Reimbursement Models Research Articles

Over 20 years of declining Medicare reimbursement for spine surgeons: a temporal and geographic analysis from 2000 to 2021.

Procedural reimbursement for spine surgery has changed drastically over the past 20 years. A comprehensive understanding of these trends is important as major changes in reimbursement models of spine surgery continue to evolve within various spine specialties as well as broader national healthcare policy. In this study the authors evaluated the monetary trends in Medicare reimbursement rates for the 15 most common spinal surgery procedures from 2000 to 2021. The National Surgery Quality Improvement Project database (2019) was queried to determine the 15 most commonly performed spine surgery procedures. The Current Procedural Terminology (CPT) codes for each of these procedures were obtained from the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services, and comprehensive reimbursement data for each code were extracted. Changes in Medicare reimbursement rates were calculated and averaged for each procedure as both raw percent changes and percent changes adjusted for inflation to 2021 US dollars (USD) based on the consumer price index (CPI). The adjusted R2 value, the compound annual growth rate (CAGR), and both the average annual and the total percent change in reimbursement were calculated based on these adjusted trends for all included procedures. After adjustment for inflation, average reimbursement for all procedures decreased by 33.8% from 2000 to 2021. The greatest mean decrease was seen in anterior cervical arthrodesis (-38.7%), while the smallest mean decrease was in vertebral body excision (-17.1%). From 2000 to 2021, the adjusted reimbursement rate for all included procedures decreased by an average of 1.9% each year, with an average R2 value of 0.69. This is the first study to evaluate monetary trends in Medicare reimbursement for spine surgery procedures. After adjusting for inflation, Medicare reimbursement for the 15 most commonly performed spine procedures has steadily decreased from 2000 to 2021. Increased awareness of these trends and the forces driving them will be critical in the coming years as negotiations regarding reimbursement models continue to unfold. Greater understanding of spine surgery reimbursement among policy makers, hospitals, and surgeons will be important to ensure continued access to quality surgical spine care in the United States.

116. Risk adjustment in bundled payment models: medical comorbidities as risk factors for reduced reimbursement following lumbar fusion and decompression in the Medicare population

116. Risk adjustment in bundled payment models: medical comorbidities as risk factors for reduced reimbursement following lumbar fusion and decompression in the Medicare population

P135. Patient specific risk factors for reduced profitability of a private insurance bundled payment model for lumbar fusion and decompression

<h3>BACKGROUND CONTEXT</h3> Health care reimbursements have started to shift from fee-for-service to bundled payments. Given this trend, there is a need to assess the performance of bundled reimbursement models and adjust target costs appropriately. <h3>PURPOSE</h3> The purpose of this study is to evaluate how patient demographics, individual medical comorbidities and surgical variables affect the net profits or losses for care episodes in a private insurance bundled payment model. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study. <h3>PATIENT SAMPLE</h3> A consecutive series of primary and revision thoracolumbar fusion and decompression care episodes were retrospectively reviewed at a single academic institution from 2018-2019 using bundled payment claims data from two private insurers. <h3>OUTCOME MEASURES</h3> Net profits or losses per care episode. <h3>METHODS</h3> Patients were divided into cohorts based on the net profit or loss at the end of each episode, which was calculated from target costs set by the historical performance of the bundle. Patient demographics, individual medical comorbidities and clinical outcomes were collected for all patients. Stepwise multivariate logistic regression models were developed to measure the effect of patient demographics and medical comorbidities on the likelihood of a care episode resulting in a net loss. Pvalues < 0.05 were considered statistically significant. <h3>RESULTS</h3> A total of 325 lumbar fusions and/or decompressions were included in the analysis (177 fusions: 98 profits, 79 losses; 148 decompressions: 99 profits, 49 losses). For fusion episodes, the average net profit was $17,687 for profitable procedures compared to $-34,211 for nonprofitable procedures (p < 0.001). Among patients who underwent fusion, cardiac arrhythmias (OR=3.20, p=0.047) and an increased number of levels fused (OR=1.58, p=0.031) significantly increased the likelihood of a care episode resulting in a loss. For decompression episodes, the average net profit was $3,035 for profitable procedures compared to $-9,532 for nonprofitable procedures (p < 0.001). Among patients who underwent decompression, hypertension (OR=2.60, p=0.038), hypercholesterolemia (OR=3.14, p=0.015), and an increased number of levels decompressed (OR=5.15, p < 0.001) significantly increased the likelihood of a care episode resulting in a loss. <h3>CONCLUSIONS</h3> Surgeons should understand how medical comorbidities, including arrhythmias, hypertension and hypercholesterolemia, may impact total episode of care target prices in a private insurance bundled payment model. Further study is required to determine if target costs in bundled payment models need to be adjusted to appropriately compensate for certain medical comorbidities. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

The American Society for Radiation Oncology Workforce Statement

Although concerns regarding an imbalance in the radiation oncology workforce were raised nearly a decade ago,1 the radiation oncology workforce has continued to grow. The annual number of positions and trainees increased for several years and then plateaued, with some programs requesting larger resident complements and/or filling unmatched positions through the Supplemental Offer and Acceptance Program (SOAP). At the same time, rising concerns exist regarding radiation therapy (RT) utilization, including the decline in demand/revenue in fraction-based reimbursement models with increasing use of hypofractionation, omission of RT due to greater availability of systemic therapy options, and increased acceptability of watchful waiting/surveillance (eg, breast and prostate cancers).

The past, present, and future of antibiotics.

Antibiotics have transformed modern medicine. They are essential for treating infectious diseases and enable vital therapies and procedures. However, despite this success, their continued use in the 21st century is imperiled by two orthogonal challenges. The first is that the microbes targeted by these drugs evolve resistance to them over time. The second is that antibiotic discovery and development are no longer cost-effective using traditional reimbursement models. Consequently, there are a dwindling number of companies and laboratories dedicated to delivering new antibiotics, resulting in an anemic pipeline that threatens our control of infections. The future of antibiotics requires innovation in a field that has relied on highly traditional methods of discovery and development. This will require substantial changes in policy, quantitative understanding of the societal value of these drugs, and investment in alternatives to traditional antibiotics. These include narrow-spectrum drugs, bacteriophage, monoclonal antibodies, and vaccines, coupled with highly effective diagnostics. Addressing the antibiotic crisis to meet our future needs requires considerable investment in both research and development, along with ensuring a viable marketplace that encourages innovation. This review explores the past, present, and future of antimicrobial therapy.

Implementation and Impact of Choosing Wisely Recommendations in Oncology.

The Choosing Wisely (CW) campaign, launched in 2012, includes oncology-specific recommendations to promote evidence-based care and deimplementation of low-value practices. However, it is unclear to what extent the campaign has prompted practice change. We systematically reviewed the literature to evaluate the uptake of cancer-specific CW recommendations focusing on the period before the declaration of the COVID-19 pandemic. We used Grimshaw's deimplementation framework to thematically group the findings and extracted information on implementation strategies, barriers, and facilitators from articles reporting on active implementation. In the 98 articles addressing 32 unique recommendations, most reported on passive changes in adherence pre-post publication of CW recommendations. Use of active surveillance for low-risk prostate cancer and reduction in staging imaging for early breast cancer were the most commonly evaluated recommendations. Most articles assessing passive changes in adherence pre-post CW publication reported improvement. All articles evaluating active implementation (10 of 98) reported improved compliance (range: 3%-73% improvement). Most common implementation strategies included provider education and/or stakeholder engagement. Preconceived views and reluctance to adopt new practices were common barriers; common facilitators included the use of technology and provider education to increase provider buy-in. Given the limited uptake of oncology-specific CW recommendations thus far, more attention toward supporting active implementation is needed. Effective adoption of CW likely requires a multipronged approach that includes building stakeholder buy-in through engagement and education, using technology-enabled forced functions to facilitate change along with policy and reimbursement models that disincentivize low-value care. Professional societies have a role to play in supporting this next phase of CW.

Exploring barriers and facilitators to pharmacist-provided diabetes self-management education and support

BackgroundPharmacists have the necessary clinical experience and medication knowledge to effectively provide diabetes self-management education and support (DSMES); however, barriers exist to DSMES implementation by community pharmacists. ObjectiveThe aim of this study is to explore DSMES from the community pharmacists’ perspectives, identify barriers and facilitators to pharmacist DSMES implementation, and guide development of pharmacist-provided DSMES programs in Idaho. MethodsImplementation climate, the theoretical framework for this project, is focused on how community pharmacists in Idaho perceive they will be supported by patients, health care providers, and insurers in DSMES implementation. Pharmacist investigators with qualitative research experience conducted semistructured interviews with 6 licensed community pharmacists from Idaho via Zoom between March and June 2020. Recordings were transcribed verbatim and analyzed using HyperRESEARCH 4.5.1. Themes, patterns, and dominant concepts that emerged from respondents’ about DSMES were explored, labeled, and categorized into modifiable and nonmodifiable barriers and facilitators. This study was granted expedited approval by the Idaho State University Investigational Review Board. ResultsRelevant themes included current scope of practice, barriers, and facilitators. Subthemes related to the current scope of pharmacy practice included unclear roles and responsibilities and legislative constraints to practice. For barriers, subthemes included cost of set-up, billing and coding education, and the sustainability of services based on current reimbursement models. For facilitators, subthemes included the need for additional collaborations (external and internal), technology access, and trained pharmacy staff. ConclusionPharmacists are underutilized health care providers, capable of providing DSMES services if provided the necessary resources. This work identifies barriers and facilitators to pharmacist-led DSMES that can be considered by others when implementing DSMES or other disease management services.

Trainee Perspectives on Race, Antiracism, and the Path toward Justice in Kidney Care.

Trainee Perspectives on Race, Antiracism, and the Path toward Justice in Kidney Care.

Trends in Medicare Reimbursement for the Top 20 Surgical Procedures in Craniofacial Trauma.

Research regarding financial trends in craniofacial trauma surgery is limited. Understanding these trends is important to the evolvement of suitable reimbursement models in craniofacial plastic surgery. The purpose of this study was to evaluate the trends in Medicare reimbursement rates for the top 20 most utilized surgical procedures for facial trauma. The 20 most commonly utilized Current Procedural Terminology (CPT) codes for facial trauma repairs in 2018 were queried from The National Summary Data File from the Centers for Medicare & Medicaid Services (CMS). Reimbursement data for each procedure was then extracted from The Physician Fee Schedule Lookup Tool. Changes to the United States consumer price index (CPI) were used to adjust all gathered data for inflation to 2021 US dollars (USD). The average annual and the total percent change in reimbursement were calculated for the included procedures based on the adjusted trends from the years 2000 to 2021. From 2000 to 2021, the average reimbursement for all procedures decreased by 16.6% after adjusting for inflation. Closed treatment of temporomandibular joint dislocation and closed treatment of nasal bone fractures without manipulation demonstrated the greatest decrease in mean adjusted reimbursement at -48.7% and -48.3%, respectively, while closed treatment of nasal bone fractures without stabilization demonstrated the smallest mean decrease at -1.4% during the study period. Open treatment of nasal septal fractures with or without stabilization demonstrated the greatest increase in mean adjusted reimbursement at 18.9%, while closed treatment of nasal septal fractures with or without stabilization demonstrated the smallest increase at 1.2%. The average reimbursement for all closed procedures in the top 20 decreased by 19.3%, while that for all open procedures decreased by 15.5%. The adjusted reimbursement rate for all top 20 procedures decreased by an average of 0.8% each year. To the best of our knowledge, this is the first study to comprehensively evaluate trends in Medicare reimbursement for facial trauma surgical repairs. Adjusting for inflation, Medicare reimbursement for the top 20 most commonly utilized procedures has largely decreased from 2000 to 2021. Consideration of these trends by surgeons, hospital systems, and policymakers will be important to assure continued access to meaningful surgical facial trauma care in the United States.

Characteristics of chronic intestinal failure in the USA based on analysis of claims data.

This study investigated the prevalence, characteristics, and management of patients with chronic intestinal failure (CIF) in the United States in 2012-2020, based on parenteral support (PS) prescription claims and healthcare utilization. Patients with CIF were identified from the Integrated DataVerse® claims database if they had at least two PS prescriptions within 6 months and a relevant diagnosis. Analysis included prevalence and characteristics of patients with CIF, their travel distance to receive PS prescriptions, and the distribution of PS providers and their prescribing history. Up to 24,048 patients with CIF were identified, equivalent to 75 patients per million. CIF affected people of all ages, being more prevalent in women than in men. Many providers signed PS orders for small patient groups over short time periods, whereas few providers signed PS orders for large patient groups long term, indicating a lack of centralization. The distribution of PS providers suggested a disparity in healthcare coverage in rural vs urban areas, leading to patients traveling considerable distances to receive PS prescriptions. This may be exacerbated by a decline of providers with expertise in CIF and nutrition. Healthcare disparities for patients with CIF have likely been obscured by the lack of CIF-specific diagnostic and procedure codes, obliging providers to code for their patients under other codes. Effective policy changes, including centralized care, revision of reimbursement models, and expansion of nutrition-focused education in addition to the newly introduced International Classification of Diseases codes, are needed to provide the best care for patients.

Cost Drivers in Two-Stage Treatment of Hip Periprosthetic Joint Infection With an Antibiotic Coated Cement Hip Spacer

BackgroundThe current gold standard for treating chronic Periprosthetic Joint Infection (PJI) is a 2-stage revision arthroplasty. There has been little investigation into what specific patient and operative factors may be able to predict higher costs of this treatment. MethodsAn institutional electronic health record database was retrospectively queried for patients who developed a PJI after a total hip arthroplasty, and underwent removal of the prosthesis and implantation of an antibiotic-impregnated articulating hip cement spacer. Patient demographics, surgical variables, hospital readmissions, emergency department visits, and post-operative complications were collected. Total costs were captured through an internal accounting database through 2 years post-operatively. Negative binomial regressions were utilized for multivariable analyses. A total of 55 hips with PJI were available for cost analyses. ResultsA comorbidity index score was associated with a 70% increase (Odds Ratio (OR): 1.7 [1.18-2.5], P = .003) in total costs at 2-years. Illicit drug use was associated with a 70% increase in costs at 1-year post-operatively (OR 1.7 [1.18-2.5], P = .003). Metal-on-poly liners were associated with a 22% decrease in cost at 2-years post-operatively when compared to Cement-on-Bone articulating spacers, and Metal-on-poly -constrained liners accounted for 38% lower costs at 1-year (OR 0.62 [0.44-0.87], P = .004). Use of an intraoperative extended trochanteric osteotomy was associated with a 46 and 61% increase in cost at 1-year (OR 1.46 [1.14-1.89]) and 2-years (OR 1.61 [1.26-2.07], P < .001) post-operatively. ConclusionAge, comorbidity index score, drug use, and extended trochanteric osteotomy were associated with increased costs of PJI treatment. This may be used to improve reimbursement models and target areas of cost savings.

Impact of Medicare eligibility on informal caregiving for surgery and stroke.

To assess whether the intensity of family and friend care changes after older individuals enroll in Medicare at age 65. Health and Retirement Study survey data (1998-2018). We compared informal care received by patients hospitalized for stroke, heart surgery, or joint surgery and who were stratified into propensity-weighted pre- and post-Medicare eligibility cohorts. A regression discontinuity design compared the self-reported likelihood of any care receipt, weekly hours of overall informal care, and intensity of informal care (hours among those receiving any care) at Medicare eligibility. Not applicable. A total of 2270 individuals were included; 1674 (73.7%) stroke, 240 (10.6%) heart surgery, and 356 (15.7%) joint surgery patients. Mean (SD) care received was 20.0 (42.1) weekly hours. Of the 1214 (53.5%) patients who received informal care, the mean (SD) care receipt was 37.4 (51.7) weekly hours. Mean (SD) overall weekly care received was 23.4 (45.5), 13.9 (35.8), and 7.8 (21.6) for stroke, heart surgery, and joint surgery patients, respectively. The onset of Medicare eligibility was associated with a 13.6 percentage-point decrease in the probability of informal care received for stroke patients (p=0.003) but not in the other acute care cohorts. Men had a 16.8 percentage-point decrease (p=0.002) in the probability of any care receipt. Medicare coverage was associated with a substantial decrease in family and friend caregiving use for stroke patients. Informal care may substitute for rather than complement restorative care, given that Medicare is known to expand the use of postacute care. The observed spillover effect of Medicare coverage on informal caregiving has implications for patient function and caregiver burden and should be considered in episode-based reimbursement models that alter professional rehabilitative care intensity.

On Structural Racism and Mental Illness

On Structural Racism and Mental Illness

Procedural Trends in Medicare Reimbursement and Utilization for Breast Reconstruction: 2000-2019.

Development of appropriate reimbursement models for breast reconstruction in the United States requires an understanding of relevant economic trends. The purpose of this study is to evaluate longitudinal patterns in Medicare reimbursement for frequently performed breast reconstruction procedures between 2000 and 2019. Reimbursement data for 15 commonly performed breast reconstruction procedures were analyzed using the Centers for Medicare & Medicaid Services Physician Fee Schedule Look-Up Tool for each Current Procedural Terminology code. By utilizing changes to the US consumer price index, monetary data were adjusted for inflation to 2019 US dollars. Inflation-adjusted trends were used to calculate average annual and total percentage changes in reimbursement over time. From 2000 to 2019, average adjusted reimbursement for all procedures fell by 13.32%. All procedures demonstrated a negative adjusted reimbursement rate other than immediate insertion of breast prosthesis, which increased by 55.37%. The largest mean decrease was observed in breast reconstruction with other technique (-28.63%), followed by single pedicle transverse rectus abdominis myocutaneous flap (-26.02%), single pedicle transverse rectus abdominis myocutaneous flap with microvascular anastomosis (-23.33%), latissimus dorsi flap (-19.65%), and free flap reconstruction (-19.36%). There has been a steady yet substantial decline in Medicare reimbursement for the majority of breast reconstruction procedures over the last 20 years. Given increasing medical costs and the financial uncertainty of the US health care system, an understanding of Medicare reimbursement trends is vital for policymakers, administrators, and physicians to develop agreeable reimbursement models that facilitate growth and economic vitality of breast reconstruction in the United States.

Potential Patient Bias by Insurance Coverage on CG-CAHPS Surveys: Impact on Physician Reimbursement

Objectives: Investigate the relationship between payor type and patient experience scores. Design: Cross-sectional retrospective study. Setting: Academic orthopaedic outpatient clinic. Patients: All patients seen in our clinic were given a Press Ganey survey. 2,934 surveys were collected between January 1, 2016 and December 31, 2020. Intervention: Press Ganey patient satisfaction survey overall satisfaction with physician. Main outcome measurement: Physician overall rating by patients stratified according to payor type. Results and conclusions: Medicare patients reported the highest satisfaction scores (91.98 ± 0.06), followed by Worker’s Compensation (90.49 ± 0.12), other government coverage (89.91 ± 0.45), commercial insurance (89.36 ± 0.12), Medicaid (88.74 ± 0.30), and self-pay/uncompensated (88.26 ± 0.48). ANOVA analysis resulted in an F value of 270.2205 (p &lt; 0.001). Tukey-Kramer demonstrated statistically significant difference between the means of all payor groups except Medicaid vs. self-pay/uncompensated. Our data indicates that patient experience scores are influenced by payor type. These biases may negatively impact physician reimbursement, even in the setting of high-quality care. Thus, orthopedic physicians should be mindful of payor type bias when selecting MIPS quality reporting metrics, and policymakers should consider adjusting reimbursement models according to payor-mix. Level of Evidence: Level III Keywords: Business, Insurance, Patient Bias, Reimbursement (J Ortho Business 2022; Volume 2, Issue 3:pages 1-4)

Pharmacy Practice Standards for Outpatient Nephrology Settings

Patients with kidney disease represent a medically complex group of patients with high medication burdens that could benefit from clinical pharmacy services as part of the interdisciplinary care team to optimize medication use. The “Advancing American Kidney Health” executive order includes new value-based reimbursement models to be tested by the Center for Medicare and Medicaid Innovation beginning January 2021 and January 2022. Advancing American Kidney Health executive order poses opportunities for the inclusion of comprehensive medication management. Following an iterative process integrating input from a diverse expert panel, published standards, clinical practice guidelines, peer review, and stakeholder feedback, our group developed practice standards for pharmacists caring for patients with kidney disease in health care settings. The standards focus on activities that are part of direct patient care and also include activities related to public health and advocacy, population health, leadership and management, and teaching, education and dissemination of knowledge. These standards are intended to be used by a variety of professionals, from pharmacists starting new practices to practice managers looking to add a pharmacist to the clinical team, to create standardization in services provided.

The state of the art for artificial intelligence in lung digital pathology.

Lung diseases carry a significant burden of morbidity and mortality worldwide. The advent of digital pathology (DP) and an increase in computational power have led to the development of artificial intelligence (AI)‐based tools that can assist pathologists and pulmonologists in improving clinical workflow and patient management. While previous works have explored the advances in computational approaches for breast, prostate, and head and neck cancers, there has been a growing interest in applying these technologies to lung diseases as well. The application of AI tools on radiology images for better characterization of indeterminate lung nodules, fibrotic lung disease, and lung cancer risk stratification has been well documented. In this article, we discuss methodologies used to build AI tools in lung DP, describing the various hand‐crafted and deep learning‐based unsupervised feature approaches. Next, we review AI tools across a wide spectrum of lung diseases including cancer, tuberculosis, idiopathic pulmonary fibrosis, and COVID‐19. We discuss the utility of novel imaging biomarkers for different types of clinical problems including quantification of biomarkers like PD‐L1, lung disease diagnosis, risk stratification, and prediction of response to treatments such as immune checkpoint inhibitors. We also look briefly at some emerging applications of AI tools in lung DP such as multimodal data analysis, 3D pathology, and transplant rejection. Lastly, we discuss the future of DP‐based AI tools, describing the challenges with regulatory approval, developing reimbursement models, planning clinical deployment, and addressing AI biases. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Rural mistrust of public health interventions in the United States: A call for taking the long view to improve adoption.

Rural mistrust of public health interventions in the United States: A call for taking the long view to improve adoption.

A New Agenda for Optimizing Investments in Community Mental Health and Reducing Disparities

The Biden-Harris Administration's FY22 budget includes $1.6 billion for the Community Mental Health Services Block Grant program, more than double the FY21 allocation, given the rising mental health crises observed across the nation. This is timely since there have been two interrelated paradigm shifts: one giving attention to the role of the environmental context as central in mental health outcomes, the other moving upstream to earlier mental health interventions at the community level rather than only at the individual level. An opportunity to reimagine and redesign the agenda of mental health research and service delivery with marginalized communities opens the door to more community-based care interventions. This involves establishing multisector partnerships to address the social and psychological needs that can be addressed at the community level rather than the clinical level. This will require a shift in training, delivery systems, and reimbursement models. The authors describe the scientific evidence justifying these programs and elaborate on opportunities to target investments in community mental health that can reduce disparities and improve well-being for all. They select levers where there is some evidence that such approaches matter substantially, are modifiable, and advance the science and public policy practice. They conclude with specific recommendations and the logistical steps needed to support this transformational shift.

Prototype precision oncology learning ecosystem: Norwegian precision cancer medicine implementation initiative.

e13634 Background: Norway, a country with a publicly funded health care system, was in 2018-19 lagging behind with respect to implementation of precision cancer medicine (PCM). Methods: Our approach mid-2019 was very simple and set out three aims: i) To establish access to advanced molecular diagnostics to allow identification and stratification of cancer patients into clinical trials; ii) To increase the volume of clinical trials with a PCM approach to gain experience and build competence; and iii) In parallel work for implementation of PCM into standard of care. Results: In a trans-disciplinary project we worked along four lines: i) Gathered support to have oncologists, hematologists, pathologists and cancer researchers join a nation-wide, bottom-up initiative with a few common priorities; ii) Liaised with executives and regulators in regional health care systems, The Ministry of Health and other public stakeholders and charities to have the top-down approaches meet the bottom-up initiative; iii) Aligned with industry to explore the possibility of a public-private partnership and iv) Coordinated with other PCM initiatives internationally. Over the past two years we have thus built and raised funding for: a) The InPreD-Norway national infrastructure delivering precision cancer diagnostics for patient identification and stratification into clinical trials (publicly reimbursed) and operating the national molecular tumor board; b) the IMPRESS-Norway national researcher-initiated PCM intervention trial (https://impressnorway.com), which opened for inclusion Q2 2021 and runs at all hospitals that treat cancer patients (18 hospitals). The trial is modelled on and coordinated with the Dutch DRUP trial and aligned with similar trials in the Nordic countries; c) the INSIGHT/INCLUDE projects for research on control cohorts, use of real world evidence (RWE), health economics and reimbursement models, and ethics, legal aspects and governance; and d) the CONNECT public-private partnership (https://www.connectnorway.org) for PCM implementation with 29 partners (14 pharma &amp; biotech companies, 9 public partners and 4 NGOs) for interaction with InPreD and IMPRESS initiatives and providing a forum that includes regulators and payors for policy discussions of reimbursement models and regulatory framework. Conclusions: Our experience could serve as a model for building a functioning ecosystem for implementation of PCM. Unique aspects include the nation-wide initiative, the population effect of the diagnostics to be offered and the integration of a public-private partnership.