Reimbursement For Services Research Articles

474 Potential contribution of community pharmacists in suicide prevention in Nigeria: key informants’ perspective

Abstract Introduction Globally, over 700,000 people die by suicide yearly, and 77% of the suicide global burden is reported in Low middle-income countries, including Nigeria (1). Community pharmacists are often the most visited healthcare providers for locals in Nigeria. However, there is sparse knowledge about their contributory role in suicide prevention (2). Aim To explore key informants’ perspectives on the potential contribution of community pharmacists in Nigeria to suicide prevention and gain insight into the potential barriers and facilitators in incorporating a suicide prevention programme within community pharmacies. Method Online semi-structured interviews were conducted with global key informants. The key informants were recruited based on their expertise in suicide prevention, public health, mental health, and pharmacy practice from low- and high-income countries. In addition, key informants were either author from literature reviews or referred by the informants. All key informants were contacted through emails, agreed informants gave both verbal and written consent. The topic guide questions were modified according to each key informant’;s professional role and country. The recruitment and interviews were done from March 2022 to September 2022. The interviews were audio, and video recorded, transcribed verbatim and thematically analysed using NVivo software.Codes were generated by the lead researcher and reviewed by the study team. Results A total of 22 key informants consisting of 6 pharmacists, 5 researchers, 4 mental health consultants, 2 policy makers, 2 cognitive behavioural therapists, 2 psychiatrists and 1 suicide and self-harm analyst with different geographical background participated in this study. Each key informant presented perspective on how suicide prevention effort is being handled in their country and how the potential community pharmacist’s role in Nigeria could work. The major themes identified are :(i) The need for a suicide prevention programme in community pharmacies, and this includes (ii) Restricting access to means. This could be achieved by (iii) Education and Training, (iv) Pharmacy service reimbursement and (v) a referral system with other health professionals. (vi) stigma and (vii) pharmacy environment were highlighted as barriers. Conclusion Global Key informants were open to the community pharmacist’;s role in suicide prevention, expecting it would help fill the psychiatric professional gap in Nigeria’;s mental health system. However, some expressed concerns about community pharmacists’ lack of knowledge and awareness in this area and where they could distinctively fit in suicide prevention strategies. Perceptions of stigma underpinned much of key informants’ discussion. All key informants indicated the high existence of cultural and professional stigma and its impact on suicide prevention. This is the first study to explore a broad global perspective on community pharmacists’ role in suicide prevention. However, some key informants are registered pharmacists, and others have a particular interest in suicide prevention and training, thus may be biased towards community pharmacists’ role in suicide prevention. To further explore the practical implication of any recommendations about this role, our identified themes will help to develop our Delphi study to determine consensus on the scope of the future contribution of community pharmacists to suicide prevention efforts in Nigeria.

502 The effects of removing the requirement for prior reimbursement approval on anticoagulant use in Ireland: A cross sectional study

Abstract Introduction Prior approval for reimbursement is a cost containment policy, aimed at reducing demand (1). It has been used temporarily in the Irish Healthcare system to deal with the initial financial challenges posed by the shift in use towards the Direct Oral Anticoagulants (DOACs) (apixaban, rivaroxaban, edoxaban and dabigatran) from warfarin. Improved safety of DOACs use was a secondary aim of this policy. The use of prior approval policies is increasing in Ireland but studies assessing their effectiveness are limited. Aim To examine the effect of removing the cost containment policy of prior approval for reimbursement of apixaban and rivaroxaban using a national pharmacy claims database. Methods The Health Service Executive-Primary Care Reimbursement Service database in Ireland was used in this cross-sectional study. The prescribing frequencies and associated costs of the oral anticoagulants; ((OACs) apixaban, rivaroxaban, and warfarin) listed in the top 100 most frequently prescribed drugs on the Community Drug Schemes (CDS), between 2018 and 2021 were examined. Levothyroxine was used as a negative control to detect any external deviances in the prescribing data records. Interrupted time series Poisson regression was used to assess the impact of removing the approval requirement of apixaban in September 2019 followed by the other DOACs in November 2020. Results The prescribing frequency of OACs increased by almost 20% during the study period. Figure1 shows the prescribing frequencies of apixaban , rivaroxaban , warfarin and levothyroxine on each of the three community drug schemes – General medical scheme (GMS), Drug payments scheme (DPS) and Long term illness scheme (LTI) during the study period.Timelines at September 2019 and November 2020 show the removal of prior approval for apixaban and all DOACs respectively. This study showed there were significant differences in the proportion of OACs prescribed among the CDS. A statistically significant decreased use of apixaban (<1%, p<0.05) occurred when prior approval was removed for all DOACs. Conclusion The removal of prior approval for reimbursement of DOACs in Ireland had a minimal impact on the prescribing frequency trends of the OACs. Future use of these potentially useful policies by healthcare systems requires careful consideration of drug type, approval criteria and length of time the policy remains in place.

MP39-06 DISPARITY IN COST AND HEALTH SERVICE USE IN TERMINAL PHASE AMONG PROSTATE CANCER PATIENTS

You have accessJournal of UrologyCME1 Apr 2023MP39-06 DISPARITY IN COST AND HEALTH SERVICE USE IN TERMINAL PHASE AMONG PROSTATE CANCER PATIENTS Ravishankar Jayadevappa, S Bruce Malkowicz, Thomas Guzzo, and Sumedha Chhatre Ravishankar JayadevappaRavishankar Jayadevappa More articles by this author , S Bruce MalkowiczS Bruce Malkowicz More articles by this author , Thomas GuzzoThomas Guzzo More articles by this author , and Sumedha ChhatreSumedha Chhatre More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003277.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Research shows considerable racial and ethnic variation in the structure and process of care that has implications for care choices and cost. Objective is to assess the racial and ethnic disparity in the cost and health service use in terminal phase among prostate cancer patients. METHODS: Population-based cohort study using data from Surveillance, Epidemiological, and End Results-Medicare (SEER-Medicare). Cohort consisted of patients diagnosed with prostate cancer between 1996 and 2013, and deceased as of 12/31/2013. One-year period prior to death was considered as terminal phase. We operationalized cost as sum of Medicare reimbursement for inpatient, outpatient and provider services. Cost during the terminal phase was assessed for four racial and ethnic groups: African American, white, Hispanic and other. We used GLM model for cost and Poisson models for health service use. Independent variable were socio-demographic and clinical characteristics. RESULTS: Between 1996 and 2013, 788,217 Medicare beneficiaries were diagnosed with prostate cancer, of which, 314,861 (39%) were deceased by end of year 2013 and constituted the study cohort. In our cohort, African American patient were youngest (mean age 71.6 years, standard deviation (Std) 8.9), and white patients were oldest (mean 74.9, std 8.5). GLM model indicated that race, age, and comorbidity were associated with cost. The health service use varied between racial and ethnic groups. A longitudinal comparison of mean cost in terminal phase for the four racial and ethnic groups is presented in Figure 1. The mean cost for all racial and ethnic groups increased over time; and African American patients had highest cost in all years, compared to other groups. CONCLUSIONS: This study is first of its kind to assess longitudinally the cost of terminal phase and associated disparity. The terminal phase cost almost doubled between 1995 and 2013, for all racial and ethnic groups, and continued to be highest for African American patients. Future studies need to address the overuse, underuse and misuse of care that may contribute to the high cost burden in the terminal phase and the associated racial and ethnic disparity in cost and health service use. Source of Funding: DoD W81XWH-19-1-0461 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e536 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ravishankar Jayadevappa More articles by this author S Bruce Malkowicz More articles by this author Thomas Guzzo More articles by this author Sumedha Chhatre More articles by this author Expand All Advertisement PDF downloadLoading ...

Medicaid Reimbursement For Psychiatric Services: Comparisons Across States And With Medicare

Medicaid is characterized by low rates of provider participation, often attributed to reimbursement rates below those of commercial insurance or Medicare. Understanding the extent to which Medicaid reimbursement for mental health services varies across states may help illuminate one lever for increasing Medicaid participation among psychiatrists. We used publicly available Medicaid fee-for-service schedules from state Medicaid agency websites in 2022 to construct two indices for a common set of mental health services provided by psychiatrists: a Medicaid-to-Medicare index to benchmark each state's Medicaid reimbursement with that of Medicare for the same set of services, and a state-to-national Medicaid index comparing each state's Medicaid reimbursement with an enrollment-weighted national average. On average, Medicaid paid psychiatrists at 81.0percent of Medicare rates, and a majority of states had a Medicaid-to-Medicare index that was less than 1.0 (median, 0.76). State-to-national Medicaid indices for psychiatrists' mental health services ranged from 0.46 (Pennsylvania) to 2.34 (Nebraska) but did not correlate with the supply of Medicaid-participating psychiatrists. As policy makers look to reimbursement rates as one strategy to address ongoing mental health workforce shortages, comparing Medicaid payment across states may help benchmark ongoing state and federal proposals.

Creating a Business Case for Success.

Health care is a highly competitive environment where managers must compete for finite resources. The Centers for Medicare & Medicaid Services-directed reimbursement models such as value-based purchasing and pay-for-performance heavily focused on quality improvement and nursing excellence are having a major impact on financial reimbursement for health care services in the United States. As such, nurse leaders must function in a business-focused environment where decisions regarding resource allocation are driven by quantifiable data, the potential return on investment, and the organization's ability to provide quality patient care in an efficient manner. It is imperative for nurse leaders to recognize the financial impact of potential additional revenue streams, as well as avoidable costs. Nurse leaders must also be skilled at translating the return on investment for nursing-centric programs and initiatives, often hidden in anecdotal terms and cost avoidance rather than revenue generation, to ensure appropriate resource allocation and budgetary assumptions. This article uses a case study framed within the business case to review a structured approach to operationalizing nursing-centric programs and highlights key strategies for success.

The Future of Public Mental Health: Challenges and Opportunities.

Policy Points Social policies such as policies advancing universal childcare to expand Medicaid coverage of home- and community-based care for seniors and people with disabilities and for universal preschool are the types of policies needed to address social determinants of poor mental health. Population-based global budgeting approaches like accountable care and total cost of care models have the potential to improve population mental health by incentivizing health systems to control costs while simultaneously improving outcomes for the populations they serve. Policies expanding reimbursement for services delivered by peer support specialists are needed. People with lived experience of mental illness are uniquely well suited to helping their peers navigate treatment and other support services.

Patient-specific Risk Factors Increase Episode of Care Costs After Lumbar Decompression.

Retrospective cohort analysis. To determine, which patient-specific risk factors increase total episode of care (EOC) costs in a population of Centers for Medicare and Medicaid Services beneficiaries undergoing lumbar decompression. Lumbar decompression is an effective option for the treatment of central canal stenosis or radiculopathy in patients unresponsive to nonoperative management. Given that elderly Americans are more likely to have one or more chronic medical conditions, there is a need to determine, which, if any, patient-specific risk factors increase health care costs after lumbar decompression. Care episodes limited to lumbar decompression surgeries were retrospectively reviewed on a Centers for Medicare and Medicaid Service reimbursement database at our academic institution between 2014 and 2019. The 90-day total EOC reimbursement payments were collected. Patient electronic medical records were then matched to the selected care episodes for the collection of patient demographics, medical comorbidities, surgical characteristics, and clinical outcomes. A stepwise multivariate linear regression model was developed to predict patient-specific risk factors that increased total EOC costs after lumbar decompression. Significance was set at P <0.05. A total of 226 patients were included for analysis. Risk factors associated with increased total EOC cost included increased age (per year) (β = $324.70, P < 0.001), comorbid depression (β = $4368.30, P = 0.037), revision procedures (β = $6538.43, P =0.012), increased hospital length of stay (per day) (β = $2995.43, P < 0.001), discharge to an inpatient rehabilitation facility (β = $14,417.42, P = 0.001), incidence of a complication (β = $8178.07, P < 0.001), and readmission (β = $18,734.24, P < 0.001) within 90 days. Increased age, comorbid depression, revision decompression procedures, increased hospital length of stay, discharge to an inpatient rehabilitation facility, and incidence of a complication and readmission within 90 days were all associated with increased total episodes of care costs.

Importance and Limitations of Healthcare Verification for Accelerating Implementation of Universal Health Coverage in Burundi

Introduction: As one of the avenues for implementing universal health coverage, healthcare verification for financing health facilities is receiving increased attention. Verification is the process of ensuring that healthcare services provided to users meet the predetermined criteria for billing and payment. The objective of this article was to examine the Burundi health system practices in healthcare verification for financing health facilities in order to identify strengths, limitations, and potential solutions for more advancement in universal health coverage implementation. Methods: A critical case study was used as the overall methodological approach and a narrative review design to draw conclusions about the case. Results: The results show that verification helps visualise the country’s level of progression in implementation of universal health coverage. While it promotes efficiency in healthcare service reimbursement by allowing payment for quality care services, verification has proven to be a resilient function to fraud, abuse, and waste in the demand for, and supply of, healthcare services. However, verification has some limitations in terms of services and population targeting, and technical effectiveness of the verification team. The most important way identified for alleviating these limitations is to separate the demand for, and supply of, healthcare services. Conclusions: More investments in research are required to recognise verification as an essential sub-function of health financing for universal health coverage implementation.

Kosten potenziell ambulant erbringbarer endoskopischer Leistungen in Fällen mit 1-Tages-Verweildauer gegenüber einer längeren Verweildauer

The transfer of patient care and medical interventions that was previously provided on an inpatient basis to outpatient settings is a stated goal of health politics. It is unclear to what extent costs of an endoscopic procedure and the disease severity depend on the duration of inpatient treatment. We therefore examined whether endoscopic services for cases with a one-day length of stay (VWD) are comparably expensive to cases with a longer VWD. Outpatient services were selected from the DGVS service catalog. Day cases with exactly one such gastroenterological endoscopic (GAEN) service were compared with cases with VWD>1 day regarding their patient clinical complexity levels (PCCL) and mean costs. Data from the DGVS-DRG project with §21-KHEntgG cost data from a total of 57 hospitals from 2018 and 2019 served as the basis. Endoscopic costs were taken from cost center group 8 of the InEK cost matrix and plausibility checked. A total of 122,514 cases with exactly one GAEN service were identified. Statistically equal costs were shown in 30 of 47 service groups. In 10 groups, the cost difference was not relevant (<10%). Cost differences >10% existed only for EGD with variceal therapy, insertion of a self-expanding prosthesis, dilatation/bougienage/exchange with PTC/PTCD in place, non-extensive ERCP, endoscopic ultrasound in the upper gastrointestinal tract, and colonoscopy with submucosal or full thickness resection, or foreign object removal. PCCL differed in all but one group. Gastroenterology endoscopy services provided as part of inpatient care but potentially performable on an outpatient basis are predominantly equally expensive for day cases as for patients with a length of stay greater than one day. The disease severity is lower. Calculated §21-KHEntgG cost data thus form a reliable basis for the calculation of appropriate reimbursement for hospital services to be provided as outpatient services under the AOP in the future.

Contextual and Policy Influences on the Implementation of Prenatal Care Coordination.

Prenatal Care Coordination (PNCC) is a Medicaid fee-for-service that provides reimbursement for supportive services to mothers and infants at high risk of adverse outcomes. Services include health education, care coordination, referral to needed services, and social support. Currently, the implementation of PNCC programs is highly variable. We aimed to identify and describe the contextual factors that influence implementation of PNCC. Using a qualitative descriptive approach and theoretical reflexive thematic analysis techniques, we conducted observation and semistructured interviews with all PNCC staff at two PNCC sites in Wisconsin, representing diversity in region and patient population. We thematically analyzed interview data to examine how contextual factors influenced program implementation with the Consolidated Framework for Implementation Research as a sensitizing model. Observational field notes were used to triangulate interview data. Overall, participants endorsed the goals of PNCC and believed in its potential. However, participants asserted that the external policy context limited their impact. In response, they developed local strategies to combat barriers and work toward better outcomes. Our findings support the need to study the implementation of perinatal public and community health interventions and consider "health in all policies." Several changes would maximize PNCC's impact on maternal health: increased collaboration among policy stakeholders would reduce barriers; increased reimbursement would enable PNCC providers to better meet the complex needs of clients; and expansions in postpartum Medicaid coverage would extend the PNCC eligibility period. Nurses who provide PNCC have unique insights that should be leveraged to inform maternal-child health policy.

A Causal View of the Role and Potential Limitations of Capitation in Promoting Whole Health System Performance

For several decades, health systems in developed countries have faced rapidly rising healthcare costs without concomitant improvements in health outcomes. Fee for service (FFS) reimbursement mechanisms (RMs), where health systems are paid based on volume, contribute to this trend. In Singapore, the public health service is trying to curb rising healthcare costs by transitioning from a volume-based RM to a capitated payment for a population within a geographical catchment area. To provide insight into the implications of this transition, we developed a causal loop diagram (CLD) to represent a causal hypothesis of the complex relationship between RM and health system performance. The CLD was developed with input from government policymakers, healthcare institution administrators, and healthcare providers. This work highlights that the causal relationships between government, provider organizations, and physicians involve numerous feedback loops that drive the mix of health services. The CLD clarifies that a FFS RM incentivizes high margin services irrespective of their health benefits. While capitation has the potential to mitigate this reinforcing phenomenon, it is not sufficient to promote service value. This suggests the need to establish robust mechanisms to govern common pool resources while minimizing adverse secondary effects.

What Is Causing the Ongoing Youth MH Crisis?

What Is Causing the Ongoing Youth MH Crisis?

Modernizing payment to critical access hospitals: A proposal for the next iteration of the Flex Program.

Modernizing payment to critical access hospitals: A proposal for the next iteration of the Flex Program.

Peer Support Specialists Can Play Important Role in Patients’ Lives

Peer Support Specialists Can Play Important Role in Patients’ Lives

Report of the American Psychological Association Presidential Task Force on Psychology and Health Equity.

There is overwhelming evidence of serious problems with access to health care services, quality of care, and unequal health outcomes among minoritized groups including Black, Indigenous, and other populations of people of color across numerous health outcomes. At the core of health inequities are structural factors that include systemic racism as well as a range of other characteristics associated with limited political, social, and economic power. The APA Presidential Task Force on Psychology and Health Equity was appointed to recommend a course of action for APA in contributing to the solution of health inequities. The Task Force developed the Resolution on Advancing Health Equity in Psychology (https://www.apa.org/about/policy/advancing-health-equity-psychology), adopted as APA policy in October 2021. The current report provides additional discussion of the limitations of current structures of psychology training, science, and professional practice in addressing health inequities. Recommendations are offered for specific actions in the following areas: (a) Education and Training, including recruitment, admissions, and retention along the pathway and curricula transformation throughout the training sequence; (b) Research and Publications, including advocacy for health equity in research funding, mitigating bias in reporting, and improving representation and inclusive excellence; and (c) Professional Practice, including developing competent professional practice models and guidelines and promoting viable service reimbursement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Transitioning to Telehealth during COVID-19: Experiences and Insights from Diabetes Prevention and Management Program Providers in Los Angeles County

The onset of the COVID-19 pandemic in March 2020 accelerated the efforts of several organizations providing the National Diabetes Prevention Program (National DPP) and the Diabetes Self-Management Education and Support (DSMES) program to rapidly transition from in-person service delivery to program administration via telehealth. Semi-structured interviews were conducted with 35 National DPP and DSMES experts and providers in Los Angeles County to gain a better understanding of the challenges and benefits associated with this transition. Interviews were completed during June to October 2021. Thematic analyses were performed using the Social-Ecological Model as a guiding framework. The analyses revealed several factors that influenced the transition, including at the individual (e.g., technology and health behaviors), interpersonal (e.g., social connections and support), organizational (e.g., provider workload and program enrollment and retention), community (e.g., recruitment), and policy (e.g., government support and reimbursement for telehealth services) levels. Findings suggest that the transition to telehealth was challenging for most National DPP and DSMES providers. However, because of its lower cost, ability to reach long distances virtually, and potential efficiency when employed as part of a hybrid approach, this delivery modality remains viable, offering benefits beyond the traditional program models.

Alcohol Use, Screening, and Brief Intervention Among Pregnant Persons — 24 U.S. Jurisdictions, 2017 and 2019

Alcohol use during pregnancy is a major preventable cause of adverse alcohol-related outcomes, including birth defects and developmental disabilities.* Alcohol screening and brief intervention (ASBI) is an evidence-based primary care tool that has been shown to prevent or reduce alcohol consumption during pregnancy; interventions have resulted in an increase in the proportion of pregnant women reporting abstinence (odds ratio=2.26; 95% CI = 1.43-3.56) (1). Previous national estimates have not characterized ASBI in populations of pregnant persons. Using 2017 and 2019 Behavioral Risk Factor Surveillance System (BRFSS) data, CDC examined prevalence of ASBI and characteristics of pregnant persons and nonpregnant women aged 18-49 years (reproductive-aged women) residing in jurisdictions that participated in the BRFSS ASBI module. During their most recent health care visit within the past 2 years, approximately 80% of pregnant persons reported being asked about their alcohol use; however, only 16% of pregnant persons who self-reported current drinking at the time of the survey (at least one alcoholic beverage in the past 30 days) were advised by a health care provider to quit drinking or reduce their alcohol use. Further, the prevalence of screening among pregnant persons who did not graduate from high school was lower than that among those who did graduate from high school or had at least some college education. This gap between screening and brief intervention, along with disparities in screening based on educational level, indicate missed opportunities to reduce alcohol use during pregnancy. Strategies to enhance ASBI during pregnancy include integrating screenings into electronic health records, increasing reimbursement for ASBI services, developing additional tools, including electronic ASBI, that can be implemented in a variety of settings (2,3).

Maternal and neonatal risk-appropriate care: gaps, strategies, and areas for further research.

Risk-appropriate care is a strategy to improve perinatal health outcomes by providing care to pregnant persons and infants in facilities with the personnel and services capable of meeting their health needs. The Association of State and Territorial Health Officials hosted discussions among state health officials, health agency staff, and clinicians to advance risk-appropriate care. The discussions focused on neonatal levels of care, levels of maternal care, ancillary services utilized for care of both populations including transport and telemedicine, and issues affecting provision of care such as standardization of state policies or approaches, reimbursement for services, gaps in risk-appropriate care, and equity. State-identified implementation strategies for improvement were presented. In this Perspective, we summarize current studies describing provision of risk-appropriate care in the United States, identify gaps in research, and highlight ongoing and proposed activities to address research gaps and support state health officials and clinicians.

Challenges and solutions to sustaining paediatric weight management programs in the United States.

Paediatric weight management (PWM) programs in the United States (US) face challenges in providing sustainable multidisciplinary care for patients. The aim of this study was to report PWM program approaches to sustaining program delivery. A survey of 39 PWM programs was administered to identify challenges and solutions to program sustainability. Common and useful strategies for optimizing reimbursement for services included the use of applicable reimbursable diagnostic codes and management, billing for assessments and non-medical personnel services, and the use of hospital outpatient department clinic billing. Increasing clinical breadth and capacity was achieved by offering telemedicine and other services, such as psychotherapy, pharmacotherapy, and metabolic and bariatric surgery, as well as active management of schedules. Securing institutional and extramural funding was also reported. One of the positive changes during the pandemic was the fast adoption of telemedicine services. Although delivering sustainable evidence-based multidisciplinary PWM under the current US payment models has its challenges, PWM programs implement practical operational strategies to support this work.

Considerations in Preparing Social Work Students to Thrive in Health Care Settings

ABSTRACT Over a quarter of the members of the social work profession are working in health related settings yet preparing students to work in such multi-disciplinary environments, with hierarchical organizations and problem-focused systems, can create value conflicts, principally with the strengths-based paradigm inherent in social work practice. In order to prepare social work students for delivering services that honor the profession’s ethics, values, and principles in medical environments, a focused academic curriculum and field experience are warranted. This conceptual paper aims to inform social work educators about the unique considerations for preparing students to practice in health care settings. We address how the underlying influence of the biomedical model, organizational culture, and billing and reimbursement services within the medical context can challenge social work values and practice. However, we illustrate how the Integrated Behavioral Health model can be applied to help students utilize clients’ inherent strengths and problem-solving capabilities while they navigate the terrain of multi-disciplinary medical environments.