Health Care Reimbursement Research Articles

Association of preconception paternal health on perinatal outcomes: analysis of U.S. claims data

To assess whether paternal health is associated with maternal peripartum and neonatal outcomes. Retrospective cohort study. University research departments. Analytic sample of children born to paired fathers and mothers covering live births within the United States between 2009-2016. Paternal health status (e.g., metabolic syndrome diagnoses, individual chronic disease diagnoses). Primary outcome of preterm birth (i.e., live birth before 37 weeks), and secondary outcomes of low birth weight, neonatal intensive care unit (NICU) stay, gestational diabetes, preeclampsia, eclampsia, and length of maternal stay. The IBM Marketscan Research database covers reimbursed health care claims data on inpatient and outpatient encounters who are privately insured through employment-sponsored health insurance. We assessed 785,809 singleton live births, with 6.6% born preterm. The presence of paternal comorbidities was associated with higher odds of preterm birth, low birth weight (LBW), and NICU stay. After adjusting for maternal factors, fathers with most or all components of the metabolic syndrome had 19% higher odds of having a child born preterm (95% CI 1.11-1.28), 23% higher odds of LBW (95% CI 1.01-1.51), and 28% higher odds of NICU stay (95% CI 1.08-1.52). Maternal morbidity (e.g., gestational diabetes or preeclampsia) was also positively associated with preconception paternal health. Increased preconception paternal comorbidity may be associated with negative infant and maternal outcomes. Although the paternal effect remains modest, these findings highlight the importance of the health of both parents, particularly the mother, on healthy pregnancy.

4:03 PM Abstract No. 124 Stop the bleeding: What interventional radiologists need to know about the Medicare physician fee schedule cut

Health care reimbursement occurs through private insurance or government programs such as Medicare and Medicaid (CMS). We evaluate the models of physician payments and discuss current policies affecting interventional radiology (IR) practices. We evaluated CMS Physician Fee Schedule (PFS) proposed rules for 2020-2021. CMS accepted the American Medical Association (AMA) procedural terminology (CPT) codes and AMA Relative Value Scale Update Committee recommendations. The terms included re-direction and increased reimbursement for primary care and nonprocedural specialties, while negatively impacting procedure-based specialties. IR outpatient clinic data was collected from Jan to Sept 2019 and used to estimate the economic impact of the proposed changes to health policy rules were to be implemented. Following implementation of the CMS 2020 ruling, IR PFS rates will decrease by 4% for bone biopsy, lumbar spine puncture, abdominal aortography, angiography, and duplex ultrasound. In addition, proposed changes to E/M code payment are predicted to result in additional 2% cuts, with an overall 6% reduction in Medicare payments by 2021. Total allowable Medicare charges for IR are $432,000,000, therefore, this reduction may equate to approximately $26,000,000 lost reimbursement. In our institution’s outpatient IR practice with 1,559 clinic visits over nine months and $251,964 in billings (mean, $162 per visit), this estimates to potential payment reductions of $20,000 per year or $10 per visit in E/M reimbursement only. This reduction can be compounded by ineffective E/M documentation. Advocacy efforts to mitigate this reduction include communication with legislators through Comment Letters to CMS and Grassroots Programs, as well as educational resources for IR physicians to optimize documentation. The proposed 2020-2021 Physician Fee Schedule rate reduction is predicted to decrease reimbursement for IR services by at least 6%. Support of SIR Advocacy efforts is needed to mitigate the undervaluing of IR services.

Compensation and Benefits Survey 2019

Compensation and Benefits Survey 2019

Benchmarking patient satisfaction scores in a colorectal patient population.

Healthcare reimbursement is rapidly moving away from a fee-for-service model toward value-based purchasing. An integral component of this new focus on quality is patient-centered outcomes. One metric used to define patient satisfaction is the Press Ganey Patient Satisfaction Survey. Data are lacking to accurately benchmark these scores based on diagnosis. We sought to identify if different colorectal disease processes affected a patient's perception of their healthcare experience. Adult colorectal patients seen between July 2015 and September 2016 in a tertiary hospital colorectal clinic were mailed a Press Ganey survey. Patients were stratified based on diagnosis: neoplasia, IBD, anorectal and benign colorectal disease. Survey scores were compared across the groups with adjustment for confounding variables. 312 patients responded and formed the cohort. The mean age was 61 (range 18-93) and 56% were women. The cohort breakdown was 38% neoplasia, 32% anorectal, 21% benign, and 9% IBD. In a multivariable model, there was a difference in PG scores by diagnosis; patients with neoplasia had higher Overall scores (β 10.2; Std Error 4.0; p = 0.01), Care Provider scores (β 8.5; Std Error 4.2; p = 0.04), Nurse Assistant scores (β 15.0; Std Error 5.7; p = 0.01), and Personal Issues scores (β 11.8; Std Error 5/0; p = 0.01). Press Ganey scores were found to vary significantly. Patients with a neoplasia diagnosis reported higher overall satisfaction, Care Provider, Nurse Assistant, and Personal Issues scores. Adjustment for disease condition is important when assessing patient satisfaction as an indicator of quality and as a metric for reimbursement. This study adds to increasing evidence about bias in these scores.

Reducing Readmissions for Heart Failure.

Reducing Readmissions for Heart Failure.

Current Opinions and Practices of Bariatric Surgery in Adolescents: A Survey among Pediatric Surgeons.

Bariatric surgery is performed at increasing rate in severely obese adolescents who do not respond to conservative treatment. In the United States, this treatment is generally accepted, yet in Europe, surgeons are more reluctant because of concerns regarding safety and (long-term) efficacy. We evaluated in which (European) countries bariatric surgery is allowed and performed, and the opinion of the members of the European Paediatric Surgeons' Association (EUPSA) regarding bariatric surgery in adolescents. Information was obtained with an online questionnaire sent to all EUPSA members. A total of 108 pediatric surgeons (PSs) from 33 countries (of which 25 European) completed the survey. Sixty-two PSs (57.4%) from 22 countries stated that bariatric surgery in adolescents was allowed in their country. In only 14 countries, the costs were (partially) covered by health care insurances. Overall, 65.7% of the surgeons (n = 71) believed bariatric surgery may offer a valuable contribution to obtain substantial long-term weight loss in severely obese adolescents. Fifty-one (47.2%) reported that these procedures should be performed by a combination of a bariatric and a PS, while 20 (18.5%) and 16 (14.8%) preferred that these procedures should be performed solely by a PS or bariatric surgeon, respectively. Although allowed in most European countries, bariatric surgery in adolescents is only practiced on a small scale, and the treatment is often excluded from regular health care reimbursement. The majority of PSs acknowledge the value of bariatric surgery, which should be performed by a combination of PS and bariatric surgeon.

Healthcare utilisation, follow-up of guidelines and practice variation on rhinosinusitis in adults: A healthcare reimbursement claims study in The Netherlands.

ObjectivesTo provide insight into healthcare utilisation of rhinosinusitis, compare data with clinical practice guideline recommendations and assess practice variation.DesignAnonymised data from claims reimbursement registries of healthcare insurers were analysed, from 1 January 2016 until 31 December 2016.SettingSecondary and tertiary care in the Netherlands.ParticipantsPatients ≥18 years with diagnostic code “sinusitis.”Main outcome measuresHealthcare utilisation (prevalence, co‐morbidity, diagnostic testing, surgery), costs, comparison with guideline recommendation, practice variation.ResultsWe identified 56 825 patients, prevalence was 0.4%. Costs were € 45 979 554—that is 0.2% of total hospital‐related care costs (€21 831.3 × 106). Most patients were <75 years, with a slight female preponderance. 29% had comorbidities (usually COPD/asthma). 9% underwent skin prick testing, 61% nasal endoscopy, 2% X‐ray and 51% CT. Surgery rate was 16%, mostly in daycare. Nearly, all surgical procedures were performed endonasally and concerned the maxillary and/or ethmoid sinus. Seven recommendations (25%) could be (partially) compared to the distribution of claims data. Except for endoscopy, healthcare utilisation patterns were in line with guideline recommendations. We compared results for three geographical regions and found generally corresponding rates of diagnostic testing and surgery.ConclusionPrevalence was lower than reported previously. Within the boundaries of guideline recommendations, we encountered acceptable variation in healthcare utilisation in Dutch hospitals. Health reimbursement claims data can provide insight into healthcare utilisation, but they do not allow evaluation of the quality and outcomes of care, and therefore, results should be interpreted with caution.

Financial and resource costs of transvenous lead extraction in a high-volume lead extraction centre

ObjectivesTransvenous lead extraction (TLE) poses a significant economic and resource burden on healthcare systems; however, limited data exist on its true cost. We therefore estimate real-world healthcare reimbursement costs of...

Health Care Reimbursement, Service Utilization, and Outcomes among Medicare Beneficiaries with Multiple Myeloma Receiving Autologous Hematopoietic Cell Transplantation in Inpatient and Outpatient Settings.

Autologous hematopoietic stem cell transplantation (auto-HCT) is a complex procedure that can be performed in both inpatient (IP) and outpatient (OP) care settings. We examined reimbursement, service utilization, and patient financial responsibility among Medicare beneficiaries with multiple myeloma who underwent auto-HCT in the IP and OP settings using a merged dataset of the Center for International Blood and Marrow Transplant Research observational database and Centers for Medicare & Medicaid Services Medicare administrative claims data. Selection criteria included first auto-HCT, time from diagnosis to auto-HCT <18 months, and continuous enrollment in Medicare Parts A and B for 30 days before HCT index claims and 100 days post-HCT or until death. Total reimbursement and patient responsibility were adjusted for patient and disease characteristics using a weighted generalized linear model. The final cohort comprised 1640 patients, 1445 (88%) who received IP-HCT and 195 (12%) who received OP-HCT. The adjusted total mean reimbursement was higher for IP-HCT compared with OP-HCT ($82,368 [95% CI, $77,643 to $87,381] versus $46,824 [95% CI, $43,567-$50,325]; P < .0001). Adjusted total mean patient responsibility was $4736 for IP-HCT (95% CI, $4731 to $5133) and $6944 for OP-HCT (95% CI, $6296 to $7658) (P < .0001). Within 100 days post-HCT, 107 of the 195 OP-HCT recipients (55%) had at least 1 subsequent admission, compared with 348 of the 1445 IP-HCT recipients (24%). Reimbursement, service utilization, and financial responsibility varied by HCT setting. As the number of Medicare beneficiaries who undergo auto-HCT increases, coverage policy needs to consider how location of services leads to variations in the financial burden for both hospital systems and patients.

Impact of Healthcare Delivery System Type on Clinical, Utilization, and Cost Outcomes of Patient-Centered Medical Homes: a Systematic Review.

As healthcare reimbursement shifts from being volume to value-focused, new delivery models aim to coordinate care and improve quality. The patient-centered medical home (PCMH) model is one such model that aims to deliver coordinated, accessible healthcare to improve outcomes and decrease costs. It is unclear how the types of delivery systems in which PCMHs operate differentially impact outcomes. We aim to describe economic, utilization, quality, clinical, and patient satisfaction outcomes resulting from PCMH interventions operating within integrated delivery and finance systems (IDFS), government systems including Veterans Administration, and non-integrated delivery systems. We searched PubMed, the Cochrane Library, and Embase from 2004 to 2017. Observational studies and clinical trials occurring within the USA that met PCMH criteria (as defined by the Agency for Healthcare Research and Quality), addressed ambulatory adults, and reported utilization, economic, clinical, processes and quality of care, or patient satisfaction outcomes. Sixty-four studies were included. Twenty-four percent were within IDFS, 29% were within government systems, and 47% were within non-IDFS. IDFS studies reported decreased emergency department use, primary care use, and cost relative to other systems after PCMH implementation. Government systems reported increased primary care use relative to other systems after PCMH implementation. Clinical outcomes, processes and quality of care, and patient satisfaction were assessed heterogeneously or infrequently. Published articles assessing PCMH interventions generally report improved outcomes related to utilization and cost. IDFS and government systems exhibit different outcomes relative to non-integrated systems, demonstrating that different health systems and populations may be particularly sensitive to PCMH interventions. Both the definition of PCMH interventions and outcomes measured are heterogeneous, limiting the ability to perform direct comparisons or meta-analysis.

2017 National Standards for Diabetes Self-Management Education and Support.

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends. The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision. Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes. Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Towards evidence-based management: A nationwide administrative data-based audit of acute myocardial infarction in Latvia

ABSTRACT When care for an individual patient is determined by evidence-based medical guidelines, the management of the whole clinical process also needs to be based on evidence. In Latvia, an careful retrospective data analysis is needed to suggest evidence-based organizational interventions for the care of acute myocardial infarction (AMI), since a 30-day AMI mortality here remains one of the highest among the OECD Member States. An audit based on Healthcare reimbursement data linked to the causes of death registry from 2014-2018 was performed. Analysed 11 065 ST-elevation AMI cases reveals lower mortality for patients directly admitted to hospitals able to perform percutaneous coronary intervention (preferred reperfusion option according to guidelines) compared to patients initially admitted to a large group of local hospitals (able to perform only thrombolysis-based reperfusion). However, no statistically significant type-of-hospital effect for this group of hospitals is found, when other factors - including treatment type - are accounted for in logistic regression analysis of factors influencing AMI-mortality. That combined with vastly improved survival opportunities if any reperfusion procedure is used suggests that decreasing the proportion of non-reperfusion patients by applying any reperfusion procedure might be one of the main directions for the improvement of AMI outcomes in Latvia.

Nothing Like Living with a Family: A Qualitative Study of Subjective Well-Being and its Determinants among Migrant and Local Elderly in Dongguan, China.

Chinese economic development has led to a significant rise in internal migration over the last 20 years, including large numbers of elderly. When elderly Chinese people migrate, they still register their residency to their place of origin and often do not register with the new administrative office at the destination due to the household registration (hukou) system in China. Thus, most of these migrant elderly do not receive full social services, possibly leading to poor subjective well-being. This study aims to qualitatively examine the level of subjective well-being and its determinants among migrants and local elderly in Dongguan City of Guangdong province, one of the most rapid economically developing areas in China. We also present the results of in-depth interviews among 27 elderly, 15 elderly migrants and 12 local elderly living in Dongguan. The results reveal that the overall subjective well-being of the two groups were good. Most migrants believed their well-being had remained stable or even improved over time due to family reunion and a better physical environment. Elderly’s most valuable needs and the main reason of migration is family reunion; however, inadequacy of social support, including community support and government support (e.g., gift during holiday season, free health examination, healthcare expenditure reimbursement), cannot be neglected for maintaining a good level of well-being. The well-being of migrant elderly can be further enhanced by promoting social services and welfare, recreational activities, and enhancing healthcare reimbursement in their new home.

Incidence and Outcomes of Sepsis in Korea: A Nationwide Cohort Study From 2007 to 2016.

This study aimed to estimate the incidence and clinical outcomes of sepsis in Korea from 2007 to 2016. Retrospective observational study. Nationwide study with population-based healthcare reimbursement claims database. Using data from the National Health Insurance Service of Korea, patients who were hospitalized with a diagnosis of sepsis from 2007 to 2016 were analyzed. The incidence of sepsis was calculated using mid-year census population and analyzed according to year, age, and sex. The Elixhauser Comorbidity Index score was calculated to adjust for the impact of comorbidities on clinical outcome. In-hospital mortality, hospital length of stay, ICU admission rates, and risk factors for in-hospital mortality were also analyzed. None. The incidence of sepsis increased from 173.8 per 100,000 population in 2007 to 233.6 per 100,000 population in 2016. In-hospital mortality decreased from 30.9% in 2007 to 22.6% in 2016 (p < 0.0001). From 2007 to 2016, hospital length of stay and ICU admission rates associated with sepsis decreased from 26.0 ± 33.5 days to 21.3 ± 24.4 days (p < 0.0001) and from 16.2% to 12.7% (p < 0.0001), respectively. Male sex, age greater than 50 years, Elixhauser Comorbidity Index greater than 10, and mechanical ventilation were identified as risk factors for in-hospital mortality after adjusting for baseline characteristics. The incidence of sepsis in Korea increased from 2007 to 2016, while the associated in-hospital mortality, hospital length of stay, and ICU admission rates decreased.

HIV infections and HIV testing during pregnancy, Germany, 1993 to 2016.

BackgroundElimination of mother-to-child transmission (MTCT) of HIV by 2020 is a goal of the World Health Organization (WHO) action plan for the European Region. However, data to monitor progress towards MTCT elimination are not readily available in Germany.AimWe aimed to estimate the number of pregnant women with HIV and MTCT rates in Germany.MethodsWe triangulated retrospectively obtained data from: (i) healthcare reimbursement for HIV screening tests, (ii) a statutory health insurance subsample of prevalent and incident HIV diagnoses among pregnant women, (iii) a mathematical model of the German HIV epidemic with number, region of origin and risk factors for women of childbearing age, and (iv) the statutory anonymous HIV registry on children infected through HIV MTCT.ResultsThe number of women aged 15–49 years with HIV increased from ca 6,000 in 1993 to ca 11,000 in 2016. Risk of injecting drug use (IDU) declined from 65% in 1993 to 16% in 2016. The annual proportion of women living with HIV giving live birth increased from a mean of 1.9% during 1993 to 1998 to 4.9% in 2011 to 2015. HIV screening rates during pregnancy increased from ca 50% in 2001 to ca 90% in 2016. The HIV MTCT rate dropped from 6.8% in 2001 to 1.1% in 2016.ConclusionsThe population of women living with HIV in Germany shifted from predominantly IDU-associated infections to predominantly sexually acquired infections, while fertility rates more than doubled. MTCT rates dropped, mainly because of improved detection and management of HIV in pregnancy.

Using Policy to Improve Access to Care for Persons With Alzheimer's Disease.

As Americans increase life expectancies, one disease that has captured federal attention is Alzheimer's disease. Annually, health care professionals see provider billing codes changing to meet regulatory guidelines. In 2017, the Centers for Medicare & Medicaid Services enacted billing code G0505 to provide health care reimbursements for care planning services for clients with Alzheimer's disease. In-depth assessments and screenings included a patient-centered approach with familial interventions. Due to lack of awareness, health care providers demonstrated <1% use of these assessments in eligible older adults. Congress has proposed a bill (H.R. 1873/S880) to promote provider awareness and education training on its key elements. By educating future health care providers on updated legislation, providers will be able to offer an interdisciplinary approach in meeting the health care needs of the aging population. Health care providers can maintain patient advocacy while creating a vision of change for enabling policies specific to identified demographic populations. [Journal of Gerontological Nursing, 45(12), 7-11.].

CHANGES IN THE MEDICARE HOME HEALTH CARE MARKET: THE IMPACT OF ACA REIMBURSEMENT POLICY

This study evaluated the effect of recent ACA changes to Medicare Home Health Care (HHC) reimbursements on the mix of agencies and staff in the HHC market. We used Provider of Services (POS) data and logistic regression, to determine which agency characteristics were associated with the likelihood of exiting the HHC market and likelihood of decreasing staff before (n=13,878) and after (n=13,702) implementation of the ACA-mandated reimbursement cuts. Free standing agencies had 1.35 times the odds of exiting from the HHC market post ACA cuts. There were no differences in the odds of exiting the HHC market between for-profit and non-profit agencies. Agencies in the New York, Atlanta, and Chicago regions had a greater likelihood of exiting the HHC market post ACA cuts. Small agencies had two times the odds of exiting (aOR= 2.09) and agencies with one or more branch had less than half the odds of exiting (aOR= 0.46) from the HHC market. The average number of all staff was similar before and after the ACA cuts; however, office staff and home health aides experienced the greatest decrease in number. Agencies that were for-profit, free-standing, small, and/or with one or more branch were more likely to decrease staff post the ACA cuts. Agencies in the New York, Atlanta, Chicago, Dallas and Kansas regions were more likely to decrease staff. Overall, the reimbursement cut effects varied by geographic region and had greater impact on more vulnerable agencies and staff that were non-skilled.

Untreated alcohol use disorder in people who inject drugs: a major barrier to HCV treatment uptake

Abstract Aims Although people who inject drugs (PWID) are the core at-risk population in the hepatitis C (HCV) epidemic in industrialized countries, few initiate treatment. Alcohol use disorder (AUD), common within this population, has been identified as a barrier to HCV treatment uptake in the general population. We investigated whether the arrival of new and well-tolerated HCV treatments (direct-acting antivirals: DAA) has improved HCV treatment uptake in French PWID compared with former treatments (pegylated interferon-based treatments: Peg-IFN). Methods Analyses were based on exhaustive care delivery data collected between 2012 and 2016 (study period) in the French national healthcare reimbursement database. Chronic HCV-infected individuals who received opioid agonist therapy (OAT) at least once during the study period were included. Separate analyses were performed for 2012-2013 (Peg-IFN era, 19,700 patients) and 2014-2016 (DAA era, 22,545 patients). Using discrete-time Cox proportional hazards models, we tested for associations between AUD (i.e. AUD-related long-term illness status, diagnosis coding during hospitalization or AUD pharmacological treatment) and first HCV treatment delivery, after adjusting for gender, age, complementary universal health cover, liver disease severity and type of OAT received. Results Incidence rate of HCV treatment uptake per 100 person-years [95% confidence interval] was 6.56 [6.30-6.84] and 5.70 [5.51-5.89], for Peg-IFN-based treatment (2012-2013) and DAA (2014-2016), respectively. After multiple adjustment, people with AUD not receiving related medication had 30% and 14% lower Peg-IFN-based treatment and DAA uptake, respectively, than those without AUD (hazard ratio [95%CI]: 0.70 [0.62-0.80] and 0.86 [0.78-0.94]). No difference was observed between those treated for AUD and those without AUD. Conclusions Despite the benefits of DAA, untreated AUD is still a major barrier to HCV treatment access for PWID in France. Key messages AUD is still a barrier to HCV treatment for French PWID. DAA availability improved HCV treatment uptake for PWID with AUD.

The existing scenario of haemophilia care in Canada and China - A review.

Hemophilia is an X-linked recessive genetic disorder which affects approximately 400,000 people globally. Differing healthcare reimbursement systems, budgetary constraints and geographical and cultural factors make it difficult for any country to fully deliver ideal care. Although developed countries have sufficient treatment products available, they are burdened by the higher expectation of outcomes, coupled with insufficient supportive care to monitor adherence and outcomes and to implement regular follow-up. In contrast, developing regions may not have ready access to factor replacement, but have developed excellent physiotherapy and rehabilitation programs. Although there are multiple studies that have attempted to assess country-specific variations in hemophilia care, very few compare hemophilia care between economically unequal countries and the challenges in achieving optimal hemophilia care. This literature review tries to bridge this gap and throws light on the country-specific differences in epidemiology, standard of hemophilia care and challenges faced in Canada and China. Data sources resulted in 20 studies (11 from Canada and 9 from China), which were reviewed. In a developed country, the main advantages are: the early treatment of bleeding episodes and the presence of a specialized interdisciplinary and comprehensive treatment concept. This is not the case in most developing countries, where the government does not have the resources to buy the necessary quantities of coagulation factors in the face of more urgent health priorities and hardly a few patients can afford to pay for their own treatment, even the on-demand home therapy.

Tackling the 3 Big Challenges Confronting Health Technology Assessment Development in Asia: A Commentary

There has been continuous development in the field of health technology assessment (HTA) owing to the added value of HTA in supporting healthcare reimbursement decisions. Collaboration and engagement among countries in Asia has been carried out to share experiences and learning on the barriers and factors facilitating the implementation and use of HTA in policy making. A symposium on the topic of Health Technology Assessment (HTA): Selecting the Highest Value Care was held on January 10, 2019 at the National University of Singapore, during which 3 major challenges confronting HTA development in Asia were identified. The symposium also offered possible ways to overcome the challenges.