Reimbursement Mechanisms Research Articles

Cancer Patient Navigator Tasks across the Cancer Care Continuum

Cancer patient navigation (PN) programs have been shown to increase access to and utilization of cancer care for poor and underserved individuals. Despite mounting evidence of its value, cancer patient navigation is not universally understood or provided. We describe five PN programs and the range of tasks their navigators provide across the cancer care continuum (education and outreach, screening, diagnosis and staging, treatment, survivorship, and end-of-life). Tasks are organized by their potential to make cancer services understandable, available, accessible, affordable, appropriate, and accountable. Although navigators perform similar tasks across the five programs, their specific approaches reflect differences in community culture, context, program setting, and funding. Task lists can inform the development of programs, job descriptions, training, and evaluation. They also may be useful in the move to certify navigators and establish mechanisms for reimbursement for navigation services.

Current progress in the management of rare diseases and orphan drugs in China.

Currently, the issues of how to treat rare diseases and to improve accessibility to orphan drugs are arousing more and more concerns in China. Here we describe the push and pull incentive policies for rare diseases and orphan drugs and analyze the coverage and reimbursement level of rare diseases in the current Chinese medical insurance system. Three key obstacle factors that hinder Chinese patients' accessibility to timely drug treatment are summarized. Based on a comprehensive analysis, the measures of orphan drugs legislation, incentive mechanism, supply mechanism, and reimbursement mechanism are urgently expected to be established with the purpose of improving healthcare for patients with rare diseases in China.

Equilibrium with limited-recourse collateralized loans

We address a general equilibrium model with limited-recourse collateralized loans and securitization of debts. Each borrower is required to pledge physical collateral, and bankruptcy is filed against him if claims are not fully honored. Moreover, agents have a positive amount of wealth exempt from garnishment and, for at least a fraction of them, commodities used as collateral are desirable. In this context, equilibrium exists for any continuous garnishment rule and multiple types of reimbursement mechanisms.

Economic crisis, austerity and the Greek public health system

For 2 years the Greek financial crisis has captured global attention. In return for loans from the International Monetary Fund (IMF) and European institutions, Greece agreed on harsh across-the-board austerity measures, yet most commentators offer little hope for recovery, at least in the short run. The economy is expected to contract by a further 6.1% in 2011 and 3% in 2012, while unemployment is projected to reach 18.5% in 2012 up from 7.7% in 2008. The Greek health-care system has been accumulating structural problems for a decade1 that have been exacerbated by the economic crisis. In terms of expenditure, a failure to contain costs, in part due to an absence of explicit funding criteria, created budget deficits for sickness funds. Although the system is highly centralized, resource allocation suffers from a lack of planning and coordination, weak managerial and administrative capacity, and underdeveloped mechanisms for assessing needs and setting priorities. In addition, an oversupply of specialist physicians coexists with an undersupply of general practitioners and nurses. The combination of an absence of a functioning referral system and irrational pricing and reimbursement mechanisms leads to poor coordination of care, large out-of-pocket payments and a sizable black economy, impeding the system's ability to deliver equitable financing and access to services. Since the onset of the crisis, …

Practice models and challenges in teledermatology: a study of collective experiences from teledermatologists.

BackgroundDespite increasing practice of teledermatology in the U.S., teledermatology practice models and real-world challenges are rarely studied.MethodsThe primary objective was to examine teledermatology practice models and shared challenges among teledermatologists in California, focusing on practice operations, reimbursement considerations, barriers to sustainability, and incentives. We conducted in-depth interviews with teledermatologists that practiced store-and-forward or live-interactive teledermatology from January 1, 2007 through March 30, 2011 in California.ResultsSeventeen teledermatologists from academia, private practice, health maintenance organizations, and county settings participated in the study. Among them, 76% practiced store-and-forward only, 6% practiced live-interactive only, and 18% practiced both modalities. Only 29% received structured training in teledermatology. The average number of years practicing teledermatology was 4.29 years (SD±2.81). Approximately 47% of teledermatologists served at least one Federally Qualified Health Center. Over 75% of patients seen via teledermatology were at or below 200% federal poverty level and usually lived in rural regions without dermatologist access. Practice challenges were identified in the following areas. Teledermatologists faced delays in reimbursements and non-reimbursement of teledermatology services. The primary reason for operational inefficiency was poor image quality and/or inadequate history. Costly and inefficient software platforms and lack of communication with referring providers also presented barriers.ConclusionTeledermatology enables underserved populations to access specialty care. Improvements in reimbursement mechanisms, efficient technology platforms, communication with referring providers, and teledermatology training are necessary to support sustainable practices.

Examining the influence of insurance and moral hazard on the utilisation of practitioner-based complementary and alternative medicine

Moral hazard (excess consumption of clinical services) is representative of consumer behaviour associated with the utilisation of services reimbursed from third-party payers. Within the USA, CAM is supported by numerous commercial and public insurance programmes. The objective of this article is to assess the utilisation of CAM when paid for by third-party payers. Data from the 2007 US National Health Interview Survey were examined to measure the relationship between insurance coverage and the utilisation of practitioner-based alternative medicine. Participant use of chiropractic, osteopathic manipulation and acupuncture was compared with health insurance coverage. The analysis applied standard epidemiological risk ratios to the data in order to calculate the effect of insurance coverage on CAM and moral hazard. The presence of health insurance was a strong facilitator of utilisation, with up to a 40% increase in utilisation when reimbursement mechanisms were introduced. The finding suggests that market-based strategies for dealing with moral hazard have little influence when applied to practitioner-based CAM, while insurance coverage plays a significant role in its delivery. Consequently, factors related to behavioural economics and agency modelling may undermine efficient utilisation and payment for CAM services.

Vertical integration and optimal reimbursement policy

Health care providers may vertically integrate not only to facilitate coordination of care, but also for strategic reasons that may not be in patients' best interests. Optimal Medicare reimbursement policy depends upon the extent to which each of these explanations is correct. To investigate, we compare the consequences of the 1997 adoption of prospective payment for skilled nursing facilities (SNF PPS) in geographic areas with high versus low levels of hospital/SNF integration. We find that SNF PPS decreased spending more in high integration areas, with no measurable consequences for patient health outcomes. Our findings suggest that integrated providers should face higher-powered reimbursement incentives, i.e., less cost-sharing. More generally, we conclude that purchasers of health services (and other services subject to agency problems) should consider the organizational form of their suppliers when choosing a reimbursement mechanism.

Management of Acute Neurorehabilitation Programs

Outcome management, performance improvement, evidence-based practice, and policy payment mechanisms are critical operational drivers at every level of health care delivery. It is essential that all health care providers involved in patient care have a working knowledge of health care operations, including the policies and reimbursement mechanisms that drive their particular clinical practice. Providing excellent patient care includes understanding health care policies, regulations, and outcomes that have a historical and current impact on health care delivery. Some of these factors include patient access, patient safety, and information measurement and management. Inpatient acute neurorehabilitation programs have standard outcome measures and a unique set of fiscal rules and regulations. This article discusses the most common variables and terms found in program evaluation systems for acute neurorehabilitation programs as well as some of the clinical and regulatory requirements and reimbursement and level-of-care considerations that are critical for neurorehabilitation health care practitioners. The current health care environment requires providers to understand and continually evaluate quality outcomes, patient access, and patient safety, all within the confines of an efficacy-based care delivery system.

TH-C-224-01: Reimbursement: Resources and Updates

Healthcare reimbursement is a complex, changing environment with multiple payers and multiple sets of rules. The practicing medical physicist should be familiar with reimbursement and coding so that he/she can: 1) assure that fair reimbursement is received for the physics work performed, 2) assure that physics billing is done correctly and in compliance with applicable rules and procedures, and 3) justify the physics staffing levels necessary in the clinic. This presentation will build upon previous general reviews of the mechanisms of Medicare reimbursement and will cover practical aspects for the practicing physicist including where to find information on reimbursement and coding. The National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUE) and their effect on daily billing will be reviewed. In addition, proposed changes in the Hospital Outpatient Prospective Payment System (HOPPS) and Medicare Physician Fee Schedule (MPFS) for calendar year 2012 will be discussed. Learning Objectives: 1. Become familiar with available resources for reimbursement and coding 2. Understand the National Correct Coding Initiative and Medically Unlikely Edits 3. Be aware of proposed changes in Medicare reimbursement for 2012

Hematopoietic Stem Cell Transplantation and Implications for Cell Therapy Reimbursement

As costly stem cell treatments progress from experimental concepts toward licensed products and routine procedures, governmental and private payers grapple with shrinking budgets to cover more lives. We describe efforts underway in the US to create mechanisms for reimbursement of cell therapies and discuss other reimbursement-related issues for the stem cell community.

Implementing a Web-Based Home Monitoring System within an Academic Health Care Network: Barriers and Facilitators to Innovation Diffusion

The practice of outpatient type 2 diabetes management is gradually moving from the traditional visit-based, fee-for-service model to a new, health information communication technology (ICT)-supported model that can enable non-visit-based diabetes care. To date, adoption of innovative health ICT tools for diabetes management has been slowed by numerous barriers, such as capital investment costs, lack of reliable reimbursement mechanisms, design defects that have made some systems time-consuming and inefficient to use, and the need to integrate new ICT tools into a system not primarily designed for their use. Effective implementation of innovative diabetes health ICT interventions must address local practice heterogeneity and the interaction of this heterogeneity with clinical care delivery. The Center for Connected Health at Partners Healthcare has implemented a new ICT intervention, Diabetes Connect (DC), a Web-based glucose home monitoring and clinical messaging system. Using the framework of the diffusion of innovation theory, we review the implementation and examine lessons learned as we continue to deploy DC across the health care network.

Economic concerns about global healthcare in lung, head and neck cancer: meeting the economic challenge of predictive, preventive and personalized medicine

The introduction of biological science into the practice of medicine was a big transforming event for the profession, leading to different new medical models such as predictive, preventive and personalized medicine. Each of them is a rapidly emerging field that helps us to determine the risk for individuals to develop specific diseases, detect the disease’s earliest onset and prevent or intervene early enough to provide maximum benefit for each patient. However, to realize this new potential, new healthcare models must be created, improved and validated. New healthcare models that are more proactive than reactive because prevention is less expensive than reactive medicine. Current knowledge about predictive, preventive and personalized medicine is already sufficient to implement this approach, but there are no effective practice models, delivery systems and appropriate reimbursement mechanisms. In the course of this review, we describe the economic components and benefits of a predictive, preventive and personalized health plan for lung as well as head and neck cancer and show how prospective care could relate to a community or group of covered individuals.

Regionalized Care for Time‐critical Conditions: Lessons Learned From Existing Networks

The 2010 Academic Emergency Medicine (AEM) consensus conference "Beyond Regionalization" aimed to place the design of a 21st century emergency care delivery system at the center of emergency medicine's (EM's) health policy research agenda. To examine the lessons learned from existing regional systems, consensus conference organizers convened a panel discussion made up of experts from the fields of acute care surgery, interventional cardiology, acute ischemic stroke, cardiac arrest, critical care medicine, pediatric EM, and medical toxicology. The organizers asked that each member provide insight into the barriers that slowed network creation and the solutions that allowed them to overcome barriers. For ST-segment elevation myocardial infarction (STEMI) management, the American Heart Association's (AHA's) Mission: Lifeline aims to increase compliance with existing guidelines through improvements in the chain of survival, including emergency medical services (EMS) protocols. Increasing use of therapeutic hypothermia post-cardiac arrest through a network of hospitals in Virginia has led to dramatic improvements in outcome. A regionalized network of acute stroke management in Cincinnati was discussed, in addition to the effect of pediatric referral centers on pediatric capabilities of surrounding facilities. The growing importance of telemedicine to a variety of emergencies, including trauma and critical care, was presented. Finally, the importance of establishing a robust reimbursement mechanism was illustrated by the threatened closure of poison control centers nationwide. The panel discussion added valuable insight into the possibilities of maximizing patient outcomes through regionalized systems of emergency care. A primary challenge remaining is for EM to help to integrate the existing and developing disease-based systems of care into a more comprehensive emergency care system.

The Imbalance between Patient Needs and the Limited Competence of Top-Level Health Providers in Urban China: An Empirical Study Based on a 2008 National Household Survey

Objective: To show the pattern of patient satisfaction with top-level delivery organizations (Level 2 and Level 3 hospitals), and using neo-institutionalism approach to explain the relatively low satisfaction and to explore the limitations with top providers, focusing on how to improve the competence of Level 2 and Level 3 hospitals at both the individual hospital level and the whole delivery system level.Data Sources/Study Setting: The household survey by the National Bureau of Statistics in China in 2008; China Health Statistics Yearbooks.Data Collection/Extraction Methods: The analysis uses a 2008 sample medical experiences of 5,036 residents from 17 provinces collected in a household survey by the National Bureau of Statistics in China. The linear regression model, the structural difference regression model, and the ordered probit model are used in our framework.Principal Findings: The imbalance between the needs of patients and the limited competence of top-level providers, and the conflict between the business expansion and the limited competence of those providers are deeply and widely influenced by patterns of patient needs, the top providers’ expansion, and the institutional environment.Conclusions: In order to effectively respond to patient needs, top and lower level providers need to set their own individual priorities. The government needs to improve institutional arrangements to respond to patient needs with the development of a fair and appropriate reimbursement and compensation pricing mechanism, and with further evaluation of top level providers’ advanced and limited health services.

DRG, BSC and EBM: time to work with one another

There has been much evidence provided on the appropriateness of Diagnosis Related Groups (DRGs) as a useful tool for funding, and/or a reimbursement mechanism. DRGs have also proven valuable for management and review of utilization, as well as in conducting research into health systems. Many people believe that DRG–based funding (and performance) holds hospitals accountable for costs, but its impact on quality of care and health outcomes is unclear. This, in turn, undermines its utilization either for funding or management purposes. If classification of similar patients into the classes of DRGs paves the way toward achieving the objectives of evidence-based practice in medicine and the health system, then this will have a significant effect on the utilization of DRGs around the globe.

Workload of Attending Physicians at an Academic Center in Taiwan

Since the fee-for-service reimbursement mechanism has been under the global budget of the National Health Insurance program, physicians' workloads have been increasing. Attending physicians in medical centers usually have long working hours because of their clinical work as well as teaching, research, and other administrative responsibilities. Many studies regarding reasonable work hours for physicians have been undertaken globally, but few have been conducted in Taiwan. In this study, we focused on the difference in working hours among physicians in different departments. Using attending physicians from a major teaching hospital as the study population, we adopted self-administered questionnaires to investigate physicians' time allocations for 4 major categories: clinical work, teaching, research, and administrative work. We distributed 432 questionnaires and received 380 filled-out questionnaires, yielding a response rate of 88%. After eliminating questionnaires with incomplete responses, the valid sample size was 376. We used t test and 1-way ANOVA to analyze the association between physicians' characteristics and workload and used multiple linear regression to examine factors influencing physicians' work hours. The average weekly work time among attending physicians was 65.6 hours; physicians under the age of 40 worked an average of 69.8 hours. Males worked an average of 66.2 hours weekly and females an average of 62.7 hours. Total work hours and hours of clinical work, teaching, research, and administrative work all reached significant differences among departments. Physicians who were under 40 years old, those with a doctoral degree, those with a teaching position as associate professor or above, and those working in anesthesiology had longer total work hours. This study found that work hours among departments differed significantly and that physicians in surgical departments spend the longest hours in clinical work. Those in administrative positions are most involved in clinical work. However, work hours do not definitely represent work intensity, and to define the workload by working hours may be inappropriate for some departments. This possible difference between work hours and work intensity merits further consideration.

Pulmonary/Critical Care Physicians and Hospice Patients: Billing Specialty Care for Patients Enrolled in a Hospice Program

Hospice care now represents the standard of care for many patients in the last months of life. Not just for patients with cancer or progressive neurologic diseases, hospice care is increasingly common for patients with end-stage cardiac, renal, liver, and pulmonary diseases. For specialist physicians in pulmonology, cardiology, and critical care, the practical issues about coding and billing for specialist services for hospice-enrolled patients may be problematic. This article briefly reviews hospice care and the potential barriers to appropriate and timely referral. Coding for specialist services related to hospice care is reviewed, as well as delineation of how and when reimbursement is better carried out through the Medicare hospice benefit, rather than through the usual reimbursement mechanisms.

Mental Health vs Mental Disorders

IN THE CALL FOR PAPERS FOR THIS JAMA THEME ISSUE ON mental health, I noted the irony that in an issue devoted to mental health most of the articles would undoubtedly beaboutmentaldisorders,withthesimpleexplanationthat mental disorders are the problem and mental health is the goal; and that the goal for the JAMA theme issue on mental health was to“beofassistance tocliniciansandpolicymakers inhelping patients, families, and communities move in that positive direction.” Readers can now evaluate the extent to which this themeissueachieves thatgoal.A totalof182submissionswere received for consideration for the theme issue, and 6 major articles, 4 Commentaries, a Cover Story describing the circumstancessurroundingVincentVanGogh’shospitalizations,apowerful A Piece of My Mind essay, and several book reviews and Medical News & Perspectives pieces are now published in it. One area of need is that the number of persons requiring treatment for mental disorders far exceeds the capacity of the mental health specialty sector to provide that treatment. A potential solution for this problem is to expand the capacity to identify and effectively treat mental disorders in the primary care sector. An approach to providing effective evidencebased treatments for mental disorders in primary care is “collaborative care,” in which appropriately trained clinicians collaborate with primary physicians to evaluate and treat primary care patients, with mental health specialty consultation as needed. The effectiveness of this strategy for depressive disorders is now rather well established, but its use for anxiety disorders, despite their frequency in primary care, has not been well studied. The randomized controlled trial reported by Roy-Byrne et al involving an intervention called Coordinated Anxiety Learning and Management (CALM) provides a welcome assessment of a flexible and practical treatment delivery model for common anxiety disorders (panic disorder, generalized anxiety disorder, social anxiety disorder, and posttraumatic stress disorder) in the primary care setting. This trial was conducted in 17 primary care clinics in 4 US cities and found significantly better improvement in anxiety symptom ratings and also in rates of response and remission using the CALM collaborative care intervention compared with usual care. As the authors note, analyses of the cost of CALM will be important and “implementation of this model will require reimbursement mechanisms for care management that are not currently available.” Inanother randomizedcontrolled trial in this issue,Piacentini et al report the results of a behavioral treatment intervention called habit reversal training for Tourette disorder and chronic tic disorder. This study is notable not only for calling attention to an evidence-based nonpharmacologic intervention for these neuropsychiatric disorders, but also because it useda timeandattentioncontrol treatmentof supportivepsychotherapy and education as a “placebo” comparator, an improvement over many studies of psychotherapeutic interventions that use only no treatment or waiting list controls and thus do not control for the nonspecific effects of time and attention. Significantly more children receiving the behavioral treatment (53%) were rated as very much or much improved comparedwithchildrenreceiving thecontrol treatment(19%) after 10 weeks, with 87% of available responders to behavior therapy showing continued benefit 6 months after treatment. Concernsabout injuredsoldiers inIraqandAfghanistanhave recently focusedattentiononpersonswithtraumaticbrain injuries and their needs for rehabilitation. In addition to physical and cognitive impairment, psychological impairments associated with traumatic brain injuries are of concern. The occurrence of major depressive disorder (MDD) in individuals with traumatic brain injuries is one such concern. Bombardier et al report that in a cohort of 559 consecutively hospitalized adults with traumatic brain injuries (most commonly due to motor vehicle crashes), 53% met criteria for MDD at least once during the first year after their injury, with an increased risk for MDD associated with MDD at the time of injury, history ofMDDpriorto injury,youngerage,andlifetimealcoholdependence. Clearly, identification of and treatment for MDD are important issues for further research, clinical care, and rehabilitation of persons with traumatic brain injuries. In an article about the occurrence and effect of major depression in the course of another medical disorder, Hedayati et al report that the presence of a major depressive episode was associated with an increased risk of hospitalization and initiation of dialysis in patients with chronic kidney disease. Previous studies have found that depression is an independent risk factor for hospitalization and death in maintenance dialysis patients, but the new report shows that depression is associated with worse outcomes in chronic kidney disease patients not yet undergoing dialysis. Research on the efficacy and safety of treatments for depression in this patient population is clearly needed. In an analysis of an intriguing natural experiment, Costello et al report longer-term follow-up results from their 2003 JAMA report on the effects of an income supplement provided to Cherokee Indian families when a casino was opened on their reservation in 1996. The earlier report

Achieving Reimbursement for Regenerative Medicine Products in the USA

Achieving reimbursement for regenerative medicine products is potentially a greater challenge than gaining US FDA approval, making it a decisive factor in the success or failure of small businesses. However, the mechanisms by which reimbursement is achieved are still seen as something of a 'black box', especially to those outside of the USA. This report aims to provide insights into the mechanisms of reimbursement and variety of payers in the USA, and to act as a starting point for a successful US reimbursement strategy. Fundamental concepts such as coverage, payment and coding are explained and linked with the factors that potentially determine the successful reimbursement of regenerative medicine products, including cost of goods and clinical study design. Finally, important considerations for the design of clinical studies that satisfy both the payers and the FDA are discussed and the key elements of a successful company strategy identified.

Defensive Medicine and Tort Reform: A Wide View

Defensive Medicine and Tort Reform: A Wide View