Payments Adjustment Research Articles

The 2018 Merit-based Incentive Payment System: Participation, Performance, and Payment Across Specialties.

The Merit-based Incentive Payment System (MIPS) incorporates financial incentives and penalties intended to drive clinicians towards value-based purchasing, including alternative payment models (APMs). Newly available Medicare-approved qualified clinical data registries (QCDRs) offer specialty-specific quality measures for clinician reporting, yet their impact on clinician performance and payment adjustments remains unknown. We sought to characterize clinician participation, performance, and payment adjustments in the MIPS program across specialties, with a focus on clinician use of QCDRs. We performed a cross-sectional analysis of the 2018 MIPS program. During the 2018 performance year, 558,296 clinicians participated in the MIPS program across the 35 specialties assessed. Clinicians reporting as individuals had lower overall MIPS performance scores (median [interquartile range (IQR)], 80.0 [39.4-98.4] points) than those reporting as groups (median [IQR], 96.3 [76.9-100.0] points), who in turn had lower adjustments than clinicians reporting within MIPS APMs (median [IQR], 100.0 [100.0-100.0] points) (P<0.001). Clinicians reporting as individuals had lower payment adjustments (median [IQR], +0.7% [0.1%-1.6%]) than those reporting as groups (median [IQR], +1.5% [0.6%-1.7%]), who in turn had lower adjustments than clinicians reporting within MIPS APMs (median [IQR], +1.7% [1.7%-1.7%]) (P<0.001). Within a subpopulation of 202,685 clinicians across 12 specialties commonly using QCDRs, clinicians had overall MIPS performance scores and payment adjustments that were significantly greater if reporting at least 1 QCDR measure compared with those not reporting any QCDR measures. Collectively, these findings highlight that performance score and payment adjustments varied by reporting affiliation and QCDR use in the 2018 MIPS.

Quality measures in dementia care across a network of memory clinics: An implementation study

AbstractBackgroundIn 2015 the American Academy of Neurology and American Psychiatric Association updated the Dementia Management Measurement Set from 2009. Out of the nine measures proposed, four have been included by the Centers for Medicare and Medicaid Services (CMS) in their Merit‐Based Incentive Payment System, which is used to determine payment adjustments in pay‐for‐reporting program. In 2018, the Wisconsin Alzheimer’s Institute (WAI) developed a process to track the performance of these measures across the WAI Dementia Diagnostic Clinic Network, which consists of 44 statewide clinics across 24 healthcare systems.MethodIn September 2018, WAI launched the following implementation strategies to improve adoption of the quality measures: audit and feedback, new de‐identified forms, and development of a codebook with definitions and examples on how to fill the new forms. Clinics submit de‐identified forms containing demographics, diagnosis and process measures that are used to calculate performance on the quality measures. Descriptive analyses were performed, and performance was calculated according to criteria set by CMS.ResultOver 24 months, 23 clinics have submitted information on 3,247 patients. Early adopters demonstrated a high performance on the measures, but as more clinics participate, the distribution has shown regression to the mean (Table 1). When comparing clinic performance between Oct 2019 – Oct 2020 with CMS benchmarks for 2020, the percentage of clinics performing above the CMS average were: 68% for measure #2; 91% for measure #3; 48% for measure #4; and 86% for measure #5 (Figure). Variations in performances have been attributed to unique characteristics of each clinic, for example, some do not follow‐up individuals and only provide recommendations to primary care providers; this lowers their metrics in measures that require management of behaviors or conditions.ConclusionImplementation of the quality measures across the WAI network has been facilitated by the use of clinical care models that promote interdisciplinary care. Further research is required to explore additional mechanisms that increase participation of clinics, and to develop new data collection methods that can explore the impact of these measures on health outcomes.

Anesthesia provider performance in the first two years of merit-based incentive payment system: Shifts in reporting and predictors of receiving bonus payments

Study objectiveThe Merit-Based Incentive Payment System (MIPS) program was intended to align CMS quality and incentive programs. To date, no reports have described anesthesia clinician performance in the first two years of the program. DesignObservational retrospective cohort study. SettingCenters for Medicare and Medicaid Services public datasets for their Quality Payment Program. PatientsAnesthesia clinicians who participated in MIPS for 2017 and 2018 performance years. InterventionsDescriptive statistics compared anesthesia clinician characteristics, practice setting, and MIPS performance between the two years to determine associations with MIPS-based payment adjustments. MeasurementsLogistic regression identified independent predictors of bonus payments for exceptional performance. Main resultsCompared with participants in 2017 (n = 25,604), participants in 2018 (n = 54,381) had a higher proportion of reporting through groups and alternative payment models (APMs) than as individuals (p < 0.001). The proportion of clinicians earning performance bonuses increased from 2017 to 2018 except for those MIPS participants reporting as individuals. Median total MIPS scores were higher in 2018 than 2017 (84.6 vs. 82.4, p < 0.001), although median total scores fell for participants reporting as individuals (40.9 vs 75.5, p < 0.001). Among clinicians with scores in both years (n = 20,490), 10,559 (51.3%) improved their total score between 2017 and 2018, and 347 (1.7%) changed reporting from individual to APM. Reporting as an individual compared with group reporting (OR: 0.75; 95% CI: 0.71 to 0.80; p < 0.001) was associated with lower rates of bonus payments, as was having a greater proportion of patients dual-eligible for Medicaid and Medicare. Reporting through an APM (OR: 149.6; 95% CI: 110 to 203.4; p < 0.001) and increasing practice group size were associated with higher likelihood of bonus payments. ConclusionsAnesthesia clinician MIPS participation and performance were strong during 2017 and 2018 performance years. Providers who reported through groups or APMs have a higher likelihood of receiving bonus payments.

Comparing provider payment adjustments across 20 countries during COVID-19

Abstract COVID-19 has affected health providers economically in two main ways. First, some providers lost income due to postponed services or patients refraining from seeking care. Second, other providers took on new tasks by treating (high volumes of) COVID-19 patients. All providers faced higher costs due to new hygiene and distance requirements. We reviewed if and how countries have adjusted payments to health providers during 2020 using an analytical framework and data from 20 countries. The analysis is based on information collected in the COVID-19 Health System Response Monitor (HSRM) and complemented by grey literature by country representatives who are experts on health policy and have reported the developments and responses to the pandemic since is very onset. We found that payments were not adjusted for many providers whose income did not depend on activity such as salaries, capitations and budgets. Most of the compensatory payments were in the form of new salaries and budgets that substituted activity-based payments, and some higher fees to compensate for activity shortfalls. New FFS payments were created to incentivize virtual services. Payments for COVID-19 related costs included mainly new fees for services. Hospitals also received new budgets to cover the costs of adjusting wards, creating new (ICU) beds, and hiring more workforce. Some countries also created new per diem and DRG tariffs to pay for COVID-19 patients. Consumables such as personal protective equipment and hygiene material were provided in-kind or reimbursed in-cash. Overall, governments bore many COVID-19 financial risks. Payment adjustments should be carefully designed in order to protect providers from income shortfalls without undermining productivity, access or quality of care. Payments for COVID-19 services should promote provision without leading to overtreatment or overspending.

10.B. Workshop: The COVID-19 Health Systems Response Monitor: what can we learn for the future

Abstract The Health Systems Response Monitor (HSRM) was established in March 2020 at the beginning of the COVID-19 pandemic to collect and organize up-to-date information on how 50 countries in the WHO European Region and Canada are responding to the crisis. The HSRM uses a structured template, focusing primarily on the responses of health systems but also capturing wider public health initiatives. The HSRM is a joint undertaking of the WHO Regional Office for Europe, the European Observatory on Health Systems and Policies, and the European Commission. The HSRM builds on the Health Systems and Policy Network of the European Observatory, which brings together an international group of high-profile institutions from Europe and beyond with high academic standing in health systems and policy analysis. The content collected on the HSRM platform has been used to enhance cross country learnings through topical snapshots, papers, webinars and more. At the end of 2020, the European Observatory initiated a Health Policy Special Issue (SI) based on the work of the HSRM containing both thematic policy papers and full comparative descriptions and analysis of country responses. Overall, work from the HSRM aims to provide coherent and comprehensive insight on lessons learned from the COVID-19 response so far to support policymakers for future waves or in case of future pandemics. This workshop aims to provide the audience with an overview of the COVID-19 HSRM and the insights gleaned from the SI. An introductory overview will briefly introduce the COVID-19 HSRM and the SI. The first presentation will compare provider payment adjustments across 20 countries. The second presentation will focus on how countries planned services for potential surge capacity, managed care provision, and maintained routine services in both hospital and outpatient settings during the first wave of the pandemic. The third presentation will zoom in on experiences in primary health care. The last presentation will feature one of the country comparison papers from social health insurance countries. The workshop will conclude with an audience discussion about the lessons learned from the COVID-19 HSRM, and future opportunities for research using the HSRM. Key messages The COVID-19 Health System Response Monitor has tracked the progression of health policies throughout the pandemic and captures particularly policy relevant aspects. Both thematic and cross-country comparisons can illuminate how health systems have responded to the COVID-19 pandemic and provide lessons for future waves and pandemics.

Balancing financial incentives during COVID-19: A comparison of provider payment adjustments across 20 countries

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries.We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff.We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care.

How Did Orthopaedic Surgeons Perform in the 2018 Centers for Medicaid & Medicare Services Merit-based Incentive Payment System?

The Merit-based Incentive Payment System (MIPS) is the latest value-based payment program implemented by the Centers for Medicare & Medicaid Services. As performance-based bonuses and penalties continue to rise in magnitude, it is essential to evaluate this program's ability to achieve its core objectives of quality improvement, cost reduction, and competition around clinically meaningful outcomes. We asked the following: (1) How do orthopaedic surgeons differ on the MIPS compared with surgeons in other specialties, both in terms of the MIPS scores and bonuses that derive from them? (2) What features of surgeons and practices are associated with receiving penalties based on the MIPS? (3) What features of surgeons and practices are associated with receiving a perfect score of 100 based on the MIPS? Scores from the 2018 MIPS reporting period were linked to physician demographic and practice-based information using the Medicare Part B Provider Utilization and Payment File, the National Plan and Provider Enumeration System Data (NPPES), and National Physician Compare Database. For all orthopaedic surgeons identified within the Physician Compare Database, there were 15,210 MIPS scores identified, representing a 72% (15,210 of 21,124) participation rate in the 2018 MIPS. Those participating in the MIPS receive a final score (0 to 100, with 100 being a perfect score) based on a weighted calculation of performance metrics across four domains: quality, promoting interoperability, improvement activities, and costs. In 2018, orthopaedic surgeons had an overall mean ± SD score of 87 ± 21. From these scores, payment adjustments are determined in the following manner: scores less than 15 received a maximum penalty adjustment of -5% ("penalty"), scores equal to 15 did not receive an adjustment ("neutral"), scores between 15 and 70 received a positive adjustment ("positive"), and scores above 70 (maximum 100) received both a positive adjustment and an additional exceptional performance adjustment with a maximum adjustment of +5% ("bonus"). Adjustments among orthopaedic surgeons were compared across various demographic and practice characteristics. Both the mean MIPS score and the resulting payment adjustments were compared with a group of surgeons in other subspecialties. Finally, multivariable logistic regression models were generated to identify which variables were associated with increased odds of receiving a penalty as well as a perfect score of 100. Compared with surgeons in other specialties, orthopaedic surgeons' mean MIPS score was 4.8 (95% CI 4.3 to 5.2; p < 0.001) points lower. From this difference, a lower proportion of orthopaedic surgeons received bonuses (-5.0% [95% CI -5.6 to -4.3]; p < 0.001), and a greater proportion received penalties (+0.5% [95% CI 0.2 to 0.8]; p < 0.001) and positive adjustments (+4.6% [95% CI 6.1 to 10.7]; p < 0.001) compared with surgeons in other specialties. After controlling for potentially confounding variables such as gender, years in practice, and practice setting, small (1 to 49 members) group size (adjusted odds ratio 22.2 [95% CI 8.17 to 60.3]; p < 0.001) and higher Hierarchical Condition Category (HCC) scores (aOR 2.32 [95% CI 1.35 to 4.01]; p = 0.002) were associated with increased odds of a penalty. Also, after controlling for potential confounding, we found that reporting through an alternative payment model (aOR 28.7 [95% CI 24.0 to 34.3]; p < 0.001) was associated with increased odds of a perfect score, whereas small practice size (1 to 49 members) (aOR 0.35 [95% CI 0.31 to 0.39]; p < 0.001), a high patient volume (greater than 500 Medicare patients) (aOR 0.82 [95% CI 0.70 to 0.95]; p = 0.01), and higher HCC score (aOR 0.79 [95% Cl 0.66 to 0.93]; p = 0.006) were associated with decreased odds of a perfect MIPS score. Collectively, orthopaedic surgeons performed well in the second year of the MIPS, with 87% earning bonus payments. Among participating orthopaedic surgeons, individual reporting affiliation, small practice size, and more medically complex patient populations were associated with higher odds of receiving penalties and lower odds of earning a perfect score. Based on these findings, we recommend that individuals and orthopaedic surgeons in small group practices strive to forge partnerships with larger hospital practices with adequate ancillary staff to support quality reporting initiatives. Such partnerships may help relieve surgeons of growing administrative obligations and allow for maintained focus on direct patient care activities. Policymakers should aim to produce a shortened panel of performance measures to ensure more standardized comparison and less time and energy diverted from established clinical workflows. The current MIPS scoring methodology should also be amended with a complexity modifier to ensure fair evaluation of surgeons practicing in the safety net setting, or those treating patients with a high comorbidity burden. Level III, therapeutic study.

Emergency clinician participation and performance in the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System.

The Merit-based Incentive Payment System (MIPS) is the largest national pay-for-performance program and the first to afford emergency clinicians unique financial incentives for quality measurement and improvement. With little known regarding its impact on emergency clinicians, we sought to describe participation in the MIPS and examine differences in performance scores and payment adjustments based on reporting affiliation and reporting strategy. We performed a cross-sectional analysis using the Centers for Medicare & Medicaid Services 2018 Quality Payment Program (QPP) Experience Report data set. We categorized emergency clinicians by their reporting affiliation (individual, group, MIPS alternative payment model [APM]), MIPS performance scores, and Medicare Part B payment adjustments. We calculated performance scores for common quality measures contributing to the quality category score if reported through qualified clinical data registries (QCDRs) or claims-based reporting strategies. In 2018, a total of 59,828 emergency clinicians participated in the MIPS-1,246 (2.1%) reported as individuals, 43,404 (72.5%) reported as groups, and 15,178 (25.4%) reported within MIPS APMs. Clinicians reporting as individuals earned lower overall MIPS scores (median [interquartile range {IQR}]=30.8 [15.0-48.2] points) than those reporting within groups (median [IQR]=88.4 [49.3-100.0]) and MIPS APMs (median [IQR]=100.0 [100.0-100.0]; p<0.001) and more frequently incurred penalties with a negative payment adjustment. Emergency clinicians had higher measure scores if reporting QCDR or QPP non-emergency medicine specialty set measures. Emergency clinician participation in national value-based programs is common, with one in four participating through MIPS APMs. Those employing specific strategies such as QCDR and group reporting received the highest MIPS scores and payment adjustments, emphasizing the role that reporting strategy and affiliation play in the quality of care.

Impacts of the Home Health Value‐Based Purchasing (HHVBP) Model After the First Payment Adjustment Year

Research ObjectiveThe Home Health Value‐Based Purchasing (HHVBP) Model provides financial incentives for quality improvement to home health agencies in nine states with the goal of improving quality and efficiency of care for Medicare beneficiaries. The maximum Medicare payment adjustment increases during each of the five years of the model, ranging from ±3% in 2018 to ±8% in 2022. Our goal is to understand the early impact of the HHVBP Model on quality, utilization, and Medicare spending during its first three years (2016–2018), which includes the first year in which payment adjustments to agencies took effect.Study DesignCMS randomly selected nine states to participate in the HHVBP Model starting January 2016, with mandatory participation from all agencies. Agencies in these states received performance scores for 20 measures of quality of care used to determine their payment adjustment relative to other agencies within their state. To evaluate the effects of HHVBP, we used a difference‐in‐differences design and multivariate linear regression to compare differences in the changes in outcomes of the nine HHVBP states with those in the 41 comparison states for three years pre‐intervention (2013–2015) through the first three years of the model (2016–2018). We evaluated agency performance using Outcome and Assessment Information Set (OASIS)‐based quality measures and measures of claims‐based Medicare fee‐for‐service (FFS) health care utilization and spending.Population StudiedMedicare and Medicaid patients receiving home health care in the nine HHVBP states and forty‐one comparison states.Principal FindingsWe found evidence of slightly greater improvements in most measures of improved functional status used to determine payment adjustments in HHVBP states relative to non‐HHVBP states. Compared to non‐HHVBP states, Medicare FFS beneficiaries who received home health care in the nine HHVBP states had a relative decrease in unplanned hospitalization rate (−1.8%) and in skilled nursing facility (SNF) stays (−4.9%) from pre‐HHVBP implementation average levels. Conversely, we observed a 2.4% increase in emergency department (ED) visits relative to the average pre‐implementation rates for HHVBP states. Overall, we found evidence of a 1.2% reduction in Medicare spending due to HHVBP, corresponding to an average $141 million reduction in annual Medicare spending in HHVBP states over the first three years of the model. The reduction in spending among home health Medicare FFS patients was driven primarily by reductions in inpatient hospital spending (−2%) and SNF spending (−4%). We did not find an appreciable difference in savings between the third year—in which payment adjustments were applied—and the first two years of the model prior to HHVBP agencies receiving payment adjustments.ConclusionsThrough the HHVBP Model's first three years—which includes the first year of payment adjustments to agencies—we found modest impacts of HHVBP: lower growth in Medicare spending, declines in unplanned hospitalizations and use of SNFs, somewhat greater increases in ED use, and somewhat greater improvements in many OASIS‐based quality measures among home health patients in the HHVBP states.Implications for Policy or PracticeThe findings from current and subsequent research will inform policymakers, home health care patients, and other stakeholders about potential benefits of expanding the model to include agencies in other states.Primary Funding SourceCenters for Medicare and Medicaid Services.

Disparity in Medicare payments by gender and training track in female pelvic medicine and reconstructive surgery

Gender disparities in medicine have been demonstrated in the past, including differences in the attainment of roles in administration and in physician income. Our objective was to determine the differences in Medicare payments based on the provider gender and training track among female pelvic medicine and reconstructive surgeons. Medicare payments from the Provider Utilization Aggregate Files were used to determine the payments made by Medicare to urogynecologists. This database was merged with the National Provider Identifier registry with information on subspecialty training, years since graduation, and the geographic pricing cost index used for Medicare payment adjustments. Physicians with <90% female patients and those who graduated medical school <7 years ago in obstetrics and gynecology or <8 years ago in urology were excluded. The effects of gender, specialty of training, number of services provided, years of practice, and geographic pricing cost index on physician reimbursement were evaluated using linear mixed modeling. A total of 578 surgeons with female pelvic medicine and reconstructive surgery subspecialty training met the inclusion criteria. Of those, 517 (89%) were trained as gynecologists, whereas 61 (11%) were trained as urologists. Furthermore, 265 (51%) of the gynecology-trained surgeons and 39 (80%) of the urology-trained surgeons were women. Among the urology-trained surgeons, the median female surgeon was paid $85,962 and their male counterparts were paid $121,531 (41% payment difference). In addition, urology-trained female pelvic medicine and reconstructive surgery surgeons performed a median of 1135 services and their male counterparts performed a median of 1793 services (57% volume difference). Similarly, among gynecology-trained surgeons, the median female payment was $59,277 with 880 services performed, whereas male gynecology-trained surgeons received a median of $66,880 with 791 services performed, representing a difference of 12% in payments and 11% in services. With linear mixed modeling, male physicians were paid more than female physicians while controlling for specialty training, number of services performed, years of practice, and geographic pricing cost index (P<.001). Although Medicare payments are based on an equation, differences in reimbursement by physician gender exist in female pelvic medicine and reconstructive surgery with female surgeons receiving lower payments from Medicare. The differences in reimbursement could not be solely explained by differences in patient volume, area of practice, or years of experience alone, suggesting that, similar to other fields in medicine, female surgeons in female pelvic medicine and reconstructive surgery are not paid as much as their male counterparts.

How to fix the Merit-based Incentive Payment System (MIPS) in emergency medicine.

How to fix the Merit-based Incentive Payment System (MIPS) in emergency medicine.

BALANCE OF PAYMENTS AND ITS IMPACT ON THE MONETARY POLICY

The paper monitors the balance of payments in the Republic of North Macedonia, which determines the amount of the exchange rate through the supply and demand of foreign currency, as well as the impact of the exchange rate on the balance of payments movements. Real exchange rates are essentially equilibrium exchange rates. exchange rate that will keep the balance of payments in balance without taking measures for foreign exchange control, without pronounced inflation and deflationary tendencies and without constant expectation of monetary and foreign exchange reserves.There are several methods by which balance of payments can be established: by devaluation, by currency control and by deflation. When considering the relationship between the national currency exchange rate and the balance of payments of a national economy in terms of their interconnections, one should depart from their causal link of impacts. The exchange rate affects the balance of payments, as well as the balance of payments affects the exchange rate.The first part of the paper elaborates in detail the key activities of the balance of payments adjustment and the exchange rate adjustment, as well as their mutual impact.We use the adjustment mechanism to restore balance once the initial equilibrium has been disturbed. The payment adjustment process takes two different forms. One, under certain conditions, has adjustment factors that automatically contribute to balancing. Second, in the event that automatic adjustment fails to strike a balance, the government adopts a discretionary policy to achieve this goal

Evaluation of the Merit-Based Incentive Payment System and Surgeons Caring for Patients at High Social Risk

The latest step in the Centers for Medicaid & Medicare transformation to pay-for-value is the Medicare Merit-Based Incentive Payment System (MIPS). Value-based payment designs often do not account for uncaptured clinical status and social determinants of health in patients at high social risk, and the consequences for clinicians and patients associated with their use have not been explored. To evaluate MIPS scoring of surgeons caring for patients at high social risk to determine whether this implementation threatens disadvantaged patients' access to surgical care. A retrospective cohort study of US general surgeons participating in MIPS during its first year in outpatient surgical practices across the US and territories. The study was conducted from September 1, 2020, to May 1, 2021. Data were analyzed from November 1, 2020, to March 30, 2021 (although data were collected during the 2017 calendar year and reported ahead of 2019 payment adjustments). Characteristics of surgeons participating in MIPS, overall MIPS score assigned to clinician. and practice-level disadvantage measures. The MIPS scores can range from 0 to 100. For the first year, a score of less than 3 led to negative payment adjustment; a score of greater than 3 but less than 70 to a positive adjustment; and a score of 70 or higher to the exceptional performance bonus. Of 20 593 general surgeons, 10 252 participated in the first year of MIPS. Surgeons with complete patient data (n = 9867) were evaluated and a wide range of dual-eligible patient caseloads from 0% to 96% (mean [SD], 27.1% [14.5%]) was identified. Surgeons in the highest quintile of dual eligibility cared for a Medicare patient caseload ranging from 37% to 96% dual eligible for Medicare and Medicaid. Surgeons caring for the patients at highest social risk had the lowest final mean (SD) MIPS score compared with the surgeons caring for the patients at least social risk (66.8 [37.3] vs 71.2 [35.9]; P < .001). Results of this cohort study suggest that implementation of MIPS value-based care reimbursement without adjustment for caseload of patients at high social risk may penalize surgeons who care for patients at highest social risk.

Monetary Policy Variables Relevance on Balance of Payments Adjustment in Nigeria 1980-2020

This study examines monetary policy relevance on the Nigerian balance of payments adjustment, form 1980-2020. Objectives are; to examine the relevance of monetary policy variables such as Exchange rate, Inflation rate, Balance of trade, Real Gross Domestic Product and Domestic Credit on the Nigerian balance of payments adjustment. Evaluate the significant speed of adjustment of monetary policy variables such as Exchange rate, Inflation rate, Balance of trade, Real Gross Domestic Product and Domestic Credit on the balance of payments adjustment within the period under study. The study employed the following advanced econometric techniques; Augmented Dickey-Fuller (ADF) and Phillips-Perron (PP) tests, chow test, ECM model OLS model, statistical tests &amp; Co-integration test. Based on the above econometric techniques conducted, it was observed that group unit root test result shows that variables used in the study became stationary after the first differenced at degree of order one I(I). There is Co-integration (long run relations) among variables used in the study. Our results indicated rejection of the two null hypotheses of this study and acceptation of the alternative three hypotheses that said; Nigerian monetary policy variables such as Exchange rate, Inflation rate, Balance of trade and Domestic Credit have significant relevance on the Nigerian balance of payments adjustment. Nigerian monetary policy variables used have significantly three years to adjust balance of payments adjustment in the Nigerian economy within the period of the study. The researcher recommends that; the need to manage domestic liquidity wisely in view of the tremendous pressure on the balance of payments of excess money. A determined effort to mobilize resources through private saving and the implementation of a prudent fiscal policy through efficient collection of tax revenues, rationalization of government expenditure towards growth enhancing and poverty reduction programmes will also enable the government to pursue its development programs without having to rely on the monetization of its budget deficit. Overall concentration on monetary tools solely should be reduced and employ other policy instruments to correct the balance of payment fluctuation. The government should also be cautious of budget deficit that are often time financed by internal borrowings.

An Update: The Association between the CXO Role and Hospital Patient Experience Scores

Due to the healthcare industry’s shift from fee-for-service to value-based purchasing (VBP), many hospitals have changed their internal structure to adapt to the new environment by including a new C-suite leader, a Chief Experience Office (CXO). Payers have implemented various performance models to incentivize hospitals and other providers to incorporate the concept of patient-centeredness for improving the patient experience. The patient experience domain of the HCAHPS survey is an integral part of CMS’ hospital VBP program payment adjustment. Considering that most hospitals operate with under two percent profit margins, payment incentives or penalties can have a significant impact on their financial sustainability. So this study aimed to answer the question, does a hospital receive a return on a CXO investment in way of higher patient experience scores? Using Breen and colleagues (in-press) study data, we wanted to explore if our findings, post three years, would be consistent with their findings, that is, to determine if hospitals that continue to employ a formal full-time CXO role report higher HCAHPS scores than hospitals without this C-suite position. Our study’s findings were consistent with the Breen et al. study in that hospitals that have a formal CXO role are more likely to have higher HCAHPS scores as determined by the patient recommendation question as well as the hospital overall rating question included in the HCAHPS survey. We also provide additional insight into the organization characteristics of hospitals and the market factors associated with those hospitals that have filled the CXO role.

Otolaryngologist Performance in the Merit-Based Incentive Payment System in 2018.

In 2017, the Centers for Medicare and Medicaid Services transitioned clinicians to the Merit-Based Incentive Payment System (MIPS), the largest mandatory pay-for-performance program in health care history. The first full MIPS program year was 2018, during which the Centers for Medicare and Medicaid Services raised participation requirements and performance thresholds. Using publicly available Medicare data, we conducted a retrospective cross-sectional analysis of otolaryngologist participation and performance in the MIPS in 2017 and 2018. In 2018, otolaryngologists reporting as individuals were less likely (P < .001) to earn positive payment adjustments (n = 1076/1584, 67.9%) than those participating as groups (n = 2802/2804, 99.9%) or in alternative payment models (n = 1705/1705, 100.0%). Approximately one-third (n = 1286/4472, 28.8%) of otolaryngologists changed reporting affiliations between 2017 and 2018. Otolaryngologists who transitioned from reporting as individuals to participating in alternative payment models (n = 137, 3.1%) achieved the greatest performance score improvements (median change, +23.4 points; interquartile range, 12.0-65.5). These findings have important implications for solo and independent otolaryngology practices in the era of value-based care.

Pay Factor Analysis for Highway Pavements through Percentage of Material within Specification Limits and Monte Carlo Simulation

Many state highway agencies (SHAs) have adopted pay adjustment provisions in their acceptance plans for construction and materials. In these payment adjustment acceptance plans, the percentage of material within specification limits (PWL) has been selected as the quality measure to relate production quality to pay factors, and pay equations are used to determine a pay factor for a lot based on PWL. Various pay equations have been proposed by the highway community for adoption in SHAs’ specifications. However, the effectiveness of these pay equations has not been fully evaluated. Another issue concerning the pay adjustment acceptance plans is the risk associated with single and multiple pay factors. The purpose of this study was to evaluate the effects of different pay equations commonly used by SHAs and the risks associated with pay adjustment acceptance plans. This was achieved by developing operating characteristic curves associated with various pay factors and expected pay curves and Monte Carlo simulation for assessing the effects in the long run. The methodology suggested in this paper is transferable elsewhere where similar materials and specifications are used for the acceptance of pavements.

Healthcare Reimbursement and Service Utilization for One Year of Post-Allogeneic Hematopoietic Cell Transplantation (alloHCT) Care for Medicare Beneficiaries Ages 65 and Older with Acute Myeloid Leukemia

Objective: Acute myeloid leukemia (AML) is the most common indication for alloHCT in the United States (US) for Medicare beneficiaries. An increasing number of older patients are now able to undergo alloHCT; however, there is a significant gap in knowledge about their healthcare costs. The primary objective of this study was to assess healthcare reimbursement, service utilization, and overall survival for designated time points up to 1-year post-alloHCT for Medicare beneficiaries ages 65 and older in the US with an AML diagnosis.Methods: Medicare claims data from 2010 - 2012 were merged with Center for International Blood & Marrow Transplant Research (CIBMTR) clinical outcomes data. Patients were excluded who underwent alloHCT before 3/1/10 or after 12/31/11 (to allow for 2 months prior and 1-year follow-up), had a prior autologous or alloHCT, or were not enrolled in both Parts A and B 60 days prior to and on date of HCT. The total amount of reimbursement for 1-year post-transplant included the Medicare payment, secondary payer payments, and coinsurance and out-of-pocket payments made by beneficiaries. Cumulative reimbursement for Part A facility inpatient services, outpatient services, home health and hospice services and Part B physician services were inflation-adjusted to 2017 dollars using Centers for Medicare and Medicaid Services (CMS) Market Baskets. Weighted generalized linear models were used to identify key drivers of total reimbursement adjusting for age, gender, transplant center region, year of transplant, Karnofsky score, disease status, donor type, graft type, Sorror comorbidity score, cytomegalovirus (CMV) serostatus, conditioning intensity, graft-versus-host disease (GVHD) prophylaxis, anti-thymocyte globulin (ATG)/Alemtuzumab (Campath) use, and 2-month total reimbursement prior to the index HCT hospitalization or outpatient HCT date. Service utilization was measured by counts of reported claims and total service days. The Kaplan-Meier method was used to estimate the probability of overall survival (OS) stratified by disease status and conditioning intensity.Results: A total of 250 patients met inclusion criteria. Mean age at HCT was 68.7 yrs. The total cumulative reimbursement for the entire cohort were $166,032 (95% confidence interval (CI): $153,931, $178,133) at 100-days and $230,815 (95% CI: $214,381, $247,249) at 1-year post-alloHCT with inpatient reimbursement accounting for more than 80% of the total at each designated time point (Figure 1). The cumulative total reimbursements were $148,684 (95% CI: $137,994, $159,375) for patients surviving 100 days and $186,254 (95% CI: $166,765, $205,744) for patients surviving 1-year post-alloHCT. Counts of claims and total service days by service component and time point post transplant are shown (Tables 1 and 2). In multivariate analysis, patients who received cord blood compared to peripheral blood stem cell had significantly higher adjusted reimbursement (p=0.006). Similarly, myeloablative (MA) conditioning was associated with significantly higher reimbursement compared to non-myeloablative (NMA) (P < 0.0001). The Northeast (p=0.0275) and West (p=0.0323) regions had significantly higher reimbursement compared to the Midwest region. OS at 1-year post-alloHCT was 52% (95% CI: 46%-59%). Patients undergoing alloHCT in CR1/CR2 had better survival (p=0.0030) as did those who received NMA conditioning (P=0.0067).Conclusions: This unique dataset facilitated an analysis of key drivers of Medicare reimbursement for AML by patient and HCT related variables and outcomes. It was not surprising that a cord blood graft was a driver of reimbursement, likely due to acquisition costs, prolonged time to engraftment and subsequent hospitalization. The variation in reimbursement by region may be partly due to geographic adjustment of Medicare payments or transplant center billing practices. Interestingly, NMA conditioning not only led to lower 1-year reimbursement but also improved survival and may inform clinical practice. Future research will stratify each component of post-transplant reimbursement into specific cost categories to evaluate Medicare reimbursement and effects of practice patterns. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

11 Differences in medicare payments by gender and training track in female pelvic and reconstruction medicine and surgery

Gender disparities in medicine have been well established, with differences in attainment of roles in administration, and differences in physician income. Our objective was to determine Medicare payment differences by gender and specialty training track of FPMRS surgeon. Medicare payments from the Provider Utilization Aggregate Files were used to determine the payments made by Medicare to urogynecologists. This database was merged with the NPI registry with information on subspecialty training and years since graduation, along with the geographic pricing cost index to account for Medicare payment adjustments. Physicians with <90% female patients, and graduated medical school <7 (OBGYN) and <8 years ago (urology) were excluded. Effects of gender, specialty of training, number of services, years of practice, and geographic pricing cost index on physician reimbursement were evaluated using linear mixed modeling. There were 578 surgeons with FPMRS subspecialty training met inclusion criteria. Of those 517 (89%) trained as gynecologists, while 61 (11%) trained as urologists. 265 (51%) of the gynecology trained surgeons were women, and 39 (80%) of urology trained surgeons were women. Among urology trained surgeons the median female surgeon was paid $85,962 while the males were paid $121,531, or a 41% difference in payments, while women urology trained FPMRS surgeons performed a median of 1,135 services, while male surgeons performed a median of 1,793 services or a 57% difference in volume. Among gynecology trained surgeons the median female payments were $59,277 while performing 880 services, and male gynecology trained surgeons received a median of $66,880 and performed 791 services, representing a difference of 12% in payments and 11% in services. Male physicians were paid more than female physicians while controlling for specialty training, number of services, years of practice, and geographic pricing cost index. Despite Medicare payments being based on an equation, differences in reimbursement by physician gender continue to exist in FPMRS. Female surgeons in FPMRS receive lower payments from Medicare. The differences in reimbursement could not be solely explained by differences in patient volume, area of practice, or years of experience, suggesting that similar to other fields in medicine, women in FPMRS are not paid as much as male physicians.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Current Interventional Radiology-Related Benchmarked Clinical Quality Measures Are Less Likely to be “Capped” Than Diagnostic Radiology Clinical Quality Measures

In the merit-based incentive payment system (MIPS), quality measures are considered topped out if national median performance rates are ≥95%. Quality measures worth 10 points can be capped at 7 points if topped out for ≥2 years. This report compares the availability of diagnostic radiology (DR)-related and interventional radiology (IR)-related measures worth 10 points. A total of 196 MIPS clinical quality measures were reviewed on the Center for Medicare and Medicaid Services MIPS website. There are significantly more IR-related measures worth 10 points than DR measures (2/9 DR measures vs 9/12 IR measures; P = .03), demonstrating that clinical IR services can help mixed IR/DR groups maximize their Center for Medicare and Medicaid Services payment adjustment.