Reimbursement Practices Research Articles

Inpatient Teledermatology: a Review.

Purpose of ReviewInpatient teledermatology is a rapidly growing field with significant potential to add value and streamline patient care. This review summarizes the current literature on inpatient teledermatology, primarily focusing on its diagnostic and clinical management utility as compared to live dermatologic evaluation.Recent FindingsThe COVID-19 pandemic has accelerated the adoption of inpatient teledermatology, which has been shown to be comparable to live hospitalist evaluation for triage, diagnosis, and management of hospitalized patients for a wide variety of conditions. Despite its comparative cost-effectiveness and recent changes in reimbursement practices, inpatient teledermatology still lacks sufficient reimbursement incentive for widespread implementation.SummaryInpatient teledermatology is an effective, efficient, accurate, and cost-effective means of managing the hospital burden of skin disease, especially in areas where access to dermatologic care is limited. It is essential that dermatologists and referring providers comprehend the use and potential pitfalls of inpatient teledermatology to effectively incorporate it into hospital practice.

How Do We Jump-Start Self-measured Blood Pressure Monitoring in the United States? Addressing Barriers Beyond the Published Literature.

Hypertension is highly prevalent in the United States, and many persons with hypertension do not have controlled blood pressure. Self-measured blood pressure monitoring (SMBP), when combined with clinical support, is an evidence-based strategy for lowering blood pressure and improving control in persons with hypertension. For years, there has been support for widespread implementation of SMBP by national organizations and the federal government, and SMBP was highlighted as a primary intervention in the 2020 Surgeon General's Call to Action to Control Hypertension, yet optimal SMBP use remains low. There are well-known patient and clinician barriers to optimal SMBP documented in the literature. We explore additional high-level barriers that have been encountered, as broad policy and systems-level changes have been attempted, and offer potential solutions. Collective efforts could modernize data transfer and processing, improve broadband access, expand device coverage and increase affordability, integrate SMBP into routine care and reimbursement practices, and strengthen patient engagement, trust, and access.

The Impact of Reimbursement Practices on the Pharmaceutical Market for Off-Patent Medicines in Slovakia.

Background: The aim of this study was to investigate the impact of selected legislative initiatives and their implementation for off-patent medicinal products in Slovakia compared with the rest of the Visegrád Group (V4 countries). Methods: We analyzed the development of applications for the reimbursement of generic and biosimilar drugs. Particular emphasis was placed on a) the availability and penetration of biosimilars from 2006 to 2020 in Slovakia, b) a comparative analysis of biosimilars in V4 countries based on the national reimbursement lists of medicinal products for August 2021. Data relating to the sales of generic and biosimilar medicines in Czechia, Hungary, Poland, and Slovakia were based on the IQVIA MIDAS MAT July 2021. Results: The number of applications for the reimbursement of generic drugs decreased from 296 in 2016 to 165 in 2020. In financial terms, the sales of generic medicines in Slovakia increased from 21.7% in 2015 to 22.3% in 2020. Over the same period, the sales of generic drugs in Poland fell from 40.4% in 2015 to 35.0% in 2020, from 26.2 to 22.1% in Hungary, and from 29.6 to 20.4% in Czechia. When considering the 66 biosimilars registered by the European Medicines Agency 38 drugs (58%) were available on the Slovak market as of August 1, 2021; this compared to 32 drugs (48%) in Poland, 38 drugs (58%) in Hungary, and 40 drugs (61%) in Czechia. In financial terms, the sales of biosimilars in Slovakia increased from 0.94% in 2015 to 2.00% in 2020. Over the same period, the sales of biosimilars in Poland increased from 0.59% in 2015 to 1.29% in 2020, from 0.72 to 2.23% in Hungary, and from 0.76 to 2.15% in Czechia. Conclusion: To intensify the use of generic and biosimilar medicines, we suggest the comprehensive re-evaluation of combinations of the three-threshold entry, the amount of mandatory price reductions, and external reference pricing requirements (as the average of the three lowest prices among the official prices of a medicinal product in other Member States) for generic and biosimilar drugs. We also suggest cancellation of the exception from the fixed co-payment of the insured.

Disrupting the biological clock: Fertility benefits, egg freezing and proactive fertility management.

In the last decade, the in-vitro fertilization (IVF) sector has witnessed a shift from so-called ‘reactive IVF’ to a new model of proactive fertility care. Whereas IVF was traditionally developed to treat people who found they were unable to conceive, the indication for IVF has broadened significantly to include a much wider group of potential patients through a new focus on proactive treatment of future (in)fertilities. This shift combines a number of new trends pertaining to preservation, prediction, private equity and platformization, all of which have gained influence in contemporary assisted reproduction. This article focuses on the emergence of company-sponsored fertility benefits, which combines each of these trends.Whereas fertility benefits – especially egg freezing insurance – have primarily been discussed in terms of women’s empowerment or disenfranchisement, this article instead calls attention to the discursive, clinical and infrastructural shifts in contemporary assisted reproduction that have emerged with the rising popularity of these benefits. The analysis addresses these underdiscussed aspects of fertility benefits by focusing on the dynamics of demand; the shifts in the rationalization of intensified treatment pathways in the face of new reimbursement practices; and the online, platform-based infrastructures that are built to provide these treatments. In doing so, it analyses how this remaking of fertility towards an ethos of proactive fertility management reflects broader capitalist tailwinds.

The Bridge Between Racial Justice and Clinical Practice.

The Bridge Between Racial Justice and Clinical Practice.

Coming Up…

Virtual: A meeting presented by the National Institute on Drug Abuse entitled “Research needed to advance the impact of medications for opioid use disorder: Focus on benefit design and payor reimbursement practices” will be held Oct. 25, 1:00 – 5:00 pm. For more information, go to https://apps1.seiservices.com/nida/nidamoud/

AMA Code of Medical Ethics' Opinions Related to Palliative Surgical Care.

The AMA Code of Medical Ethics offers guidance on the significance of palliative surgical care in Opinion 5.6, "Sedation to Unconsciousness in End-of-Life Care," and Opinion 5.5, "Medically Ineffective Interventions." The American Medical Association's House of Delegates policies further outline ways in which physicians should navigate palliative care intervention through spreading awareness of and advancing research on palliative care and improving reimbursement practices. This article defines palliative care, examines the risks associated with palliative surgery, and discusses AMA Code guidance.

Strategies to Improve Video Visit Use in Persons With Liver Disease

Strategies to Improve Video Visit Use in Persons With Liver Disease

Money makes the world go 'round: A qualitative examination of the role funding plays in large-scale implementation and sustainment of youth evidence-based practice.

Funding is posited to affect evidence-based practice implementation, yet the complex interplay between financial matters and successful implementation is understudied. This study examined stakeholder perspectives on the impact of funding in evidence-based practice implementation. All participants were key stakeholders (e.g., clinicians, case managers, agency leaders; N = 41) involved in a trauma-focused cognitive-behavioral therapy implementation effort using a community-based learning collaborative model within the community's child welfare system. Semistructured interviews were conducted and qualitatively analyzed as part of a program evaluation of the implementation effort. Funding emerged as a key theme influencing implementation within this program evaluation from the perspective of all stakeholders. Thirty-four participants (83%) independently raised funding as an important factor affecting implementation outcomes across seven specific themes: (a) the impact of privatization, (b) turfism, (c) money as a primary implementation facilitator, (d) implementation costs impacting participation, (e) burden associated with funding evaluation efforts, (f) need for reimbursement practices to align with the use of trauma-informed treatment, and (g) a sense of shared mission to serve clients above money. Recommendations for addressing these challenges are provided. Future research should examine funding qualitatively and quantitatively across diverse communities and funding systems to improve understanding of the impact of funding on implementation and, ultimately, care provided to clients. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The challenge of value-based pricing in combination therapy: the case of trastuzumab and pertuzumab in HER2+ metastatic breast cancer

ABSTRACT Background Under current reimbursement (CR) practice even though an add-on drug in a combination therapy may produce marginal value in terms of health gain, the original therapy may also share in the reward for this additional value. We examine an alternative ‘marginal value-based reimbursement’ (MVBR) model in which an original therapy would not share in the marginal value. Methods In a case study for treatment of HER2+ metastatic breast cancer, we computed the incremental cost-effectiveness ratios (ICERs) of adding pertuzumab to trastuzumab and docetaxel (PHT) vs. trastuzumab and docetaxel (HT) under the CR and the MVBR models, respectively. We further estimated the revised cost of pertuzumab under three alternative willingness-to-pay thresholds based on (a) using the current ICER of PHT vs. HT, (b) the historical ICER of HT vs. docetaxel, and (c) applying the oft-used $150,000/quality-adjusted life year (QALY) gained. Results If reimbursement were changed from CR to MVBR, at the current price of pertuzumab, the ICER would decline from $409,213 to $323,236/QALY gained. If the price were adjusted under the three thresholds, the payment for pertuzumab would be increased by between 32% and 93%. Conclusion The proposed MVBR model would provide a stronger economic incentive to develop add-on drugs.

Policy solutions to address community pharmacy working conditions

ObjectiveIncreasing attention has been drawn to poor working conditions in community pharmacy, the impact on patient safety, and the role of pharmacy benefit managers (PBMs) in the United States. This study assessed community pharmacists’ perceptions of potential solutions to improve working conditions. MethodsThis mixed-methods, survey-based study explored pharmacists’ proposed solutions for improving working conditions. The participants’ perceptions of solutions at the company and state or national levels were assessed using a 7-point Likert-type response format (from 1 = strongly disagree to 7 = strongly agree). Multiple regression assessed the relationships between participant perceptions and pharmacy type (e.g., national chain, grocery, or independent), pharmacy degree, age, average number of prescriptions processed daily (prescription volume), and years of experience. The participants’ perceptions of how to improve working conditions were explored to provide more depth and nuance to the understanding of these issues. ResultsThe sample size was 1222 participants. Respondents working for national chains were statistically significant more in favor of limiting the number of prescriptions verified per pharmacist and less in favor of addressing reimbursement issues than those working for grocery or big-box stores (P = 0.001 and P = 0.006, respectively) and independent pharmacies (P < 0.001 and P < 0.001, respectively), when controlling for years of experience, degree, and prescription volume. Although addressing staffing issues and changing corporate priorities were immediate concerns, the participants felt that regulating PBM reimbursement practices should be the first priority. ConclusionIdentifying solutions from employee stakeholders may be an effective way to inform actions that both employers and extraorganizational entities can take to improve pharmacist working conditions and patient care. Restricting PBMs was the most preferred solution, followed by direct and indirect reimbursement for nondispensing services. However, working conditions in community pharmacy are influenced by multiple factors that often are dependent on one another. Thus, a multifaceted approach will likely be required to improve working conditions.

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

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

Financial Reimbursement and Enteral Access

Enteral access procedures can represent a significant proportion of many surgical and gastroenterologist’s practices (Reference) and a fundamental understanding of coding and reimbursement practices can assist in ensuring compensation for time, energy, and expertise devoted to these efforts. There is minimal medical literature and training available to clinicians to allow for some rudimentary comprehension of this very complex system. This review will discuss the basics of coding terminology and focus specifically on factors relevant to enteral access.

A Preliminary Overview of Music Therapy Reimbursement Practice in the United States

Abstract Music therapy services are currently being reimbursed through state and private insurance funding streams, yet to date, there is no known systematic exploration on music therapy reimbursement practices. Such information would be helpful to include when communicating with third-party payers and can assist in tracking reimbursement trends. Thus, we sought to provide baseline information on how music therapy services are currently being reimbursed in the United States, with a focus on approved treatment parameters, referral sources, Current Procedural Terminology (CPT) codes used, and types of music interventions and music therapy experiences implemented. Board-certified music therapists in private practice who had successfully obtained reimbursement for music therapy services between 2012 and 2018 completed a 28-item online survey. In total, 7 respondents provided information on 55 unique reimbursement cases from 5 different states, most of which were based on Medicaid waiver programs. We conducted descriptive analyses to summarize music therapy reimbursement practices. Most of the clients were referred by doctors or physician’s assistants. The most common CPT code utilized was 97530 (Therapeutic Activities, one-on-one, each 15 minutes), and most of the International Classification of Diseases, 10th Revision (ICD-10) diagnostic codes were based on specific diagnoses rather than general clinical needs. In most of the cases, reimbursement of music therapy was ongoing, and services incorporated a variety of music therapy methods, with few specific music interventions identified. Most notably, reimbursement practice varied by state; thus, we recommend the creation and dissemination of state-specific surveys.

Hospital responses to the refinement of reimbursements by treatment intensity in DRG systems.

Many OECD countries have replaced per-diem hospital reimbursement with lump sum payments by diagnosis-related groups. This study analyzes hospital responses to a large-scale refinement of reimbursement practices in Germany on January 1, 2006, in which regulating authorities introduce reimbursements by treatment intensity in the market for stroke disorder. We find that the share of admissions receiving high-intensity treatments jumps by approximately 7 percentage points around the turn of the year. At the same time, a decrease in the average clinical severity of patients receiving these high-intensity treatments reveals that the marginal high-intensity treated patient in 2006 might be less appropriate for high-intensity treatments compared to 2005. We do not find accompanying (short-term) changes in the quality of care, such as decreases in in-hospital mortality.

PIN143 Analysis of the Time to Market Access in Bulgaria of New Daa Medicines for Chronic HCV Infection Authorized UNDER the EMA Specific Procedures for EARLY Access

European medicines agency (EMA) supports early patient access to innovative therapies, especially in areas with unmet medical needs or high social burden (oncology, rare diseases, chronic diseases, etc) with the introduction of several specific procedures - conditional approval, accelerated assessment, approval under exceptional circumstances and compassionate use. The objective of the study is to evaluate time to market access since marketing authorization of new direct acting antivirals (DAA) for HCV. First, we analysed the EMA database for type of specific procedure and the Bulgarian Positive drug list (PDL) for time of inclusion of the new DAAs. Time to market access is evaluated as the elapsed time from EMA's marketing authorization to inclusion in Bulgaria's Positive Drug List as well as to the actual time of reimbursement by the National Health Insurance Fund Second (NHIF). EMA introduced the specific procedures for early access in 2002 and since then has issued 29 conditional approvals, 34 exceptional circumstances and 39 accelerated assessments. 7 out 8 authorized DAAs for chronic HCV infection are authorized with accelerated assessment. All of the medicines are included in PDL as time inclusion in PDL in Bulgaria since marketing authorization in the EU is 1-1.5 years on average in 2014-2016 and 2 years in 2017-2019. Time to reimbursement varies from 6 months to 1 to year since inclusion in PDL. The difference in time to market access between the two observed periods may be attributed to the dynamic pharmaceutical legislation in 2016-2019 which experienced a lot of changes in the health technology assessment domain. Nevertheless there are mechanisms in place to foster patient access of innovative medicines for unmet medical needs and diseases with high social burden, there are still some barriers to earlier market access attributed to nationally specific pricing and reimbursement practices.

PDG45 “the Domino Effect”: An International Comparison of Economic Evaluation Submission Sequences in Advanced Melanoma

Pharmaceutical companies apply for reimbursement at different times in every country. The rationale for such practices resides in opaque profit-maximising launch strategies, influenced by factors like reference pricing. The objective was to identify sequences in the timing of drug economic evaluation submissions across the world. First, relevant economic evaluation bodies for medicines’ reimbursement, or lack thereof, were identified. Advanced melanoma was chosen as a recent therapy area with few drugs and homogeneous indications to validate our hypothesis before widening focus. Relevant databases were found and searched for the main treatments: nivolumab, pembrolizumab, ipilimumab, dabrafenib, trametinib, cobimetinib, vemurafenib, and their combinations. Submission dates were collected and ranked. Each country has its specific reimbursement process, with few countries leveraging economic evaluation. Those who do seldom share their conclusions. Even fewer publish details about the timelines of assessments, especially for older products. When they are available, methodological difficulties arise from interpreting the different types of dates published. Based on the data available, we estimated the months of submission for Canada, Brazil, England, France, Ireland, New Zealand, Norway and Romania. Submissions for treatments were made in a different sequence for all products and no trend can be identified, even for the same company, and some countries are not applied to. The main commonality is that England is generally one of the first submission countries. Pharmaceutical companies’ launch strategies seem to go beyond a set sequence. Sequences cannot be identified through economic submissions for advanced melanoma products. This reflects varied reimbursement practices but also a lack of transparency conceivably politics or resource-driven. The disparities between countries highlight the need for harmonisation that is an incentive for agencies to collaborate through organisations like EUnetHTA. Disclosing information used for decision making is key to involving more stakeholders like patients in HTA processes and improving accountability.

Towards a fair and transparent research participant compensation and reimbursement framework in Vietnam.

BackgroundProviding compensation for participants in clinical research is well established and while international guidelines exist, defining a context-specific and fair compensation for participants in low-resource settings is challenging due to ethical concerns and the lack of practical, national compensation and reimbursement frameworks.MethodsWe reviewed Oxford University Clinical Research Unit (OUCRU) internal reimbursement documentation over a 10-y period and conducted a scoping literature review to expand our knowledge of compensation and reimbursement practices including ethical concerns. We developed a preliminary reimbursement framework that was presented to community advisory boards (CAB) and clinical investigators to assess its applicability, fairness and transparency.ResultsThe main topics discussed at the workshops centered on fairness and whether the reimbursements could be perceived as financial incentives. Other decisive factors in the decision-making process were altruism and the loss of caregivers’ earnings. Investigators raised the issue of additional burdens, whereas the CAB members were focused on non-monetary elements such as the healthcare quality the patients would receive. All elements discussed were reviewed and, where possible, incorporated into the final framework.ConclusionOur new reimbursement framework provides a consistent, fair and transparent decision-making process and will be implemented across all future OUCRU clinical research in Vietnam.

Development and Implementation of an Influenza Point-Of-Care Testing Service in a Chain Community Pharmacy Setting.

Point-of-care testing is becoming increasingly commonplace in community pharmacy settings. These tests are often used in the management of chronic disease, such as blood sugar, hemoglobin A1c and lipid levels, but can also be used for acute conditions such as influenza infection and group A streptococcus pharyngitis. When used for these acute infections, point-of-care tests can allow for pharmacist-initiated treatment. In this study, an influenza point-of-care testing service was developed and implemented in a chain community pharmacy setting and a retrospective review was conducted to assess the service. Of patients tested, 29% tested positive for influenza A and/or B; 92% of patients testing positive received a prescription as a result. While health insurance cannot be billed for the service due to current pharmacy reimbursement practices, this did not appear to negatively affect patient willingness to participate. As point-of-care testing services become more commonplace in community pharmacy settings, patient awareness will similarly increase and allow for more widespread access to acute outpatient care.

PARC report: a perspective on the state of clinical pharmacogenomics testing.

In this Perspective, the authors discuss the state of pharmacogenomics testing addressing a number of advances, challenges and barriers, including legal ramifications, changes to the regulatory landscape, coverage of testing and the implications of direct-to-consumer genetic testing on the provision of care to patients. Patient attitudes toward pharmacogenomics testing and associated costs will play an increasingly important role in test acquisition and subsequent utilization in a clinical setting. Additional key steps needed include: further research trials demonstrating clinical utility and cost-effectiveness of pharmacogenetic testing, evidence review to better integrate genomic information into clinical practice guidelines in target therapeutic areas to help providers identify patients that may benefit from pharmacogenetic testing and engagement with payers to create a path to reimbursement for pharmacogenetic tests that currently have sufficient evidence of clinical utility. Increased adoption of testing by payers and improved reimbursement practices will be needed to overcome barriers, especially as the healthcare landscape continues to shift toward a system of value-based care.