Reimbursement Reform Research Articles

Cardiovascular Imaging Payment and Reimbursement Systems: Understanding the Past and Present in Order to Guide the Future

Uncertainty regarding the future of cardiovascular (CV) services and reimbursement systems in this era of rapid change in health care delivery may lead to further confusion among imagers. This article provides a brief history of national payment and reimbursement systems, and discusses potential changes that will impact CV imaging in the coming years. Data over the last decade are presented on payment and utilization of services to demonstrate the impact of reimbursement reforms and education on imaging use.

Medicare Reimbursement Reform for Provider Visits and Health Outcomes in Patients on Hemodialysis.

The relation between the quantity of many healthcare services delivered and health outcomes is uncertain. In January 2004, the Centers for Medicare and Medicaid Services introduced a tiered fee-for-service system for patients on hemodialysis, creating an incentive for providers to see patients more frequently. We analyzed the effect of this change on patient mortality, transplant wait-listing, and costs. While mortality rates for Medicare beneficiaries on hemodialysis declined after reimbursement reform, mortality declined more - or was no different - among patients whose providers were not affected by the economic incentive. Similarly, improved placement of patients on the kidney transplant waitlist was no different among patients whose providers were not affected by the economic incentive; payments for dialysis visits increased 13.7% in the year following reform. The payment system designed to increase provider visits to hemodialysis patients increased Medicare costs with no evidence of a benefit on survival or kidney transplant listing.

Radiology Update 2013—Things Are Looking Up after 7 Lean Years!

711 More broad-based changes in provider payments as well as newer models of care delivery will cause us to adapt. Some of these changes may, in fact, attempt to reduce the differential in compensation between primary care and subspecialty physician services. However, we are in a large boat here with many other similarly concerned specialties. In our favor, we have responded to reimbursement reforms by becoming much more efficient and more adept at managing change. The future of the specialty is quite strong. Continued innovation and collaboration with clinical colleagues have made us indispensable. Our capacity to positively impact patients’ lives is ever more obvious and increasing. Howard P. Forman Section Editor for Health Care Policy and Quality, Yale School of Medicine, Yale School of Public Health howard.forman@yale.edu

Uncertain Prognosis for High-Quality Diagnostics: Clinical Challenges, Economic Barriers and Needed Reforms

Quality healthcare, as measured by outcomes and costs, needs high-quality diagnostics whose use governs the evidence-based flow of patients from screening to treatment to outcomes monitoring. The current patent, regulatory and reimbursement environment may be inadequate to spur their development, thereby placing in jeopardy the goals of healthcare reform and the aspirations of personalized medicine. Policy actions to ensure consistent quality standards and to increase development incentives through research support, reimbursement reform, increased intellectual property protection and market-making activities may be required to obtain the well-characterized, clinically proven diagnostics that US healthcare requires.

Engaging Consumers in Medicaid Nursing Home Reimbursement Policy: Lessons From New York and Minnesota

This study draws lessons for successful consumer engagement in Medicaid nursing home (NH) reimbursement policy from New York and Minnesota. In these two states, resident advocates have influenced reimbursement policy to better encourage access, care quality, and quality of life. Twenty-four semi-structured interviews were conducted, including consumer advocates, state agency officials, legislators/legislative staff, and NH industry representatives. Transcripts were coded to identify recurring themes and patterns in responses. Related documents were reviewed as well. Interviewees report that consumer advocates should participate in NH reimbursement policy making to provide a unique perspective distinct from other stakeholder groups. Skills necessary for successful participation include developing, demonstrating, and sharing expertise to gain credibility as a legitimate actor. Effective strategies include participating on state workgroups and taskforces and developing and accessing relationships with key legislative and executive branch officials. A division of labor may be useful with those consumer advocates possessing expertise in NH reimbursement policy partnering with other organizations with the experience and resources necessary to marshal grassroots support. State and federal reimbursement reform provide opportunities for consumer advocacy influence during the design and implementation process. The experience of consumer groups in New York and Minnesota provide lessons for advocates looking to influence these and other reimbursement initiatives.

Reforming reimbursement of public hospitals in Greece during the economic crisis: Implementation of a DRG system

ObjectivesUntil recently, in-patient NHS hospital care in Greece was reimbursed via an anachronistic and under-priced retrospective per diem system, which has been held primarily responsible for continuous budget deficits. The purpose of this paper is to present the efforts of the Ministry of Health (MoH) to implement a new DRG-based payment system. MethodsAs in many countries, the decision was to adopt a patient classification from abroad and to refine it for use in Greece with national data. Pricing was achieved with a combination of activity-based costing with data from selected Greek hospitals, and “imported” cost weights. Data collection, IT support and monitoring are provided via ESY.net, a web-based facility developed and implemented by the MoH. ResultsAfter an initial pilot testing of the classification in 20 hospitals, complete DRG reimbursement data was reported by 113 hospitals (85% of total) for the fourth quarter of 2011. The recorded monthly increase in patient discharges billed with the new system and in revenue implies increasing adaptability by the hospitals. However, the unfavorable inlier vs. outlier distribution of discharges and revenue observed in some health regions signifies the need for corrective actions. ConclusionsThe importance of this reimbursement reform is discussed in light of the current crisis faced by the Greek economy. There is yet much to be done and many projects are currently in progress to support this effort; however the first cost containment results are encouraging.

The Patient‐Centered Medical Home: History, Components, and Review of the Evidence

The US healthcare system is plagued by unsustainable costs and yields suboptimal outcomes, indicating that new models of healthcare delivery are needed. The patient-centered medical home is one model that is increasingly regarded as a promising strategy for improving healthcare quality, decreasing cost, and enhancing the experience of both patients and providers. Conceptually, the patient-centered medical home may be described as combination of the core attributes of primary care-access, continuity, comprehensiveness, and coordination of care-with new approaches to healthcare delivery, including office practice innovations and reimbursement reform. Implementation efforts are gaining momentum across the country, fueled by both private-payer initiatives as well as supportive public policy. High-quality evidence on the effectiveness of the patient-centered medical home is limited, but the data suggest that, under some circumstances, patient-centered medical home interventions may lead to improved outcomes and generate moderate cost savings. Although the patient-centered medical home enjoys broad support by multiple stakeholders, significant challenges to widespread adoption of the model remain.

L5.5 The Information Based Transformation to Value Based, Personalized Healthcare

Global healthcare systems are facing fundamental challenges as well as opportunities as a result of a combination of macro-economic, technological, demographic and scientific forces. These include but are not limited to reimbursement reform, rapid advances in science, the explosion of molecular data, and financial pressures to operate more efficiently. It's widely recognized that healthcare IT (HIT) will play a critical role in addressing these challenges - whether that is viewed through the lens of new value based reimbursement schemes or molecularly driven personalized medicine. However, much of the focus on HIT has centered on the core clinical transactional systems and basic interoperability. This new paradigm will require new information management and analytical systems to successfully leverage the diversity of electronic information available to improve quality of care, understand what value means in healthcare and accelerate the translation of research discoveries into practice by providing physicians, researchers, administrators and consumers with actionable data at the right time and place. The need for these new data management systems is particularly imperative in cancer today, where new molecular profiling technologies are first being adopted in clinical practice. The bottleneck is no longer the generation of molecular data but the analysis of that data in a broader clinical context. As a result, successful research and clinical enterprises of the future will be differentiated not by the mere existence of core clinical systems, but by their ability to manage, integrate, analyze and leverage clinical, financial, genomic and other biomedical information from across their enterprise and external to their enterprise. This presentation will focus on the new HIT platforms that will be required to provide a scalable, secure platform for personalized cancer medicine that accelerates biomarker discovery, validation and ultimately decision making at the point of care. This session will also discuss the challenges associated with integrating cross platform ‘omics’ data in a manner that scales to thousands of whole genome sequences whilst integrating with longitudinal clinical data from EMRs, case reports, registries and other “real world” data sources to provide an integrated view across genotype and phenotype. [Display omitted] [Display omitted]

On reimbursement reforms and stockpiling of prescription drugs: The case of insulin

ObjectivesTo show that care should be taken in studies which aim at linking prescription drug prices to purchased quantities due to anticipation and stockpiling effects. MethodsUsing purchasing records for a 20% random sample of the entire Danish population, the effects of increasing co-payments are estimated using fixed effects techniques. ResultsThe results indicate that insulin-takers react to announced changes in reimbursement policies by stockpiling on their medications. ConclusionUsing before-and-after comparisons to identify the price responsiveness of prescription drug demand can be very misleading, when changes in co-payments are announced.

Is Clinical Decision Support the Missing Link in Prevention?

Is Clinical Decision Support the Missing Link in Prevention?

A qualitative analysis of an advanced practice nurse-directed transitional care model intervention.

The purpose of this study was to describe barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers lead by advanced practice nurses (APNs). APNs implemented an evidence-based protocol to optimize transitions from hospital to home. An exploratory, qualitative directed content analysis examined 15 narrative case summaries written by APNs and fieldnotes from biweekly case conferences. Three central themes emerged: patients and caregivers having the necessary information and knowledge, care coordination, and the caregiver experience. An additional category was also identified, APNs going above and beyond. APNs implemented individualized approaches and provided care that exceeds the type of care typically staffed and reimbursed in the American health care system by applying a Transitional Care Model, advanced clinical judgment, and doing whatever was necessary to prevent negative outcomes. Reimbursement reform as well as more formalized support systems and resources are necessary for APNs to consistently provide such care to patients and their caregivers during this vulnerable time of transition.

Policy challenges for the pediatric rheumatology workforce: Part I. Education and economics.

For children with rheumatic conditions, the available pediatric rheumatology workforce mitigates their access to care. While the subspecialty experiences steady growth, a critical workforce shortage constrains access. This three-part review proposes both national and international interim policy solutions for the multiple causes of the existing unacceptable shortfall. Part I explores the impact of current educational deficits and economic obstacles which constrain appropriate access to care. Proposed policy solutions follow each identified barrier.Challenges consequent to obsolete, limited or unavailable exposure to pediatric rheumatology include: absent or inadequate recognition or awareness of rheumatic disease; referral patterns that commonly foster delays in timely diagnosis; and primary care providers' inappropriate or outdated perception of outcomes. Varying models of pediatric rheumatology care delivery consequent to market competition, inadequate reimbursement and uneven institutional support serve as additional barriers to care.A large proportion of pediatrics residency programs offer pediatric rheumatology rotations. However, a minority of pediatrics residents participate. The current generalist pediatrician workforce has relatively poor musculoskeletal physical examination skills, lacking basic competency in musculoskeletal medicine. To compensate, many primary care providers rely on blood tests, generating referrals that divert scarce resources away from patients who merit accelerated access to care for rheumatic disease. Pediatric rheumatology exposure could be enhanced during residency by providing a mandatory musculoskeletal medicine rotation that includes related musculoskeletal subspecialties. An important step is the progressive improvement of many providers' fixed referral and laboratory testing patterns in lieu of sound physical examination skills.Changing demographics and persistent reimbursement disparities will require workplace innovation and legislative reform. Reimbursement reform is utterly essential to extending patient access to subspecialty care. In practice settings characterized by a proportion of Medicaid-subsidized patients in excess of the national average (> 41%), institutional support is vital. Accelerating access to care will require the most efficient deployment of existing, limited resources. Practice redesign of such resources can also improve access, e.g., group appointments and an escalating role for physician extenders. Multidisciplinary, team-oriented care and telemedicine have growing evidence basis as solutions to limited access to pediatric rheumatology services.

Physicians' Opinions About Reforming Reimbursement

Several strategies have been proposed to reform physician reimbursement while improving quality of care. Despite much debate, physicians' opinions regarding reimbursement reform proposals have not been objectively assessed. We conducted a national survey of randomly selected physicians between June 25 and October 31, 2009. Physicians rated their support for several reimbursement reform proposals: rewarding quality with financial incentives, bundling payments for episodes of care, shifting payments from procedures to management and counseling services, increasing pay to generalists, and offsetting increased pay to generalists with a reduction in pay for other specialties. Support for the different reform options was compared with physician practice characteristics. The response rate was 48.5% (n = 1222). Four of 5 physicians (78.4%) indicated that under Medicare, some procedures are compensated too highly and others are compensated at rates insufficient to cover costs. Incentives were the most frequently supported reform option (49.1%), followed by shifting payments (41.6%) and bundling (17.2%). Shifting payments and bundling were more commonly supported by generalists than by other specialists. There was broad support for increasing pay for generalists (79.8%), but a proposal to offset the increase with a 3% reduction in specialist reimbursement was supported by only 39.1% of physicians. Physicians are dissatisfied with Medicare reimbursement and show little consensus for major proposals to reform reimbursement. The successful adoption of payment reform proposals may require a better understanding of physicians' concerns and their willingness to make tradeoffs.

Presenteeism: Are We Hurting the Patients We are Trying to Help?

Presenteeism: Are We Hurting the Patients We are Trying to Help?

How to buy a medical home? Policy options and practical questions.

In this paper, we describe a range of payment options to support the PCMH, identifying their conceptual strengths and weaknesses. These include enhanced FFS payment for office visits to the PCMH; paying additional FFS for "new" PCMH services; variations of traditional FFS combined with new PCMH-oriented per patient per month capitation; and combined capitation payments for traditional primary care medical services as well as new medical home services. In discussing options for PCMH payment reform we consider issues in patient severity adjustment, performance payment, and the role of payments to community service organizations to collaborate with the PCMH. We also highlight some of the practical challenges that can complicate reimbursement reform for primary care and the PCMH. Through this discussion we identify key dimensions to provider payment reform relevant to promoting enhanced primary care through the patient centered medical home. These consist of paying for the basic medical home services, rewarding excellent performance of medical homes, incentivizing medical home connections to other community health care resources, and overcoming implementation challenges to medical home payments. Each of these overarching policy issues invokes a substantial subset of policy relevant research questions that collectively comprise a robust research agenda. We conclude that the conceptual strengths and weaknesses of available payment models for medical home functions invoke a complex array of options with varying levels of real-world feasibility. The different needs of patients and communities, and varying characteristics of practices must also be factors guiding PCMH payment reform. Indeed, it may be that different circumstances will require different payment approaches in various combinations.

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

Individuals with serious mental illness often are unable to access consumer- and family-oriented community care, resulting in repeated hospitalizations, incarceration, and homelessness. The "medical home" concept was developed in primary care to provide accessible and accountable services for individuals with chronic medical conditions. Building on the work done in primary care, the authors propose a "mental health home." The model of care incorporates medical home characteristics, such as access to and coordination of services, integration of primary and preventive care, adoption of recovery orientation and evidence-based practices, and family and community outreach. Barriers to and strategies for implementation of mental health homes are discussed.

Increased antimicrobial consumption following reimbursement reform in Turkey

This study examined antibiotic utilization patterns in Turkey between 2001 and 2006. A comprehensive collection and analysis of Turkish antibiotic data from 2001 to 2006 was conducted. The anatomical therapeutic chemical (ATC) classification and the defined daily dose (DDD) methodology were used to calculate antibiotic consumption. Data were presented as DDD/1000 inhabitant-days, and the relation between antimicrobial consumption and governmental reimbursement policy was evaluated. Total utilization of antibiotics increased from 14.62 to 31.36 DDD/1000 inhabitant-days between 2001 and 2006. The largest increase took place after the implementation of social insurance reform (SIR) in 2005, as evidenced by the DDD ratio increasing 1.87-fold after SIR went into effect. The largest increase occurred in the prescription of penicillins, from 7.13 in 2001 to 14.09 in 2006. In Turkey, antibiotic consumption increased markedly in recent years, in a close relationship, to a new reimbursement policy following the implementation of the SIR, which facilitated the prescription and consumption of drugs compared with the earlier SIR conditions.

How Much Time Do Physicians Spend Providing Care Outside of Office Visits?

People with chronic illness require care outside of office visits, much of which is not reimbursed under current Medicare guidelines. To describe the amount of time geriatricians spend and the nature of care they provide outside of office visits. Cross-sectional study on the time spent by physicians in clinical interactions outside of patient visits during 3 randomly sampled, 1-week periods. An academic geriatric medicine ambulatory practice. 16 physicians. Information on the method, content, outcome, and participants in clinical interactions outside of office visits was collected on a structured form. There were 472 discrete interactions, representing 296 episodes of care for 226 patients. Fifty-four percent of interactions were linked as multistep episodes, whose mean duration (range; 25th, 75th percentiles) was 18.9 minutes (3 to 70 minutes; 9, 21 minutes). Thirty-six percent of episodes involving a new medical symptom resulted in medication use, 27% resulted in an office visit, and 9% resulted in a referral to another physician. Mean time spent per physician per week was 112.2 minutes (range, 36 to 260 minutes), which represents an additional 6.7 minutes (range, 1.7 to 13.8) of care provided outside of office visits for every 30 minutes of time spent scheduled to see ambulatory patients. For a full-time physician scheduled to see 14 patients per day in 30-minute visits over a 5-day workweek, this would represent an extra 7.8 hours of clinical work per week. Data were self-reported and were limited to an academic geriatric medicine practice. Physicians spend a considerable amount of time providing care outside of office visits for patients with chronic illness. This study suggests that collecting empirical data on the amount and nature of nonreimbursed care activities is feasible and should be done in more generalizable settings to inform debates about reimbursement reform.

Pharmaceutical pricing and reimbursement reforms in Greece

Pharmaceutical price regulation in Greece is centralized. The National Drug Organization (EOF) is the main regulatory authority functioning under the auspices of the Ministry of Health and Social Solidarity. In 2004, total pharmaceutical expenditure in Greece reached the level of 2.9 billion euro, of which 77.9% were public expenditure and the remaining 22.1% private. According to Organization for Economic Cooperation and Development (OECD) data the total per-capita expenditure on pharmaceutical care in Greece is among the lowest in Europe, representing 58% of the EU-12 average. In 1998, Greece introduced a reimbursement list, and the lowest reference pricing system among the 15 European Union member states with the purpose of controlling the growth of pharmaceutical expenditure. The measures proved to be ineffective since pharmaceutical expenditure, after a short-term reduction, continued to increase at similar rates to those before the introduction of price control mechanisms. The average annual increase of pharmaceutical expenditure in Greece over the period 1998-2003 was 7.9%, which is among the highest in the OECD countries (average 6.1%). New pharmaceutical legislation, no. 3457, was enacted on May 8th 2006, aiming at greater access to medicines, improvements to citizens' quality of life, effective and efficient utilization of health resources, transparency in public management, protecting public health, and maintaining long-term financial viability of the insurance system. The innovative aspect of the new legislation is the abolition of the positive list and the establishment of a rebate system granting the National Insurance Funds a rebate rate paid by the pharmaceutical companies. The purpose of this paper is twofold. First to assess the effectiveness of the positive list introduced in 1988 in Greece, using simple econometric models. Second to present the recent pharmaceutical reforms aimed at the introduction of a rebate system and establishing reimbursement pricing based on the average of the three lowest European prices.