Reimbursement Challenges Research Articles

We Are Not Speaking the Same Language: Current Procedural Terminology Coding and Provision of Care in Lymphatic Reconstruction.

Current Procedural Terminology (CPT) codes provide a uniform language for medical billing, but specific codes have not been assigned for lymphatic reconstruction techniques. The authors hypothesized that inadequate codes would contribute to heterogeneous coding practices and reimbursement challenges, ultimately limiting surgeons' ability to treat patients. A 22-item virtual questionnaire was offered to 959 members of the American Society of Reconstructive Microsurgeons to assess the volume of lymphatic reconstruction procedures performed, CPT codes used for each procedure, and challenges related to coding and providing care. The survey was completed by 66 board-certified/board-eligible plastic surgeons (6.9%), who unanimously agreed that lymphatic surgery is integral to cancer care, with 86.4% indicating that immediate lymphatic reconstruction should be offered after lymphadenectomy. Most performed lymphovenous bypass, immediate lymphatic reconstruction, liposuction, and vascularized lymph node transfer.Respondents reported that available CPT codes failed to reflect procedural scope. A wide variety of CPT codes was used to report each type of procedure. Insurance coverage problems led to 69.7% of respondents forgoing operations and 32% reducing treatment offerings. Insurance coverage and CPT codes were identified as significant barriers to care by 98.5% and 95.5% of respondents, respectively. Respondents unanimously agreed on the importance of lymphatic reconstruction in cancer care, and most identified inadequate CPT codes as causing billing issues, which hindered their ability to offer surgical treatment. Appropriate and specific CPT codes are necessary to ensure accuracy and consistency of reporting and ultimately to improve patient access to care.

Brief Report on Global Clinician Practices in the First-Line Management of Metastatic Non-Small Cell Lung Cancer

IntroductionIn the dynamic landscape of metastatic NSCLC (mNSCLC) management, marked by several frontline options and the integration of next generation sequencing (NGS) for informed decision-making, barriers persist despite advancements. This includes challenges in clinical trial recruitment. To gain global insights into clinicians’ practices, we conducted a survey on their testing and management approaches for patients with mNSCLC. MethodsThe survey, conducted from July 12 to August 20, 2023, utilized multiple-choice questions and qualitative research questions, employing the Likert Scale for comprehensive insights. ResultsA total of 127 individuals responded, with 72% affiliated with academic health systems, and 55% practicing in the USA. Regarding testing practices, 93% consistently ordered NGS for non-squamous histology, while 54% did so for squamous cell histology. Concurrent tissue and liquid biopsies were routinely ordered by 28%, while 39% reported ordering both testing platforms concurrently for select cases only. Respondents cited logistical barriers, such as insufficient tissue and lack of infrastructure, as the most common hindrance to molecular testing (76%), followed by reimbursement challenges (56%) and concerns about delayed turnaround time (50%). While most respondents were confident in interpreting NGS results, 22% lacked confidence. Concerning treatment decisions, 72% preferred awaiting molecular testing results before initiating systemic therapy. Less than 50% routinely referred patients for clinical trials in the frontline setting for mNSCLC. For patients with disease expressing high PD-L1 levels, most oncologists preferred pembrolizumab monotherapy. For disease with low PD-L1 expression, a platinum doublet chemotherapy regimen combined with pembrolizumab was favored. In disease cases with negative PD-L1 expression, a platinum doublet chemotherapy regimen with pembrolizumab was preferred. Key factors influencing oncologists' preferred immune checkpoint inhibitor (ICI) included experience with one ICI over another, preferred status per national guidelines, availability of trial data with a significant follow-up period, and consideration of drug cost. ConclusionAlthough this study demonstrates an improved awareness and adoption of ordering NGS for the management of mNSCLC, it underscores the persistence of various barriers that must be addressed to improve upon the quality of care for patients diagnosed with mNSCLC.

Integrating pharmacogenomic testing into personalized medicine practices in the USA: Implications for medication quality control and therapeutic efficacy

This concept paper explores the integration of pharmacogenomic testing into personalized medicine practices in the USA and its implications for medication quality control and therapeutic efficacy. By leveraging genetic information to optimize medication selection and dosing, this paper aims to improve patient outcomes and minimize adverse drug reactions, thereby enhancing medication safety and efficacy in clinical practice. Integrating pharmacogenomic testing into personalized medicine practices has the potential to revolutionize healthcare by improving medication quality control and therapeutic efficacy. This concept paper explores the implications of pharmacogenomic testing for personalized medicine practices in the USA. The paper begins by discussing the current landscape of personalized medicine and the role of pharmacogenomic testing in optimizing medication selection and dosing. It then examines the benefits of integrating pharmacogenomic testing into clinical practice, including improved medication safety, efficacy, and cost-effectiveness. Key considerations for implementing pharmacogenomic testing in personalized medicine practices are discussed, including regulatory considerations, reimbursement challenges, and ethical considerations. The paper also highlights the importance of healthcare provider education and patient engagement in the successful implementation of pharmacogenomic testing. Through a comprehensive analysis, this concept paper aims to provide insights into the implications of integrating pharmacogenomic testing into personalized medicine practices in the USA. By leveraging pharmacogenomic testing, healthcare providers can personalize medication selection and dosing, leading to improved medication quality control and therapeutic efficacy for patients.

Association of Medicaid Reimbursement Policies with Provision of Long-Acting Reversible Contraception in the Postpartum Period, 2012-2018.

Background: To address reimbursement challenges associated with long-acting reversible contraception (LARC) in the postpartum period, state Medicaid programs have provided additional payments ("carve-outs"). Implementation has been heterogeneous, with states providing separate payments for the device only, procedure only, or both the device and procedure. Methods: Claims data were drawn from 210,994 deliveries in the United States between 2012 and 2018. Using generalized estimating equations, we assess the relationship between Medicaid carve-out policies and the likelihood of LARC placement at (1) 3 days postpartum, (2) 60 days postpartum, and (3) 1 year postpartum, in Medicaid and commercially insured populations. Results: Among Medicaid beneficiaries, the likelihood of receiving LARC was higher in states with any carve-out, compared with states without carve-outs, at 3 days (adjusted odds ratio [aOR] 1.49 [95% confidence interval: 1.33-1.67], p < 0.001), 60 days (aOR: 1.40 [95% CI: 1.35-1.46], p < 0.001), and 1 year postpartum (aOR: 1.15 [95% CI: 1.11-1.20], p < 0.001). Adjustments were made for geographic region, seasonality, and patient age. Heterogeneity was observed by carve-out type; device carve-outs were consistently associated with greater likelihood of postpartum LARC placement, compared with states with no carve-outs. Similar trends were observed among commercially insured patients. Conclusion: Findings support the effectiveness of Medicaid carve-outs on postpartum LARC provision, particularly for device carve-outs, which were associated with increased postpartum LARC placement at 3 days, 60 days, and 1 year postpartum. This outcome suggests that policies to address cost-related barriers associated with LARC devices may prove most useful in overcoming barriers to immediate postpartum LARC placement, with the overarching aim of promoting reproductive autonomy.

Mapping the Common Barriers to Optimal COPD Care in High and Middle-Income Countries: Qualitative Perspectives from Clinicians.

Chronic obstructive pulmonary disease (COPD) poses a significant global health burden despite being largely preventable and treatable. Despite the availability of guidelines, COPD care remains suboptimal in many settings, including high-income countries (HICs) and upper-middle-income countries (UMICs), with varied approaches to diagnosis and management. This study aimed to identify common and unique barriers to COPD care across six countries (Australia, Spain, Taiwan, Argentina, Mexico, and Russia) to inform global policy initiatives for improved care. COPD care pathways were mapped for each country and supplemented with epidemiological, health-economic, and clinical data from a targeted literature review. Semi-structured interviews with 17 respiratory care clinicians were used to further validate the pathways and identify key barriers. Thematic content analysis was used to generate the themes. Six themes were common in most HICs and UMICs: "Challenges in COPD diagnosis", "Strengthening the role of primary care", "Fragmented healthcare systems and coordination challenges", "Inadequate management of COPD exacerbations", "Limited access to specialized care" and, "Impact of underfinanced and overloaded healthcare systems". One theme, "Insurance coverage and reimbursement challenges", was more relevant for UMICs. HICs and UMICs differ in patient and healthcare provider awareness, primary care involvement, spirometry access, and availability of specialized care. Both face issues with healthcare fragmentation, guideline adherence, and COPD exacerbation management. In addition, UMICs also grapple with resource limitations and healthcare infrastructure challenges. Many challenges to COPD care are the same in both HICs and UMICs, underscoring the pervasive nature of these issues. While country-specific issues require customized solutions, there are untapped possibilities for implementing global respiratory strategies that support countries to manage COPD effectively. In addition to healthcare system-level initiatives, there is a crucial need for political prioritization of COPD to allocate the essential resources it requires.

Uptake of orphan drugs in the WHO essential medicines lists.

We evaluated the uptake of medicines licensed as orphan drugs by the United States Food and Drug Administration (FDA) or European Medicines Agency (EMA) into the WHO Model list of essential medicines and the WHO Model list of essential medicines for children from 1977 to 2021. We collated and analysed data on drug characteristics, reasons for adding or rejecting medicines, and time between regulatory approval and inclusion in the lists. We compared trends in listing orphan drugs before and after revisions to the inclusion criteria of the essential medicines lists in 2001, as well as differences in trends for listing orphan and non-orphan drugs, respectively. The proportion of orphan drugs in the essential medicines lists increased from 1.9% (4/208) in 1977 to 14.6% (70/478) in 2021. While orphan drugs for communicable diseases have remained stable over time, we observed a considerable shift towards more orphan drugs for noncommunicable diseases, particularly for cancer. The median period for inclusion in the essential medicines lists after either FDA or EMA first approval was 13.5years (range: 1-28 years). Limited clinical evidence base and uncertainty about the magnitude of net benefit were the most frequent reasons to reject proposals to add new orphan drugs to the essential medicines lists. Despite lack of a global definition of rare diseases, the essential medicines lists have broadened their scope to include medicines for rare conditions. However, the high costs of many listed orphan drugs pose accessibility and reimbursement challenges in resource-constrained settings.

Balancing medical innovation and affordability in the new healthcare ecosystem in China: Review of pharmaceutical pricing and reimbursement policies

AbstractThe China Basic Medical Insurance Program was created in 1999 with three objectives: equal accessibility, affordability, and quality. Today, it has become the biggest medical insurance program in the world, covering 95% of China's population. Since 2015, China's healthcare ecosystem has been reshaped by increasing innovation, which has in turn been driven by regulatory reform, enhancement of research and development capability, and capital market development. There has also been improved regulatory efficiency to reduce lags in launching drugs. In 2022, nearly 20% of novel active substances launched globally were from China. China has also risen to become the second biggest contributor to innovation in terms of pipelines. Using a “fast‐follow” strategy, many locally developed innovative drugs can compete with products from multinational companies in their quality and pricing. However, China's pharmaceutical and biotechnology industry will continue to face challenges in pricing and reimbursement, as well as a shortened product lifecycle with rapid price erosion. The government has already accelerated the timeline for updating the drug reimbursement list and is willing to create a high‐quality medical insurance program. However, some obstacles are hard to overcome, including reimbursement for advanced therapies, limited funding and an increasing burden of disease due to an aging population. This article reviews the trajectory of medical innovation in China, including the challenges. Looking forward, balancing affordability and innovation will be critical for China to continue the trajectory of growth. The article also offers some suggestions for future policy reform, including optimizing reimbursement efficiency with a focus on high‐quality solutions, enhancing the value assessment framework, payer repositioning from “value buyer” to “strategic buyer”, and developing alternative market access pathways for innovative drugs.

Implementation of an office-based addiction treatment model for Medicaid enrollees: A mixed methods study

IntroductionMedications for opioid use disorder (MOUD) are the most effective treatment for opioid use disorder (OUD) but remain underutilized. To reduce barriers to MOUD prescribing and increase treatment access, New Jersey's Medicaid program implemented the Office-Based Addiction Treatment (OBAT) Program in 2019, which increased reimbursement for office-based buprenorphine prescribing and established newly reimbursable patient navigation services in OBAT clinics. Using a mixed-methods design, this study aimed to describe stakeholder experiences with the OBAT program and to assess implementation and uptake of the program. MethodsThis study used a concurrent, triangulated mixed-methods design, which integrated complementary qualitative (semi-structured interviews) and quantitative (Medicaid claims) data to gain an in-depth understanding of the implementation of the OBAT program. We elicited stakeholder perspectives through interviews with 22 NJ Medicaid MOUD providers and 8 policy key informants, and examined trends in OBAT program utilization using 2019–2020 NJ Medicaid claims for 5380 Medicaid enrollees who used OBAT services. We used cross-case analysis (provider interviews) and a case study approach (key informant interviews) in analyzing qualitative data, and calculated descriptive statistics and trends for quantitative data. ResultsProvider enrollment and utilization of OBAT services increased steadily during the first two years of program implementation. Interviewees reported that enhanced reimbursements for office-based MOUD incentivized greater MOUD prescribing, while coverage of patient navigation services improved patient care. Despite increasing enrollment in the OBAT program, the proportion of primary care physicians in the state who enrolled in the program remained limited. Key barriers to enrollment included: requirements for a patient navigator; concerns about administrative burdens and reimbursement delays from Medicaid; lack of awareness of the program; and beliefs that patients with OUD were better served in comprehensive care settings. Patient navigation was highlighted as a critical and valuable element of the program, but navigator enrollment and reimbursement challenges may have prevented greater uptake of this service. ConclusionsImplementation of an OBAT model that enhanced reimbursement and provided coverage for patient navigation likely expanded access to MOUD in NJ. Results support initiatives like the OBAT program in improving access to MOUD, but program adaptations, where feasible, could improve uptake and utilization.

Confronting High Costs And Clinical Uncertainty: Innovative Payment Models For Gene Therapies.

Gene therapies offer potentially life-changing benefits for patients, but their unprecedented high prices exacerbate challenges for reimbursement. Payers must confront high budgetary impacts, as a large up-front payment for each patient makes it difficult to predict and absorb costs. Payers also face considerable clinical uncertainty, as evidence for efficacy and durability is limited at approval. Alternative payment models may address these reimbursement problems and ensure equitable patient access. We developed a taxonomy of possible payment mechanisms for gene therapies, including installments, risk pools, reinsurance, price-volume agreements, expenditure caps, subscriptions, outcomes-based payments and rebates, warranties, population outcomes-based agreements, and coverage with evidence development. We illustrate how these payment models take three main approaches: amortization, which mitigates initial budget impact by spreading payments over time; risk spreading, which makes budgets more predictable by pooling costs with other payers or capping costs based on expected volume; and performance-based payment, which addresses clinical uncertainty by tying prices to patient- or population-level outcomes. We discuss each payment model, its advantages and challenges, and considerations for US payers.

70 Neuropsychological Consulting in Concussion Management: Remote Models Increase Access to Care

Objective:Neuropsychological assessment is the cornerstone of concussion management, and the nature of its delivery can vary widely. While literature concerning post-concussion care typically revolves around in-person evaluation, the proliferation of computerized neuropsychological tests (CNTs) has allowed for some distance between concussion patients and the neuropsychologist. In the wake of a global pandemic, several papers describing the use of telehealth for concussion care have emerged; however, the small samples found in these studies may suggest that access to care remains an issue. Additionally, telehealth may not be a sustainable fee-for-service approach as CMS aims to curtail telehealth reimbursement for behavioral health clinicians. The objective of the present study is to describe a remote neuropsychological consultation model of concussion management and evaluate its productivity and impact in a rural setting.Participants and Methods:In this model, a neuropsychologist based at an academic medical center in the northeastern United States consulted to middle school, high school, and collegiate concussion management programs. Students typically were administered baseline ImPACT tests prior to participation in sports, and all students in the current sample completed post-injury ImPACT tests as part of return to play protocols. The neuropsychologist read test results through the test’s online portal, then communicated interpretation and recommendations via email or phone to the school’s representative (e.g., athletic trainer, athletic director, or school nurse). 837 unique concussions were recorded between 2019 and 2022. After removing abnormal cases (e.g., COVID-19 school closures, extended college breaks, non-concussions, and non-return to play decisions), 790 unique concussions (51.4% male) were included for analysis, with a mean age of 16.84 years (SD=2.17). Descriptive statistics were used to characterize the sample.Results:Across 790 unique concussions, 7 were middle school, 571 were high school, and 212 were college students. 1,750 total postinjury ImPACT tests were administered over the three-year period. Per concussion, an average of 2.22 (SD=0.90) tests were used. Average time to the last ImPACT given was 18.47 days (SD=16.59), with a median of 15 days. Ten concussions (1.27% of total concussions) occurred within 3 months of a previous injury. The distance between schools and the medical center ranged from 2.4 to 102 miles (M=60.29; SD=34.34).Conclusions:The current study suggests that there is value in a remote model of neuropsychological consultation for concussion management. While telehealth offers a promising method of evaluation for concussion, it may be inaccessible and present reimbursement challenges. The remote consultation model described here increases access to care by eliminating in-person visits, which decreases demand for physical space at medical centers and increases access to rural populations with seemingly no negative effect on care. This consultation model also allows neuropsychologists working in concussion management more flexibility, potentially increasing the volume of cases they can assess. This program evaluation suggests remote models have merit, but replication studies in different regions of the country are needed.

Adoption of robotics in arthroplasty- a survey of perceptions, utilization and challenges with technology amongst Indian surgeons

IntroductionTotal joint replacement surgeries are standard procedures for managing end-stage hip or knee arthritis. Despite advances in technology, some patients experience dissatisfaction after total knee arthroplasty (TKA). Robotic technology has evolved significantly and has shown promise in improving component positioning, alignment, and surgical outcomes. However, the widespread adoption of robotics in arthroplasty faces challenges such as high costs, a steep learning curve, and limited evidence on long-term outcomes. MethodsThis cross-sectional observational study used a structured self-administered online survey to assess the perceptions of Indian arthroplasty surgeons regarding robotic technology. The survey included questions about the surgeon's background, experience, perceptions of robotic joint replacement, and limiting factors for robotic usage. A total of 417 responses were collected from practising arthroplasty surgeons. ResultsMost participants(78.1 %) expressed a willingness to adopt robotics in their arthroplasty practice if the cost of installation was reduced. Robotic users were more convinced about the benefits of robotics, including improved alignment, reduced pain, faster rehabilitation, and better outcomes. High-volume robotic surgeons demonstrated a greater belief in the broader potential of robotics beyond implant positioning and alignment. The major barriers to adoption were the high cost of installation and limited insurance coverage for robotic-assisted procedures. Lack of formal robotic training opportunities, resistance from corporate management, patient acceptance issues, and limited published literature supporting robotic advantages were also cited as limiting factors. ConclusionRobotic technology is increasingly being adopted in India for TKA. The main obstacle to widespread adoption is the high cost of installation. As technology costs decrease, we can expect a rise in the number of installations across the country. Advocacy from national orthopaedic organizations may be needed to address insurance reimbursement challenges. Overall, this study provides valuable insights into the perceptions and challenges associated with the adoption of robotic technology in arthroplasty in India.

Shared Decision-Making and Cardiovascular Health: A Scientific Statement From the American Heart Association.

Shared decision-making is increasingly embraced in health care and recommended in cardiovascular guidelines. Patient involvement in health care decisions, patient-clinician communication, and models of patient-centered care are critical to improve health outcomes and to promote equity, but formal models and evaluation in cardiovascular care are nascent. Shared decision-making promotes equity by involving clinicians and patients, sharing the best available evidence, and recognizing the needs, values, and experiences of individuals and their families when faced with the task of making decisions. Broad endorsement of shared decision-making as a critical component of high-quality, value-based care has raised our awareness, although uptake in clinical practice remains suboptimal for a range of patient, clinician, and system issues. Strategies effective in promoting shared decision-making include educating clinicians on communication techniques, engaging multidisciplinary medical teams, incorporating trained decision coaches, and using tools (ie, patient decision aids) at appropriate literacy and numeracy levels to support patients in their cardiovascular decisions. This scientific statement shines a light on the limited but growing body of evidence of the impact of shared decision-making on cardiovascular outcomes and the potential of shared decision-making as a driver of health equity so that everyone has just opportunities. Multilevel solutions must align to address challenges in policies and reimbursement, system-level leadership and infrastructure, clinician training, access to decision aids, and patient engagement to fully support patients and clinicians to engage in the shared decision-making process and to drive equity and improvement in cardiovascular outcomes.

Current Diagnostic Pathways for Alzheimer's Disease: A Cross-Sectional Real-World Study Across Six Countries.

Diagnostic pathways for patients presenting with cognitive complaints may vary across geographies. To describe diagnostic pathways of patients presenting with cognitive complaints across 6 countries. This real-world, cross-sectional study analyzed chart-extracted data from healthcare providers (HCPs) for 6,744 patients across China, France, Germany, Spain, UK, and the US. Most common symptoms at presentation were cognitive (memory/amnestic; 89.86%), followed by physical/behavioral (87.13%). Clinical/cognitive tests were used in > 95%, with Mini-Mental State Examination being the most common cognitive test (79.0%). Blood tests for APOE ɛ4/other mutations, or to rule out treatable causes, were used in half of the patients. Clinical and cognitive tests were used at higher frequency at earlier visits, and amyloid PET/CSF biomarker testing at higher frequency at later visits. The latter were ordered at low rates even by specialists (across countries, 5.7% to 28.7% for amyloid PET and 5.0% to 27.3% for CSF testing). Approximately half the patients received a diagnosis (52.1% of which were Alzheimer's disease [AD]). Factors that influenced risk of not receiving a diagnosis were HCP type (higher for primary care physicians versus specialists) and region (highest in China and Germany). These data highlight variability in AD diagnostic pathways across countries and provider types. About 45% of patients are referred/told to 'watch and wait'. Improvements can be made in the use of amyloid PET and CSF testing. Efforts should focus on further defining biomarkers for those at risk for AD, and on dismantling barriers such low testing capacity and reimbursement challenges.

Use of molecular NGS vs single gene testing differs by clinical setting and physician’s specialty in mNSCLC management.

e18547 Background: Genomic profiling is an important entrée to Precision Medicine (PM) therapies for treating metastatic non-small cell lung cancer (mNSCLC) with 16 new PM therapies approved since 2018, and 10 advancing from second (2L) to the first (1L) line. However, absent or suboptimal predictive biomarker testing leads to patients not benefiting from appropriate PM treatments (64% inappropriate; Sadik et al., 2022). Disparities in testing practices and perceptions remain when considering Next Generation Sequencing (NGS) versus Single Gene (SG) testing. We hypothesized that testing rates are associated with physician’s specialty/clinical setting, and assessed this in real-world data for USA mNSCLC patients. Methods: The DXRX database contains real-world claims and laboratory data covering 60% of USA mNSCLC population (Surveillance, Epidemiology, and Results program - SEER comparison). NGS and SG testing rates for newly diagnosed (1L) and 2L mNSCLC patients (~186K patients from 2018 to 2021) were evaluated by physician specialty and affiliation (self-populated on National Plan and Provider Enumeration System - NPPES). Oncologists and Pathologists referred 63% and 15% of the patients respectively. Results: Oncologists (ONCs) had higher NGS testing rates than pathologists (PATHs), with double the testing rates in 2L. NGS testing rates were higher in academic vs community settings, regardless of specialty. Conversely PATHs had higher SG testing rates than ONCs, particularly in community settings (Table). NGS testing rates were generally higher in 2L and SG testing higher in 1L. Conclusions: NGS is the optimal molecular testing modality for mNSCLC patients, however, there is a disparity of testing rates across physician specialties and treatment settings in decreasing order: academic ONCs &gt; community ONCs &gt; academic PATHs &gt; community PATHs, who favor SG testing. This could be influenced by turnaround time needs, reimbursement challenges, and/or technology diffusion rate. As most mNSCLC patients are treated in the community setting, efforts are needed to tackle disparities in appropriate testing. [Table: see text]

Biosimilar uptake and cost savings analysis before and after implementation of a pharmacist-driven substitution program within a National Community Oncology Network: One-year follow-up.

6516 Background: As of December 2022, 22 of the 40 biosimilar approvals in the United States, are used for the treatment of cancer or for the supportive care of patients with cancer. Our organization is a network of community oncology practices, representing 107 oncologists at 76 locations across 17 states. Because our network faces formulary selection and reimbursement challenges related to a diverse payor mix across multiple states, we sought to see the impact of utilizing regional clinical pharmacists (RCPs) to assist with selection of the most cost-effective biosimilar products. Methods: In October 2021, our network initiated an RCP-driven biosimilar substitution program, whereby the RCP acts as a liaison between providers and financial teams to evaluate existing drug orders and their financial impact. We previously presented data on the financial impact to payors and providers before and after implementation of the program from 4/1/2021 to 4/1/2022. This study evaluates the one-year results following program implementation. Additionally, outcomes related to biosimilar utilization as well as financial impacts to payors, patients, and providers were assessed. Payor savings is defined as the difference of the calculated 80% Medicare ASP+6 for the administered biosimilar compared to the originator; patient savings is defined as the difference of the calculated 20% Medicare ASP+6 co-insurance for the administered biosimilar compared to the originator; provider savings is defined as the difference between the invoiced cost of the biosimilar compared to the originator. Results: By the end of 2022, preferred product utilization was achieved for &gt;90% of bevacizumab, trastuzumab, and rituximab orders. Use of the preferred pegfilgrastim product increased from &lt;20% in 4/2021 to &gt;60% by 12/2022. Use of filgrastim biosimilar product increased from &lt;75% in 4/2021 to &gt;90% by 4/2022, then decreased to 55% by 12/2022 due to trending ASP. Payor preference prevented biosimilar switching in approximately 34% of cases. Conclusions: Use of institution-preferred biosimilar products increased across all agents in this study after implementation of the RCP-driven biosimilar substitution program, except for filgrastim. Significant cost savings were noted for payors, patients, and providers. Barriers to switching to institution-preferred products included non-medical switching requirements by payors, patient assistance and compassionate use programs, and patient and/or provider preferences. [Table: see text]

Rapid Review of "No Surprise" Medical Billing in the United States: Stakeholder Perceptions and Challenges.

Surprise medical bills received after care delivery in both emergency and non-emergency situations for out-of-network (OON) or other contractual health plan regulations adds additional stress upon the care guarantor, most often the patient. The passing and continued implementation of the federal No Surprises Act (NSA) and related state-level legislation continues to influence the processes of care delivery in the United States. This rapid review evaluated the literature specific to surprise medical billing in the United States since the passing of the No Surprise Act, guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) protocol. A total of 33 articles were reviewed by the research team and the results demonstrate industry stakeholder perceptions related to two primary industry themes (constructs) surrounding surprise billing: healthcare stakeholder perspectives and medical claim dispute (arbitration) processes. Further investigation identified sub-constructs for each: the practice of balance-billing patients for OON care and healthcare provider, and facility equitable reimbursement challenges (primary theme 1), and arbitration observations and challenges surrounding (a) the NSA medical dispute process, (b) state-level arbitration processes and perceptions, and (c) use of the Medicare fee schedule as a benchmark for arbitration decisions (primary theme 2). The results indicate the need for formative policy improvement initiatives to address the generation of surprise billing.

Provider Financial Pressures Mount in 2023

After a turbulent year in 2022, provider groups will enter 2023 with significant headwinds via external economic factors and industry-specific reimbursement challenges. Optimizing revenue through core services and managing tighter expense budgets will be critical as our industry weathers this recessionary environment. These factors may further accelerate the consolidation we have seen in previous years as health systems grow and merge and as private equity expands its reach into the provider space.

Virtual Clinics for Diabetes Care.

Virtual Clinics for Diabetes Care.

Tough times never last too long: the future of psychopharmacology.

Tough times never last too long: the future of psychopharmacology.

An evaluation of managed access agreements in England based on stakeholder experience.

The objective of this research was to evaluate managed access policy in England, drawing upon the expertise of a range of stakeholders involved in its implementation. Seven focus groups were conducted with payer and health technology assessment representatives, clinicians, and representatives from industry and patient/carer organizations within England. Transcripts were analyzed using framework analysis to identify stakeholders' views on the successes and challenges of managed access policy. Stakeholders discussed the many aims of managed access within the National Health Service in England, and how competing aims had affected decision making. While stakeholders highlighted a number of priorities within eligibility criteria for managed access agreements (MAAs), stakeholders agreed that strict eligibility criteria would be challenging to implement due to the highly variable nature of innovative technologies and their indications. Participants highlighted challenges faced with implementing MAAs, including evidence generation, supporting patients during and after the end of MAAs, and agreeing and reinforcing contractual agreements with industry. Managed access is one strategy that can be used by payers to resolve uncertainty for innovative technologies that present challenges for reimbursement and can also deliver earlier access to promising technologies for patients. However, participants cautioned that managed access is not a "silver bullet," and there is a need for greater clarity about the aims of managed access and how these should be prioritized in decision making. Discussions between key stakeholders involved in managed access identified challenges with implementing MAAs and these experiences should be used to inform future managed access policy.