Provider Payment Research Articles

Trends in Medicare Utilization and Reimbursement of Tracheostomy From 2000 to 2022.

To analyze the utilization and reimbursement for tracheostomy. Retrospective Cross-Sectional Study. Centers for Medicare & Medicaid Services (CMS) Medicare Provider Utilization and Payment Data (2013 and 2021) and Part B Medicare Fee-For-Service National Summary Data (2000-2022). Utilization, payment, and specialty breakdown were analyzed for planned tracheostomy (Current Procedural Terminology [CPT] codes 31600, 31601, 31610) and emergency tracheostomy (CPT codes 31603, 31605). From 2000 to 2022, there was a 48.9% decrease (40,754-20,812) in number of planned tracheostomies and a 75.3% decrease (3277-811) in number of emergency tracheostomies, leading to an overall decrease of 51%. Similarly, there was a 59.3% inflation-adjusted decrease ($13.4-$5.5 million) in total reimbursement for planned tracheostomies and an 82.1% inflation-adjusted decrease ($1.1 million-$205 thousand) in total reimbursement for emergency tracheostomies. There was a 20.3% inflation-adjusted decrease ($329-$262) in reimbursement per planned tracheostomy and a 27.7% inflation-adjusted decrease ($349-$252) in reimbursement per emergency tracheostomy. In our sample of 280 high-volume tracheostomy providers in 2021 (28.2% otolaryngology, 28.2% general surgery, 14.6% thoracic surgery, 14.3% pulmonary disease, 6.4% critical care), the average provider performed 15.8 tracheostomies and was reimbursed $5362. Despite significant declines in tracheostomy utilization and reimbursement, understanding trends for these lifesaving procedures are critical for otolaryngologists and other providers in delivering high-quality care, and can be used by surgeons, hospital systems, and policymakers to guide future health care legislation.

Health care provider payment schemes in Central and Eastern European countries

Abstract Background Health care provider payment schemes are key elements of the health care system that influence providers behavior, quality of care, and efficient use of resources. In recent decades, Central and Eastern European (CEE) counties have implemented various reforms that have changed payments methods and other elements of the purchasing process. The aim of the study was to provide an overview of the current provider payment schemes within the public health system in selected CEE countries and identify the main directions of their reforming. Methods Based on existing literature, a theoretical framework and data collection form were first developed. Next, desk research was conducted to collect data on provider payment methods and other elements of the purchasing process in primary care, outpatient specialized care, hospital care, and long-term care. The collected information was verified and supplemented though consultations with national experts. Nine countries were included: Bulgaria, Croatia, Czechia, Estonia, Latvia, Lithuania, Hungary, Poland, and Romania. The study was conducted in 2023. Results Capitation, fee-for-service, and case-based payments are the most commonly used methods in the analyzed countries. The countries are increasingly using blended payment methods. Primary and hospital care have the most diverse payment method mix and have experienced the most substantial changes in their payment schemes since 2010. The most common changes focused on modifying existing methods (detailing payment categories, changing the principles of tariff valuation), and introducing additional methods to pay for specific services or performance (fee-for-service, bonus payments). Conclusions CEE countries are following similar directions in reforming provider payment systems, with the goal of strengthening primary health care, shifting emphasis from inpatient to outpatient care and improving cooperation between health care providers. Key messages • CEE countries largely use output-based methods to pay for health care services. • Provider payment systems are becoming more blended as countries look for the most effective payment method mix to meet policy objectives.

Differences in Utilization of Preventive Services for Primary Care Clinicians Participating in MIPS and ACOs.

Value-based payment programs link payments to the performance of providers on cost and quality of care to incentivize high-value care. To improve quality and lower costs, the Centers for Medicare and Medicaid Services (CMS) implemented the Quality Payment Program (QPP) for clinicians in 2017. Under the Medicare QPP, most eligible clinicians participate in one of the payment models: (a) Advanced Alternative Payment Models (A-APMs) through eligible APMs like Accountable Care Organizations (ACOs) or (b) the Merit-based Incentive Payment System (MIPS). ACO and MIPS clinicians participating in QPP differ in quality reporting requirements, and these differences are likely to affect the utilization of different quality measures, including preventive services. This study evaluated the differences in the utilization of preventive services by primary care clinicians participating in MIPS and ACOs. We use difference-in-difference regressions to compare preventive services in MIPS versus ACOs. Since preventive services like immunization and certain cancer screening are mandatory reporting measures for ACOs and voluntary measures for MIPS, the treatment group for this study is ACO clinicians and the comparison group is non-ACO MIPS clinicians. We obtained the rates of influenza immunization, pneumonia vaccination, tobacco use cessation intervention, depression screening, colorectal cancer screening, breast cancer screening, and wellness visits per 10000 Medicare beneficiaries from Medicare Provider Utilization and Payment Public Use File (2012-2018). We had 508144 total observations (ACO=25.78% and MIPS=74.22%) from 72592 unique primary care clinicians. Compared to MIPS clinicians, ACO clinicians had significantly higher rates of pneumonia vaccination (incidence rate ratio [IRR] 1.25; 95% confidence interval [CI], 1.10-1.43) but lower rates of colorectal cancer screening (IRR 0.69; 95% CI, 0.50-0.96). Similarly, clinicians in ACO shared savings-only models had significantly higher rates of pneumonia vaccination (IRR 1.28; 95% CI, 1.11-1.48), depression screening (IRR 1.72; 95% CI, 1.09-2.71), and wellness visits (IRR 1.27; 95% CI, 1.09-1.47) compared to MIPS clinicians. There were no differences between ACO and MIPS clinicians on the utilization of breast cancer screening procedures and tobacco use cessation interventions. ACO clinicians may have prioritized relatively low-cost services such as pneumonia vaccination, depression screening, and wellness visits to improve their performance under QPP. Policymakers may need to alter incentives in performance-based payment programs to ensure that clinicians are improving all types of quality measures, including cancer screening.

Preparedness, Challenges, and Opportunities for Digital Intervention for Chronic Disease Management: A Qualitative Study in Rural Areas of South Korea

ABSTRACT Motivated by the prevalence of an aging population and the associated increase in chronic diseases, coupled with rising medical expenditure, the Korean government initiated a pilot project in Pyeongchang-gun, Gangwon-do, a rural area, to implement a “smart online-to-offline (O2O) digital health care model” aimed at managing and preventing chronic diseases. However, there is limited understanding regarding perspectives and levels of preparedness for digital health among stakeholders at various levels. In-depth focus group interviews were conducted with elderly and non-elderly community members, health care providers, and staff members at Pyeongchang Health and Medical Center. The study found the presence of both positive and negative perceptions and a lack of preparedness across different levels. At the end-user level, it was observed that community members, especially the elderly, have low levels of health and digital literacy, compounded by limited access to social support. At the health care provider level, there was uncertainty about the acceptance of the digital health program. At the area level, the need to bolster health staff members and enhance their capacity was observed. Recommendations include: customizing the design of the online and offline service components by considering end-user factors (such as age, occupation, and household type) that may contribute to disparities in health; establishing a platform for providers to share their experiences to facilitate the effective incorporation of digital health into their practices; and preparing an appropriate provider payment mechanism.

Uptake of biosimilars in China: a retrospective analysis of the case of trastuzumab from 2018 to 2023

BackgroundThe Chinese biosimilar industry has demonstrated rapid growth in recent years. Limited evidence is available about biosimilar uptake at the national level. This study aimed to assess biosimilar uptake in the case of trastuzumab and to explore potential factors influencing the biosimilar penetration at national and provincial levels.MethodsThis study employed an interrupted time series analysis to assess the level and trend changes of national trastuzumab originator consumption and the overall trastuzumab consumption after the price reduction of the originator and the introduction of the first biosimilar using the China Hospital Pharmacy Audit procurement data from March 2018 to February 2023. A latent class trajectory model (LCTM) was also adopted to estimate the biosimilar penetration across 30 provincial-level administrative divisions (PLADs). Based on the LCTM grouping results, provincial characteristics were analyzed.ResultsAfter rapid growth, the penetration of biosimilars demonstrated a moderate ascending trend at the national level, reaching 27% in February 2023. Following the introduction of the first biosimilar in July 2021, the consumption of the originator decreased by 0.5% per month (P = 0.008), and the growth rate of overall trastuzumab consumption decreased by 1.1% per month (P = 0.014). LCTM fit the best when the number of trajectory classes was two, dividing 30 PLADs into a group demonstrating a faster increase in biosimilar penetration and the other with a slower increase. The PLADs in the fast-increasing group had a higher proportion of the population covered by the national basic health insurance, a lower proportion of the urban population, a lower proportion of the population covered by the urban employee health insurance program, a lower gross domestic product per capita, a lower total health expenditure per capita, and a lower out-of-pocket expenditure.ConclusionsThe uptake of trastuzumab biosimilars in China was lower compared with major European countries. The introduction of trastuzumab biosimilars presented a substitutional effect. Perceptions of physicians and patients, the medicines procurement model, competition from other biologics, and health insurance payment methods may influence biosimilar uptake. Enhancing a comprehensive understanding of biosimilars among physicians and patients, including biologics with biosimilars in the national pooled procurement, and implementing provider payment reforms could foster biosimilar penetration.

Advanced Practice Providers in Burn Care, 2013-2022.

This study evaluated the prevalence characteristics of advanced practice providers, including nurse practitioners and physician assistants, who provide care related to burns in the United States from 2013 to 2022 using national claims data. Our analysis was a retrospective, large cohort study evaluating debridement, wound care, and office-based services provided by advanced practice providers from 2013 to 2022 using the Medicare Provider Utilization and Payment Data Public Use Files from the CMS. The reported provider type and billing codes were used to identify healthcare professionals providing burn care. Trends over the study period and available data about care provided were analyzed. From 2013 to 2022, burn care providers included 6,918 (43.3%) surgeons, 4,264 (26.7%) other physicians, and 4,783 (30.0%) advanced practice providers. Overall, the number of advanced practice providers who billed for burn care increased by 250.4% from 714 in 2013 to 2,502 in 2022. Compared with physicians, advanced practice providers were more likely to be female and provide care in micropolitan areas with less than 50,000 people. Based on these trends, we project that the number of APPs providing services related to burns will increase by 56.7% from 2,502 in 2022 to 3,921 (95% CI, 3,541-4,303; R2=0.97) in 2030. With a growing need for burn care and predicted shortages in the surgeon workforce, the scope of practice and integration of advanced practice providers merits further discussion and evaluation.

A Framework for the Design of Risk-Adjustment Models in Health care Provider Payment Systems.

Prospective payments for health care providers require adequate risk adjustment (RA) to address systematic variation in patients' health care needs. However, the design of RA for provider payment involves many choices and difficult trade-offs between incentives for risk selection, incentives for cost control, and feasibility. Despite a growing literature, a comprehensive framework of these choices and trade-offs is lacking. This article aims to develop such a framework. Using literature review and expert consultation, we identify key design choices for RA in the context of provider payment and subsequently categorize these choices along two dimensions: (a) the choice of risk adjusters and (b) the choice of payment weights. For each design choice, we provide an overview of options, trade-offs, and key references. By making design choices and associated trade-offs explicit, our framework facilitates customizing RA design to provider payment systems, given the objectives and other characteristics of the context of interest.

Direct Economic Burden of Cubital Tunnel Surgery in the United States: Total Payments and Components of Cost

Despite its widespread prevalence, the cost of cubital tunnel syndrome (CuTS) in the United States to patients and insurers is not well understood. The purpose of this study was to quantify the direct payments associated with operative treatment of CuTS. We hypothesized that CuTS represents a substantial cost to the payer in facility fees, surgeon fees and other expenses. Utilizing the MarketScan database of insured patients (commercial and Medicaid), we identified a cohort of 41,777 patients aged 18-64 years with surgically treated CuTS from 2006 to 2018. We estimated the median 90-day payments from encounters associated with cubital tunnel release (CuTR) and/or ulnar nerve transposition surgery by summing all payments for claims within 90 days after the index surgery. Published estimates of the annual number of cubital tunnel surgeries were used to calculate the annual expenditure. Of 41,777 patients, the median (interquartile range [IQR]) values of total direct payments were $5,522 [$3,426, $9,541]. With an estimated 94,645 cases/year, this leads to an annual payment of more than $522 million. Index facility payments (median[IQR] $2,555 [$1,359, $4,708] were the highest, followed by index provider payments ($1,691 [$1,328, $2,217]). The median index surgeon payment (median[IQR] $905 [$707, $1,184]) represented just over half of the provider payments. Post-operative care had a median [IQR] payment of $377 ($424, $1,987). Limitations of claims databases prevented assessment of other indirect costs associated with cubital tunnel surgery. Payments for the surgical treatment of CuTS from the index surgery to 90 days post-operatively have an estimated median of $5,522 per patient, totaling $52 million annually. Index facility fees are responsible for more than 46% of payments, while index payments to surgeons represent approximately 16%. Defining this data is critical to understanding one component of the economic impact of CuTS. Level IV.

Disparities in the real-world prescription pattern of oral anticoagulants for US Medicare beneficiaries: a geospatial analysis

ObjectivesThis study was conducted to examine urban–rural differences in the real-world prescribing pattern of oral anticoagulants and geographic variations in the prescribing pattern among clinicians serving Medicare beneficiaries in the...

Prevalence and Practice Characteristics of Advanced Practice Providers in Upper-Extremity Surgery, 2013–2021

This study evaluated the prevalence, characteristics, and reimbursement of advanced practice providers, including nurse practitioners and physician assistants, who provide care related to the diagnosis and treatment of diseases and conditions of the hand, wrist, and upper extremities in the United States from 2013 to2021. Our analysis was a retrospective cohort study evaluating the diagnostic, procedural, and therapeutic services provided by advanced practice providers from 2013 to 2021 using the Medicare Provider Utilization and Payment Data Public Use Files from the Centers for Medicare and Medicare Services. The reported provider type and billing codes were used to identify health care professionals providing upper-extremity care such as ordering radiographs, applying casts and splints, and performing procedures on the hand, wrist, or other anatomic regions of the upper extremity. Trends over the study period and available data about services provided were analyzed. From 2013 to 2021, providers of upper-extremity care included 19,525 (64.7%) doctor of medicine or doctor of osteopathic medicine upper-extremity surgeons, 7,612 (25.2%) physician assistants, and 3,042 (10.1%) nurse practitioners. The nonsurgeon providers were more likely to be women and provide care in micropolitan areas with less than 50,000 people compared with upper-extremity surgeons. Overall, the number of advanced practice providers who billed for upper-extremity care increased by 170.9% from 1,965 in 2013 to 5,324 in 2021. Based on these trends, the growth of APPs providing upper-extremity care is expected to continue. There is a growing prevalence of advanced practice providers in upper-extremity care, and this trend is expected to continue. With a growing need for upper-extremity care and predicted shortages in the surgeon workforce, the scope of practice and integration of advanced practice providers merits further discussion and evaluation.

Assessing the prevalence of Beers medication utilization in the Medicare Part D population in 2020.

Medication utilization has been increasing in the U.S. year-over-year for several decades. As older adults take more medications, there is a higher risk of them being exposed to drug-drug or drug-disease interactions. The American Geriatrics Society in 2019 updated their Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults. The objective of this study was to assess the prevalence of utilization of medications included in the 2019 Beers Criteria. An analysis was conducted using the Medicare Part D Provider Utilization and Payment Data Public Use File for calendar-year 2020. Medications identified in the 2019 Beers Criteria were applied to the analysis. Two categories of medications were assessed: (1) "Avoid" and (2) "Use With Caution." In 2020, 56 million prescriptions were dispensed to Medicare patients 65 years and older that are recommended to be avoided without exception (4.7% of all prescriptions) totaling $957 million in medication costs. The most utilized medication classes in this category were benzodiazepines (25,949,994 prescriptions), "Z-drugs" (6,204,909 prescriptions), long-acting sulfonylureas (5,306,577 prescriptions), 1st-generation antihistamines (5,049,289 prescriptions), and tricyclic antidepressants (4,190,062 prescriptions). Additionally, 135 million prescriptions were dispensed to Medicare beneficiaries 65 years and older for medications which the Beers Criteria states to use caution (11.3% of all prescriptions) exceeding $2.85 billion in medication costs. The most utilized medications for this category were diuretics (74,599,126 prescriptions), selective serotonin reuptake inhibitors (30,033,121 prescriptions), serotonin and norepinephrine reuptake inhibitors (11,858,968 prescriptions), tramadol (11,450,878 prescriptions), and mirtazapine (5,737,304 prescriptions). Even with the existence of the AGS Beers Criteria for PIM Use in Older Adults and its continued updated versions, 16% of medications dispensed to Medicare Part D were potentially inappropriate. Future studies are needed to assess if this has led to worsened outcomes among older adults who utilized these PIM.

Alternative payment models in Dutch hospital care: what works, how, why and under what circumstances? Protocol for a realist evaluation study

IntroductionThe predominant provider payment models in healthcare, particularly fee-for-service, hinder the delivery of high-value care and can encourage healthcare providers to prioritise the volume of care over the value of...

How hospital autonomy affects provider payment reform effectiveness.

Provider payment reforms (PPRs) have demonstrated mixed results for improving health system efficiency. Since PPRs require health care organisations to interpret and implement policies, the organizational characteristics of hospitals may affect the effectiveness of PPRs. Hospitals with more autonomy have the flexibility to respond to PPRs more efficiently, but they may not if the autonomy previously facilitated behaviours that counter the PPR's objective. This study examines whether hospitals with higher autonomy responds to PPRs more effectively. We used data from a matched-pair, cluster randomized controlled PPR intervention in a resource-limited Chinese province between 2014 and 2018. The intervention reformed the reimbursement method from the publicly administered New Cooperative Medical Scheme (NCMS) from fee-for-service to global budget. We interacted measures of hospital autonomy over surplus, hiring, and procurement (drugs, consumables, equipment, and overall index) with the difference-in-difference estimator to examine how autonomy moderated the intervention's effect. Autonomy over surplus (p<0.01) and procurement of equipment (p<0.01) were associated with relatively faster NCMS expenditure growth, demonstrating worse PPR response. They were also associated with higher expenditure shifting to out-of-pocket expenditures (p>0.05). Post hoc analysis suggests that hospitals with surplus autonomy had higher OOP per admission (p<0.01), suggesting profiteering tendencies. Other dimensions of autonomy demonstrated imprecise association. Hospitals with more autonomy may not necessarily respond more effectively to PPRs that incentivise efficiency when they had previously been encouraged to maximise profit. Policymakers should assess the extent of perverse incentives before granting autonomy and adjust the incentives accordingly.

Trends in Medicare Charges, Reimbursements, and Utilization for Ophthalmic Versus Non-Ophthalmic Procedures: Medicare Charges in Ophthalmic Procedures

ObjectiveTo investigate trends in Medicare charges, reimbursements, and utilization for ophthalmic and non-ophthalmic procedures. MethodsWe examined all ophthalmic, non-ophthalmic, and the 15 most performed ophthalmic medical/surgical procedures in Medicare Provider Utilization and Payment Data from 2013 to 2019. Monetary values were adjusted for inflation based on the 2019 United States (US) dollar using the Bureau of Labor Statistics Consumer Price Index. We calculated annual procedural utilization by adjusting service counts per million Medicare beneficiaries and examined trends for ophthalmic and non-ophthalmic procedures from 2013-2019 using descriptive statistics. ResultsFrom 2013-2019, Medicare inflation-adjusted charges and reimbursements changed by -14% and -23%, respectively, for ophthalmic procedures compared to +14% and +5%, for non-ophthalmic procedures, and -24% and -31% for the 15 most common ophthalmic procedures. Utilization of ophthalmic, non-ophthalmic, and common ophthalmic procedures changed by +2%, -15%, and +17%, respectively. ConclusionsLower reimbursements likely compensate for higher utilization in ophthalmology, especially since the magnitude of change in charges and reimbursements was larger for the 15 most performed ophthalmic procedures. In future reimbursement deliberations, policymakers should consider the declining reimbursements for procedures in ophthalmology relative to other medical specialties. Public Interest SummaryMedicare reimbursement rates for common ophthalmic procedures decreased by 31% from 2011-2020. These reductions may lead to lower hospital revenue and, subsequently, higher prices. This shifts the financial burden onto uninsured and underinsured patients and is a potential barrier to care. Additionally, as there are not enough ophthalmologists in the US to adequately meet demand, further reimbursement reductions may influence student interest and contribute to earlier retirements in the existing ophthalmic workforce. This study identifies a decline in charges and reimbursements as utilization concurrently increased for ophthalmic procedures. In contrast, there has been an increase in charges and reimbursements with a decrease in utilization for non-ophthalmic procedures. Policymakers should take these findings into consideration in future decisions on reimbursement changes for ophthalmology.

Surgeon Preference for Maximizing Medical Care Is Associated with Recommending More Extensive Surgery for Low-Risk Thyroid Cancer.

Background: While patient-level determinants of total thyroidectomy use have been well described, surgeon-level drivers of more extensive surgery are present and less well described. This survey sought to examine the associations between surgeons' operative recommendations, their beliefs about cancer, and their attitudes about medical maximizing-minimizing. Methods: A mixed-mode, cross-sectional survey was administered in September 2020 via mail and email to 222 thyroid surgeons identified in the Centers for Medicare & Medicaid Services Provider Utilization and Payment Physician and Other Practitioners dataset. Participants were asked their treatment recommendation for a healthy 45-year-old woman with a solitary 2.0-cm papillary thyroid cancer. Surgeons were assessed with the Brief Worry Scale and a validated, single-item measure of cancer-related worry. The Clinician Maximizer-Minimizer scale was used to assess the extent of medical care that physicians tend to favor with their patients. Participants were categorized into terciles based on their responses to the Maximizer-Minimizer scale. The highest scoring tercile ("Maximizers") was compared with the two lower terciles by Student's t-tests, chi-square, ANOVA, and logistic regression. Results: Of the 149 surgeons (response rate 67.1%), 34.9% recommended total thyroidectomy with or without central neck dissection (CND), and 65.1% recommended lobectomy. Overall, the medical Maximizer-Minimizer scale had an average score of 24.6 (SD 6.8). There were no differences between surgeons' age, race, annual thyroidectomy volume, or practice setting by their Maximizer-Minimizer classification. Participants who recommended total thyroidectomy with or without CND had significantly higher Maximizer-Minimizer scores than those recommending lobectomy (25.9 ± 7.2 vs. 23.8 ± 6.4, p = 0.03). Those classified as maximizers also had more cancer-related worry on both the single-item and Brief Worry Scales (p = 0.02). On logistic regression controlling for age, sex, race, specialty training, practice setting, and annual thyroidectomy volume, maximizers were still more likely to recommend total thyroidectomy with or without a CND (OR 2.4, [CI 1.01-5.55], p = 0.047). Conclusions: Medical maximizing-minimizing tendencies represent one of potentially many unmeasured surgeon characteristics that may explain persistent patterns of over-diagnosis, over-treatment, and over-screening. Surgeons may benefit from awareness of how their own tendencies influence their surgical recommendations in patients with low-risk thyroid cancer.

Gender-Based Variations in Medicare Reimbursements Among Different Surgical Subspecialties

Gender inequities and limited representation are an obstacle to surgical workforce diversification. There has been limited examination of gender-based disparities in billing practices among surgeons. To evaluate variations in practice metrics and billing practices among female and male surgeons and identify factors associated with gender disparities in Medicare reimbursements. This retrospective cross-sectional study used publicly available Medicare Fee-for-Service Provider Utilization and Payment data from January to December 31, 2021, to identify demographics, annual services provided, and financial payments and charges for general surgeons, surgical oncologists, and colorectal surgeons. Data were analyzed from November 2023 to February 2024. The primary exposure of interest was surgeon gender (ie, female or male). The annual total submitted charges and payments submitted in 2021 by female and male surgeons were assessed. Additionally, the total number and types of services provided each year and the number of beneficiaries treated were examined. Multivariable linear regression models were used to evaluate the association of surgeon gender with payments, number of services, and beneficiaries. A total of 20 549 general surgeons (5036 [24.5%] female; 15 513 [75.5%] male), 1065 surgical oncologists (450 [42.3%] female; 615 [57.7%] male), and 1601 colorectal surgeons (432 [27.0%] female; 1169 [73.0%] male) were included. Across all surgical subspecialties, female surgeons billed fewer mean (SE) Medicare charges (general surgeons: 30.1% difference; $224 934.80 [$3846.97] vs $321 868.50 [$3933.57]; surgical oncologists: 27.5% difference; $277 901.70 [$22 857.37] vs $382 882.90 [$19 566.06]; colorectal surgeons: 21.7% difference; $274 091.70 [$10 468.48] vs $350 146.10 [$8741.66]; all P < .001) and received significantly lower mean (SE) reimbursements (general surgeons: 29.0% difference; $51 787.61 [$917.91] vs $72 903.12 [$890.35]; surgical oncologists: 23.6% difference; $57 945.18 [$3853.28] vs $75 778.22 [$2622.75]; colorectal surgeons: 24.5% difference; $63 117.01 [$2248.10] vs $83 598.53 [$1934.77]; all P < .001). On multivariable analysis, a reimbursement gap remained across all 3 surgical subspecialties (general surgeons: -$14 963.46 [95% CI, -$18 822.27 to -$11 104.64] [P < .001]; surgical oncologists: -$8354.69 [95% CI, -$15 018.12 to -$1691.25] [P = .01]; colorectal surgeons: -$4346.73 [95% CI, -$7660.15 to -$1033.32] [P = .01]). In this cross-sectional study, there was considerable gender-based variation in practice patterns and reimbursement among different surgical subspecialties serving the Medicare population. Differences in mean payment per service were associated with variations in billing and coding strategies among female and male surgeons.

Association Between Medicare Site-Based Payment Policy, Physician Practice Characteristics, and Vertical Integration Among Oncologists.

Medicare's differential payments for services delivered in physician offices versus hospital outpatient settings incentivize hospital-physician integration (ie, vertical integration) across many specialties, but evidence for oncologists is mixed. We examined the association of Medicare site-based payment policy and physician practice characteristics, including service volume and diversity, with vertical integration among oncologists in 2013-2019. Using the Medicare Provider Utilization and Payment Data and Medicare Data on Provider Practice and Specialty in 2013-2019, we extracted nonintegrated medical/hematologic oncologists (hereafter oncologists) in 2013 and followed them through 2019. We quantified the incentives from Medicare site-based payment policy using the hospital-office ratio-total Medicare payments if all services were delivered in the hospital outpatient department (HOPD) versus physician office. Vertical integration was defined as billing >10% of services to HOPD in a year. Multivariable linear probability regressions estimated the association between hospital-office ratio and vertical integration in 2014-2019 with and without accounting for provider characteristics. In 2013, the average hospital-office ratio was 1.63, which increased to 1.99 in 2018. A 25th-to-75th percentile increase in the hospital-office ratio was negatively associated with integration (-1.01 percentage points [ppts], 95% CI = -1.45 to -0.57, p < .001) not accounting for physician practice characteristics; this association was attenuated (-0.30 ppts, 95% CI = -0.67 to 0.07, p = .11) after adjusting for these characteristics. Higher baseline (ie, 2013) service volume (Quartile4 v Quartile1 = -3.00 ppts, 95% CI = -4.42 to -1.59, p < .001), more diverse services (Quartile4 v Quartile1 = -3.55 ppts, 95% CI = -4.97 to -2.13, p < .001), and urban location (-5.23 ppts, 95% CI = -6.89 to -3.57, p < .001) were more strongly associated with vertical integration. Compared to Medicare site-based payment policy, oncologists' practice characteristics emerged as more potent factors for integration and should be considered to ensure the intended impacts of site-based payment reform. Our finding raises questions about the effectiveness of ongoing movements toward site-neutral payment for drug administration services to deter vertical integration in oncology.

Trends in the providers’ uptake of advance care planning from 2016 to 2021.

1538 Background: Advance care planning (ACP) facilitates meaningful discussions and preparation for future medical decisions. This person-centered approach has been recognized for its potential to improve care quality and reduce unnecessary aggressive care at the end of life, especially among cancer patients. We examined the trends in ACP visits across specialty groups that may involve cancer care and between rural and urban areas. Methods: We used publicly available data from the Centers for Medicare &amp; Medicaid Services, the Provider Utilization and Payment Data Physician and Other Practitioners Dataset – By Provider and Service files (2016-2021). We included providers in 3 specialty groups that may encounter cancer patients needing ACP: Cancer-Related Specialties, Hospice and Palliative Medicine (HPM), and Midlevel Providers. The primary outcome was billing for any ACP services each year, identified through Healthcare Common Procedure Coding System codes (99497 and 99498). Geographical areas were classified using Rural-Urban Commuting Area codes into metropolitan and non-metropolitan areas. Trends in the percent of providers billing any ACP and average ACP service volumes were described, with Wilcoxon tests used for statistical comparisons. Results: The primary analytic sample consists of 1,280,656 provider-years from 2016 to 2021 (Cancer-Related Specialties: 113,012, HPM: 7,320, and Midlevel: 1,160,324). The percentage of providers billing ACP visits tripled from 1.0% in 2016 to 3.3% in 2021. The highest uptake was among HPM physicians (12.8% to 36.9%) compared to cancer-related specialists and midlevel providers (Table). Average ACP service volume was higher in non-metropolitan areas among Cancer-Related Specialties (53.6 vs. 142.9). However, the average ACP service volume by metropolitan status was similar among HPM (75.0 vs. 66.7, P=0.65) and higher in metropolitan areas among Midlevel providers (70.2 vs. 54.8, P&lt;.001). Conclusions: The proportion of physicians billing ACP codes increased including those in HPM and cancer-related specialties, but adoption remained low. Rural-urban disparities in average ACP service volume among cancer-related specialties might reflect a shortage of specialty-trained HPM physicians to provide ACP services. Particularly noteworthy is the absence of HPM specialty in non-metropolitan areas. A comprehensive strategy involving education, awareness, enhanced training capacity, innovative care models for advanced practice nurses, and increased resources, is needed to promote APC use and patient-centeredness in cancer care.[Table: see text]

Facilitators and barriers to supply-side maternal, newborn, and child health service availability in DRC: a systematic review and narrative synthesis

Background This study is a systematic review of barriers and facilitators of supply-side maternal, newborn, and child health (MNCH) service availability in the Democratic Republic of the Congo (DRC). Given gaps in understanding of the factors affecting supply-side service availability, authors reviewed the literature to describe the DRC’s landscape and inform future research and programming. # Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, authors searched two databases and grey literature, using the Quality Assessment with Diverse Studies tool to assess quality. Authors identified key themes and used a narrative approach to analyze extracted data. # Results The search identified 2160 articles, with 26 meeting the inclusion criteria. Authors grouped them according to the following key themes: facility readiness, human resources for health (HRH), geography and transportation, conflict, financing, and governance. MNCH service availability was hindered by lack of supplies, logistical challenges, weak infrastructure, unmet staffing needs, HRH turnover, poor HRH distribution, career and payment obstacles, long distances to facilities and poor transportation, system strain and disruption due to conflict, low government expenditure, high out of pocket costs, fragmented stakeholders, and low government prioritization. Authors found facilitating factors in each key theme, including parallel supply chains and buffer stocks, proactive staffing policies, motivated HRH, novel transportation methods, health posts, concentrations of stakeholders in conflict zones, universal health coverage policies, provider payment reforms, stakeholder coordination, and horizontal integration efforts. # Conclusions The DRC faces substantial supply-side barriers to MNCH service availability. Progress towards the Sustainable Development Goals and better MNCH outcomes requires additional work to build on existing facilitators and investments in service availability. Additional research on demand-side factors and quality of care could inform these efforts.

How Variable are Patient Comorbidity Profiles Among Practicing Otolaryngologists?

To determine whether certain groups of otolaryngologists (ORLs) are treating cohorts of patients with more comorbidities. Cross-sectional population-based analysis. 2019 Medicare Provider Utilization and Payment Dataset. Each ORL's average Medicare hierarchical condition category (HCC) risk score, a comorbidity index calculated from a patient's comorbidities, was collected. These were stratified and compared by various physician characteristics, including practice region and rurality, years in practice, gender, subspecialty, and setting (academic vscommunity). Among 8959 ORLs, the mean HCC risk score for Medicare patients was 1.35 ± 0.35. On univariate analysis, ORLs practicing in urban (compared to rural), ORLs in academic settings (compared to community), and early career ORLs all had a patient population with a higher HCC risk score (P < .001 for all). On multivariate analysis controlling for gender, rurality, graduation year, and region, rural setting was associated with decreased odds of having a high-risk patient population (odds ratio: 0.58 [95% confidence interval,CI: 0.48-0.71]; P < .001), while those more recently graduated has an increased risk (2000-2009: 1.41 [1.01-1.96], P = .046; 2010-2015: 2.30 [1.63-3.25], P < .001). In a separate subgroup analysis, subspecialty differences were seen and community setting was associated with decreased odds of having a high-risk patient population (0.36 [0.23-0.55]; P < .001). There is variability in patient comorbidity profiles among ORLs, with those in urban settings, those more recently graduated, and those in academic settings treating a group with more comorbidities. As the comorbidity burden may increase the cost of practice and complications, these findings may have important implications for health inequity.