Reimbursement Fees Research Articles

Navigated laser in diabetic macular edema: the impact of reduced injection burden on patients and physicians-who wins and who loses?

We inquired the impact of reduced therapy discontinuation in diabetic macular edema (DME) on physician's revenue considering anti-vascular endothelial growth factor (VEGF) monotherapy and its combination with Navilas treatment. Data were collected on injection frequency, treatment discontinuation and reimbursement fees for DME treatment with anti-VEGF compared to anti-VEGF in combination with navigated laser. Based on these data an economic model was built to compare physicians revenue over a 5y period using either therapy for 4 European countries and the USA. Due to patients' higher therapy adherence, physicians using navigated laser therapy with anti-VEGF generate similar or higher revenues compared to VEGF monotherapy in all analyzed countries. The use of Navilas decreases the patient's injection burden at the same clinical outcome, while the physician's revenue remained stable or increased. Therewith, therapy discontinuation in DME can be reduced using the combination therapy with Navilas.

Islet transplantation in Italy.

Two centers have now an active islet transplant program in Italy, both placed in Milan: the San Raffaele Scientific Institute and the Niguarda Hospital. Up to 2018 in Italy about 200 patients affected by type 1 diabetes mellitus received an islet allotransplantation and about 100 patients received an islet auto-transplantation after a partial or total pancreatectomy. In spite of this large volume of activities, there is not a specific reimbursement fee for islet isolation and current reimbursement based on the Diagnosis-related group covers only partially the hospitalization and the islet transplantation costs.

Impact of pharmacy collaborating services in an outpatient clinic on improving adverse drug reactions in outpatient cancer chemotherapy

Collaboration between pharmacists, doctors, and nurses in outpatient treatment is beneficial; however, such services are limited in Japan due to the lack of a healthcare reimbursement fee for outpatient pharmacy services at outpatient clinic. We evaluated the impact of a service in which clinical pharmacists collaborated with an oncologist at an outpatient clinic in the treatment of adverse drug reactions in outpatient cancer chemotherapy. We performed a retrospective cohort study using patients' medical records and treatment diaries. Subjects were patients who received outpatient chemotherapy via a clinical pharmacist collaboration service provided by six outpatient pharmacists and an oncologist at an outpatient clinic between June and August 2016. During the study period, the total number of outpatient services was 2508, with 2055 (81%) related to chemotherapy. The six outpatient pharmacists provided interventions to 498 of the 2055 cases (24%). Of the 498 interventions, 103 (20%), in addition to oncologist's prescription, were suggested treatments for adverse drug reactions due to cancer chemotherapy. Oncologists approved a total of 82 prescription suggestions from pharmacists (79%) to 63 patients. Fifty-seven percent (n = 47) of the adverse drug reactions were improved following the pharmacists' suggested prescriptions. This is the first study to clarify the benefits of outpatient pharmacy services in which pharmacists collaborate with oncologists at an outpatient clinic for the management of adverse drug reactions in cancer patients in Japan.

Evaluation of new reimbursement fee for care of pharmacists in Japan

There were so many criticisms of the pharmacy services that were reimbursed from the National Health Services in Japan In order to overcome to this criticism and endorse the pharmacies and pharmacists to play pivotal functions in Japanese aging society the Ministry of Health Labor and Welfare MHLW published ldquo Pharmacy Vision for Patients rdquo and introduced the Your Pharmacist Reimbursed Program On October of the MHLW published ldquo Pharmacy Vision for Patients rdquo The vision endorsed that pharmacist dispenses the patient medications unitarily according to all of the patient prescriptions from every hospitals and clinics On the revision of reimbursement program in which included establish the new reimbursement fee ldquo Your Pharmacist Reimbursed Program ldquo was conducted in order to make the vision would be put into practice These actions have given tremendous impact for Japanese pharmacists and pharmacies In this manuscript we introduced the YPRP and evaluate the impact of YPRP that affect the care of pharmacists and behavior of patients using the public data from Central Social Insurance Medical Council which is the government council body organizing the Japanese medical insurance program Introducing the YPRP has seen that relationship between pharmacists and patients have been closer and improved and also pharmacists could provide medication therapy management to the patients continuously and exclusively While for patients change in consciousness has been founded that expectation for family pharmacists is growing that family pharmacists could observe all taken medications for each patient It seems that the YPRP gave good effect and impact to the medication therapy in Japan The MHLW has announced the new policies to enhanced pharmacists pharmacies to play the pivotal role for medication therapy management of patients in Japanese aging society Japanese pharmacies pharmacists have to change the function and role of pharmacy to meet patient needs and demands from public society with using the new policies which is introduced by the MHLW Furthermore pharmacies pharmacists have to use the newly established YPRP in careful manner and improve the satisfaction of patients and then pharmacies pharmacists have to step up to the next stage to adapt to the progressive aging society by expanding and developing the YPRP

Treatment strategy modification and its implication on the medical cost of fractional flow reserve-guided percutaneous coronary intervention in Japan

BackgroundFractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) could improve outcome compared with angiography-guided PCI. However, the economic impact of FFR-guided PCI remains largely unknown in the medical system in Japan. We evaluated the impact of treatment strategy modification by FFR measurement on the direct medical cost using a model analysis with a decision tree model in Japan. MethodsFor the clinical parameters set in the model, the findings from CVIT-DEFER registry were adopted. Cost parameters were considered on the assumption that coronary angiography, FFR measurement, and the treatment are performed at Diagnosis Procedure combination (DPC) hospitals, and the costs were calculated based on the medical fee reimbursement systems in Japan. ResultsThe probability of deferral of PCI in patients who were allocated to PCI based on coronary angiography was set as 90.1% based on the CVIT-DEFER registry. In the model analysis, the cost of tests was increased by 185,660 JPY per patient by the addition of FFR measurement, but the cost of treatment with PCI was reduced by 561,425 JPY per patient, and the entire cost of treatment was reduced by 322,675 JPY, resulting in the expected reduction in the total expected medical cost by 137,015 JPY per patient. ConclusionUnder contemporary Japanese practice, FFR-guided PCI has potential to reduce the medical cost by effective reassessment of coronary stenosis and reducing inappropriate application of PCI.

Assessment of the benefits of and barriers to HIV pharmacist credentialing

ObjectivesTo ascertain the reasons for, benefits of, and barriers to pursuing the American Academy of HIV Medicine (AAHIVM) HIV Pharmacist (AAHIVP) credential. MethodsA cross-sectional study using an electronic self-administered survey was used. Two separate invitations to participate in online surveys were sent to pharmacists who practice in HIV-related settings: 1 to pharmacists with the AAHIVP credential and 1 to members of key pharmacy organizations and employers without the credential. The surveys assessed demographics, concurrent credentials and certifications, and factors influencing the pursuit of and benefits gained from having the AAHIVP credential (credentialed population) or barriers to pursuing the AAHIVP credential (credentialed and noncredentialed populations). ResultsThere were 192 participants (survey response rate 38.8%) in the credentialed population and 212 participants in the noncredentialed population. Perceived recognition as an HIV expert from pharmacist (n = 174; 90.6%) and physician (n = 162; 84.4%) peers was the main reason for credentialing; only 20.4% (n = 23/113) of participants’ employers reimbursed for the credential. Common reasons for nonpursuit included lack of employer incentive (n = 46; 26.6%) and lack of fee reimbursement (n = 38; 21.9%) in those aware of the credential. However, a majority of these noncredentialed participants reported they would be interested in pursuing credentialing (n = 152; 80.4%). ConclusionAAHIVP credentialing is sought and maintained on the basis of perceived intangible benefits, such as peer recognition, over tangible benefits, such as increased salary and reimbursement by third-party payers. Despite interest, a lack of employer reimbursement is perceived to be a barrier to AAHIVP credentialing among those who have not yet been credentialed.

Hospital-Based Emergency Department Visits With Dental Conditions: Impact of the Medicaid Reimbursement Fee for Dental Services in New York State, 2009-2013

ObjectivesHospital-based emergency department (ED) visits for dental problems have been on the rise. The objectives of this study are to provide estimates of hospital-based ED visits with dental conditions in New York State and to examine the impact of Medicaid reimbursement fee for dental services on the utilization of EDs with dental conditions. MethodsNew York State Emergency Department Database for the year 2009-2013 and Health Resources and Services Administration's Area Health Resource File were used. All ED visits with diagnosis for dental conditions were selected for analysis. ResultsThe present study found a total of 325,354 ED visits with dental conditions. The mean age of patient was 32.4 years. A majority of ED visits were made by those aged 25-44 years (49%). Whites comprised 52.1% of ED visits. Proportion of Medicaid increased from 22% (in 2009) to 41.3% (in 2013). For Medicaid patients, the mean ED charges and aggregated ED charges were $811.4 and $88.1 million, respectively. Eleven counties had fewer than 4 dentists per 10,000 population in New York State. ConclusionHigh-risk groups identified from the study are those aged 25-44 years, uninsured, covered by Medicaid and private insurance, and residing in low-income areas. The study highlights the need for increased Medicaid reimbursement for dentists and improves access to preventive dental care especially for the vulnerable groups.

PERCEPTION OF PEOPLE ON AADHAAR (LINKAGE, USAGE & VOTING) A CASE STUDY (2014-16) WITH REFERENCE TO CHITTOOR DISTRICT AP, INDIA

This article is a survey done to know how the people linked their aadhaar number to the voter id, gas cylinder, fee reimbursement, Bank account, House & Water tax, Birth Certificate, Admission in a School, RTO license, Raitu Runa Mafi, Employer data, Income/Caste/ Nativity. This article also collected the information on how is the usage of aadhaar as a proof of identity and the people voting on continue the aadhaar and linking of aadhaar.

Editor's Choice – Carotid Stenosis Treatment: Variation in International Practice Patterns

The aim was to determine current practice for the treatment of carotid stenosis among 12 countries participating in the International Consortium of Vascular Registries (ICVR). Data from the United States Vascular Quality Initiative (VQI) and the Vascunet registry collaboration (including 10 registries in Europe and Australasia) were used. Variation in treatment modality of asymptomatic versus symptomatic patients was analysed between countries and among centres within each country. Among 58,607 procedures, octogenarians represented 18% of all patients, ranging from 8% (Hungary) to 22% (New Zealand and Australia). Women represented 36%, ranging from 29% (Switzerland) to 40% (USA). The proportion of carotid artery stenting (CAS) among asymptomatic patients ranged from 0% (Finland) to 26% (Sweden) and among symptomatic patients from 0% (Denmark) to 19% (USA). Variation among centres within countries for CAS was highest in the United States and Australia (from 0% to 80%). The overall proportion of asymptomatic patients was 48%, but varied from 0% (Denmark) to 73% (Italy). There was also substantial centre level variation within each country in the proportion of asymptomatic patients, most pronounced in Australia (0-72%), Hungary (5-55%), and the United States (0-100%). Countries with fee for service reimbursement had higher rates of treatment in asymptomatic patients than countries with population based reimbursement (OR 5.8, 95% CI 4.4-7.7). Despite evidence about treatment options for carotid artery disease, the proportion of asymptomatic patients, treatment modality, and the proportion of women and octogenarians vary considerably among and within countries. There was a significant association of treating more asymptomatic patients in countries with fee for service reimbursement. The findings reflect the inconsistency of the existing guidelines and a need for cooperation among guideline committees all over the world.

Efficacy of Fee Reimbursement Scheme:A Social Psychology Perspective

The purpose of fee reimbursement scheme (which was initiated in the year 200818 in Andhra Pradesh by the then government) is to bring engineering, medical and other significant courses closer to a large number of students from economically weaker sections of the society who could not afford education in expensive private colleges. When the scheme was introduced, the burden on the- Andhra Pradesh Government was less than Rs. 2,00018 crore; and according to the latest budget estimate, the burden would be about Rs. 4,00018 crore every year. An economist would see an opportunity cost and advice the government to invest the same money in building irrigation projects that will considerably enhance agriculture production and productivity in water-scarce regions. A scientist would see an opportunity to invest in nuclear projects for power generation. Likewise, every expert looks for opportunity in purposeful investments and hope for better return on investments. In this paper, the author explores the efficacy of fee-reimbursement scheme from a social psychology perspective. Every scheme, or an idea, is theoretically good. However, if the idea or scheme is not properly implemented, the purpose is lost. In this paper, the author takes into consideration socio-psychological concepts such as reward, punishment and motivation and analyzed their impact on fee-reimbursement scheme. The author also suggests the effective ways by which the scheme may be implemented in the best interests of all.

Cost analysis and implications of routine deep venous thrombosis duplex ultrasound scanning after endovenous ablation.

Duplex ultrasound (DUS) is performed by the majority of physicians after endovenous ablation (EVA) of the great saphenous vein to screen for endovenous heat-induced thrombosis (EHIT) at the saphenofemoral junction extending into the femoral vein. Several factors should be considered in assessing the value and cost of routine DUS after EVA: the natural history of EHIT is poorly defined, the incidence appears low, and the majority are both asymptomatic and Kabnick type 2 (projecting only slightly into the femoral vein). Moreover, routine postoperative DUS screening is not recommended for procedures with higher thromboembolic complication rates, such as joint replacement or bariatric surgery. Data on the incidence of death, EHIT, and deep venous thrombosis (DVT) were derived from a systematic review after either radiofrequency or laser ablation of the saphenous vein from two sources: (1) EVA randomized controlled trials (N= 1482) and a (2) large (>150 patients) EVA case series (N= 12,363). The number of tests required to detect one case of EHIT/DVT was calculated from the incidence in the EVA and case series data bases; the cost to detect a case was estimated using the 2013 Medicare global fee schedule for the cost of a unilateral venous DUS study. This analysis included 13,845 EVA-treated limbs. There were no reported deaths. The incidence of DUS-detected venous thromboembolism after EVA is 0.7%. The cost of unilateral DUS according to the Medicare global reimbursement fee for office-based studies is $106.71. The total cost of performing DUS in this study population is estimated to be at least $1,477,399, and the amount of dollars expended per venous thromboembolism detected is $14,667. The current Society for Vascular Surgery/American Venous Forum recommendation is to perform screening DUS after EVA within 72 hours postoperatively with a weak level of recommendation (grade 2C). The current analysis demonstrates a low incidence of EHIT/DVT with a corresponding high cost to detect each case with routine DUS screening. These data combined with the unclear clinical significance of EHIT suggest that the policy of universal post-EVA screening should be revised in the near future.

Cost-Minimization Analysis of Open and Endoscopic Carpal Tunnel Release.

Carpal tunnel release is the most common upper-limb surgical procedure performed annually in the U.S. There are 2 surgical methods of carpal tunnel release: open or endoscopic. Currently, there is no clear clinical or economic evidence supporting the use of one procedure over the other. We completed a cost-minimization analysis of open and endoscopic carpal tunnel release, testing the null hypothesis that there is no difference between the procedures in terms of cost. We conducted a retrospective review using a private-payer and Medicare Advantage database composed of 16 million patient records from 2007 to 2014. The cohort consisted of records with an ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis of carpal tunnel syndrome and a CPT (Current Procedural Terminology) code for carpal tunnel release. Payer fees were used to define cost. We also assessed other associated costs of care, including those of electrodiagnostic studies and occupational therapy. Bivariate comparisons were performed using the chi-square test and the Student t test. Data showed that 86% of the patients underwent open carpal tunnel release. Reimbursement fees for endoscopic release were significantly higher than for open release. Facility fees were responsible for most of the difference between the procedures in reimbursement: facility fees averaged $1,884 for endoscopic release compared with $1,080 for open release (p < 0.0001). Endoscopic release also demonstrated significantly higher physician fees than open release (an average of $555 compared with $428; p < 0.0001). Occupational therapy fees associated with endoscopic release were less than those associated with open release (an average of $237 per session compared with $272; p = 0.07). The total average annual reimbursement per patient for endoscopic release (facility, surgeon, and occupational therapy fees) was significantly higher than for open release ($2,602 compared with $1,751; p < 0.0001). Our data showed that the total average fees per patient for endoscopic release were significantly higher than those for open release, although there currently is no strong evidence supporting better clinical outcomes of either technique. Value-based health-care models that favor delivering high-quality care and improving patient health, while also minimizing costs, may favor open carpal tunnel release.

Pharmacists' barriers and facilitators on implementing a post-discharge home visit

Introducing a post-discharge community pharmacist home visit can secure continuity of care and prevent drug-related problems. Currently, this type of pharmaceutical care is not standard practice and implementation is challenging. Mapping the factors influencing the implementation of this new form of care is crucial to ensure successful embedding. To explore which barriers and facilitators influence community pharmacists' adoption of a post-discharge home visit. A mixed methods study was conducted with community pharmacists who had recently participated in a study that evaluated the effectiveness of a post-discharge home visit in identifying drug-related problems. Four focus groups were held guided by a topic guide based on the framework of Greenhalgh etal. After the focus groups, major barriers and facilitators were formulated into statements and presented to all participants in a scoring list to rank for relevance and feasibility in daily practice. Twenty-two of the eligible 26 pharmacists participated in the focus groups. Twenty pharmacists (91%) returned the scoring list containing 21 statements. Most of these statements were perceived as both relevant and feasible by the responding pharmacists. A small number scored high on relevance but low on feasibility, making these potential important barriers to overcome for broad implementation. These were the necessity of dedicated time for performing pharmaceutical care, implementing the home visit in pharmacists' daily routine and an adequate reimbursement fee for the home visit. The key to successful implementation of a post-discharge home visit may lay in two facilitators which are partly interrelated: changing daily routine and reimbursement. Reimbursement will be a strong incentive, but additional efforts will be needed to reprioritize daily routines.

Evolving Physician Reimbursement Structures: Moving the Medical Group to Value-Based Success

With passage of the Medicare Access and CHIP Reauthorization Act, what changes can physicians expect with regard to payment incentive models?Repeal of the Medicare SGR formula and passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) are bringing about significant changes to the Medicare physician fee schedule and reimbursement methodology (Centers for Medicare & Medicaid Services [CMS], 2015). MACRA established annual positive or flat fee updates for 10 years and implemented a two-track fee update thereafter. In addition, MACRA created MIPS and consolidated the current Medicare fee-for-service incentive initiatives. The law also provides a mechanism for physicians to participate in alternative payment methods, including the patient-centered medical home model and others to be defined. In repealing the SGR and passing MACRA, Congress's intent was to move away from the fee-for-service payment methodology and toward a value-based payment system.In preparation for changes to current fee-for-service incentive models, physicians and physician groups should be aware that 2016 is the last reporting period under the current Physician Quality Reporting System (PQRS) methodology. The 2016 reporting period will affect 2018 reimbursement, meaning that providers who do not meet reporting and participation requirements in 2016 will experience a 2% reduction in Medicare reimbursement in 2018 (CMS, 2016b). Satisfactory participation currently includes reporting on nine measures in three quality domains, as defined by CMS. Changes for 2016 include adding measures where gaps exist and eliminating measures that have topped out, are duplicative, or have been replaced by more robust measures.Legislative changes to the Electronic Health Record (EHR) Incentive Program are leading to a stricter definition of certified EHRs. These changes will align with the Office of the National Coordinator for Health Information Technology and govern the requirements for information and how it can be submitted. In addition, the current Meaningful Use (MU) program will be restructured and consolidated into MIPS.CMS will continue a phased approach to public reporting on the Physician Compare website. In addition to providing access to all individual- and group-level reported measures, Physician Compare will post scores for providers who report satisfactory performance on the new PQRS Cardiovascular Prevention measures and received a positive adjustment for the Value-Based Payment Modifier (VBPM) program. By including the downloadable VBPM database, Physician Compare will provide consumers with information regarding performance (i.e., high, low, or neutral on cost and quality) and indicate if a provider or group did not report data on these measures.Implementation of MACRA will drive the consolidation of the current incentive plans. Beginning in 2017, MACRA will include elements of each of the three programs (PQRS, MU, and VBPM) as well as a fourth-clinical practice improvement activities (CPIA)-currently under development. These programs will be rolled together and result in a composite score for practitioners and practices. Each provider or practice will receive a positive, neutral, or negative adjustment in reimbursement on the basis of the score in relation to a threshold. The incentive or penalty will be based on reporting and performance 2 years earlier, meaning the 2019 incentive or penalty will be based on reporting and performance in 2017. Providers or groups above the threshold will receive positive adjustments, whereas those below the threshold will receive negative adjustments. The payment adjustments will gradually increase from 4% in 2019 to 9% in 2022. CMS projects that this system will be budget neutral, meaning poor performers will pay for above-average performers. In the event that everyone is above the threshold, CMS has built in an additional $500 million in funding for the top performers between 2019 and 2024. …

Objective classification of glistenings in implanted intraocular lenses using Scheimpflug tomography

To evaluate whether ocular Scheimpflug tomography allows automated detection of glistenings in implanted intraocular lenses. Department of Ophthalmology, Goethe University, Frankfurt, Germany. Prospective, nonrandomized case series. Patients who had phacoemulsification with implantation of various types of monofocal intra-ocular lenses (IOL) were examined under mydriasis for glistenings with the following 3 methods: subjective quantification with a rating scale during slitlamp examination, manual counting in slitlamp photographs, and using a purpose-written digital-image processing program for automatic counting of glistenings in Scheimpflug images. Examinations were performed by the same examiner at least 6 months after IOL implantation. Methods were tested for consistency with the Cohen κ coefficient and single-factor analysis of variance. The subjectively graded glistenings (n = 63 patients, 63 eyes) during slitlamp examination showed the same glistening grade as the manually counted glistenings in slitlamp photographs, with a moderate agreement (κ = 0.46). The glistening count derived from Scheimpflug images was not associated with the glistening grades determined through any of the slitlamp methods (P > .05). Subjective glistening grading score showed a moderate agreement with counted score in slitlamp images. The Scheimpflug device used in this study did not provide images of required resolution to perform an automated counting of separate glistenings and thus classification. Drs. Biwer, Schmitt, Honig, Spratte, and Baumeister have no financial or proprietory interest in any material or method mentioned. Dr. Kohnen has received travel reimbursement and lecture fees and is a consultant to Abbott, Alcon, Thieme Compliance, Hoya, Rayner, Oculus, Schwind, and Zeiss.

Expanding availability of safe abortion services through private sector accreditation: a case study of the Yukti Yojana program in Bihar, India.

BackgroundRecognizing the need to increase access to safe abortion services to reduce maternal mortality and morbidity, the state government of Bihar, India introduced an innovative mechanism of accrediting private health care facilities. The program, Yukti Yojana (‘a scheme for solution’), accredits eligible health facilities and supports them in providing abortion-related services free of charge to rural and low-income urban women. This paper describes implementation of Yukti Yojana.MethodsA descriptive analysis of abortion services provided under the Yukti Yojana program was conducted using four data sources: 1) assessment of accredited facilities over 6 months; 2) induced and incomplete abortion service registers; 3) client exit interviews and associated direct observation of client-provider interaction for a sample of accredited facilities; and 4) in-depth interviews with providers and key stakeholders responsible for providing or influencing abortion services. These analyses assessed characteristics of women receiving abortion services, quality of care and client satisfaction, and barriers and facilitating factors of a successful accreditation process.ResultsForty-nine private facilities were accredited during the first two years of the program, and 84 % had begun providing abortion services, in all 27,724 women were served. Overall, 53 % of beneficiaries reported holding a “Below Poverty Line” card, while 71 % had low living standard. The majority of women (n = 569) reported satisfaction (90 %) with their care, while 68 % perceived good quality of services. Having a government-led initiative was considered a key element of success, while stringent requirements for site approval, long waiting time for accreditation, complicated and delayed reimbursement process and low reimbursement fees for abortion services were identified as barriers to implementation.ConclusionsYukti Yojana provides a model for successfully involving private OB/GYNs and general physicians to deliver safe abortion services to poor women on a large scale and offers additional evidence that public-private partnerships can be used to ensure availability of high-quality maternal health services to women in low-income countries. Private facility accreditation also offers a promising solution to the limited availability of safe abortion services in low resource settings such as Bihar, India.

Complete blood counts, liver function tests, and chest x-rays as routine screening in early-stage breast cancer: value added or just cost?

Current National Comprehensive Cancer Network guidelines for breast cancer staging include pre-treatment complete blood count (CBC) and liver function tests (LFT) to screen for occult metastatic disease. To date, the relevance of these tests in detecting metastatic disease in asymptomatic women with early-stage breast cancer (Stage I/II) has not been demonstrated. Although chest x-rays are no longer recommended in the NCCN guidelines, many centers continue to include this imaging as part of their screening process. We aim to determine the clinical and financial impact of these labs and x-rays in the evaluation of early-stage breast cancer patients. A single institution IRB-approved retrospective chart review was conducted of patients with biopsy-proven invasive breast cancer treated from January 1, 2005–December 31, 2009. We collected patient demographics, clinical and pathologic staging, chest x-ray, CBC, and LFT results at the time of referral. Patients were stratified according to radiographic stage at the time of diagnosis. We obtained Medicare reimbursement fees for cost analysis. From 2005 to 2009, 1609 patients with biopsy-proven invasive breast cancer were treated at our institution. Of the 1082 patients with radiographic stage I/II disease, 27.3 % of patients had abnormal CBCs. No additional testing was performed to evaluate these abnormalities. In the early-stage population, 24.7 % of patients had elevated LFTs, resulting in 84 additional imaging studies. No metastatic disease was detected. The cost of CBC, LFTs and chest x-rays was $110.20 per patient, totaling $106,410.99. Additional tests prompted by abnormal results cost $58,143.30 over the five-year period. We found that pre-treatment CBCs, LFTs, and chest x-rays did not improve detection of occult metastatic disease but resulted in additional financial costs. Avoiding routine ordering of these tests would save the US healthcare system $25.7 million annually.

How Do You Solve a Problem Like Agbon?: The Trials and Tribulations of Applying Diagnoses to Children of a Foreign Culture

A European mother and her young adopted African son were referred to this clinician for an evaluation due to extreme behavior problems in school and significant difficulty learning in a group. The evaluation process quickly becomes quite complex: do we assign Western diagnoses such as attention deficit hyperactivity disorder? Or do we instead consider his life experiences? The stakes are higher since only the diagnosis of a learning disorder will grant him school accommodations and fee reimbursement from the insurance. The author concludes that diagnosis does not always allow the complexity of a child to appear and be helped, and ultimately affects how a teacher will interpret the child’s character.

The 8 basic payment methods in health care.

Eight basic payment methods are applicable across all types of health care. Each method is defined by the unit of payment (per time period, beneficiary, recipient, episode, day, service, dollar of cost, or dollar of charges). These methods are more specific than common terms, such as capitation, fee for service, global payment, and cost reimbursement. They also correspond to the division of financial risk between payer and provider, with each method reflecting a risk factor within the health care spending identity. Financial risk gradually shifts from being primarily on providers when payment is per time period to being primarily on payers when payment is per dollar of charges. Method 4 (per episode) marks the line between epidemiologic and treatment risk. The 8 methods are typically combined to balance risk and thus balance incentives between payers and providers. This taxonomy makes it easier to understand trends in payment reform-especially the shifting division of financial risk and the movement toward value-based purchasing-and types of payment reform, such as bundling, accountable care organizations, medical homes, and cost sharing. The taxonomy also enables prediction of conflicts between payers and providers. For each unit of payment, providers are rewarded for increasing units while decreasing their own cost per unit. No payment method is neutral on quality because each encourages and discourages the provision of care overall and in particular situations. Many professional norms and business practices have been established to mitigate undesirable incentives. Health care differs from many other industries in that the unit of payment remains variable and unsettled.

Medicaid Reimbursement Fees and its Effect on the Provision of Care

Medicaid Reimbursement Fees and its Effect on the Provision of Care