Payment Models Research Articles

NATIONAL HEALTH INSURANCE POLICY AND PROGRAMME AND ACCESS TO HEALTH CARE SERVICE AMONG FEDERAL GOVERNMENT WORKERS IN NIGERIA

The study examined the effect of National Health Insurance on health care service delivery Among Federal Workers in Nigeria. This mixed research design study investigates the relationships between primary and secondary health care service providers and the provision of essential healthcare services to enrollees in Nigeria. The population of the study encompasses federal governamnt workers with primary and secondary health care facilities across various regions in Nigeria. A sample size of 400 enrollees and 50 health care providers was selected using stratified random sampling techniques. Data were collected through structured interviews and surveys, focusing on the perceptions and experiences of both health care providers and enrollees regarding the provision of affordable health care, testing and diagnostic services, and referral services. The collected data were analyzed usingboth qualitative and quantitative methods, including thematic analysis and correlation analysis. The findings reveal significant relationships between primary health care service providers and the provision of affordable health care and testing and diagnostic services to enrollees in Nigeria. Moreover, the study identifies a significant relationship between secondary health care service providers and the provision of referral services to enrollees, highlighting the importance of collaboration between primary and secondary healthcare sectors to ensure comprehensive healthcare delivery in Nigeria. These results underscore the need for policy interventions and resource allocation strategies aimed at strengthening primary and secondary healthcare systems to improve access to essential healthcare services for all enrollees in Nigeria. The study recommends that Federal Government through the NHIA shouldimplement policies that aim to increase the affordability of healthcare services for all citizens, especially those in lower socioeconomic strata. This may involve subsidizing healthcare costs, expanding insurance coverage, or introducing targeted assistance programs for vulnerable populations. Additionally, encourage healthcare providers to offer transparent pricing structures and explore innovative payment models, such as sliding-scale fees or income-based discounts, to improve access for individuals with varying financial capacities.

County medical community, medical insurance package payment, and hierarchical diagnosis and treatment-Empirical analysis of the impact of the pilot project of compact county medical communities in Sichuan Province.

Hierarchical diagnosis and treatment (HDT) is an important exploration direction to alleviate the rising pressure of health expenses and medical insurance fund expenditure in China, and to maintain and protect the public health in this country. In recent years, the construction of compact county medical communities (CCMC) has become the primary approach for implementing the HDT. Utilizing the quasi-natural experiment of the pilot project of CCMC in Sichuan Province in 2019, coupled with county-level data extracted from the ' Sichuan Provincial Health Statistics Yearbook ' spanning the years 2008 to 2021, this research evaluates the effect of the pilot project of CCMC on promoting HDT under the medical insurance package payment model. The results show that the pilot project of CCMC has significantly increased the number of consultations per capita of medical and health institutions in pilot counties by 0.434 times, of which the number of consultations per capita of primary medical institutions has increased by 0.340 times; the number of hospitalizations per capita in public hospitals and primary medical institutions in pilot counties increased significantly, and the surgery rate of inpatients in public hospitals increased by 5% compared to before the pilot. There was no significant impact on the allocation of medical facilities and human resources in the pilot counties. Therefore, the construction of CCMC under the medical insurance package payment mode has promoted the realization of the county-level HDT. These findings provide valuable insights for healthcare policy, especially in developing and implementing effective strategies for HDT in county-level medical institutions.

Factors that influence scope-of-practice decisions of early-career family physicians: Focus group study in Canada.

To explore perceptions of early-career family physicians on the personal, educational, organizational, community, and system factors that had influenced their scope-of-practice decisions and to compare the similarities and differences among these factors across all 13 Canadian jurisdictions. Qualitative descriptive study. Canada. Fifty-nine early-career family physicians who were 2 to 5 years into independent practice. Data were collected using focus groups and were analyzed using deductive and inductive analysis techniques to identify patterns in the data within and across jurisdictions. Participants across all jurisdictions highlighted that personal factors (ie, interest, work-life balance and family life, financial considerations, and self-perceived competence and confidence) were most influential on scope-of-practice decisions. Educational (ie, exposure during training, mentorship), organizational (ie, collegial support), community (ie, needs), and system (ie, payment models, funding for team-based care, governance) factors also influenced decisions about scope of practice. Experiences were similar across all jurisdictions for personal factors. Differences in experiences were reported across jurisdictions for educational, organizational, community, and system factors. Decisions about scope of practice by early-career family physicians are highly influenced by personal factors followed by organizational, educational, community, and system factors. These findings suggest numerous strategies are needed to increase individuals' interest in providing comprehensive care in Canada. Educators should cultivate interest in comprehensive care among learners, strategically recruit trainees, provide targeted exposure and experiences, ensure competence and confidence are evaluated throughout and at the end of training, and introduce formal mentorship programs. Policy-makers should invest in the spread of effective team models and alternative payment models. Together, these strategies could broaden the scopes of practice of family physicians and their capacity to deliver accessible and comprehensive care to Canadians.

Demographic and Socioeconomic Trends of Patients Undergoing Total Knee Arthroplasty From 2013 to 2022—An Analysis From an Urban Orthopaedic Hospital

BackgroundAs worldwide utilization of total knee arthroplasty (TKA) broadens, demographic trends can help make projections to inform access to care. This study aimed to assess the temporal trends in the socioeconomic and medical demographics of patients undergoing TKA. MethodsA retrospective review of 15,848 patients who underwent primary, elective TKA at an urban, New York City-based academic medical center between January 2013 and September 2022 was performed. Trends in patients’ age, body mass index (BMI), socioeconomic status (SES) (based on median income by patients’ ZIP code), race, and Charlson comorbidity index were evaluated using the Mann-Kendall test. ResultsIn the last decade, mean patient age (65 to 68 years, P < .001) and Charlson comorbidity index (1.4 to 2.3, P < .001) increased significantly. The proportion of patients who had a BMI ≥ 30 and < 40 increased (43.8 to 51.2%, P = .002), while the proportion of patients who had a BMI ≥ 40 (13.7 to 12.1%, P = .015) and BMI < 30 (42.5 to 36.8%, P = .020) decreased. The distribution of patients’ race and SES did not change from 2013 to 2022; Black (18.1 to 16.8%, P = .211) and low SES (12.9 to 11.3%, P = .283) patients consistently represented a minority of TKA patients. ConclusionsOver the last decade, the average age and comorbidity burden of TKA patients at our institution have increased. This portends the need for higher levels of preoperative optimization and postoperative management for TKA patients. A decreased prevalence of BMI ≥40 could reflect optimization efforts. However, the consistently low prevalence of Black and low-SES patients suggests that recent payment models did not improve access to care for these populations. Level of EvidenceIV.

EPA 2024, Budapest - Abstract - ePoster Viewing Digital Psychiatric Innovations from a Business Perspective – new era, new business models

IntroductionThe advent of digital innovations in psychiatry has ushered in a new era in mental healthcare. These innovations offer the potential for enhanced diagnosis, treatment, and patient care. Establishing scientifically backed, dynamic, and adaptive business models is necessary to launch sustainable innovations onto the healthcare market.ObjectivesThis poster aims to provide a comprehensive understanding of the complex business-related challenges posed by digital innovations in psychiatry and to offer insights into potential strategies to address these challenges. The objectives include illuminating the dynamic landscape of digital psychiatric care from a business perspective.MethodsA systematic review of the current literature was conducted, encompassing scholarly articles, industry reports, and expert perspectives. This method enabled the synthesis of insights regarding how digital innovations are reshaping the business models of psychiatric medical markets and the unique challenges.ResultsDigital innovations in psychiatry are catalyzing a transformation of business models in the field. Telepsychiatry, Digital platforms, VR technologies, and AI-driven diagnostic tools have expanded the reach of psychiatric services, potentially attracting new patient populations and offering innovative payment models. The opportunities presented by these technologies are promising. However, substantial challenges exist in parallel. Safeguarding data privacy and security is paramount, given the sensitive nature of patient information. Navigating the evolving regulatory, managing the costs associated with the adoption and maintenance of these technologies pose significant hurdles. Complex pricing structures and reimbursement models further add to the complexity of the challenges, necessitating adaptability and innovative strategies.ConclusionsThis poster underscores the dynamic and multifaceted nature of business models in the market of psychiatric innovations. While these innovations offer expanded service reach, improved patient engagement, potential for innovative payment models, addressing the business-related challenges is of utmost importance. Compliance with data privacy regulations, cost management, adaptability in pricing and reimbursement strategies are fundamental for psychiatric innovators. Proactive measures are pivotal as the mental healthcare field continues to embrace digital innovations. By addressing these challenges, the mental health industry can fully harness the transformative potential of these innovations to enhance patient care, improve access to services, and ensure the sustainability of high-quality psychiatric care. The evolving business models in psychiatry require astute management and innovation to thrive in this digital era.Disclosure of InterestNone Declared

On the Willingness to Pay for social media/messenger services taking into account personality and sent/received messages among WhatsApp users

WhatsApp has billions of users worldwide. Instead of paying a subscription fee, users provide their data for the use allowance. This data is used by Meta – the company behind WhatsApp – to obtain insights into user characteristics and monetize those insights. However, this data business model is among others criticized for fostering a loss of privacy that arises when platforms analyze user data, and for the use of design elements to attract users to the platform when they are not online or to extend their online time. Therefore, an increasing number of scientists are discussing whether other payment models are needed to overcome those disadvantages, like a monetary payment model. However, users would probably only pay for improved social media products. This paper provides an empirical basis for understanding the user perspective and, in particular, whether and how much users are willing to pay for improved social media products. For this, 2924 WhatsApp users’ perspectives on this topic were investigated. They were asked whether and how much they are willing to pay money for a messenger/social media service when its quality would be improved. Variables potentially influencing Willingness to Pay (i.e., personality, sent/received messages) were studied as well.47% of the participants were unwilling to pay for a healthier messenger service, and about a quarter were willing or stayed neutral. Further analysis revealed that more agreeable people were more willing to pay. Further: Higher Extraversion was associated with more sent/received messages, but the number of sent/received messages was not linked to Willingness to Pay. The present study shows that many users still are not willing to pay for social media (here messengers), which indicates that the advantages of paying for social media with money instead of with one's own data might need to be better communicated.

Association of Hospitals' Experience with Bundled Payment for Care Improvement Model with the Diffusion of Acute Hospital Care at Home.

To examine whether hospitals' experience in a prior payment model incentivizing care coordination is associated with their decision to adopt a new payment program for a care delivery innovation. Data were sourced from Medicare fee-for-service claims in 2017, the list of participants in Bundled Payment for Care Improvement initiatives (BPCI and BPCI-Advanced), the list of hospitals approved for Acute Hospital Care at Home (AHCaH) between November 2020 and August 2022, and the American Hospital Association Survey. Retrospective cohort study. Hospitals' adoption of AHCaH was measured as a function of hospitals' BPCI experiences. Hospitals' BPCI experiences were categorized into five mutually exclusive groups: (1) direct BPCI participation, (2) indirect participation through physician group practices (PGPs) after dropout, (3) indirect participation through PGPs only, (4) dropout only, and (5) no BPCI exposure. All data are derived from pre-existing sources. General acute hospitals eligible for both BPCI initiatives and AHCaH are included. Of 3248 hospitals included in the sample, 7% adopted AHCaH as of August 2022. Hospitals with direct BPCI experience had the highest adoption rate (17.7%), followed by those with indirect participation through BPCI physicians after dropout (11.8%), while those with no exposure to BPCI were least likely to participate (3.2%). Hospitals that adopted AHCaH were more likely to be located in communities where more peer hospitals participated in the program (median 10.8% vs. 0%). After controlling for covariates, the association of the adoption of AHCaH with indirect participation through physicians after dropout was as strong as with early BPCI adopter hospitals (average marginal effect: 5.9 vs. 6.2 pp, p < 0.05), but the other categories were not. Hospitals that participated in the bundled payment model either directly or indirectly PGPs were more likely to adopt a care delivery innovation requiring similar competence in the next period.

Early Experiences With Bundled Payments for Care Improvement for Major Bowel Surgery.

Bundled Payment (BP) models are becoming more common in surgery. We share our early experiences with Bundled Payments for Care Improvement for major bowel surgery. Patients undergoing major bowel surgery between January and October 2021 were identified using Medicare Severity-Diagnosis Related Group (MS-DRG) codes. Major drivers of cost in a BP model are reported and compared to the Fee-For-Service (FFS) payment model. A total of 202 cases (173 FFS vs 29 BP) were analyzed. The mean BP cost per Clinical Episode was $28,340. Eleven patients (38%) in the BP model had costs greater than the Target Price. The drivers of cost in the BP model were 59% acute care facility, 17% physician services, 9% post-acute care facilities, 8% other, and 7% readmissions. Clinical Episode of care costs varied considerably by MS-DRG case complexity. Robotic surgery increased costs by 35% (mean increase $3724, P < .01). The 90-day readmission rate was 17% for a mean cost of $11,332 per readmission. Three patients (10%) were discharged to a skilled nursing facility at an average cost of $11,009, while fifteen patients (52%) received home health services at a mean cost of $2947. Acute care facility costs were similar in the BP vs FFS groups (mean difference $1333, P = .22). Patients undergoing major bowel surgery are a heterogeneous population. Physicians are ideally positioned to deliver high-value, patient-centered care and are crucial to the success of a BP model. The post-acute care setting is a key component of improving efficiency and quality of care.

Analyzing the 20-year declining trend of hospital length-of-stay in European countries with different healthcare systems and reimbursement models

The study aims to investigate the last 20-year (2000–2019) of hospital length of stay (LOS) trends and their association with different healthcare systems (HS) among 25 European countries. A panel dataset was created using secondary data from Eurostat and Global Burden of Disease study databases, with dependent and control variables aggregated at the national level over a period of 20 years. A time trend analysis was conducted using a weighted least squares model for panel data to investigate the association between LOS, HS models [National Health Service (NHS), National Health Insurance, Social Health Insurance (SHI), and Etatist Social Health Insurance], healthcare reimbursement schemes [Prospective Global Budget (PGB), Diagnosis Related Groups (DRG), and Procedure Service Payment (PSP)], and control variables. The study showed a reduction of average LOS from 9.20 days in 2000 to 7.24 in 2019. SHI was associated with a lower LOS compared to NHS (b = − 0.6327, p < 0.05). Both DRG (b = 1.2399, p < 0.05) and PSP (b = 1.1677, p < 0.05) reimbursement models were positively associated with LOS compared to PGB. Our results confirmed the downward trend of LOS in the last 20 years, its multifactorial nature, and the influence of the SHI model of HS. This could be due to the financial incentives present in fee-for-service payment models and the role of competition in creating a market for healthcare services. These results offer insight into the factors influencing healthcare utilization and can inform the design of more effective, efficient, and sustainable HS.

Determinants of global cardiac implantable electrical device remote monitoring utilization – Results from an international survey

Despite near-global availability of remote monitoring (RM) in patients with cardiac implantable electronic devices (CIED), there is a high geographical variability in the uptake and use of RM. The underlying reasons for this geographic disparity remain largely unknown. To study the determinants of worldwide RM utilization and identify locoregional barriers of RM uptake. An international survey was administered to all CIED clinic personnel using the Heart Rhythm Society global network collecting demographic information, as well as information on the use of RM, the organization of the CIED clinic, and details on local reimbursement and clinic funding. The most complete response from each center was included in the current analysis. Stepwise forward multivariate linear regression was performed to identify determinants of the percentage of patients with a CIED on RM. A total of 302 responses from 47 different countries were included, 61.3% by physicians and 62.3% from hospital-based CIED clinics. The median percentage of CIED patients on RM was 80% (interquartile range, 40-90). Predictors of RM use were gross national income per capita (0.76% per US$1000, 95% CI 0.72-1.00, P < .001), office-based clinics (7.48%, 95% CI 1.53-13.44, P=.014), and presence of clinic funding (per-patient payment model 7.90% [95% CI 0.63-15.17, P = .033); global budget 3.56% (95% CI -6.14 to 13.25, P = .471]). The high variability in RM utilization can partly be explained by economic and structural barriers that may warrant specific efforts by all stakeholders to increase RM utilization.

Is Primary Care Adapting to Medicaid Managed Care in North Carolina? Implications for Expansion and Future Managed Care Transitions.

Realizing North Carolina's comprehensive vision for Medicaid transformation requires strengthening the state's primary care infrastructure. This can be done by build-ing upon the value-based care incentives in the Advanced Medical Home model, strengthening payor data, aligning quality measures, easing administrative burdens, investing in primary care and its workforce pipeline, and ensuring pay-ment models adequately support serving Medicaid expan-sion and the growing number of Medicaid health plans.

The economic burden of cervical cancer on women in Uganda: Findings from a cross-sectional study conducted at two public cervical cancer clinics.

There is limited research on how a cervical cancer diagnosis financially impacts women and their families in Uganda. This analysis aimed to describe the economic impact of cervical cancer treatment, including how it differs by socio-economic status (SES) in Uganda. We conducted a cross-sectional study from September 19, 2022 to January 17, 2023. Women were recruited from the Uganda Cancer Institute and Jinja Regional Referral Hospital, and were eligible if they were ≥ of 18 years and being treated for cervical cancer. Participants completed a survey that included questions about their out-of-pocket costs, unpaid labor, and family's economic situation. A wealth index was constructed to determine their SES. Descriptive statistics were reported. Of the 338 participants, 183 were from the lower SES. Women from the lower SES were significantly more likely to be older, have ≤ primary school education, and have a more advanced stage of cervical cancer. Over 90% of participants in both groups reported paying out-of-pocket for cervical cancer. Only 15 participants stopped treatment because they could not afford it. Women of a lower SES were significantly more likely to report borrowing money (higher SES n = 47, 30.5%; lower SES n = 84, 46.4%; p-value = 0.004) and selling possessions (higher SES n = 47, 30.5%; lower SES n = 90, 49.7%; p-value = 0.006) to pay for care. Both SES groups reported a decrease in the amount of time that they spent caring for their children since their cervical cancer diagnosis (higher SES n = 34, 31.2%; lower SES n = 36, 29.8%). Regardless of their SES, women in Uganda incur out-of-pocket costs related to their cervical cancer treatment. However, there are inequities as women from the lower SES groups were more likely to borrow funds to afford treatment. Alternative payment models and further economic support could help alleviate the financial burden of cervical cancer care in Uganda.

A Two-Generation, Early Childhood Advanced Primary Care Model.

It is well recognized that early experiences produce long-term impacts on health outcomes, yet many children are at risk of not achieving their full potential because of health and service disparities related largely to poverty and racism. Although many pediatric primary care (PPC) models address these needs, most are isolated, add-on efforts that struggle to be scalable and sustainable. We describe 3-2-1 IMPACT (Integrated Model for Parents and Children Together), an initiative to transform the model of PPC delivered within New York City Health + Hospitals, the largest public hospital system in the United States, to address the full range of child and family needs in early childhood. Taking advantage of the frequent contact with PPC in the early years and linking to prenatal services, the model assesses family mental, social, and physical health needs and offers evidence-based parenting supports and integrated mental health services. Launching and sustaining the model in our large health system has required coalition building and sustained advocacy at the state, city, and health system levels. Long-term sustainability of the IMPACT model will depend on the implementation of early childhood-focused advanced payment models, on which we have made substantial progress with our major contracted Medicaid managed care plans. By integrating multiple interventions into PPC and prenatal care across a large public-healthcare system, we hope to synergize evidence-based and evidence-informed interventions that individually have relatively small effect sizes, but combined, could substantially improve child and maternal health outcomes and positively impact health disparities.

Values, challenges, and responses associated with high-priced potential cures: perspectives of diverse stakeholders in South Korea

BackgroundThe emergence of high-priced potential cures has sparked significant health policy discussions in South Korea, where the healthcare system is funded through a single-payer National Health Insurance model. We conducted focus group interviews (FGIs) and accompanying surveys with diverse stakeholders to comprehensively understand related issues and find better solutions to the challenges brought by these technologies.MethodsFrom October to November 2022, 11 FGIs were conducted with stakeholders from various sectors, including government payers, policy and clinical experts, civic and patient organisations, and the pharmaceutical industry, involving a total of 25 participants. These qualitative discussions were supplemented by online surveys to effectively capture and synthesise stakeholder perspectives.ResultsAffordability was identified as a critical concern by 84% of stakeholders, followed by clinical uncertainty (76%) and limited value for money (72%). Stakeholders expressed a preference for both financial-based controls and outcome-based pricing strategies to mitigate these challenges. Despite the support for outcome-based refunds, payers raised concerns about the feasibility of instalment payment models, whether linked to outcomes or not, due to the specific challenges of the Korean reimbursement system and the potential risk of ‘cumulative liabilities’ from ongoing payments for previously administered treatments. In addition, the FGIs highlighted the need for clear budgetary limits for drugs with high uncertainties, with mixed opinions on the creation of special silo funds (64.0% agreement). Less than half (48%) endorsed the use of external reference pricing, currently applied to such essential drugs in South Korea. A significant majority (84%), predominantly non-pharma stakeholders, advocated for addressing cost-effectiveness uncertainty through re-assessment once long-term clinical data become available.ConclusionsThis study uncovers a broad agreement among stakeholders on the need for more effective value assessment methodologies for high-priced potential cures, stressing the importance of more robust and comprehensive re-assessment supported by long-term data collection, rather than primarily relying on external reference pricing. Each type of stakeholders exhibited a cautious approach to their specific uncertainties, suggesting that new funding strategies should accommodate these uncertainties with predefined guidelines and agreements prior to the initiation of managed entry agreements.

Where Are All the Specialists? Current Challenges of Integrating Specialty Care Into Population-Based Total Cost of Care Payment Models.

The Centers for Medicare & Medicaid Services Innovation Center (CMMI) has set the goal for 100% of traditional Medicare beneficiaries to be part of an accountable care relationship by 2030. Lack of meaningful financial incentives, intolerable or unpredictable risk, infrastructure costs, patient engagement, voluntary participation, and operational complexity have been noted by the provider and health care delivery community as barriers to participation or reasons for exiting programs. In addition, most piloted and implemented population-based total cost of care (PB-TCOC) payment models have focused on the role of the primary care physician being the accountability (that is, attributable) leader of a patient's multifaceted care team as well as acting as the mayor of the "medical neighborhood," leaving the role of specialty care physicians undefined. Successful provider specialist integration into PB-TCOC models includes meaningful participation of specialists in achieving whole-person, high-value care where all providers are financially motivated to participate; there is unambiguous prospective attribution and clearly defined accountability for each participating party throughout the care journey or episode; there is a known care attribution transition accountability plan; there is actionable, transparent, and timely data available with appropriate data development and basic analytic costs covered; and there is advanced payment to the accountable person or entity for management of the care episode that is part of a longitudinal care plan. Payment models should be created to address the 7 challenges raised here if specialists are to be incented to join TCOC models that achieve CMMI's goal.

Joe's Story: How a Capitated Payment Model Lets Me Be the Physician I Want to Be.

For many years I cared for Joe, following him through diagnoses of strokes, end-stage renal disease, and metastatic prostate cancer. Gaining his trust, coordinating his care across specialist visits and hospitalizations, and helping him and his family clarify goals of care took an investment of time and relationship-building. I was able to spend this time with Joe, and all of my medically complex patients, because I had taken a job in a Program of All-Inclusive Care for the Elderly (PACE), a fully capitated model of care. With care organized around the patient instead of the visit, this payment model transformed my work life. As I reflect on the care that I provided for Joe over the years, I consider how health care organization and finance can either help or hinder our ability to provide patient-centered, coordinated, continuous care for our patients. Evolving payment models can help make space for family physicians to provide the robust primary care we are trained to deliver.

The value equation for specialist palliative care: design and delivery principles.

The value of specialist palliative care (SPC) is multi-faceted. Patients, families, healthcare providers, health systems and payors all benefit in different ways when SPC is included in the care of those with serious illness; they all have a shared interest in the availability and success of SPC. We propose a new value equation for SPC: SPC services must employ optimal design and standardized delivery of SPC to ensure that the payment model, care model, and needs of the patients are all aligned; and suitable payment models are necessary to provide stable, sustainable resources for the interdisciplinary palliative care teams; when these conditions are met, the cascade of beneficial outcomes of SPC can be produced reliably. We propose a set of 10 design and delivery principles describing these inputs and outcomes, applicable to SPC in all settings-hospital, clinic, and home. Amidst shifts in health policy and financing, the SPC field in the US continues to evolve with new innovations, additional evidence, and a clearer vision of what is valuable. An enduring component of the value equation of SPC continues to be the moderation of the total cost of care for payors. This articulation of the value equation for SPC is based on evidence and experience of palliative care providers and payors in the US, but the framework and principles are likely useful to guide and evaluate SPC in other countries as well.

Differences in Healthcare Utilization in Children with Developmental Disabilities Following Value-Based Care Coordination Policies.

To address healthcare spending growth, coordinate care, and improve primary care utilization, a majority of states in the United States have adopted value-based care coordination programs. The objective of this study was to identify changes in national healthcare utilization for children with developmental disabilities (DDs), a high-cost and high-need population, following the broad adoption of value-based care coordination policies. This retrospective study included 9,109 children with DDs and used data from 2002-2018 Medical Expenditure Panel Survey. We applied an interrupted time series design approach to compare pre- and post-Affordable Care Act (ACA) care coordination policies concerning healthcare utilization outcomes, including outpatient visits, home provider days, emergency department (ED) visits, inpatient discharge, and inpatient nights of stay. We found statistically significant increases in low-cost care post-ACA, including outpatient visits (5% higher, p <.001) and home provider days (11% higher, p <.001). The study findings also showed a statistically significant increase in inpatient nights of stay post-ACA (4% higher, p =.001). There were no changes in the number of ED and inpatient visits. Overall, broad implementation of care coordination programs was associated with increased utilization of low-cost care without increases in the number of high-cost ED and inpatient visits for children with DDs. Our study also found changes in population composition among children with DDs post-ACA, including increases in Hispanic (16.9% post-ACA vs. 13.4% pre-ACA, p =.006) and non-Hispanic multiracial children (9.1% post-ACA vs. 5.5% pre-ACA, p =.001), a decrease in non-Hispanic Whites (60.2% post-ACA vs. 68.6% pre-ACA, p =.001), more public-only insurance (44.3% post-ACA vs. 35.7% pre-ACA, p =.001), fewer children with DDs from middle-income families (27.4% post-ACA vs. 32.8% pre-ACA, p <.001), and more children with DDs from poor families (28.2% post-ACA vs. 25.1% pre-ACA, p =.043). These findings highlight the importance of continued support for broad care coordination programs for U.S. children with DDs and potentially others with complex chronic conditions. Policymakers and healthcare leaders might consider improving care transitions from inpatient to community or home settings by overcoming barriers such as payment models and the lack of home care nurses who can manage complex chronic conditions. Healthcare leaders also need to understand and consider the changing population composition when implementing care coordination-related policies. This study provides data regarding trends in hospital and home care utilization and evidence of the effectiveness of care coordination policies before the COVID-19 interruption. These findings apply to current healthcare management because COVID-19 has incentivized home care, which may have a strong potential to minimize high-cost care for people with complex chronic conditions. More research is warranted to continue monitoring care coordination changes over a longer period.

Geographical Differences in Surgeon Reimbursement, Volume, and Patient Characteristics in Primary Total Hip Arthroplasty

BackgroundThe purpose of this study was to evaluate changes in regional and national variations in reimbursement to arthroplasty surgeons, procedural volumes, and patient populations for total hip arthroplasty (THA) from 2013 to 2021. MethodsThe Medicare Physician and Other Practitioners database was queried for all billing episodes of primary THA for each year between 2013 and 2021. Inflation-adjusted surgeon reimbursement, procedural volume, physician address, and patient characteristics were extracted for each year. Data were stratified geographically based on the United States Census regions and rural–urban commuting codes. Kruskal–Wallis and multivariable regressions were utilized. ResultsBetween 2013 and 2021, the overall THA volume and THAs per surgeon increased at the highest rate in the West (+48.2%, +20.2%). A decline in surgeon reimbursement was seen in all regions, most notably in the Midwest (−20.3%). Between 2013 and 2021, the average number of Medicare beneficiaries per surgeon declined by 12.6%, while the average number of services performed per beneficiary increased by 18.2%. In 2021, average surgeon reimbursement was the highest in the Northeast ($1,081.15) and the lowest in the Midwest ($988.03) (P < .001). Metropolitan and rural areas had greater reimbursement than micropolitan and small towns (P < .001). Patient age, race, sex, Medicaid eligibility, and comorbidity profiles differ between regions. Increased patient comorbidities, when controlling for patient characteristics, were associated with lower reimbursement in the Northeast and West (P < .01). ConclusionsTotal hip arthroplasty (THA) volume and reimbursement differ between US regions, with the Midwest exhibiting the lowest increase in volume and greatest decline in reimbursement throughout the study period. Alternatively, the West had the greatest increase in THAs per surgeon. Patient comorbidity profiles differ between regions, and increased patient comorbidity is associated with decreased reimbursement in the Northeast and the West. This information is important for surgeons and policymakers as payment models regarding reimbursement for arthroplasty continue to evolve.

Analysis of Medicare Patients Treated with Pimavanserin versus Other Atypical Antipsychotics: A Cost-Offset Model Evaluating Skilled Nursing Facility Stays and Long-Term Care Admissions in Parkinson's Disease Psychosis.

Patients with Parkinson's disease psychosis (PDP) treated with pimavanserin (PIM) versus other atypical antipsychotics (AAPs) including quetiapine (QUE) may have health-care cost savings due to fewer skilled nursing facility-stays (SNF-stays) and long-term care admissions (LTCA). A decision analytic model was developed using the 2019 Medicare Patient Driven Payment Model (PDPM) to estimate SNF-stays and LTCA associated per-patient- per-year (PPPY) facility and rehabilitation costs among patients that initiated PIM vs QUE or vs other-AAPs (i.e, quetiapine, risperidone, olanzapine, aripiprazole). Model inputs were derived for: (i) annual SNF-stay and LTCA rates from an analysis of Medicare beneficiaries with PDP, and (ii) annual mean rehabilitation and resident care-stay costs from PDPM case-mix adjusted value-based payment rates for 5 rehabilitation components (ie, physical-therapy, occupational-therapy, nursing, speech-language pathology, non-therapy ancillary), and an additional variable-per-diem for room/board services. PPPY costs were estimated from (i) SNF-stay and (ii) LTCA rates multiplied by annual mean costs of stay in 2022 USD. Probabilistic sensitivity analysis (PSA) was performed using 1000 Monte Carlo simulations. Overall SNF-stay rates of 20.2%, 31.4%, and 31.7%, and LTCA rates of 23.2%, 33.8%, 34.6% were observed for PIM, QUE, and other-AAPs, respectively. Based on annual mean costs, PPPY SNF-stay rehabilitation and resident related costs for PIM ($41,808) vs QUE ($65,172) or vs other-AAPs ($65,664), resulted in $23,364 and $23,856 PPPY cost savings, respectively. Similarly, PPPY LTCA rehabilitation and resident related costs for PIM ($47,957) vs QUE ($70,091) or vs other-AAPs ($71,566) resulted in $22,134 and $23,609 PPPY cost-savings for PIM, respectively. PSA suggested PIM would provide cost-savings vs QUE or other-AAPs in >99% of iterations. In this analysis, PIM demonstrated nearly 36% and 32% lower PPPY SNF-stays and LTCA costs, respectively, vs QUE or other-AAPs. Research examining additional cost-offsets (i.e., fewer falls/fractures) associated with SNF-stay or LTCA may be needed.