Reimbursement Fees Research Articles

Comparing health care outcomes before and after employing nurse practitioners in cardiovascular hospitals in Japan: A retrospective chart review.

There are approximately 872 certified nurse practitioners (NPs) in Japan as of April 2024. However, research on the results of their specific activities is still scarce. This study aimed to compare health care outcomes before (i.e., 2019) and after (i.e., 2021) employing NPs in cardiovascular hospitals in Japan. We conducted a retrospective chart review and analyzed 114 patients who underwent cardiac surgery in Hospital A and 381 patients who received pacemaker implantation/replacement in Hospital B. Hospital A hired one NP for cardiac surgery service, and Hospital B hired one NP for pacemaker device service. The NPs assisted in the surgical procedures and provided postsurgical management. In Hospital A, the median length of hospitalization and intubation were shorter in 2021 than in 2019 (p = .02 and .01, respectively). In Hospital B, medical fee reimbursement was lower in 2021 (p < .001) than in 2019, and the median procedure duration was shorter (p = .01), which remained statistically significant after controlling for age, comorbidities, and device types. Some outcomes improved following the employment of NPs, whereas others remained unchanged. Nurse practitioners managed surgical patients well and contributed to the quality care of cardiovascular medicine. The employment of NPs in Japan is encouraged because even a single NP can have a positive, although not large, impact on patients and organizations.

Unveiling the Hidden Discrepancies Between Medicare Physician Reimbursement Rates and Inflation Across Different Surgical Specialties.

This study aimed to analyze the trends of Medicare physician reimbursement from 2011 to 2021 and compare the rates across different surgical specialties. Knowledge of Medicare is essential because of its significant contribution in physician reimbursements. Previous studies across surgical specialties have demonstrated that Medicare, despite keeping up with inflation in some areas, has remained flat when accounting for physician reimbursement. The Physician/Supplier Procedure Summary data for the calendar year 2021 were queried to extract the top 50% of Current Procedural Terminology codes based on case volume. The Physician Fee Schedule look-up tool was accessed, and the physician reimbursement fee was abstracted. Weighted mean reimbursement was adjusted for inflation. Growth rate and compound annual growth rate were calculated. Projection of future inflation and reimbursement rates were also calculated using the US Bureau of Labor Statistics. After adjusting for inflation, the weighted mean reimbursement across surgical specialties decreased by -22.5%. The largest reimbursement decrease was within the field of general surgery (-33.3%), followed by otolaryngology (-31.5%), vascular surgery (-23.3%), and plastic surgery (-22.8%). There was a significant decrease in median case volume across all specialties between 2011 and 2021 (P < 0.001). This study demonstrated that, when adjusted for inflation, over the study period, there has been a consistent decrease in reimbursement for all specialties analyzed. Awareness of the current downward trends in Medicare physician reimbursement should be a priority for all surgeons, as means of advocating for compensation and to maintain surgical care feasible and accessible to all patients.

State-to-State Variation in Medicaid Reimbursement for Neurosurgical Procedures: Implications for Healthcare Access in Vulnerable Populations.

Medicaid payment for healthcare services traditionally reimburses less than Medicare and commercial insurance. This disparity in reimbursement seems to be an important driver of limited access to care among Medicaid beneficiaries. This study seeks to examine the degree of variation in Medicaid and Medicare reimbursement for the most common neurosurgical current procedural terminology codes and determine its potential impact on provider accessibility. In this cross-sectional study, maximum allowed physician reimbursement fees for 20 common neurosurgical codes reported in the literature were obtained from the 2022 Medicare Physician Fee Schedule and individual state Medicaid Fee-for-Service Schedules. The Medicaid-Medicare Index (MMI), which measures Medicaid reimbursement as a fraction of Medicare allowed amounts, was calculated for each procedure across 49 states and the District of Columbia. Lower MMI indicates a greater disparity, or "discount," between Medicaid and Medicare reimbursement. The proportion of providers accepting new Medicaid patients and total Medicaid enrollment were compared across states as a function of MMI. The average national MMI was 0.79, with a range of 0.37 in NY/NJ to 1.43 in NE. Maximum allowed amounts for Medicare reimbursement (coefficient of variation = 0.09) were less variable than those for Medicaid (coefficient of variation = 0.26, P < .01). The largest absolute disparity was observed for intracranial aneurysm clipping in NY, where the maximum Medicaid reimbursement is $3496.52 less than that of Medicare. Higher MMI was associated with a significantly larger proportion of providers accepting new Medicaid patients (R2 = 0.43, P < .01). Moreover, MMI varied inversely with the number of Medicaid beneficiaries (R2 = 0.12, P = .01). Medicaid reimbursement varies between states reflecting the disparate methods of fee schedule calculation. Lower reimbursement is associated with more limited provider enrollment, especially in states with a greater number of beneficiaries.

Did Medicaid Reimbursements Shape the Effects of Medicaid Expansion on Access to Health Care Among the Low-Income Population?

Whether variation in Medicaid reimbursement fees influenced the impacts of the Medicaid expansions is not well understood. We examine whether changes in health care access associated with Medicaid expansion are different in states with comparatively high Medicaid reimbursement rates compared against expanding in states with lower Medicaid reimbursement rates. Using a difference-in-difference-in-difference (DDD or triple-difference) regression approach, we compare relative differences in Medicaid expansion effects between lower and higher reimbursement states. 512,744 low-income adults aged 20-64 in the 2011-2019 Behavioral Risk Factor Surveillance System. Health insurance coverage status, unmet medical needs due to cost, regular source for health care, and a regular/scheduled checkup within the past year. Medicaid expansion has significant and positive impacts on health coverage and access in both high- and low-fee states. In states with fee levels above the median Medicare-to-Medicaid ratios, expanding Medicaid eligibility reduced uninsurance rate by 15.2 percentage point (ppt, p < 0.01), shrank the cost-associated unmet medical need by 10.3 ppt (p < 0.01), improved access to usual source of care by 1.9 ppt (p < 0.1), and increased regular checkup by 14.4 ppt (p < 0.01), while such effects in low-fee states were 11.7 ppt (p < 0.01), 8.3 ppt (p < 0.01), 3.1 ppt (p < 0.1), and 12.3 ppt (p < 0.01), respectively. Our results suggest that Medicaid expansion effect on unmet medical need due to cost in higher-reimbursing states was 2.98 ppt (p < 0.05) larger than in lower-reimbursing states. Evidence suggests modest increases in health care access were more strongly associated with expansions in higher-fee states. Medicaid's fee structure should be considered as a factor influencing large-scale coverage expansions.

Impact of fee-revision policy for gastrostomy on its implementation among older adults with dementia in Japan

ObjectivesThis study aimed to evaluate the impact of the policy to reduce the reimbursement fee for percutaneous endoscopic gastrostomy (PEG) on the number of PEG procedures performed among older adults with dementia. Study designInterrupted time series (ITS). MethodsWe used the monthly aggregated data of the number of PEG procedures in older adults with dementia (both broad and narrow definitions), between 2012 and 2018, from the claims data in Fukuoka Prefecture, Japan. A single ITS design was used to estimate changes in the outcome following each intervention (i.e., first, second, and third interventions performed in 2014, 2015, and 2016, respectively). A controlled ITS design was applied to estimate the effects after the sequence of interventions (pre-intervention: 2012–2014; post-intervention: 2016–2018). The control group comprised patients with malignant head and neck tumors who underwent PEG procedures outside the scope of this policy restriction. ResultsThe number of PEG procedures decreased significantly only in the month wherein the third intervention was introduced (broad definition: IRR = 0.11, CI = 0.03–0.49; narrow definition: IRR = 0.15, CI = 0.03–0.75). No significant difference was observed between the treatment and control groups during the post-intervention phase. ConclusionsThe impact of fee-revision policy for PEG on the decrease in PEG procedures among older adults with dementia is remarkably minimal. It is difficult to reduce unnecessary PEG procedures by relying on this financial incentive alone. Policy decision-makers should consider methods to prevent inappropriate use of artificial nutrition for older adults at their end-of-life stage by reforming the health delivery system.

Abstract 15616: Decline in Temporal Trends of Medicare Physician Reimbursement for Cardiovascular Procedures

Introduction: Utilization of cardiac procedures are common among Medicare beneficiaries and projected to increase over time. Temporal trends of physician fee reimbursement for CV procedures have not been studied. Methods: Cross-sectional study was conducted for national payment amounts that were extracted from Centers for Medicare &amp; Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool using Current Procedural Terminology (CPT) codes. Study time period ranged from 2013 through 2023. CPT codes were analyzed for coronary (percutaneous coronary intervention, coronary artery bypass graft), valvular (surgical aortic, mitral, tricuspid repair/replacement), and structural (transcatheter aortic valve replacement, mitral transcatheter edge-to-edge repair, left atrial appendage occlusion) procedures. All prices were adjusted for inflation to January 2023 US dollars. Primary outcomes were unadjusted and adjusted mean percentage changes (annual and total over 10-year period) and compound annual growth rates for each CV procedure. Results: From 2013 to 2023, mean total unadjusted percentage changes ranged from -0.54% to -21.78%; which decreased further after adjusting for inflation, ranging from -21.07% to -39.83%. The decline was seen in all studied CV procedures. Annual rates (mean and compound) were -3% for most procedures after adjusting for inflation. Conclusions: Our findings suggest a declining trend in physician reimbursement for CV procedures by Medicare, which may adversely influence access to procedures, affect commercial insurance pricing/coverage, and inform trainees and practicing CV physicians of current financial situation. Emphasis needs to be placed on value-based payment model for sustainable and efficient CV care.

Variation in Ischemic Stroke Payments in the USA: A Medicare Beneficiary Study

Introduction: The growing cost of stroke care has created the need for outcome-oriented and cost-saving payment models. Identifying imbalances in the current reimbursement model is an essential step toward designing impactful value-based reimbursement strategies. This study describes the variation in reimbursement fees for ischemic stroke management across the USA. Methods: This Medicare Fee-For-Service claims study examines USA beneficiaries who suffered an ischemic stroke from 2021Q1 to 2022Q2 identified using the Medicare-Severity Diagnosis-Related Groups (MS-DRGs). Demographic national and regional US data were extracted from the Census Bureau. The MS-DRG codes were grouped into four categories according to treatment modality and clinical complexity. Our primary outcome of interest was payments made across individual USA and US geographic regions, assessed by computing the mean incremental payment in cases of comparable complexity. Differences between states for each MS-DRG were statistically evaluated using a linear regression model of the logarithmic transformed payments. Results: 227,273 ischemic stroke cases were included in our analysis. Significant variations were observed among all DRGs defined by medical complexity, treatment modality, and states (p < 0.001). Differences in mean payment per case with the same MS-DRG vary by as high as 500% among individual states. Although higher payment rates were observed in MS-DRG codes with major comorbidities or complexity (MCC), the variation was more expressive for codes without MCC. It was not possible to identify a standard mean incremental fee at a state level. At a regional level, the Northeast registered the highest fees, followed by the West, Midwest, and South, which correlate with poverty rates and median household income in the regions. Conclusions: The payment variability observed across USA suggests that the current reimbursement system needs to be aligned with stroke treatment costs. Future studies may go one step further to evaluate accurate stroke management costs to guide policymakers in introducing health policies that promote better care for stroke patients.

Price setting in the Brazilian private health insurance sector.

Brazil's private health insurance market is the second largest in the world, behind only the United States, making it a valuable source of real-world evidence. This paper documents how physicians' inpatient reimbursement fees vary in the country and explores the relationship between these fees and the market share of health providers and health insurance companies. We implement a fixed-effects panel regression and take advantage of an unprecedented database that contains national administrative records of inpatient procedures paid by health insurance companies in 2016. We find a positive correlation between reimbursement for ICU procedures and provider market share. Conversely, we observe a negative correlation with insurers' market share. Additionally, we document substantial variation in procedure prices, both across and within Brazilian states, and observe that more competitive markets in Brazil tend to have higher population and GDP levels. Overall, our research enhances our understanding of the price setting dynamics of physician reimbursement fees in the context of a developing country. The insights gained from this study can assist policymakers in formulating appropriate regulations to ensure appropriate access to healthcare services.

The COVID-19 Pandemic and the Private Health Sector: Profiting without Socially Contributing.

The COVID-19 pandemic necessitated the mobilization of all available health care resources, including private, for-profit ones. The aim of this multiple methods study (combination of document and secondary data analysis) was to assess government regulations facilitating the private health sector's participation in the COVID-19 response in Greece. During the pandemic, the government made three successive increases in private providers' reimbursement fees, provided additional financial incentives to private providers, and allocated €280 million of emergency funding for the private sector's involvement in the national COVID-19 response. In response, private hospitals made available on average 2.2% of their total bed capacity per epidemic wave for the treatment of COVID-19 patients and 1.7% of their total bed capacity for the treatment of non-COVID-19 patients transferred from National Health System (NHS) hospitals. In 2020 the five largest health care corporate groups maintained their revenues, while in 2021 they increased them by 18.7%-a striking comparison with the 9% recession experienced by the Greek economy in 2020 and its 8.4% recovery in 2021. In a time of an acute public health crisis, private health care providers responded to society's pressing health care needs by insulating their facilities from COVID-19 patients and NHS patient transfers, minimizing their social contribution and safeguarding their revenues and profits.

Surgeons' response to reimbursement changes for alternative procedures: Evidence from spine fusion in the U.S.

AbstractSpinal fusion is the highest operating room expense in the U.S. and the performed procedure depends largely on surgeon preference. We use national claims data for 2010–2014 to study changes in the relative frequency of substitutable spinal fusion procedures, following a one‐time cut in Medicare reimbursement fees that switched the ranking of the two procedures with the highest surgical fees. Relative to lower‐fee alternatives with better clinical outcomes, patients were 6.3% more likely to receive the highest‐fee procedure after the policy change. We find no evidence of cost savings following the reimbursement change.

Development and Validation of txSim: A Model of Advanced Lung Cancer Treatment in Australia.

Since 2016, new therapies have transformed the standard of care for lung cancer, creating a need for up-to-date evidence for health economic modelling. We developed a discrete event simulation of advanced lung cancer treatment to provide estimates of survival outcomes and healthcare costs in the Australian setting that can be updated as new therapies are introduced. Treatment for advanced lung cancer was modelled under a clinician-specified treatment algorithm for Australia in 2022. Prevalence of lung cancer subpopulations was extracted from cBioPortal and the Sax Institute's 45 and Up Study, a large prospective cohort linked to cancer registrations. All costs were from the health system perspective for the year 2020. Pharmaceutical and molecular diagnostic costs were obtained from public reimbursement fees, while other healthcare costs were obtained from health system costs in the 45 and Up Study. Treatment efficacy was obtained from clinical trials and observational study data. Costs and survival were modelled over a 10-year horizon. Uncertainty intervals were generated with probabilistic sensitivity analyses. Overall survival predictions were validated against real-world studies. Under the 2022 treatment algorithm, estimated mean survival and costs for advanced lung cancer 10years post-diagnosis were 16.4months (95% uncertainty interval [UI]: 14.7-18.1) and AU$116,069 (95% UI: $107,378-$124,933). Survival and costs were higher assuming optimal treatment utilisation rates (20.5 months, 95% UI: 19.1-22.5; $154,299, 95% UI: $146,499-$161,591). The model performed well in validation, with good agreement between predicted and observed survival in real-world studies. Survival improvements for advanced lung cancer have been accompanied by growing treatment costs. The estimates reported here can be used for budget planning and economic evaluations of interventions across the spectrum of cancer control.

The invisible cost of pain management by the current International Classification of Diseases coding system: a study in a tertiary care inpatient setting.

The International Classification of Diseases ( ICD ) is applied worldwide for public health data collection among other use cases. However, the current version of the ICD ( ICD-10 ), to which the reimbursement system is linked in many countries, does not represent chronic pain properly. This study aims to compare the ICD-10 with the ICD-11 in hospitalized patients in terms of specificity, clinical utility, and reimbursement for pain management. The medical records of hospitalized patients consulted for pain management at Siriraj Hospital, Thailand, were reviewed, and all pain-related diagnoses were coded into ICD-10 and ICD-11 . The data of 397 patients showed unspecified pain was coded 78% in the ICD-10 and only 0.5% in the ICD-11 version. The difference gap in the proportion of unspecified pain between the 2 versions is wider than in the outpatient setting. The 3 most common codes for ICD-10 were other chronic pain, low back pain, and pain in limb. The 3 most common codes for ICD-11 were chronic cancer pain, chronic peripheral neuropathic pain, and chronic secondary musculoskeletal pain. As in many other countries, no pain-related ICD-10 codes were coded for routine reimbursement. The simulated reimbursement fee remained the same when adding 397 pain-related codings, even if the cost of pain management, such as cost of labor, existed. Compared with the ICD-10 version, the ICD-11 is more specific and makes pain diagnoses more visible. Thus, shifting from ICD-10 to ICD-11 has the potential to improve both the quality of care and the reimbursement for pain management.

115 State-to-State Variation in Medicaid and Medicare Reimbursement: Implications for Healthcare Access Among Vulnerable Populations

INTRODUCTION: Medicaid and Medicare are social insurance programs providing coverage for specific populations, namely low-income and aged individuals. While Medicare is a federally indexed health insurance program, Medicaid is largely administered by individual states resulting in varying policies and practices. METHODS: Maximum allowed physician reimbursement fees for twenty common neurosurgical codes were obtained from the 2022 Medicare Physician Fee Schedule and individual state Medicaid Fee-for-Service Schedules. The Medicaid-Medicare Index (MMI), which measures Medicaid reimbursement as a fraction of Medicare allowed amounts, was calculated for each procedure across 49 states and the District of Columbia. MMI &lt;1 or &gt;1 indicates that Medicaid reimburses less than or greater than Medicare, respectively. The proportion of providers accepting new Medicaid patients and total Medicaid enrollment were compared across states as a function of MMI. RESULTS: Maximum allowed amounts for Medicare reimbursement (CV = 0.09) were less variable than Medicaid (CV = 0.26, p &lt; 0.01). The average national MMI was 0.79 with a range of 0.37 in NY/NJ to 1.43 in NE. The largest absolute disparity was observed for intracranial aneurysm clipping in NY, where the maximum Medicaid reimbursement is $3,496.52 less than that of Medicare. Higher MMI was associated with a significantly larger proportion of providers accepting new Medicaid patients (R2 = 0.43, p &lt; 0.01). Moreover, MMI varied inversely with the number of Medicaid beneficiaries (R2 = 0.12, p = 0.01). CONCLUSIONS: Medicaid reimbursement varies drastically between states reflecting the disparate methods of fee calculation. Lower reimbursement is associated with more limited provider enrollment, especially in states with a greater number of beneficiaries. While more limited access to Medicaid-accepting neurosurgeons may contribute to poorer outcomes, this is an issue that warrants further exploration.

Analysis of Wholesale Drug Acquisition and Laboratory Assessment Costs Between Heparin Compared With Bivalirudin-Based Systemic Anticoagulation Strategies in Adult Extracorporeal Membrane Oxygenation.

To assess the wholistic costs of systemic anticoagulation delivery in heparin versus bivalirudin-based maintenance of adult patients supported on extracorporeal membrane oxygenation (ECMO). Single-center retrospective cohort study. Large academic ECMO center. Adults on ECMO receiving heparin or bivalirudin for primary maintenance systemic anticoagulation. None. Electronic data were abstracted from a database maintained by our ECMO center, which transitioned to a preferred bivalirudin-based anticoagulation management in 2017. The pretransition group consisted of 126 patients (123 heparin and three bivalirudin), whereas the posttransition group included 275 patients (82 heparin and 193 bivalirudin). Drug costs were estimated using the wholesale acquisition cost, and laboratory assays costs were estimated using reimbursement fee schedules. Cost data were normalized to the duration of the ECMO run and reported in U.S. Dollar per ECMO day. Following the practice change, bivalirudin patients were less likely to receive AT supplementation (31.0 vs 12.4%; p < 0.0001) and had fewer coagulation assays ordered (6.1 vs 5.4 per ECMO day; p = 0.0004). After the transition, there was a dramatic decrease in costs related to AT assay assessments ($11.78 [interquartile range {IQR}, $9.48-$13.09] vs $1.03 [IQR, $0-$5.75]; p < 0.0001) and AT supplementation ($0 [IQR, $0-$312.82] vs $0 [IQR, $0-$0]; p < 0.0001) per ECMO day. Unadjusted survival at 28 days was higher posttransition (64.3 vs 74.9%; p = 0.0286). Antithrombin assays and supplementation compromise a significant proportion of heparin-based anticoagulation costs in ECMO patients and is substantially reduced when a bivalirudin-based anticoagulation strategy is deployed. A favorable association exists between the aggregate cost of administration of bivalirudin compared with heparin-based systemic anticoagulation in adults supported on ECMO driven by reductions in antithrombin activity assessments and the cost of antithrombin replacement.

Health Policy Views and Political Advocacy of Arthroplasty Surgeons: A Survey of the American Association of Hip and Knee Surgeons Members

BackgroundThe American Association of Hip and Knee Surgeons (AAHKS) is the largest specialty society for arthroplasty surgeons in the United States and is dedicated to education, research, and advocacy. The purpose of this study was to identify the health policy views of AAHKS members and better characterize their advocacy participation. MethodsA 22 question survey was electronically distributed multiple times via email link to all 3,638 United States members of AAHKS who were in practice or training in 2022. Study results were analyzed using descriptive statistics. ResultsThere were 311 responses (9%), with 18% of respondents being within 5 years of practice and 38% having more than 20 years of practice. Respondents identified as Republicans (40%), Independents (37%), and Democrats (21%). Top policy issues included preserving physician reimbursement and equitable fee schedule representation (95%), the burden of prior authorization (53%), the impact of Center of Medicare and Medicaid Services regulations (39%), and medical liability and tort reform (39%). Members ranked maintaining appropriate physician reimbursement (44%) and advocating for patients (37%) as the top benefits to participation in advocacy. A majority of respondents (81%) stated that they spend more time on presurgery optimization now than 10 years ago. The most common barrier to advocacy participation was a lack of time (77%). ConclusionResponding AAHKS members are well-informed, politically engaged, patient-oriented, and eager for a voice in policy decisions that affect the professional future of arthroplasty surgeons. These results can be used to help direct strategic efforts of the AAHKS Advocacy Committee to further increase advocacy efforts.

Mapping the Japanese orthopedic association national registry (JOANR) to the international classification of health interventions (ICHI)

BackgroundThe Japanese Orthopedic Association launched the Japanese Orthopedic Association National Registry (JOANR), Japan's first large-scale nationwide musculoskeletal disease registry, in 2020. The World Health Organization released the International Classification of Health Interventions (ICHI) Beta-3 version in the same year. This concurrence served as an impetus to examine the relationship between domestic and international classification for orthopedic interventions.Our objective was to evaluate the possibility of utilizing JOANR for international comparison and the potential usage of ICHI in the domestic medical fee reimbursement system. This study is a novel attempt at mapping a domestic orthopedic scheme to the ICHI. MethodsWe mapped 149 codes out of 581 orthopedic surgical codes, on JOANR's registration form, to the ICHI, and then classified the nature of JOANR codes' relationship, to both ICHI single stem codes and stem codes accompanied by other additional stem codes, extension codes, and International Classification of Diseases for Mortality and Morbidity Statistics (ICD) codes, into five categories: Equivalent (exact match), Narrower (compared to ICHI; can be smoothly incorporated into ICHI), Broader (compared to ICHI), Slipped (combination of both Narrower and Broader), and None (no appropriate code). Finally, debatable issues that arose during the mapping operation were noted. ResultsThe domestic codes’ relationship to ICHI single stem code by category were Equivalent: 27 (18.1%) and Narrower: 65 (43.6%), respectively. Further, the rate of Equivalent rose to 120 (80.5%) on adding other stem codes, extension codes, and ICD codes. Additionally, certain domestic titles, which were unsuitable for classification as they included diagnostic information, and arthroscopic surgeries without corresponding ICHI codes, were recoded. ConclusionsJOANR can be converted to an international comparison standard via ICHI to a certain extent, and ICHI accompanied by ICD codes has potential for deployment in the domestic medical fee reimbursement system.

Reimbursement practices for use of digital devices in atrial fibrillation and other arrhythmias: a European Heart Rhythm Association survey.

Since digital devices are increasingly used in cardiology for assessing cardiac rhythm and detecting arrhythmias, especially atrial fibrillation (AF), our aim was to evaluate the expectations and opinions of healthcare professionals in Europe on reimbursement policies for the use of digital devices (including wearables) in AF and other arrhythmias. An anonymous survey was proposed through announcements on the European Heart Rhythm Association website, social media channels, and mail newsletter. Two hundred and seventeen healthcare professionals participated in the survey: 32.7%, reported regular use of digital devices, 45.2% reported that they sometimes use these tools, 18.6% that they do not use but would like to. Only a minority (3.5%) reported a lack of trust in digital devices. The survey highlighted a general propensity to provide medical consultation for suspected AF or other arrhythmias detected by a consumer-initiated use of digital devices, even if time constraints and reimbursement availability emerged as important elements. More than 85% of respondents agreed that reimbursement should be applied for clinical use of digital devices, also in different settings such as post-stroke, post-cardioversion, post-ablation, and in patients with palpitations or syncope. Finally, 73.6% of respondents confirmed a lack of reimbursement fees in their country for physicians' consultations (tracings interpretation) related to digital devices. Digital devices, including wearables, are increasingly and widely used for assessing cardiac rhythm and detecting AF, but a definition of reimbursement policies for physicians' consultations is needed.

The cost of total hip replacement: a multicentric TDABC comparison in Brazil

Objective: Monitoring costs is critical in searching for a more effective healthcare system. This study aimed to comprehend the care pathway and measure the costs associated with hip replacement surgeries in different hospitals in Brazil. Methods: The time-driven activity-based costing method was applied for cost data collection and analyses. Data on 62 patients were retrieved from five public hospitals. A descriptive cost analysis was followed by a comprehensive analysis of the variability in each hospital’s care process, leading to suggestions for cost-saving opportunities along with the surgical care pathway. As a final analysis, the cost of surgical treatment was contrasted with the national reimbursement fee. Results: The mean cost per patient of the total sample was $5,784 (MIN-MAX $2,525.9-$9,557.8). Pre- and post-surgery hospitalization periods demonstrated the highest variability in length of time and resource consumption among centers. Compared to the national best practice fee, the average cost per inpatient total hip arthroplasty (THA) pathway from all six hospitals was approximately 7x the national reimbursement. Conclusion: The application of the TDABC allowed us to identify differences in the surgical care pathway among hospitals, which could be explored in further studies aimed at designing a benchmark surgical pathway. Differences in how the treatment is delivered to patients also justified the high-cost variability among centers.

TeleSCOPE: A Real-World Study of Telehealth for the Detection and Treatment of Drug-Induced Movement Disorders

As a result of COVID-19, patients and clinicians rapidly shifted to telehealth. An observational survey study, Real-World Tele-Health Evaluation of Tardive Dyskinesia (TD) Symptoms Communication/Observation Procedure Evaluation in Outpatient Clinical Settings (TeleSCOPE), was conducted to better understand how this shift affected the evaluation of drug-induced movement disorders (DIMDs), including TD. Twenty-minute online quantitative surveys were conducted with neurology and psychiatry specialists (physicians and advanced practice providers) who met the following criteria: ≥3years of practice with ≥70% of time spent in a clinic; prescribed a vesicular monoamine transporter 2 (VMAT2) inhibitor or benztropine for DIMD at least once in the past 6months; and conducted telehealth visits with ≥15% of their patients from December 2020 to January 2021. Respondents included 277 clinicians (neurology=109, psychiatry=168). Telehealth visits increased after COVID-19, with significantly greater increases in psychiatry vs neurology: phone (38% vs 21%); video (49% vs 42%). Across both specialties, top drivers/prompts for further DIMD evaluation were as follows: mention of tics or movements by family members or others (86%); trouble with gait, falls, walking, or standing (82%); difficulty swallowing or eating (74%); and difficulty writing, using phone, computer (71%). However, in the 6months prior to June 2021, virtual evaluation, diagnosis, and monitoring of patients were challenging. For both specialties, many at-risk patients (ie, taking a dopamine receptor blocking agent) were not evaluated for DIMDs via video-based visits (psychiatry=45%, neurology=70%) or phone-only visits (psychiatry=76%, neurology=91%). Clinicians listed evaluation of gait/falls/walking/standing as the most challenging aspect of virtual assessment for phone-only visits (psychiatry=53%, neurology=57%) and video-based visits (psychiatry=26%, neurology=31%). Additional challenges included limited access to computers, insufficient training for clinicians and staff, and greater difficulty obtaining reimbursements (especially for complex telehealth visits). Patients without a participating caregiver, along with lower functioning patients, were at the highest risk of a missed DIMD diagnosis. During the COVID-19 pandemic, telehealth significantly reduced clinicians' ability or willingness to evaluate, diagnose, and monitor DIMDs. Clinicians stated multiple factors increased the risk of a missed or incorrect diagnosis. Challenges to optimal telehealth effectiveness included lack of patient access to computers, need for more clinician/staff training, lack of awareness of coverage, need for sufficient fee reimbursement. In-person evaluation continues to be the gold standard for assessing and treating DIMDs. However, if telehealth is necessary, the use of specific questions and directions is recommended for better communication and more accurate assessments. Neurocrine Biosciences, Inc.

Updates in Telemedicine for Gastroenterology Practices in the United States

The US COVID-19 public health emergency and related legislation facilitated a rapid acceleration of telehealth/telemedicine services by removing restrictions on patient and clinician location, waiving interstate licensure requirements, and providing for professional fee reimbursement on-par with in-person services. Telehealth claims have stabilized at 38 times higher than prepandemic levels as of July 2021.1 In a recent national survey of hepatology practitioners, 98% were using telehealth to conduct appointments, 88% viewed telehealth favorably, and 35% believed that most patients preferred telehealth over in-person visits.