[Differences in Billing Patterns Between GPs and Pediatricians Using Early Diagnostics in Children and Adolescents as an Example: Analysis of Nationwide Data from Statutory Health Insurance Physicians]. / Kompensation von Leistungen zwischen Hausärzten und Kinder- und Jugendmedizinern am Beispiel der Früherkennungsuntersuchungen bei Kindern und Jugendlichen ­ Analyse von bundesweiten KBV-Daten.

BACKGROUND: Despite a 13.1% increase in the number of pediatricians between 2011 - 2020, the capacity of pediatric care has largely stagnated. This is due to increasing flexibility in working hours and a declining willingness of doctors to establish practices. In addition, there is an imbalance in the distribution of pediatric medical care capacities. While metropolitan areas are often characterized by oversupply, there is an increasing shortage of pediatricians, especially in rural areas. As a result, general practitioners in rural areas are increasingly taking over part of pediatric care. We quantify this compensation effect using the example of examinations of general health and normal child development (U1-U9). METHODS: Basis of the analysis was the Doctors' Fee Scale within the Statutory Health Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM) from 2015 (4th quarter). Nationwide data from the National Association of Statutory Health Insurance Physicians (KBV) for general practitioners and pediatricians from 2015 was evaluated. In the first step, the EBM was used to determine the potential overlap of services between the two groups of doctors. The actual compensation between the groups was quantified using general health and normal child development as an example. RESULTS: In section 1.7.1 (early detection of diseases in children) of the EBM, there is a list of 16 options for services that can be billed (fee schedule positions, GOP) by general practitioners and pediatricians. This particularly includes child examinations U1 to U9. The analysis of the national data of the KBV for the early detection of diseases in children showed significant differences between rural and urban regions in the billing procedure. Nationwide, general practitioners billed 6.6% of the services in the area of early detection of diseases in children in 2015. In rural regions this share was 23% compared to 3.6% in urban regions. The analysis of the nationwide data showed that the proportion of services billed by general practitioners was higher in rural regions than in urban regions. CONCLUSION: The EBM allows billing of services by both general practitioners and pediatricians, especially in the area of general GOP across all medical groups. The national billing data of the KBV shows that general practitioners in rural regions bill more services from the corresponding sections than in urban regions.

Accuracy Of The Relative Value Scale Update Committee's Time Estimates And Physician Fee Schedule For Joint Replacement.

Even though relative value units guide 70 percent of physician payment, little research has assessed their accuracy. We analyzed actual service time for total hip and knee replacements at two academic hospitals in the period January 1, 2013-October 1, 2016, using electronic health record time-stamp data, and we compared that time with the Medicare Physician Fee Schedule and most recent Relative Value Scale Update Committee recommendations. We found that the committee and fee schedule overestimated the operating time of original hip replacements by 18 percent and original knee replacements by 23 percent. Revision hip replacements were overestimated by 61 percent and knee replacements by 48 percent. In a multivariate analysis we found that faster operating time was not associated with more complications or admissions to the intensive care unit. Complication rates varied tenfold across physicians and twofold across hospitals. The fee schedule and the committee significantly overestimated operating times for original and revision hip and knee replacements. Policy makers should use empirical time-stamp data instead of self-reported estimates to determine physician payment.

Formas y Estrategias de Remuneración de los Profesionales del Primer Nivel de Atención en Perú

Association Between a Centrally Reimbursed Fee Schedule Policy and Access to Cataract Surgery in the Universal Coverage Scheme in Thailand.

Importance: Uptake of cataract surgery in developing countries is much lower than that in developed countries. Cataract unawareness and financial barriers have been cited as the main causes. Under the Universal Coverage Scheme (UCS), Thailand introduced a central reimbursement (CR) system for cataract surgery. It is unknown if this financial arrangement could incentivize service provision (private or public) in areas that are hard to reach. Objective: To examine the association between the CR policy and access to cataract surgery in Thailand. Design, Setting, and Participants: Using time series analysis, hospitalization data during 2005 to 2015 for UCS members were analyzed for time trends and subnational variations in the cataract surgery rate (CSR) before and after the CR implementation. Main Outcomes and Measures: The annual growth in access was estimated using segmented regression. The CSR gap across regions was determined by the slope index of inequality (SII). Unequal access across districts was represented by the gap between the top and bottom quintiles. Results: During 2005 to 2015, a total of 0.98 million UCS members (mean [SD] age, 67.4 [11.2] years; 58.7% female) received cataract surgery. The number of cases increased from 77 897 in 2005 to 192 290 in 2015. At the national level, the CSR per 100 000 population increased from 352.0 to 378.7 cases in 2005 to 2008, to 716.3 cases in 2013, and then to 765.3 cases in 2015. With the use of mobile services through an exclusive CR, 3 private hospitals took the lead in service growth, sharing 79.2% of cases in the private sector in 2009. From 2010, the number of cases in public hospitals grew yearly by 12.6% to 13.6% until 2012, rose 21.7% in 2013, and then the rate of increase declined to that of 8.2% to 8.3% in 2014-2015. During the periods of an increase in overall access, the CSR gap across regions widened as indicated by the SII of 755.4 cases per 100 000 population in 2010 because of rapid uptake in areas with mobile services. When the national CSR became adequately large and mobile services were discouraged in 2013, the gap in 2014-2015 narrowed. Conclusions and Relevance: This study found that the appropriate payment and service designs helped reduce the cataract surgery backlog. With an adequately high CSR, Thailand is on track to reach the VISION 2020 goal, aiming for blindness elimination by the year 2020, which has been achieved by most developed countries.

Influence of the revision of surgical fee schedule on surgeons' productivity in Japan: A cohort analysis of 7602 surgical procedures in 2013-2016.

The goal of this study is to evaluate the pure impact of the revision of surgical fee schedule on surgeons' productivity. We collected data from the surgical procedures performed by the surgeons working in Teikyo University Hospital from 1 April through 30 September in 2013-2016. We employed non-radial and non-oriented Malmquist model. We defined the decision-making unit as a surgeon with the highest academic rank in surgery. Inputs were defined as (1) the number of doctors who assisted surgery and (2) the time of surgical operation. The output was defined as the surgical fee for each surgery. We focused on the revisions in 2014 and 2016. We first calculated each surgeon's natural logarithms of the changes in productivity, technique and efficiency in 2013-2014, in 2014-2015 and in 2015-2016. Then, we subtracted the changes in 2014-2015 from the changes in 2013-2014 and in 2015-2016. We analyzed 62 surgeons who performed 7602 surgical procedures. The productivity changes were not significantly different from 0. Their efficiency change was significantly greater than 0, while their technical change was smaller than 0 in revision 2014. Their efficiency change was significantly smaller than 0, while their technical change was greater than 0 in revision 2016 (p < 0.05). This finding suggests that we could increase overall productivity through revision if we could increase both efficiency and technique.

Remuneração de três planos odontológicos da cidade de Maceió-AL em comparação à tabela VRPO-CFO / Remuneration of three dental plans from the city of Maceio-Al in comparison to the table VRPO-CFO

Objetivo: Investigar se o valor médio geral de remuneração ofertado por três planos odontológicos da cidade de Maceió-AL possuem defasagem, coerência ou ágio em relação ao estabelecido na tabela VRPO-CFO. Materiais e Métodos: foram utilizados três planos odontológicos da cidade de Maceió-AL,acreditando ser esses os de maior procura por parte dos profissionais, para uma comparação entre suas categorias de serviço e as da tabela VRPO, sendo calculado o valor percentual de acréscimo ou defasagem. Resultados: Nota-se que em todas as categorias de serviço, o plano que melhor remunerou foi o plano A, tendo as categorias prevenção, Endodontia, Radiologia e Dentística o menor percentual de defasagem, sendo eles 22%, 26%, 30% e 40%, respectivamente, as demais categorias apresentaram índice acima de 50%. O plano odontológico que pior remunerou, de acordo com a presente pesquisa, foio plano C, com média de defasagem geral de 65%, possuindo a categoria Diagnóstico como o serviço com maior defasagem (83%). Conclusão: Conclui-se que a remuneração dos procedimentos odontológicos,que envolvem todas as especialidades, oferecida por planos odontológicos de Maceió-AL aos Cirurgiões-Dentistas, estão abaixo dos valores determinados na tabela do VRPO-CFO.

Objective: To investigate whe ther the overall average amount of remuneration offered by three dental plans from the city of Maceió-AL have a discrepancy, consistency or goodwill in relation to the established VRPO-CFO table. Materials and Methods: three dental plans from the city of Maceió- ALwere used, believing that these are the most demanded by professionals, for a comparison betweentheir service categories and VRPO table, therefore calculating their increasement percentage valueor lag. Results: We notice that in all service categories, the plan that best remunerated was plan A,having the categories Prevention, Endodontics, Radiology and Dentistry the lowest percentage oflag, namely 22%, 26%, 30% and 40% respectively, the other categories had an index above 50%.The dental plan that pays worse, according to this research, was plan C, with an overall discrepancy average of 65%. Having the Diagnosis service category with the largest lag (83%). Conclusion: We conclude that the remuneration for dental procedures, involving all specialties offered by dental plans in Maceió (AL) to dentists, are lower than the ones determined on the VRPO-CFO table.

Private Carriers' Physician Payment Rates Compared With Medicare and Medicaid.

This research evaluated the 2013 published physician reimbursement rates for Medicare and Medicaid in Texas and compared the rates with the mean fees from private carriers. Physician claims data were extracted from the Truven MarketScan Commercial Claims Databases. The average allowed amounts per unit per procedure code were compiled. The 2013 Medicare physician fee schedule was obtained and filtered to Texas. The 2013 Texas Medicaid physician fee schedule was obtained. The mean commercial allowed amounts were compared with those of Medicare and Medicaid on a per-unit rate. Comparison ratios were derived for each code. The CPT© procedure codes were then grouped into the categories assigned by the American Medical Association. The ratios of private/Medicare and private/Medicaid varied greatly by procedure type and locality, with the Texas Medicaid fees well below both private and Medicare fees. The discrepancy in payment amounts demonstrates the variation in payment rates among payer sources. The practical implications demonstrate the provider challenges in managing patient mix to maintain a viable practice.

Capture of complexity of specialty care in pediatric cardiology by work RVU measures.

OBJECTIVE: We sought to determine the relationship between relative value units (RVUs) and intended measures of work in catheterization for congenital heart disease. METHODS: RVU was determined by matching RVU values to Current Procedural Terminology codes generated for cases performed at a single institution. Differences in median case duration, radiation exposure, adverse events, and RVU values by risk category and cases were assessed. Interventional case types were ranked from lowest to highest median RVU value, and correlations with case duration, radiation dose, and a cases-predicted probability of an adverse event were quantified with the Spearman rank correlation coefficient. RESULTS: Between January 2008 and December 2010, 3557 of 4011 cases were identified with an RVU and risk category designation, of which 2982 were assigned a case type. Median RVU values, radiation dose, and case duration increased with procedure risk category. Although all diagnostic cases had similar RVU values (median 10), adverse event rates ranged from 6% to 21% by age group (P < .001). Median RVU values ranged from 9 to 54 with the lowest in diagnostic and biopsy cases and increasing with isolated and then multiple interventions. Among interventional cases, no correlation existed between ranked RVU value and case duration, radiation dose, or adverse event probability (P = .13, P = .62, and P = .43, respectively). CONCLUSIONS: Time, skill, and stress inherent to performing catheterization procedures for congenital heart disease are not captured by measurement of RVU alone.

Cost-effectiveness of pharmacist-provided treatment of adult pharyngitis.

BACKGROUND: There are over 12 million ambulatory care visits for acute pharyngitis annually in the United States. Current guidelines recommend diagnosis through culture or rapid antigen detection test (RADT) and relatively straightforward treatment. Community pharmacists may provide cost-effective care for disease states such as group A streptococcus (GAS) pharyngitis. OBJECTIVES: The objective of this research is to evaluate the cost-effectiveness of a community pharmacist-as-provider program for the diagnosis and treatment of pharyngitis caused by GAS as compared with standard of care. METHODS: A cost-effectiveness analysis was conducted to compare treatment for adult pharyngitis patients. In addition to 5 physician-provided treatment strategies, the episodic costs and benefits of treatment provided by pharmacists using RADT and walk-in clinics using RADT were also considered. Model parameters were derived through a comprehensive review of literature and from the Centers for Medicare and Medicaid Services physician fee schedule. Utilities were expressed in quality-adjusted life-days (QALDs) to account for the relatively short duration of most cases of pharyngitis. RESULTS: Using a cost-effectiveness threshold of $137 per QALD, GAS treatment provided by a pharmacist was the most cost-effective treatment. Pharmacist treatment dominated all of the other methods except physician culture and physician RADT with follow-up culture. The incremental cost-effectiveness ratio (ICER) for physician culture was $6042 per QALD gained and $40,745 for physician RADT with follow-up culture. CONCLUSIONS: This model suggests that pharmacists may be able to provide a cost-effective alternative for the treatment of pharyngitis caused by GAS in adult patients.

Medicare physician fees: the data behind the numbers.

Medicare's physician fee schedule distributes nearly $60 billion annually and is a critical determinant of individual physicians' incomes, beneficiaries' access to health care services, and Medicare spending, as well as the basis for physician fees used by many private payers. The Centers for Medicare & Medicaid Services (CMS) relies on data derived from expert judgment and other sources to update the fee schedule. Although CMS's methods and data for maintaining the fee schedule have improved over the years, concerns remain about medical specialty society involvement and the lack of an effective "counterweight" to vested interests in establishing and updating the relative values in the fee schedule. This issue brief reviews the data used in the fee schedule, including the new, multispecialty practice expense survey, and the role of the American Medical Association/Specialty Society Relative Value Scale Update Committee.

Rural primary care physician payment 2006-2009: what a difference three years doesn't make.

(1) The 2007 Medicare Physician Fee Schedule Final Rule that increased compensation for cognitive (Evaluation and Management) services at a rate exceeding increases for procedural services resulted in modest increases in rural primary care physician income in a prototypical practice. (2) A prototypical cognitive primary care practice realized a higher percentage increase in income, but a prototypical procedural practice realized a larger dollar increase in income (due to a higher 2007 baseline income). (3) However, additional changes to the Medicare Physician Fee Schedule between 2006 and 2009 reduced intended primary care physician compensation increases, resulting in only minimal increases in primary care physician income when adjusted for inflation.

[Official recommendations and guidelines for the management and reimbursement of severe hypertension as a chronic disease]. / Les recommandations et le guide << Affections de longue durée >> dans l'hypertension artérielle sévère.

Severe hypertension is a major cardiovascular and cerebrovascular risk factor and places the patient in the category of high cardiovascular risk, independently of any other cardiovascular risk factors. The economic burden of hypertension is high, with severe hypertension the 4th most costly disease (5.5 billion Euros) on the French list of chronic diseases ("Affections de longue durée" or ALD) for which the national health insurance funds reimburse 100% of expenses. The French High Health Authority recently suggested removing hypertension from the ALD list. This recommendation, however, had no scientific rationale but was motivated instead by economic and political factors and may endanger the quality of management of hypertensive patients. The previous ALD criteria for severe hypertension require revision to bring them into line with the recommendations of professional and learned societies. The ALD list should include severe hypertension as well as complicated and treatment-resistant hypertension, with the diagnosis documented by ambulatory or self blood pressure monitoring.

[Cost recovery for the treatment of retinal and vitreal diseases by pars plana vitrectomy under the German DRG system]. / Kosteneffizienz von netzhaut- und glaskörperchirurgischen Eingriffen mittels ppV unter DRG-Bedingungen.

BACKGROUND: Since 2004 inpatient health care in Germany is paid according to calculated DRGs. Only a few university hospitals participated in distinct cost calculations of clinical treatment. It was the aim of this study to check the cost recovery at a University Eye Hospital for the surgical treatment of retinal and vitreal diseases by pars plana vitrectomy (ppV), which are included in DRGs C03Z and C17Z. MATERIAL AND METHODS: The performance data for both DRGs were collected for the years 2005 and 2006 using the E1 sheets according to section 21 KHEntG. The mean duration of all procedures was collected by data from the internal controlling. Costs for single operations were calculated from fixed and variable costs for the operation theatre and the ward including costs for personnel and material. RESULTS: In the 2-year period of 4,721 inpatient procedures 1,307 ppVs were performed. Each ppV had fixed surgical costs of 130.60 EUR; personnel costs varied between 575 EUR (C03Z; including cataract surgery; mean OP duration: 85 min) and 510 EUR (C17Z; no cataract surgery; mean OP duration: 73 min) at a proportion between general anaesthesia and local anaesthesia of 80/20. For a pure ppV material costs were 255 EUR. Additional adjuncts such as an encircling band, perfluorcarbon, ICG, tPA, gas and silicon oil or cataract surgery led to extra costs between 51 EUR and 250 EUR per adjunct und were used in 56% (C03Z) and 74.5% (C17Z) of all procedures. Costs for hospitalisation were about 1765 EUR at a mean residence time of 6.5 days. Thus, the overall costs of a pure basic ppV amounted to 2975 EUR (C03Z) and 2661 EUR (C17Z). In consideration of the current relative DRG weights of 1.08 and 0.957 and a current base rate of 2787.19 EUR in Bavaria, cost recovery is only given for basic ppV but not for complex ppVs having higher material and personnel costs. Additionally, the costs for multiple surgeries as occur in 5.9% of cases are not compensated by the DRG system. CONCLUSION: The reimbursement for inpatient ppVs in a University environment is not covered for complex procedures requiring more cost-effective material and personnel time. To consider an adequate cost recovery for these procedures a DRG split for both DRGs (C03Z and C17Z) in basic ppVs and complex ppVs is required. We recommend this proposal for the InEK.

Health economic analysis of fluoropyrimidine-based therapies of colorectal cancer from the perspective of statutory sickness funds.

AIMS: 1) to identify the treatment costs of different standard fluoropyrimidine-based therapies, i. e., the Mayo-Clinic and AIO/Ardalan regimens, under real-life conditions in settings routinely used for chemotherapy administration in Germany (inpatient, day-clinic or office-based oncologists) and 2) to investigate the cost implications of the routine use of capecitabine, an oral alternative for the treatment of metastatic colorectal cancer. METHODS: We analysed the actual fee-listings of office based oncologists and projected the results to several hospital-based treatment settings and to oral treatment with capecitabine from the perspective of statutory sickness funds. RESULTS: Office-based setting: the highest quarterly treatment costs of 9.874 were found for the AIO/Ardalan-regimen, followed by the Mayo-Clinic regimen, which incurred costs of 2.497. The cheapest treatment option was capecitabine with quarterly costs of 1.610. Day-clinic setting: the costs of the Mayo-Clinic protocol amounted to 2.036 in a municipal hospital and 8.455 in a university hospital. The respective costs for the AIO/Ardalan regime were 1.294 and 5.374. In-patient setting: the Mayo-Clinic protocol costs were 3.143 in a municipal hospital and 10.5609 in a university hospital. The respective costs found for the AIO/Ardalan-regimen were 1.998 and 6.717. CONCLUSION: From a health economic perspective, substantial cost savings for health insurance may be realised if patients with colorectal carcinoma were treated in the office-based setting with capecitabine instead of a hospital-based treatment. Economic consequences would be positive for municipal hospitals (avoided losses) and negative for university hospitals. Further savings could be realised if drug prices in hospital and retail pharmacies were harmonized.

Estimating direct and indirect costs of premenstrual syndrome.

OBJECTIVE: To quantify the economic impact of premenstrual syndrome (PMS) on the employer. METHODS: Data were collected from 374 women aged 18-45 with regular menses. Direct costs were quantified using administrative claims of these patients and the Medicare Fee Schedule. Indirect costs were quantified by both self-reported days of work missed and lost productivity at work. Regression analyses were used to develop a model to project PMS-related direct and indirect costs. RESULTS: A total of 29.6% (n = 111) of the participants were diagnosed with PMS. A PMS diagnosis was associated with an average annual increase of $59 in direct costs (P < 0.026) and $4333 in indirect costs per patient (P < 0.0001) compared with patients without PMS. CONCLUSIONS: A PMS diagnosis correlated with a modest increase in direct medical costs and a large increase in indirect costs.