Reimbursement Mechanisms Research Articles

A global survey of telemedicine use in epilepsy care – practices before, during and after the COVID-19 pandemic

PurposeTelemedicine was widely adopted for epilepsy care during the COVID-19 pandemic. Its role extends beyond preventing disease transmission, offering an efficient and high-quality care alternative. To understand the global scenario, an international group conducted a survey comparing telemedicine practices in epilepsy care before, during, and after the pandemic. MethodsThe survey included 26 questions on demographics, telemedicine use for epilepsy care, regulations, reimbursement mechanisms, and tools used. Responses were collected via an online survey platform from June to October 2023. ResultsTwo hundred eighty-five respondents from 60 countries participated. The average telemedicine use in daily practice was 0 %, 0–10 % (median, IQR) before the pandemic, 65 %, 30–90 % during the pandemic, and 20 %,10–50 % after the COVID pandemic. Female respondents reported higher telemedicine use than males after the pandemic (25 %, 10–50 % vs 15 %, 5 %-30 %, p = 0.002). According to respondents' perceptions, post-pandemic telemedicine regulations flexibilities were reported as expanded by 36.8 %, restricted by 17.2 %, and unchanged by 46 %. Reimbursement for telemedicine increased during the pandemic but decreased afterward (Cochran's Q test, p < 0.001). Voice calls were the most used telemedicine platform (46.6 %). Privacy issues were reported by 49 respondents (18.3 %). ConclusionTelemedicine use for epilepsy care increased during the pandemic and remained higher than pre-pandemic levels. However, improvements are needed in telemedicine applications, regulations, reimbursement, and patient privacy. International collaboration and experience sharing can enhance telemedicine's acceptance and practice globally.

Interventions to reduce racial/ethnic disparities across the breast cancer care continuum.

160 Background: In the United States, racial/ethnic disparities in adoption of breast cancer evidence-based practices (EBPs) persist along the cancer care continuum. This scoping review applied an implementation science lens to describe the current evidence base for interventions to reduce disparities, synthesizing evidence on effective interventions while highlighting gaps in the literature. Methods: A formalized search strategy identified USA-based interventional studies aiming to improve adoption of an EBP along the breast cancer care continuum among racially/ethnically minoritized patients. Relevant articles from 1/2010 - 8/2022 (Medline, Embase, Cochrane, and Scopus) were included. For each article, two reviewers screened and extracted data, with a third resolving discrepancies. The PRISMA-ScR checklist and JBO Manual for Evidence Synthesis framework were followed. Results: Our search strategy yielded 45,215 articles. After applying inclusion/exclusion criteria, 59 articles were retained, targeting screening (85%, 50 of 59), treatment (12%, 7 of 59), and survivorship (5%, 3 of 59) (2 targeted multiple areas). No articles targeted end-of-life care. Of these, 49% (29 of 59) were randomized controlled trials (RCTs). Among 24 screening RCTs, the most common interventions—and fraction with statistically significant improved screening uptake—were patient navigation (100%, 11 of 11) and patient education (80%, 4 of 5). Among 4 treatment RCTs, 3 targeted adjuvant chemotherapy uptake. Of these, 1 had significant improvements and used patient navigation. The 2 studies without significant improvements used a patient tracking tool/alert system or patient education. Among 2 survivorship RCTs, one used email interventions, resulting in significantly improved physical activity and dietary health. A second used a nurse-facilitated internet support group, resulting in significantly improved physical/psychological symptoms. Early to mid-stage implementation outcomes (acceptability, adoption, appropriateness, feasibility, or fidelity) were commonly measured (81%, 48 of 59). No study measured later stage implementation outcomes (sustainability or costs). Conclusions: In multiple studies, patient navigation and education improved breast cancer screening among racially/ethnically minoritized populations. In one study, patient navigation improved completion of adjuvant treatment. Despite these studies, patient navigation is not reimbursed for cancer screening, and adoption has not been widespread. Future studies should focus on evaluating and improving later stage implementation outcomes (sustainability and costs). Based on these results, insurance reimbursement mechanisms for screening-related navigation may be warranted. Future breast cancer care delivery disparities research should also be expanded to include treatment, survivorship, and end-of-life care.

Perceptions of risk sharing agreements in South Korea from the viewpoints of key stakeholders: a convergent parallel mixed approach

ABSTRACT Objectives In 2013, South Korea introduced risk-sharing agreements (RSAs) as a new reimbursement mechanism to enhance access to new medicines and to manage pharmaceutical expenditures. This study evaluates RSAs in South Korea from the viewpoints of key stakeholders. Methods In 2022, a survey and semi-structured interviews were conducted. Study participants were recruited from academia (n = 3), domestic (n = 4) and foreign (n = 6) manufacturers, and government agencies (n = 6) using a purposive sampling method. Results Key stakeholders perceived the objective of RSAs to be ‘access to medicines’ and understood RSAs to manage uncertainty about ‘expenditures.’ They responded that financial- and performance-based RSAs address uncertainty about ‘expenditures’ and ‘clinical effectiveness,’ respectively. All stakeholders agreed that RSAs have increased the likelihood that new medicines will be listed and have reduced out-of-pocket expenditures for patients. However, foreign manufacturers insisted that the benefits of RSAs are marginal, while the administrative burden on manufacturers is high. Conclusion The gaps in perception between stakeholders could be narrowed by conducting a comprehensive evaluation. Financial- and performance-based RSAs need to be clearly distinguished and aligned to address the uncertainties of a new medicine in health systems.

How does the role of complementary and alternative medicine in general practice differ between countries? Interviews with doctors who have worked both in Germany and elsewhere in Europe

BackgroundAvailable data suggest that general practitioners (GPs) in Germany use complementary and alternative medicine (CAM) modalities more frequently than GPs in many other countries. We investigated the country differences perceived by general practitioners who have worked in Germany and in one of four other European countries with regard to the role of complementary and alternative treatments in primary care.MethodsIn this qualitative study we conducted semi-structured interviews with 12 GPs who had worked both in Germany and Italy, the Netherlands, Norway or the United Kingdom (UK; n = 3 for each of the four countries). Participants were asked how they perceived and experienced country differences regarding health system, relevance of CAM modalities, the role of evidence-based medicine (EBM) and science, and how they handle so-called indeterminate situations. For the analysis, we followed a thematic analysis approach according to Braun and Clarke with focus on themes that cover CAM.ResultsParticipants unanimously reported that they perceived CAM to be more relevant in general practice in Germany compared to the other countries. We identified four overarching themes in relation to the perceived reasons for these differences. Firstly, physicians with experiences in countries with a strong EBM and science orientation (Netherlands, Norway and the UK) considered the deeply ingrained view in national healthcare systems and GP communities that CAM modalities are not evidence-based as the main reason for the lower use of CAM by GPs. Secondly, extensive training of communication skills was cited as a reason that reduced the need for CAM in the Netherlands, Norway and the UK. Thirdly, differences in patient expectations and demands were perceived as a factor contributing to greater utilisation of CAM by German GPs compared to the other countries. Finally, country-specific reimbursement mechanisms were considered as a factor influencing the role of CAM in general practice.ConclusionsThe study results point to major differences between countries with regard to the role of CAM in GP care. Differences in basic attitudes in the discipline of general practice, patient expectations and system conditions appear to play an important role here.

Adoption of C-reactive protein rapid tests for the management of acute childhood infections in hospitals in the Netherlands and England: a comparative health systems analysis

BackgroundThe adoption of C-reactive protein point-of-care tests (CRP POCTs) in hospitals varies across Europe. We aimed to understand the factors that contribute to different levels of adoption of CRP POCTs for the management of acute childhood infections in two countries.MethodsComparative qualitative analysis of the implementation of CRP POCTs in the Netherlands and England. The study was informed by the non-adoption, abandonment, spread, scale-up, and sustainability (NASSS) framework. Data were collected through document analysis and qualitative interviews with stakeholders. Documents were identified by a scoping literature review, search of websites, and through the stakeholders. Stakeholders were sampled purposively initially, and then by snowballing. Data were analysed thematically.ResultsForty-one documents resulted from the search and 46 interviews were conducted. Most hospital healthcare workers in the Netherlands were familiar with CRP POCTs as the tests were widely used and trusted in primary care. Moreover, although diagnostics were funded through similar Diagnosis Related Group reimbursement mechanisms in both countries, the actual funding for each hospital was more constrained in England. Compared to primary care, laboratory-based CRP tests were usually available in hospitals and their use was encouraged in both countries because they were cheaper. However, CRP POCTs were perceived as useful in some hospitals of the two countries in which the laboratory could not provide CRP measures 24/7 or within a short timeframe, and/or in emergency departments where expediting patient care was important.ConclusionsCRP POCTs are more available in hospitals in the Netherlands because of the greater familiarity of Dutch healthcare workers with the tests which are widely used in primary care in their country and because there are more funding constraints in England. However, most hospitals in the Netherlands and England have not adopted CRP POCTs because the alternative CRP measurements from the hospital laboratory are available in a few hours and at a lower cost.

Implementation of NCCARE360, a Digital Statewide Closed-Loop Referral Platform to Improve Health and Social Care Coordination: Evidence from the North Carolina COVID-19 Support Services Program.

Efforts to improve population health by being responsive to patients' social and economic conditions will benefit from care models and technologies that assess and address unmet social needs. In 2019, NCCARE360 launched in North Carolina as the first state-wide digital care coordination network to "close the loop" on referrals between community-based organizations (CBOs), health service providers, and social service agencies. The platform creates a shared network for sending and receiving electronic referrals and track client outcomes. As a case study, we compare NCCARE360 resolution rates for community resource referrals originating from a large integrated health system primarily in Durham County from September 1, 2020, through February 28, 2021. In the first year, COVID-19 Support Ser-vices Program (COVID-SSP) funding was available to reimburse associated CBOs for providing food assistance and case management services. We compared this with the same period the following year after funds had been exhausted. We present frontline implementation experiences and highlight opportunities, challenges, and recommendations for NCCARE360 implementation. Multi-level considerations for individual end users, organizations adopting the platform, and policymakers are presented. Addi-tionally, we find that when COVID-SSP funding was available, more referrals were placed (3,220 cases) and referrals were more likely to be resolved (88% resolution rate) when compared to the same time frame when funds were no longer available (860 cases; 30% resolution rate). These results underscore the importance of reimbursement mechanisms and funding. The examination of referral rates is observational and may not generalize to other contexts. The shift to value-based care is an opportunity to embrace structural solutions to health and social care fragmentation. There is also an opportunity to realize the potential of NCCARE360 and efforts like it to contain costs and improve health outcomes and equity.

Exploring the Challenges in Covering Dental Services through Complementary Insurance in Iran: A Qualitative Study.

Financial protection is crucial for attaining universal health coverage. The inclusion of costly dental services in insurance plans poses a significant challenge for all parties involved in the insurance sector. This study aimed to investigate the challenges of covering dental services by complementary insurance in Iran during 2020-2021. This qualitative research was conducted in Iran during 2020-2021. A triangulation of methods and data sources were employed to achieve a comprehensive perspective. In-depth semistructured interviews were conducted on an individual basis, and all national documents, rules, regulations, and instructions pertaining to complementary dental insurance were thoroughly reviewed. Purposeful sampling was used to select participants from all stakeholder groups engaged in dental insurance coverage, including (1) health system policymakers, (2) insurers, (3) policyholders, (4) care providers (dentists), and (5) insured people. Six open-ended questions were formulated to explore various facets of dental insurance, including (1) development, (2) management, (3) population coverage, (4) premium calculation, (5) services coverage, and (6) payment and reimbursement mechanisms. With the consent of the participants, all interviews were recorded and transcribed verbatim. The gathered data were evaluated using a framework analysis approach in the MAXQDA20 software. Finally, the primary themes, each encompassing multiple subthemes, were identified and presented. A total of 26 interviews were conducted with five groups of interviewees, and nine national documents were evaluated. Six themes were extracted, which included 18 codes from the interviews and seven codes from the documents. The extracted themes were as follows: (1) Insurance commitments and service coverage, (2) reimbursement system, (3) information system, (4) economic issues, (5) population coverage, and (6) regulation and supervision. The high cost of dental services was the most frequent challenge, followed by the insurance commitments and service coverage. The delivery of dental services through complementary insurance in Iran primarily faces economic and service coverage challenges. The resolution hinges on the collaboration between basic and complementary insurance sectors, the development of a unified information system for insured individuals, and the implementation of a risk-adjusted premium plan.

Evaluation of Clinical and Radiological Outcomes in the Management of Intracapsular Fracture Neck of Femur in Elderly Treated With Cemented Bipolar Prosthesis.

Hip fractures, including femoral neck fractures (FNFs), represent a significant health challenge globally. Fractures of the hip can be categorized as either intracapsular or extracapsular. Among the elderly, FNFsare particularly prevalent and account for approximately half of all hip fractures. This study aimed to evaluate the clinical and radiological outcomes of intracapsular FNFs in the elderly treated with cemented bipolar prostheses. Objectives: This study aims to: (i) assess the clinical outcomes, including pain relief, functional mobility, and patient satisfaction, in elderly individuals with intracapsular FNFs treated with cemented bipolar prosthesis; (ii) examine the radiological outcomes of intracapsular FNFs in the elderly following treatment with cemented bipolar prosthesis, focusing on factors such as implant stability, fracture healing, and any signs of complications. A prospective study included elderly patients (aged 55 and above) with intracapsular FNFs treated with cemented bipolar prostheses. Data were collected using a structured proforma, and outcomes were assessed through clinical and radiological evaluations at regular follow-ups. The study included 60 participants with a mean age of 65.25 years. Most fractures were subcapital, and the majority of participants did not experience complications after surgery. The average length of the pre-operative hospital stay was 2.35 days, and the post-operative hospital stay was 6.75 days. Functional outcomes, evaluated using the Harris Hip Scoring System, showed varying degrees, with 70% of participants experiencing good outcomes. The management of intracapsular femoral neck fractures in the elderly with cemented bipolar prostheses demonstrated favorable outcomes, including low morbidity, simple operative procedures, and satisfactory early functional results. The study supports the recommendation of cemented bipolar prostheses for femoral neck fractures in individuals over 60, emphasizing their superiority over bipolar hemiarthroplasty. The results contribute valuable insights for treatment decisions in hip fractures, especially considering evolving reimbursement mechanisms and merit-based incentive payments.

Medicaid Reimbursement for Community Health Workers: A Comparative State Policy Analysis with Implications for Indiana

Background: Community health workers (CHWs) promote health education, address social determinants of health, and bridge the gap between healthcare systems and underserved populations, but the lack of sustainable funding remains a challenge to greater CHW utilization. Medicaid reimbursement has been identified as a promising mechanism to fund CHWs, however, state policies vary widely. A comparative policy analysis can guide future reimbursement strategies.&#x0D; Methods: We conducted a comparative policy analysis of Medicaid reimbursement for CHWs. State government websites and legal databases were searched utilizing keyword search terms related to CHWs and Medicaid reimbursement. We identified and analyzed relevant statutes, regulations, and administrative codes for reimbursement mechanism, rates, supervision, certification, and scope of practice.&#x0D; Results: 26 states currently reimburse CHWs through Medicaid; 3 states started reimbursement in the last six months. 16 states authorize payment through State Plan Amendments (SPAs), 3 use Section 1115 demonstration waivers, 10 use Medicaid managed care organization contracts, and 4 use blended strategies. 13 states require certification and supervision for reimbursement, although the supervising licensed professional can vary. The scope of practice of CHW also varies between states. There is a large range for reimbursement rates; for example, billing code 98960 currently used by 14 states varies from $9.70 in Indiana to $55.25 in Arizona for a 30 minute visit.&#x0D; Policy Implications: This study can inform sustainable reimbursement models through Medicaid for CHWs in Indiana and other states. An SPA may be the most expedient way for Indiana to increase reimbursement for CHWs, but its narrowness and inflexibility could hinder CHWs' positive impact. The variety of strategies currently in use demonstrates that there is no single path to sustainable financing. Protocols for a set of scoping reviews will result from this comparative analysis for more in-depth investigations of key peer-reviewed and grey literature.

Assessing the family physician perception regarding the vaccines’ reimbursement mechanism in Romania

Assessing the family physician perception regarding the vaccines’ reimbursement mechanism in Romania

Selection of criteria for a telemedicine framework for designing, implementing, monitoring and evaluating telemedicine interventions: Validation using a modified Delphi process.

The call to scale up telemedicine services globally as part of the digital health transformation lacks an agreed-upon set of constructs to guide the implementation process. A lack of guidance hinders the development, consolidation, sustainability and optimisation of telemedicine services. The study aims to reach consensus among telemedicine experts on a set of implementation constructs to be developed into an evidence-based support tool. A modified Delphi study was conducted to evaluate a set of evidence-informed telemedicine implementation constructs comprising cores, domains and items. The study evaluated the constructs consisting of five cores: Assessment of the Current Situation, Development of a Telemedicine Strategy, Development of Organisational Changes, Development of a Telemedicine Service, and Monitoring, Evaluation and Optimisation of Telemedicine Implementation; seven domains: Individual Readiness, Organisational Readiness, Clinical, Economic, Technological and Infrastructure, Regulation, and Monitoring, Evaluation and Optimisation; divided into 53 items. Global telemedicine specialists (n = 247) were invited to participate and evaluate 58 questions. Consensus was set at ≥70%. Forty-five experts completed the survey. Consensus was reached on 78% of the constructs evaluated. Regarding the core constructs, Monitoring, Evaluation and Optimisation of Telemedicine Implementation was determined to be the most important one, and Development of a Telemedicine Strategy the least. As for the domains, the Clinical one had the highest level of consensus, and the Economic one had the lowest. This research advances the field of telemedicine, providing expert consensus on a set of implementation constructs. The findings also highlight considerable divergence in expert opinion on the constructs of reimbursement and incentive mechanisms, resistance to change, and telemedicine champions. The lack of agreement on these constructs warrants attention and may partly explain the barriers that telemedicine services continue to face in the implementation process.

Core outcome set for economic evaluation of dementia interventions: A consensus exercise with health economists who incorporate economic evaluations into dementia trial

AbstractBackgroundHealthcare decision‐makers worldwide are increasingly seeking to optimise allocation of resources to dementia and the incorporation of economic evaluations into randomised control trials provide definitive information for such decisions. Economic evaluations are rapidly increasing in number in dementia and standardisation of methods ensure comparability of economic evidence.MethodCore outcomes sets (COS) aim to provide international recommendations on outcome measurement in trials and currently there exists no COS for economic evaluations of dementia interventions. Our systematic searches identified over 100 economic evaluations of dementia interventions, and critical appraisal demonstrates opportunities for greater standardisation of applied economic methods. This study aims to agree standardised methods for economic measures of a) health outcomes and b) resource use that should be measured and reported in future trial‐based economic evaluation in dementia.ResultThe COS for the economic evaluation of dementia interventions will be developed from two main steps:First, a systematic review (currently being finalised) extracts information on how costs and benefits are estimated, analysed and reported. All studies published before December 2022, and confirmed as trial‐based economic evaluation, are included. Included studies all contain economic measures and we will report participant characteristics (type of dementia, severity), study design and evaluation types, type of interventions, mode of data collection and instrument(s) used to derive the health outcomes and resource uses.Second, which speaks specifically to action research at AAIC 2023, we will conduct a Delphi consensus focus groups with economists who have collaborated with dementia‐trial teams. Data extracted during the systematic review will be presented to provide a basis for the consensus recommendations on measures commonly required for economic evaluation in dementia. In the case where consensus was not reached, we may conduct additional consensus exercises. We will also consider country contexts (high versus low‐middle income, or country‐level financing and reimbursement mechanisms) in finalising recommended COS of health and resource use measures.ConclusionFindings from COS for economic evaluations of dementia intervention will be published in a dementia‐focused journal and more broadly communicated to a broad range of stakeholders.

HPR65 Pricing and Reimbursement Mechanisms for Advanced Therapeutic Medicinal Products in 20 Countries

HPR65 Pricing and Reimbursement Mechanisms for Advanced Therapeutic Medicinal Products in 20 Countries

Big Data-Enabled Analysis of Factors Affecting Medical Expenditure in the Cerebral Infarction of a Developing City in Western China.

Cerebral infarction (CI) has been one of the leading causes of death in China since 2017, and controlling the medical expenses of this disease is an urgent issue for the Chinese government. This study aims to explore the important factors that affect the hospitalization expenses of CI patients and to provide a scientific basis for establishing a reasonable reimbursement mechanism and hospitalization expense standard for CI patients. Data from 109,314 inpatients from the Healthcare Security Administration of Chengdu in western China from January 2016 to December 2018 were utilized. Descriptive statistical analysis was used for variable characteristic analysis. The Mann-Whitney test and Kruskal-Wallis test were used for single-factor analysis, and multiple linear stepwise regression was used for single-factor analysis and multiple-factor analysis. This study found that the average direct economic burden of CI in Chengdu was approximately 10,569 Chinese yuan (CNY), about 1450 US dollars, the average length of stay (LOS) was 14.47 days, the indirect economic burden was approximately 2817 CNY, and the total economic burden was 13,386 CNY for a CI inpatient. Gender, insurance type, grade of medical institution, the level of payment type, age, LOS, and complications and comorbidities (CCs) are the most important factors affecting CI medical costs. Citizens should improve their lifestyle habits to reduce disease risk to avoid the associated medical and economic burdens. Hospitals should improve their medical technology to decrease the LOS and reduce direct medical costs. The government should actively promote the hierarchical diagnosis and treatment policy to reduce the waste of medical resources caused by low-acuity patients going to high-level hospitals for treatment. The National Healthcare Security Administration should optimize the medical insurance payment method and establish a corresponding mechanism to reduce the occurrence of excessive medical treatments such as overuse.

Examining the use of psychiatric collaborative care and behavioral health integration codes at federally qualified health centers: A mixed-methods study.

Despite evidence to support the integration of behavioral health and physical health care, the adoption of Integrated Behavioral Health (IBH) has been stymied by a lack of reliable and sustainable financing mechanisms. This study aimed to provide information on the use of Psychiatric Collaborative Care Model (CoCM) and behavioral health integration (BHI) codes and the implementation of IBH in federally qualified health centers (FQHCs). This cross-sectional, mixed-methods study involved an electronic survey of administrators and follow-up qualitative interviews from a subset of survey respondents. Quantitative data were analyzed using descriptive analysis and thematic coding was used to analyze qualitative data to identify salient themes. Administrators (N = 52) from 11 states completed the survey. Use of CoCM (13%) or BHI codes (17.4%) was low. Most administrators were not aware that CoCM (72%) or BHI codes (70%) existed. Qualitative interviews (n = 9) described barriers that further complicate IBH and code use like workforce shortages and insufficient reimbursement for the cost to deliver CoCM services. Although FQHCs are working to meet the needs of the communities they serve, a lack of billing clarity and awareness and workforce issues hinder the adoption of the CoCM. FQHCs face many demands to provide care to safety net populations, yet are not fully equipped with the resources, workflows, staffing, and payment structures to support CoCM/BHI billing. Increased financial and logistical support to build practice infrastructure is needed to reduce the administrative complexity and inadequate reimbursement mechanisms that currently hinder the implementation of the CoCM and integrated care delivery. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Pricing and reimbursement mechanisms for advanced therapy medicinal products in 20 countries

Introduction: Advanced Therapy Medicinal Products are a type of therapies that, in some cases, hold great potential for patients without an effective current therapeutic approach but they also present multiple challenges to payers. While there are many theoretical papers on pricing and reimbursement (P&amp;amp;R) options, original empirical research is very scarce. This paper aims to provide a comprehensive international review of regulatory and P&amp;amp;R decisions taken for all ATMPs with centralized European marketing authorization in March 2022.Methods: A survey was distributed in July 2022 to representatives of 46 countries.Results: Responses were received from 20 countries out of 46 (43.5%). 14 countries reimbursed at least one ATMP. Six countries in this survey reimbursed no ATMPs.Conclusion: Access to ATMPs is uneven across the countries included in this study. This arises from regulatory differences, commercial decisions by marketing authorization holders, and the divergent assessment processes and criteria applied by payers. Moving towards greater equality of access will require cooperation between countries and stakeholders, for example, through the WHO Regional Office for Europe’s Access to Novel Medicines Platform.

Expanding access to high-cost medicines under the Universal Health Coverage scheme in Thailand: review of current practices and recommendations

BackgroundThere has been an increasing demand to reimburse high-cost medicines, through public health insurance schemes in Thailand.MethodsA mixed method approach was employed. First, a rapid review of select high-income countries was conducted, followed by expert consultations and an in-depth review of three countries: Australia, England and Republic of Korea to understand reimbursement mechanisms of high-cost medicines. In Thailand, current pathways for reimbursing high-cost medicines reviewed, the potential opportunity cost estimated, and stakeholder consultations were conducted to identify context specific considerations.ResultsHigh-income countries reviewed have implemented a variety of pathways and mechanisms for reimbursing high-cost medicines under specific eligibility criteria, listing processes, varying cost-effectiveness thresholds and special funding arrangements. In Thailand, high-cost medicines that do not offer good value-for-money are excluded from the reimbursement process. A framework for reimbursing high-cost medicines that are not cost-effective at the current willingness-to-pay threshold was proposed for Thailand. Under this framework, specific criteria are proposed to determine their eligibility for reimbursement such life-saving nature, treatment of conditions with no alternative treatment options, and affordability.ConclusionHigh-cost medicines may become eligible for reimbursement through alternative mechanisms based on specific criteria which depend on each context. The application of HTA methods and processes is important in guiding these decisions to support sustainable access to affordable healthcare in pursuit of Universal Health Coverage (UHC).

Implementation of pharmacy access to hormonal contraception

BackgroundStates throughout the country are enacting legislation to authorize pharmacist prescribing of hormonal contraception to decrease barriers to access. Little is known about the process of state implementation of pharmacist prescriptive authority for hormonal contraception. ObjectivesTo understand the state-level steps to enable pharmacist prescribing of hormonal contraception, including implementation challenges and facilitators. MethodsWe conducted a qualitative study of interviews with 18 key individuals, including pharmacists and other stakeholders, from ten states with laws permitting pharmacist-prescribed hormonal contraception from March 2021 to April 2022. We analyzed data using directed qualitative analysis principles and compared experiences across states. We organized the data using the Consolidated Framework for Implementation Research framework and evaluated relevant constructs in states’ implementation efforts. ResultsParticipants identified four key steps to implement pharmacist prescribing at the state level, including development of state rules and regulations, educational programs, reimbursement mechanisms, and expansion strategies to pharmacists and pharmacies. Participants identified early involvement of key stakeholders and a culture of support for clinical pharmacists as facilitators to implementation. Challenges included complexity and cost of billing mechanisms, lack of funding for implementation efforts, and competing priorities of pharmacies/pharmacists. ConclusionParticipants in states with pharmacist prescriptive authority for hormonal contraception identified development of reimbursement and billing mechanisms as the most critical state-level step in implementation. Focusing on facilitators of key steps can guide states in developing successful implementation strategies to improve contraceptive access.

AVAILABILITY OF MEDICINES AS A RESULT OF REIMBURSEMENT MECHANISMS AND MEDICAL INSURANCE IS AN ISSUE FOR DISCUSSION

Availability of medicines, their quantity, quality, and appropriate documentation organization regarding distribution, storage, and sales – is one of the priority tasks of the healthcare system of each country. In European Union countries, a significant portion of expenditures for ensuring pharmaceutical supplies is covered by the state, implementing the principle of equal access of the population to effective medicines at an affordable price, which underlies the mechanisms of pricing and reimbursement. To achieve these goals, requirements are outlined in Directive 89/105/EEC of December 21, 1989, «On the transparency of measures regulating the pricing of medicinal products for human use and their inclusion in the system of national health insurance», aimed at promoting the development of the pharmaceutical industry both in the direction of developing expensive innovative drugs and in providing patients with quality generics. Thus, the main mechanism for ensuring the availability of medicinal products and medical devices for the population is the reimbursement program – the complete or partial refunding to entities engaged in retail trade of medicinal products, of the cost of medicinal products or medical devices dispensed to patients based on prescriptions, at the expense of the State Budget of Ukraine. The main objective of regulatory activities remains comprehensive regulation. Individual healthcare questions, including the provision of medicinal products, have been explored in the works of Yu. Bytiak, V. Kolpakov, R. Maidanyk, O. Myronets, I. Seniuta and others. The purpose of this publication is to review the normative and legal regulation of the reimbursement mechanism and practical implementation issues. Different countries establish their own reimbursement mechanisms, which vary in terms of funding sources, reimbursement conditions, price regulation methods, selection criteria for medicinal products, and key nosologies for treatment. The recipients of such systems may include socially vulnerable segments of the population, individuals suffering from severe or chronic illnesses, as well as various types of pharmaceutical assistance such as inpatient and outpatient care. Depending on the specifics of healthcare systems in different countries, different compensation mechanisms may be used. For example, this may involve the reimbursement of the cost of medicines for insured individuals, where the patient’s treatment expenses are covered by the insurance company or compensated to pharmacy establishments, with settlements being made between the insurance fund, healthcare facility, and pharmacy based on contracts. In Ukraine, in the absence of a mandatory medical insurance system, the reimbursement process operates in the form of the state program «Accessible Medicines», where the state compensates pharmacy establishments for the full or partial cost of medicines from the respective list.

Digital Health Reimbursement Strategies of 8 European Countries and Israel: Scoping Review and Policy Mapping.

The adoption of digital health care within health systems is determined by various factors, including pricing and reimbursement. The reimbursement landscape for digital health in Europe remains underresearched. Although various emergency reimbursement decisions were made during the COVID-19 pandemic to enable health care delivery through videoconferencing and asynchronous care (eg, digital apps), research so far has primarily focused on the policy innovations that facilitated this outside of Europe. This study examines the digital health reimbursement strategies in 8 European countries (Belgium, France, Germany, Italy, the Netherlands, Poland, Sweden, and the United Kingdom) and Israel. We mapped available digital health reimbursement strategies using a scoping review and policy mapping framework. We reviewed the literature on the MEDLINE, Embase, Global Health, and Web of Science databases. Supplementary records were identified through Google Scholar and country experts. Our search strategy yielded a total of 1559 records, of which 40 (2.57%) were ultimately included in this study. As of August 2023, digital health solutions are reimbursable to some extent in all studied countries except Poland, although the mechanism of reimbursement differs significantly across countries. At the time of writing, the pricing of digital health solutions was mostly determined through discussions between national or regional committees and the manufacturers of digital health solutions in the absence of value-based assessment mechanisms. Financing digital health solutions outside traditional reimbursement schemes was possible in all studied countries except Poland and typically occurs via health innovation or digital health-specific funding schemes. European countries have value-based pricing frameworks that range from nonexistent to embryonic. Studied countries show divergent approaches to the reimbursement of digital health solutions. These differences may complicate the ability of patients to seek cross-country health care in another country, even if a digital health app is available in both countries. Furthermore, the fragmented environment will present challenges for developers of such solutions, as they look to expand their impact across countries and health systems. An increased emphasis on developing a clear conceptualization of digital health, as well as value-based pricing and reimbursement mechanisms, is needed for the sustainable integration of digital health. This study can therein serve as a basis for further, more detailed research as the field of digital health reimbursement evolves.