of the surrogate consent process in the U.S. means that, for patients who do not clearly opt out of life-prolonging treatment before losing decisional capacity, the path of least resistance often will lead to decisions in favour of initiating or continuing life-prolonging care. This state of affairs can lead to substantial stress for all parties concerned, along with the potential for conflict. This paper considers the potential utility and transplantability of a Canadian public decision-support mechanism in this context. In 1996, the provincial government of Ontario implemented a Consent and Capacity Board (CCB), an independent expert body charged, among other things, to mediate and resolve disputes in the context of surrogate decision-making. Two-plus decades of CCB evidence suggest this it provides a better shared, less confrontational and more robust decision-making process than is currently available within the U.S. surrogate decision-making rules. Thus, a CCB type mechanism has the potential to also improve surrogate decision-making at the end of life in the U.S. and this paper discusses the extent to which it is capable of being “transplanted” into the U.S. health system on a state-by-state basis.

PHP37 - Payer Perspectives on Gene Therapy Reimbursement in the United States

To obtain payer feedback regarding their readiness to adopt new gene therapies and the need for specific new financial models. Gene therapies, while innovative and potentially curative, are expensive treatments with uncertain durability. Current financing and reimbursement mechanisms may not be sustainable as the aggregate cost of treatments mounts. Sixty-minute telephone interviews were conducted with 23 financial decision makers from 15 United States (US) payers between August and September 2017. Interviewees from various payer segments, including commercial plans, self-insured employers, Medicare, Medicaid, Integrated Delivery Networks (IDN), and reinsurers were invited to participate. Interviewees were offered a two-page pre-read and study protocol, and voluntarily agreed to participate without financial incentive. All payer segments were represented with a minimum of 3 interviews per segment. Nearly two-thirds of interviewees held financial positions, while approximately one-third were clinicians. Plan size ranged from 4,000 lives to over 4 million lives. One-third (n=5) recently became aware of new gene therapies or were made aware through the interview process, 40% (n=6) described watchful waiting, while 26.7% (n=4) were engaged in active management. New payment models, specifically, performance-based payments and risk-pooling, were supported by 47% (n=7) of payers, while the current payment model was supported by 53% (n=8). Major challenges include uncertainty related to utilization, cost, and duration of cure. Payers cited regulation, plan turn-over, and ability to track long-term outcomes measures as barriers to implementation of new models. Access to new gene therapies may be impacted by payer ability to adsorb the cost of coverage. Variation exists in awareness of new gene therapies and level of incorporation of new costs into plan coverage. The sustainability of the current financing mechanisms varies by payer segment, profitability, and size. Payers are open to innovative financing models that improve financial predictability and reward clinical performance.

Development of sustainable community paramedicine programmes: a case study in Pennsylvania

BackgroundCommunity paramedicine (CP) models have been applied across rural and urban communities in support of healthcare delivery systems for nearly two decades. However, there is still insufficient information regarding the...

A Systematic Review of Integrated Care Interventions Addressing Perinatal Depression Care in Ambulatory Obstetric Care Settings.

This systematic review searched 4 databases (PubMed/MEDLINE, Scopus, CINAHL, and PsychINFO) and identified 21 articles eligible to evaluate the extent to which interventions that integrate depression care into outpatient obstetric practice are feasible, effective, acceptable, and sustainable. Despite limitations among the available studies including marked heterogeneity, there is evidence supporting feasibility, effectiveness, and acceptability. In general, this is an emerging field with promise that requires additional research. Critical to its real-world success will be consideration for practice workflow and logistics, and sustainability through novel reimbursement mechanisms.

A review of promoting access to medicines in China - problems and recommendations

BackgroundDespite recent reforms, distorting funding mechanisms and over-prescribing still maintain severe financial barriers to medicines access in China. Complicated and interrelated problems in the pharmaceutical sector require a common framework to be resolved as fragmented solutions do not work. We present a preliminary assessment of the impact of the national healthcare reforms on access to medicines, and propose policy recommendations for promoting universal access to medicines in China.MethodsDrawing on multiple sources of information, including a review of published literatures and official national data, field investigations in six provinces and interviews with key opinion leaders, this paper presents a preliminary assessment of the impact of the national healthcare reforms on access to medicines, and proposes policy recommendations for promoting universal access to medicines in China.ResultsPublic expenditure on medicines has been strictly controlled since the national healthcare reforms of 2009. Yet total pharmaceutical expenditure (TPE) and total health expenditure growth rates continuously outpaced the growth of gross domestic product (GDP). With 2.4% of GDP, TPE now exceeds that of most high income countries. The distorted provider and consumer incentives in the Chinese health system have not fundamentally changed. Price-setting and reimbursement mechanisms do not promote cost-effective use of medicines. Inappropriate price controls and perverse financial incentives are the un-resolved root causes of preference of originator brands for some major diseases and shortages of low-cost and low-consumption medicines. In addition, access to expensive life-saving medicines is yet systematically addressed.ConclusionsThe complicated and interdependent problems interact in a way that leads to significant system problems in China, which create dual challenges that both the developing country and the developed countries are facing. To further promote access to medicines, China should speed up the re-assessment of the quality and efficacy of domestically produced generic medicines; coordinate various reforms of price determination, insurance payments, and procurement policies; address medicine shortages through comprehensive policies and legislation; establish specific mechanisms to achieve sustainable equitable access to expensive essential medicines with health technology assessment as a tool to ensure that policy and priority setting are created in a coherent and evidence-based way.

Accelerating the adoption of bundled payment reimbursement systems: A data-driven approach utilizing claims data

ABSTRACTBundled payments as a reimbursement mechanism have the potential to reduce health care expenditures and improve the quality of care by aligning the incentives of payers, providers and, most importantly, patients. The Centers for Medicare and Medicaid Services (CMS) launched the Bundled Payments for Care Improvement (BPCI) program in April 2013 and has set ambitious goals for adopting alternative payment models on a large scale. One of the crucial components for successful implementation of a bundled payment system is the identification of procedural homogeneous groups within an episode of care (a set of services needed to treat a medical condition), to which a flat reimbursement rate can be applied. In this study, we propose a data-driven clustering approach to automatically detect and explicitly represent homogeneous sub-groups of services for a given condition. Manual detection is slow and relies on consensus decisions, but automatic detection can serve as an important foundational input for bundle building. We explore the results from analyzing two conditions, one with a low and the other with a high degree of treatment complexity. Resulting clusters characterize episodes of care by specifying included services. The automatically extracted clusters of services have different cost patterns and highlight the payer's expenditure and provider's financial risk under bundled payments. Such a data-driven approach could be used by payers (e.g., CMS) to facilitate the adoption of bundled payments by different providers. To demonstrate, we use the clusters identified to model a payment scheme that minimizes providers’ financial risk.

Prior Authorization and Canadian Public Utilization of Direct-Acting Oral Anticoagulants.

Purpose:Provincial public drug formularies in Canada have different mechanisms for reimbursement of direct-acting oral anticoagulants (DOACs). We investigate how these differences influence DOAC utilization and expenditure across the country.Methods:We conducted a population-based, cross-sectional study of all out-patient prescriptions for OACs dispensed to public beneficiaries between January 1, 2010, and June 30, 2015. We calculated quarterly rates of OAC use and expenditures stratified by OAC type and province.Results:The greatest increase in quarterly rates of DOAC utilization occurred in provinces with more liberal mechanism of drug coverage: Ontario by 462%, Alberta by 425% and Quebec by 1,924%. This translated to increased expenditure on overall OAC by 270%, 204% and 390%, respectively. In contrast, provinces with more stringent mechanisms had low rates of DOAC utilization and expenditure.Conclusions:DOAC utilization and expenditure is considerably different across Canada, associated with provincial difference in reimbursement mechanism.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.