Multiple Payers Research Articles

Cost-Effectiveness of Dabigatran (150 mg Twice Daily) and Warfarin in Patients ≥65 Years With Nonvalvular Atrial Fibrillation

Dabigatran has been shown to be superior to warfarin for stroke prevention in nonvalvular atrial fibrillation (NVAF) but with higher out-of-pocket costs for patients. Although dabigatran has been shown to be cost effective from a societal perspective, cost implications for individual patients and insurers are not well described. We aimed to assess cost perspectives of each payer (Medicare and patient) in relation to administration, monitoring, and adverse outcomes for dabigatran and warfarin in patients with and without prescription drug coverage. Using a Markov model, we performed a decision analysis comparing 2 treatment strategies (dose-adjusted warfarin and dabigatran 150 mg twice daily) in patients 65 years old with NVAF, CHADS2 scores ≥ 1, and Medicare insurance. Patients have a quality-adjusted life expectancy of 8.998 quality-adjusted life years with warfarin and 9.39 quality-adjusted life years with dabigatran 150 mg twice daily. From Medicare's perspective, the incremental cost-effectiveness ratio comparing dabigatran with warfarin was $35,311 for patients with Part D coverage and cost saving for patients without coverage. From the patient's perspective, the incremental cost-effectiveness ratio comparing dabigatran with warfarin was cost saving for patients with Part D coverage and $63,884 for those without coverage. In patients ≥ 65 years with NVAF and prescription insurance coverage, dabigatran 150 mg twice daily is both cost effective (Medicare's perspective) and cost saving (patient perspective) compared with warfarin, at a willingness-to-pay threshold of $100,000. However, patients without prescription drug coverage have a high out-of-pocket cost burden with dabigatran therapy, leading to a reduction in its cost-effectiveness compared with warfarin therapy. In conclusion, this Markov model suggests that Medicare Part D coverage influences the cost-effectiveness of dabigatran 150 mg daily compared with dose-adjusted warfarin from multiple payer perspectives.

Classification of patients with incident non-specific low back pain: implications for research

Background ContextComparing research studies of low back pain is difficult because of heterogeneity. There is no consensus among researchers on inclusion criteria or the definition of an episode. PurposeThis study aimed to determine pattern(s) of recurrent non-specific low back pain from data collected over 27 months. Study Design/SettingThis study used retrospective cohort study using administrative claims from multiple payers. Although claims are designed for capturing costs, not clinical complexity, they are valid for describing utilization patterns, which are not affected by potential “upcoding.” Patient SampleThe patient sample consisted of population-based, nationally generalizable sample of 65,790 adults with continuous medical and pharmaceutical commercial health insurance who received health care for incident, non-specific low back pain. Potential subjects were excluded for plausible cause of the pain, severe mental illness, or cognitive impairment. Outcome MeasuresDiagnostic and therapeutic health-care services, including medical, surgical, pharmaceutical, and complementary, received in inpatient, outpatient, and emergency settings were the outcome measures for this study. MethodsThe methods used for this study were latent class analysis of health-care utilization over 27 months (9 quarters) following index diagnosis of non-specific low back pain occurring in January–March 2009 and an analysis sample with 60% of subjects (n=39,597) and validation sample of 40% (n=26,193). ResultsFour distinct groups of patients were identified and validated. One group (53.4%) of patients recovered immediately. One third of patients (31.7%) may appear to recover over 6 months, but maintain a 37–48% likelihood of receiving care for low back pain in every subsequent quarter, implying frequent relapse. Two remaining groups of patients each maintain very high probabilities of receiving care in every quarter (65–78% and 84–90%), predominantly utilizing therapeutic services and pain medication, respectively. Probabilistic grouping relative to alternatives was very high (89.6–99.3%). Grouping was not related to demographic or clinical characteristics. ConclusionsThe four distinct sets of patient experiences have clear implications for research. Inclusion criteria should specify incident or recurrent cases. A 6-month clean period may not be sufficiently long to assess incidence. Reporting should specify the proportion recovering immediately to prevent mean recovery rates from masking between-group differences. Continuous measurement of pain or disability may be more reliable than measuring outcomes at distinct endpoints.

Private payers disagree with Medicare over medical device coverage about half the time.

There are multiple payers in the US health care system, each making its own coverage determinations for medical technologies. For each of the forty-seven medical devices considered in national coverage determinations (NCDs) of the Centers for Medicare and Medicaid Services (CMS) issued between February1999 and August2013, we compared CMS's coverage policy with the policies issued by the largest sixteen private payers that made their decisions publicly available. Overall, we found that NCDs were equivalent to the corresponding private payer policies roughly half of the time, more restrictive approximately a quarter of the time, and less restrictive about a quarter of the time. Our findings indicate that patients may have variable access to medical technology across Medicare and private plans. They also suggest that private plans do not necessarily follow CMS's lead in making coverage decisions.

Medicaid Proposal Updates Managed Care Rules

You have accessThe ASHA LeaderPolicy Analysis1 Aug 2015Medicaid Proposal Updates Managed Care RulesIn comments, ASHA raises issues of quality measures, continuity of care, provider enrollment and other topics. Laurie Alban HavensMA, CCC-SLP Laurie Alban Havens Google Scholar More articles by this author , MA, CCC-SLP https://doi.org/10.1044/leader.PA.20082015.26 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Proposed regulations for managed care programs under Medicaid and the Children’s Health Insurance Program (CHIP) would create more uniformity among state programs while improving beneficiary choices and quality. Issued in late May by the Centers for Medicare and Medicaid Services (CMS), the proposal updates 2002 regulations for managed care organizations. Estimates indicate that managed care enrollment in Medicaid—the largest payer of health care services in the United States—has jumped 48 percent to 46 million beneficiaries, and that almost three-quarters of Medicaid beneficiaries will be enrolled in managed care organizations by the end of 2015. Almost three-quarters of Medicaid beneficiaries will be enrolled in managed care organizations by the end of 2015. As a result of this growth, audiologists and speech-language pathologists are providing services to greater numbers of patients covered by Medicaid and CHIP managed care organizations. ASHA’s comments to CMS on the proposal address several issues that affect audiologists and SLPs who participate—or are interested in participating—as providers in Medicaid managed care plans. Alignment of plans. Because people often move among insurers, ASHA is requesting that eligibility standards for managed care programs be the same as those for other payers, such as traditional Medicaid and Medicaid expansion plans and the plans that are part of the health insurance exchanges. With standardized enrollment qualifications, a patient leaving one plan would likely qualify for another. Network adequacy. Managed care organizations should be required to update their network or providers regularly, to ensure sufficient providers to meet enrollees’ needs and to allow audiologists and SLPs who want to participate to enroll as spaces become available. Quality improvement. CMS should institute methods that adequately measure the quality of speech-language and hearing services, rather than using measures developed for other disciplines. Continuity of care. When beneficiaries qualify for both Medicare and Medicaid, managed care plans should ease the change from or among multiple payers by minimizing the wait for treatment approval from the new providers. Appeals. CMS should streamline the process for beneficiaries who want to appeal plan decisions to deny services. Historically, the timeframe to appeal denied claims has been limited, although payers have been allowed more time to provide a response. ASHA will provide more information on the effects of the regulations when the final rule is issued sometime later this year. Author Notes Laurie Alban Havens, MA, CCC-SLP, is director of ASHA private health plans and Medicaid advocacy. [email protected] Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 20Issue 8August 2015 Get Permissions Add to your Mendeley library History Published in print: Aug 1, 2015 Metrics Current downloads: 134 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2015 American Speech-Language-Hearing AssociationLoading ...

Aggregating administrative and claims data from multiple payers to estimate population-based health outcomes: A validation study.

285 Background: Health insurance claims data are increasingly used for estimating individual health outcomes. However, it is challenging to obtain population-based estimates because of difficulties obtaining and reconciling data from all insurance providers. With incomplete insurance data, methods are needed to estimate the entire insured population. Using multi-payer claims we demonstrate and validate a synthetic method to obtain county level morbidity estimates. Methods: We used data from the Integrated Cancer Information and Surveillance System (ICISS) data resource at the University of North Carolina (NC) at Chapel Hill. ICISS data represent a linked data resource comprised of beneficiaries enrolled in federal as well as private insurance plans and rich ecologic data; and represent 5.5 million unique individuals, about 55% of the NC population. Using specific ICD-9 diagnosis codes, claims data from 2008 were compared to state department of public health data. We computed county level hospitalization rates by summing data from three sub-groups: age 65 and older in the 100% Medicare sample, age younger than 65 in the 100% Medicaid sample, and age younger than 65 represented in the private payer data. For the privately insured population, we used census data to obtain estimates of the entire privately insured population and used the hospitalization rate from beneficiaries in ICISS data to estimate a numerator for the synthetic sample of privately insured beneficiaries. We used State Inpatient Data (SID) from NC County Data Book to validate our method. Results: Overall, our synthetic approach showed moderate to high validity with a Pearson correlation coefficient 0.77 for heart disease and 0.93 for flu or pneumonia. Our hospitalization estimates were slightly lower than the data from SID, because SID data include uninsured individuals and multiple hospitalizations for individuals. Conclusions: Our synthetic method can be useful in estimating population-based health outcomes using linked insurance claims data.

"Managed competition" for Ireland? The single versus multiple payer debate.

BackgroundA persistent feature of international health policy debate is whether a single-payer or multiple-payer system can offer superior performance. In Ireland, a major reform proposal is the introduction of ‘managed competition’ based on the recent reforms in the Netherlands, which would replace many functions of Ireland’s public payer with a system of competing health insurers from 2016. This article debates whether Ireland meets the preconditions for effective managed competition, and whether the government should implement the reform according to its stated timeline. We support our arguments by discussing the functioning of the Dutch and Irish systems.DiscussionAlthough Ireland currently lacks key preconditions for effective implementation, the Dutch experience demonstrates that some of these can be implemented over time, such as a more rigorous risk equalization system. A fundamental problem may be Ireland’s sparse hospital distribution. This may increase the market power of hospitals and weaken insurers’ ability to exclude inefficient or poor quality hospitals from contracts, leading to unwarranted spending growth. To mitigate this, the government proposes to introduce a system of price caps for hospital services.The Dutch system of competition is still in transition and it is premature to judge its success. The new system may have catalyzed increased transparency regarding clinical performance, but outcome measurement remains crude. A multi-payer environment creates some disincentives for quality improvement, one of which is free-riding by insurers on their rivals’ quality investments. If a Dutch insurer invests in improving hospital quality, hospitals will probably offer equivalent quality to consumers enrolled with other insurance companies. This enhances equity, but may weaken incentives for improvement. Consequently the Irish government, rather than insurers, may need to assume responsibility for investing in clinical quality. Plans are in place to assure consumers of free choice of insurer, but a key concern is a potential shortfall of institutional capacity to regulate managed competition.SummaryManaged competition requires a long transition period and the requisite preconditions are not yet in place. The Irish government should refrain from introducing managed competition until sufficient preconditions are in place to allow effective performance.

Bundled payment fails to gain a foothold In California: the experience of the IHA bundled payment demonstration.

To determine whether bundled payment could be an effective payment model for California, the Integrated Healthcare Association convened a group of stakeholders (health plans, hospitals, ambulatory surgery centers, physician organizations, and vendors) to develop, through a consensus process, the methods and means of implementing bundled payment. In spite of a high level of enthusiasm and effort, the pilot did not succeed in its goal to implement bundled payment for orthopedic procedures across multiple payers and hospital-physician partners. An evaluation of the pilot documented a number of barriers, such as administrative burden, state regulatory uncertainty, and disagreements about bundle definition and assumption of risk. Ultimately, few contracts were signed, which resulted in insufficient volume to test hypotheses about the impact of bundled payment on quality and costs. Although bundled payment failed to gain a foothold in California, the evaluation provides lessons for future bundled payment initiatives.

Recurrent hospitalization and healthcare resource use among patients with deep vein thrombosis and pulmonary embolism: findings from a multi-payer analysis.

The objective of this study was to assess deep vein thrombosis and pulmonary embolism (DVT/PE) recurrence rates and resource utilization among patients with an initial DVT or PE event across multiple payer perspectives. Retrospective analyses were performed using a software tool that analyzes health plan claims to evaluate treatment patterns and resource utilization for various cardiovascular conditions. Six databases were analyzed from three payer perspectives (Commercial, Medicare, and Medicaid). Patients were ≥18 years old with a primary diagnosis of DVT or PE associated with an inpatient and/or emergency room claim, had received an antithrombotic within 7 days before or 14 days after index, and had no diagnosis of atrial fibrillation during follow-up. Outcomes were assessed over a 1 year period following index. More PE patients were hospitalized for their index event than DVT patients (42–59 % DVT and 69–86 % PE) and had longer mean length of stay (2.35–2.95 days DVT and 3.26–3.76 days PE). Recurrent event rates among PE patients (12–32 %) were higher than those for DVT patients (6–16 %) across all payers. The highest rate of recurrence was observed among the Medicaid population [23 % overall (VTE); 16 % DVT; 32 % PE]. All-cause hospitalization in the year following their VTE episode occurred in 23–67 % DVT patients and 30–68 % PE patients. Medicaid had the highest proportion of patients with hospitalizations and ER visits. Recurrent VTE events and all-cause hospitalizations are relatively common, especially for patients who had a PE, and among those in the Medicaid payer population.

What are the patterns of prophylactic postoperative oral antibiotic use after foot and ankle surgery?

The CDC estimates 23% of healthcare-associated infections to be surgical site infections, with alarming prevalence of antibiotic-resistant organisms. While there is consensus regarding preoperative prophylaxis, orthopaedic surgeons' use of prophylactic postoperative oral antibiotics is less defined. We investigated surgeons' use of prophylactic postoperative oral antibiotics after elective outpatient foot or ankle procedures, identifying (1) frequency of use, (2) regimen preferences, (3) personal indications, and (4) associated experience and demographics. Using a cross-sectional survey design, a questionnaire was emailed to all active and candidate members of the American Orthopaedic Foot and Ankle Society. Supplementary questions captured demographic information. We invited 1136 members to participate; 22 addresses produced delivery failure messages, leaving 1114 members as potential participants. After nonresponses and exclusions, 312 (28%) responses were analyzed. Statistical analysis used Pearson's chi-square test, Fisher's exact test, and multivariate regression. The majority (75%) of respondents reported use of prophylactic postoperative oral antibiotics. Most users (69%) prescribed to fewer than 25% of patients, although 16% prescribed for all elective cases. The most frequent regimen was cephalexin 500 mg four times a day (63%) and the most common duration was 5 to 7 days (50%). Surgeons' most common indications were previous infection (71%), medical comorbidities (65%), and previous wound-healing difficulties (56%). Those who do and do not prescribe prophylactic postoperative oral antibiotics showed no difference in surgical site infection rate or any demographic category. Surgeons' reported use of prophylactic postoperative oral antibiotics after elective foot or ankle surgery was common, without demographic association. Commonalities were identified in antibiotic regimen and personal indications for this practice. Comparative clinical studies are warranted to elucidate the efficacy of prophylactic postoperative oral antibiotics and establish evidence-based guidelines for their use.

CMS--engaging multiple payers in payment reform.

CMS--engaging multiple payers in payment reform.

Beyond the pill: The move towards value-added services in the pharmaceutical industry

An increasingly competitive environment, reduced drug pipelines, multiple patent expiries and payers’ increasing demands for outcomes-based evidence are all factors currently presenting challenges to the pharmaceutical industry. Offering value-added services alongside products, as a means to improve health outcomes and provide a competitive advantage, is a strategy currently being explored by many pharmaceutical companies to confront these challenges. The aim of this study is to analyse to what extent such service strategies are and will be integrated into the pharmaceutical business model. The scope of the study is global and concentrates on pharmaceutical companies manufacturing branded products. In all, 59 experts working for the pharmaceutical industry were asked for their perceptions on current and future service strategies within the industry. Most respondents believed that service strategies are becoming increasingly important. However, there are still multiple challenges to overcome. Legal restric...

The National Commission on Physician Payment Reform: Recalibrating Fee-for-Service and Transitioning to Fixed Payment Models

The National Commission on Physician Payment Reform: Recalibrating Fee-for-Service and Transitioning to Fixed Payment Models

Population-Based Analysis Of High Hospital Utilization (HHU) Among Children and Adolescents With Sickle Cell Disease (SCD)

BackgroundSickle cell disease (SCD) is characterized by marked heterogeneity in clinical manifestations, severity and utilization of health care services. This heterogeneity is particularly evident with regards to utilization of inpatient services, which account for a large percentage of total health care costs and significant absence from school and work. Previous studies of utilization, based on analysis of administrative datasets, have been limited by inaccuracies in ICD-coding, inability to differentiate among SCD genotypes, and/or inability to capture individuals never hospitalized. Single center studies have been limited by potential disease severity referral bias, inability to capture service utilization at outside facilities, and relatively small numbers. ObjectivesWe sought to identify children and adolescents with SCD with high hospital utilization (HHU) and to determine the relationship of HHU with age, SCD genotype, and insurance coverage. We also sought to examine trends over a three year period (2010-2012) and explore the relationship of any trends in hospital utilization over time. MethodsThe clinical database of the SCD Program at Children's Healthcare of Atlanta (CHOA) was used to identify all patients with SCD, ages ≥ 5 years, who received comprehensive outpatient, acute care, and inpatient services at three CHOA facilities in metro Atlanta during 2010-2012. SCD genotype was confirmed for each patient by review of hematologic and clinical data, including results of diagnostic hemoglobin electrophoresis. All outpatient clinic, emergency department, and inpatient utilization was captured as well as insurance (payer) status at each encounter. HHU was defined as ≥3 admissions during a calendar year. Data were analyzed for significance by Chi-square. The extent to which the data were population-based was determined from the Georgia Hospital Association database with includes DRG-level data for all inpatient hospitalizations in Georgia. ResultsHospitalizations at CHOA accounted for 96.1% of all SCD admissions for children within the 28-county greater metro Atlanta area. During 2010-2012, 1348 individual children and adolescents ≥ 5yr of age with SCD received comprehensive care at CHOA (1076 in 2010, 1112 in 2011, 1159 in 2012): 928 (68.8%) had SS/S β°thal, 334 (24.8%) SC, 86 (6.4%) S β+thal. Of 1159 active patients in 2012, 441 (38.1%) were 5-9 yr of age, 419 (36.2%) 10-14 yr, 299 (25.8%) ≥ 15 yr; 474 (40.9%) had traditional medicaid (MC), 205 (17.7%) managed-care medicaid (MMC), 374 (32.3%) private payer (PP), and 105 (9.1%) multiple payers (MP). HHU (≥ 3 admissions/yr) decreased from 119 of 1076 (11.1%) in 2010 to 96 of 1112 (8.6%) in 2011 and 95 of 1159 (8.2%) in 2012 (p <.01). The Table shows percentage HHU for each year by age, genotype, and payer.TableAge (years)SCD GenotypePayerYear5-910-14≥15PSS/S βoSCS β+PMCMMCPPMPPTotal20108.19.616.9< .0113.35.84.6< .01154.47.619.8< .0111.120115.57.214.1< .0110.86.64.30.1211.85.85.611.30.018.620123.610.212< .018.68.15.80.6510.74.35.912.4< .018.2 ConclusionsFor children and adolescents with SCD, HHU decreased during the three year period. HHU was significantly associated with older age and with MC and MP insurance coverage during all three years. HHU was significantly associated with the SS/S β°thal genotype in 2010, but not in 2011-12. The extent to which the decline of HHU among patients with SS/S β°thal genotype was related to increasing use of hydroxyurea is being investigated. Disclosures:Off Label Use: Hydroxyurea is not FDA approved for use in children.

Accountable Interventional Pain Management: A Collaboration Among Practitioners, Patients, Payers, and Government

The prevalence, costs, and disability associated with chronic pain continue to escalate. So too, the numerous modalities of treatments applied in managing these patients continue to increase as well. In the period from 2000 to 2011 interventional techniques increased 228%. In addition, analysis of utilization trends and expenditures for spinal interventional techniques alone from 2000 to 2008 illustrated an increase in Medicare fee-for-service expenditures of 240% in terms of dollars spent in the United States. The Office of Inspector General (OIG) of the Department of Health and Human Services showed an increase in facet joint and transforaminal epidural injections, with a significant proportion of these services did not meet the medical necessity criteria. The increasing utilization of interventional techniques is also associated with significant variations among specialty groups and regional variations among states. Overall procedures have increased by 173%, with rate of 130% per 100,000 Medicare beneficiaries for epidural injections; 383%, with a rate of 308% for facet joint interventions; and overall 410%, or a rate of 331% for sacroiliac joint interventions. Certain high volume interventions such as lumbar transforaminal epidural injections and lumbar facet joint neurolysis have actually increased a staggering 806% and 662%. Coverage policies across ambulatory settings and by multiple payers are highly variable. Apart from variability in the development of coverage policies, payments also substantially vary by site of service. In general, amongst the various ambulatory settings the highest payments are made to hospital outpatient departments (HOPDs) the lowest to in-office procedures, and payment to ambulatory surgery centers (ASCs) falling somewhere in the middle. This manuscript describes the many differences that exist between the various settings, and includes suggestions for accountable interventional pain management with coverage for techniques with evidence, addressing excessive use of specific techniques, and equalizing payments across multiple ambulatory settings. Key words: Accountable interventional pain management, Medicare, Medicare Evidence Development &amp; Coverage Advisory Committee, epidural injections, facet joint interventions, sacroiliac joint injections, payment policies

Rethinking Pharmacare in Canada

All developed countries with universal healthcare systems provide universal coverage for prescription drugs – except Canada. Instead, Canadian provinces allocate limited public subsidies for prescriptions drugs, leaving the majority of costs to be financed out-of-pocket and through private insurance. We review three of the main approaches to provincial pharmacare policy – exemplified by British Columbia, Ontario, and Quebec – and compare them with policies in other countries. We find that Canadian models for prescription drug financing have major shortcomings.All provincial systems involve considerable patient charges and multiple payers that are not responsible for financing patients’ medical and hospital care. The costs borne by patients are known to reduce the use of medicines that might otherwise improve patient health and reduce costs elsewhere in the healthcare system. And the involvement of multiple payers adds administrative costs, diminishes purchasing power and creates funding silos that limit the potential for healthcare managers and providers to consider the full benefits and opportunity costs of prescription drugs as an input into the broader healthcare system.The performance of countries with comparable healthcare systems shows that integrating pharmaceuticals into the healthcare system by covering medically necessary prescription drugs at little or no cost to patients would result in improved performance on all key pharmacare policy goals. Countries with such coverage achieve better access to medicines, and greater financial protection for the ill, at significantly lower total cost than any Canadian province achieves. In this Commentary, we suggest that provinces expand public pharmacare programs to all segments of the population with a specific focus on promoting access to medicines of proven value-for-money in our healthcare system. Though the immediate effect of this would be an increase in government spending, this would, over time, be more than offset by savings to patients, employers and individuals who purchase stand-alone private drug coverage.

Blending group and practice site scores to increase the reliability of physician quality information.

To use an empirical Bayesian approach, blending practice, and group quality data with physician results to increase the accuracy of quality of care measures. Performance data on diabetes glycemic screening for 8,357 physicians collected from multiple payers as part of a statewide physician performance reporting initiative. A variance components analysis assessed the strength of group, practice, and physician effects compared with random error. We derived formulas to describe reliability and measurement error variances and calculated the optimal blend of physician, practice, and group data. We constructed a simulation to show what various methods can achieve. The value of blending strategies was assessed by simulating a common pay-for-performance criterion-performance in the top 25 percent. We estimated the proportion of physicians whose true percentage would place them in the top 20 percent but who would not receive payment based on the observed success rate. Blending reduced the error rate from 29.7 to 22.7 percent. Simpler empirical Bayes estimates using shrinkage alone produced no gains over simple doctor percentages. When good structural data about physician groups and practices exist, gains from blending can be substantial.

Out of Pocket, Out of Sight? An Unmeasured Component of the Burden of Cancer

Out of Pocket, Out of Sight? An Unmeasured Component of the Burden of Cancer

A survey on the appropriate level of premiums for National Health Insurance

A the National Health Insurance Law was established in 2000, the finances of workplace health insurance and regional health insurance were integrated. However, since employee health insurance (workplace insurance) and self-employed health insurance (community insurance) still use different contribution rating systems, the problem of inequity of premiums has caused ongoing controversy. Therefore, to examine the public’s satisfaction with premiums calculation methods, and collect opinions on solving the problem of inequity of premiums, this survey was performed. A computer-assisted telephone interview with multi-stage stratified sampling of the population in Korea was performed. Responses were obtained from 1,016 people aged 25 to 64 years. The analyses showed that, to the question about the premiums calculation methods, more respondents answered that they were unsatisfied (41.4%) than satisfied (36.6%). The responses differed depending on the type of health insurance. The proportion of those who were satisfied with their insurance was relatively higher among those with employee health insurance. On the other hand, among those with self-employed health insurance, the proportion of those who were dissatisfied with insurance was 3 times more common than satisfaction with it, showing that those who belong to the self-employed health insurance group are less satisfied with the premiums calculation methods. It was also found that the majority people perceive that the current single payer health insurance system should be divided into mutually separate employee and self-employed health insurance systems or a multiple payer health insurance system (60.3%). To achieve premium equity in the future, the Health Insurance Corporation should make a greater effort to determine income levels correctly. In the institutional improvement process of the premiums contribution rating system in the future, it seems necessary to carry out further research on a multiple payer insurance system reflecting the attitudes and demands of the people.

Defining the Demography of ERCP Providers Using a Statewide Registry

Purpose: ERCP is a high-risk endoscopic procedure with limited epidemiological outcomes data among low volume providers and from those outside of academic or large metropolitan areas. We use a statewide registry to describe the demography of ERCP providers to establish the relevance of studying quality benchmarks among low volume physicians. Methods: We conducted a retrospective cohort study using a health information exchange that captures data from all Medicaid and multiple commercial payers to include a cross section of patients and facilities from across Indiana. This represents 21% of actual volume based on an audit of selected providers whose total annual volume could be confirmed. ERCPs were identified using CPT and ICD-9 codes from 2001-2011. Validation was done via selective auditing of medical records to confirm the appropriate provider was linked with each ERCP. All providers were manually validated as having high likelihood of performing ERCP. Each ERCP was treated as a unique event, with capture of both patient and provider characteristics. Individual providers were then categorized into tertiles based on their annual volume. Results: We identified 16,968 ERCPs performed by 131 providers, classified as low (<10 ERCPs/yr, n=106 [80.9%]), moderate (10-116 ERCPs/yr, n=21 [16.0%]) and high (>116 ERCPs/yr, n=4 [3.1%]). The highest tertile comprised 4 physicians who performed 5,695 (33.6%) of all procedures in the cohort (table). The majority of ERCPs were performed by providers having high (>100) or low (<30) annual volume (Figure). The high tertile providers performed more procedures on outpatients (85.1%) compared to the mid (56.9%) and low (47.3%) volume groups (p<0.0001).Figure: [159] Distribution of ERCPs from 2001-2011 based on provider volume.Conclusion: The majority (81%) of physicians performing ERCP in Indiana are low volume providers, yet they perform a comparatively small proportion of all ERCPs. This confirms the need for additional studies to evaluate quality outcomes, particularly in this low volume cohort, including patient selection, utilization of ERCP-based therapies, and outcomes.Table: [159]

In Japan, All-Payer Rate Setting Under Tight Government Control Has Proved To Be An Effective Approach To Containing Costs

In Japan's health insurance system, the prices paid by multiple payers for nearly all health care goods and services are codified into a single fee schedule and are individually revised within the global rate set by the government. This single payment system has allowed total health care spending to be controlled despite a fee-for-service system with its incentives for increased volume of services; Japan's growing elderly population; and the regular introduction of new technologies and therapies. This article describes aspects of Japan's approach, as well as how that nation has expanded payment for inpatient hospital care based on case-mix. The result of the payment system is that Japan's rate of health spending growth has been well below that of other industrial nations. The percentage of gross domestic product spent on health increased from 7.7 percent in 2000 to 8.5 percent in 2008, compared to an increase from 13.7 percent to 16.4 percent in the United States. Japan's approach confirms that enlightened government regulation can maintain access to care, avoid rationing, make use of the latest technology, and allow for multiple insurance plans and an aging population--all while restraining the growth of health care spending.