Association of VA Payment Reform for Dialysis with Spending, Access to Care, and Outcomes for Veterans with ESKD.

BACKGROUND AND OBJECTIVES: Because of the limited capacity of its own dialysis facilities, the Department of Veterans Affairs (VA) Veterans Health Administration routinely outsources dialysis care to community providers. Prior to 2011-when the VA implemented a process of standardizing payments and establishing national contracts for community-based dialysis care-payments to community providers were largely unregulated. This study examined the association of changes in the Department of Veterans Affairs payment policy for community dialysis with temporal trends in VA spending and veterans' access to dialysis care and mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: An interrupted time series design and VA, Medicare, and US Renal Data System data were used to identify veterans who received VA-financed dialysis in community-based dialysis facilities before (2006-2008), during (2009-2010), and after the enactment of VA policies to standardize dialysis payments (2011-2016). We used multivariable, differential trend/intercept shift regression models to examine trends in average reimbursement for community-based dialysis, access to quality care (veterans' distance to community dialysis, number of community dialysis providers, and dialysis facility quality indicators), and 1-year mortality over this time period. RESULTS: Before payment reform, the unadjusted average per-treatment reimbursement for non-VA dialysis care varied widely ($47-$1575). After payment reform, there was a 44% reduction ($44-$250) in the adjusted price per dialysis session (P<0.001) and less variation in payments for dialysis ($73-$663). Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to veterans with ESKD from 19 to 37 facilities (per VA hospital), and there were no changes in either the quality of community dialysis facilities or crude 1-year mortality rate of veterans (12% versus 11%). CONCLUSIONS: VA policies to standardize payment and establish national dialysis contracts increased the value of VA-financed community dialysis care by reducing reimbursement without compromising access to care or survival.

Leveraging Health Department Capacities, Partnerships, and Health Insurance for Infectious Disease Response in Massachusetts, 2014-2018.

Policies facilitating integration of public health programs can improve the public health response, but the literature on approaches to integration across multiple system levels is limited. We describe the efforts of the Massachusetts Department of Public Health to integrate its HIV, viral hepatitis, sexually transmitted infection (STI), and tuberculosis response through policies that mandated contracted organizations to submit specimens for testing to the Massachusetts State Public Health Laboratory; co-test blood specimens for HIV, hepatitis C virus (HCV), and syphilis; integrate HIV, viral hepatitis, and STI disease surveillance and case management in a single data system; and implement an integrated infectious disease drug assistance program. From 2014 through 2018, the number of tests performed by the Massachusetts State Public Health Laboratory increased from 16 321 to 33 674 for HIV, from 11 054 to 33 670 for HCV, and from 19 169 to 30 830 for syphilis. Service contracts enabled rapid response to outbreaks of HIV, hepatitis A, and hepatitis B. Key challenges included lack of a billing infrastructure at the Massachusetts State Public Health Laboratory; the need to complete negotiations with insurers and to establish a retained revenue account to receive health insurance reimbursements for testing services; and time to train testing providers in phlebotomy for required testing. Investing in laboratory infrastructure; creating billing mechanisms to maximize health insurance reimbursement; proactively engaging providers, community members, and other stakeholders; and building capacity to transform practices are needed. Using multilevel policy approaches to integrate the public health response to HIV, STI, viral hepatitis, and tuberculosis is feasible and adaptable to other public health programs.

Trends in Contracting and Common Ownership Between Hospice Agencies and Nursing Homes.

BACKGROUND: In recent years, policymakers have paid particular attention to the emergence of a robust for-profit hospice sector and increased hospice use by nursing home residents. Previous research has explored financial incentives for nursing home-hospice use, but there has been limited research on nursing home-hospice partnerships and none on the extent of nursing home-hospice common ownership. OBJECTIVE: To describe trends in nursing home-hospice contracting and common ownership and to identify potential tradeoffs in care provided by nursing homes and hospice agencies that share common ownership. RESEARCH DESIGN: Retrospective cohort study of nursing home-hospice patients between 2005 and 2015. RESULTS: Between 2005 and 2015, the number of hospice agencies and nursing homes with common ownership grew substantially, now representing almost 1-in-5 providers in each sector. Relative to individuals using hospice in nursing homes without common ownership, adjusted analyses found that individuals receiving hospice from a commonly owned agency had a greater likelihood of having stays of 90 days or more [odds ratio (OR)=1.06; 95% confidence interval (CI), 1.02-1.10], having a stay resulting in a live discharge (OR=1.06; 95% CI, 1.02-1.11), and having at least 1 registered nurse/licensed practical nurse visit during the last 3 days of life (OR=1.17; 95% CI, 1.05-1.29); these individuals also had a lower mean visit hours per day (-0.07; P=0.003). CONCLUSIONS: Common ownership between hospice agencies and nursing homes is an emerging trend that reflects a broader push toward consolidation in the health care sector. Our analyses highlight potential concerns relevant to Medicare payment policy and are a first step toward improving our understanding of these trends and their implications.

Costs and Willingness to Pay for Pit Latrine Emptying Services in Kigali, Rwanda.

Kigali, Rwanda lacks a centralized sewer system, which leaves residents to choose between on-site options; the majority of residents in informal settlements use pit latrines as their primary form of sanitation. When their pits fill, the pits are either sealed, or emptied; emptying is often done by hand and then dumped in the environment, putting the residents and the broader population at risk of infectious disease outbreaks. In this paper, we used revealed and stated preference models to: (1) estimate the demand curve for improved emptying services; and, (2) evaluate household preferences and the willingness to pay (WTP) for different attributes of improved emptying services. We also quantify the costs of improved service delivery at different scales of production. The study included 1167 households from Kigali, Rwanda across 30 geographic clusters. Our results show that, at a price of US$79 per pit, 15% of all the pits would be emptied by improved emptying services, roughly the current rate of manual emptying. Grouping empties by neighborhood and ensuring that each truck services an average of four households per day could reduce the production costs to US$44 per empty, ensuring full cost coverage at that price. At a lower price of US$24, we estimate that the sealing of pits might be fully eliminated, with full coverage of improved emptying services for all pits; this would require a relatively small subsidy of US$20 per empty. Our results show that households had strong preferences for fecal sludge (FS) treatment, formalized services (which include worker protections), and distant disposal. The results from the study indicate a few key policies and operational strategies that can be used for maximizing the inclusion of low-income households in safely managed sanitation services, while also incorporating household preferences and participation.

Implementation of total laboratory automation at a tertiary care hospital in Saudi Arabia: effect on turnaround time and cost efficiency.

BACKGROUND: Total laboratory automation (TLA) is a relatively new way of improving the management of high volume clinical laboratories. TLA may reduce staff, reduce operating costs, decrease testing time and provide enhanced process control. OBJECTIVES: Establish a cost efficient TLA that is less labor intensive, improves productivity and reduces turnaround time (TAT). DESIGN: Implementation of TLA for random glucose and troponin-T as sentinel tests to compare change in TAT. SETTING: Tertiary hospital with high volume of laboratory tests. METHODS: Routine patient samples for random glucose and troponin-T were used to capture TAT. Information on staff grades and schedules before and after implementing the TLA, and cost of contracts to deliver the service were collected. MAIN OUTCOME MEASURES: TAT, cost efficiency, and reduction in labor. RESULTS: The consolidation of contracts resulted in a reduction of 28.8 million SAR in direct costs. Staffing cost was reduced by 1.14 million SAR with less senior staff required; there were reductions in staff at both senior and junior level. The overall TAT for all tests was reduced by 32% in 2016 (after TLA implementation) compared to 2012 (before TLA implementation). The median TAT for random glucose tests was reduced by 21% (to 55.7 minutes in 2016 from 70.1 minutes in 2012). Evidence of test optimization by exploring the impact of stat tests, auto-dilutions and reruns on the overall TAT of the TLA is shown by comparing troponin T TATs after reclassifying stat tests (in 2016) to routine (in 2017). At the 75th percentile, there was a 27% reduction in TAT when comparing August 2016 to March 2017 with a 19% reduction in median TAT. CONCLUSION: By moving from stat to routine assays, the TAT was reduced, which is counter-intuitive. The use of stat assays slowed down the performance of the TLA. A careful review of the mix of assays should be conducted to maximize performance and to ensure that the system delivers what is required. LIMITATIONS: Room for improvement by systematically analyzing and reviewing the impact of making minor changes that could have significant impact on TAT. CONFLICT OF INTEREST: None.

Locum physicians' professional ethos: a qualitative interview study from Germany.

BACKGROUND: In contrast to other countries, the appearance of locum physicians as independent contractors constitutes a rather new phenomenon in the German health care system and emerged out of a growing economization and shortage of medical staff in the hospital sector. Locums are a special type of self-employed professionals who are only temporally embedded in organisational contexts of hospitals, and this might have consequences for their professional practice. Therefore, questions arise regarding how locums perceive their ethical duties as medical professionals. METHODS: In this first qualitative study on German locum physicians, the locums' own perspective is complemented by the viewpoint of permanently employed physician colleagues. Eighteen semi-structured interviews were conducted in 2014 to explore the professional practice of locum physicians from both groups' perspectives with respect to doctor-patient-relationship, cooperation with colleagues and physicians' role in society. The data were analysed using qualitative content analysis, including a deductive application and an inductive development of codes. The results were related to key tenets of medical professionalism with respect to the question: how far do locums fulfil their ethical duties towards patients, colleagues and the society? RESULTS: The study indicates that although ethical requirements are met broadly, difficulties remain with respect to close doctor-patient contact and the sustainability of hiring locums as a remedy in times of staff shortage. CONCLUSIONS: Further qualitative and quantitative research on locum physicians' professional practice, including patient perspectives and economic health care system analyses, is needed to better understand the ethical impact of hiring independent contractors in the hospital sector.

Attitude towards working in rural areas: a cross-sectional survey of rural-oriented tuition-waived medical students in Shaanxi, China.

BACKGROUND: Attracting and recruiting health workers to work in rural areas is still a great challenge in China. The rural-oriented tuition-waived medical education (RTME) programme has been initiated and implemented in China since 2010. This study aimed to examine the attitudes of rural-oriented tuition-waived medical students (RTMSs) in Shaanxi towards working in rural areas and the related influencing factors. METHODS: A cross-sectional survey was conducted in 2015 among 232 RTMSs in two medical universities from the first group of students enrolled in the RTME programme in Shaanxi. Descriptive and analytical statistics were used for the data analyses. RESULTS: Of the 230 valid responses, 92.6% expressed their intentions of breaking the contract for working in rural township hospitals for 6 years after their graduation under the RTME programme. After the contract expired, only 1.3% intended to remain in the rural areas, 66.5% had no intention of remaining, and 32.2% were unsure. The factors related to a positive attitude among the RTMSs towards working in rural areas (no intention of breaking the contract) included being female, having a mother educated at the level of primary school or below, having a good understanding of the policy, having a good cognition of the value of rural medical work, and being satisfied with the policy. The factors related to a positive attitude of the RTMSs towards remaining in rural areas included being female, having a rural origin, having no regular family monthly income, having a father whose occupation was farmer, having a mother educated at the level of postsecondary or above, having the RTMSs be the final arbiter of the policy choice, having a good understanding of the policy, having a good cognition of the value of rural medical work, and being satisfied with the educational scheme. CONCLUSIONS: Related policy makers and health workforce managers may benefit from the findings of this study. Appropriate strategies should be implemented to stimulate the RTMSs' intrinsic motivation and improve their willingness to work in rural areas and to better achieve the objectives of RTME policy. Meanwhile, measures to increase the retention of RTMSs should also be advanced.

Are commercial providers a viable option for clinical bacterial sequencing?

Bacterial whole-genome sequencing in the clinical setting has the potential to bring major improvements to infection control and clinical practice. Sequencing instruments are not currently available in the majority of routine microbiology laboratories worldwide, but an alternative is to use external sequencing providers. To foster discussion around this we investigated whether send-out services were a viable option. Four providers offering MiSeq sequencing were selected based on cost and evaluated based on the service provided and sequence data quality. DNA was prepared from five methicillin-resistant Staphylococcus aureus (MRSA) isolates, four of which were investigated during a previously published outbreak in the UK together with a reference MRSA isolate (ST22 HO 5096 0412). Cost of sequencing per isolate ranged from £155 to £342 and turnaround times from DNA postage to arrival of sequence data ranged from 12 to 63 days. Comparison of commercially generated genomes against the original sequence data demonstrated very high concordance, with no more than one single nucleotide polymorphism (SNP) difference on core genome mapping between the original sequences and the new sequence for all four providers. Multilocus sequence type could not be assigned based on assembly for the two cheapest sequence providers due to fragmented assemblies probably caused by a lower output of sequence data per isolate. Our results indicate that external providers returned highly accurate genome data, but that improvements are required in turnaround time to make this a viable option for use in clinical practice.

The Current Status of Outcomes-Based Contracting for Manufacturers and Payers: An AMCP Membership Survey.

BACKGROUND: As the United States health care system shifts from traditional volume-based payments to value-based payments, outcomes-based contracts (OBCs) are gaining popularity among payers and manufacturers as a mechanism for the shift toward value. Under this model, stakeholders hope to align drug payment and value to real-world performance metrics (e.g., biomarkers and health care resource utilization). OBJECTIVE: To understand the experiences, perceptions, and needs of payers and manufacturers related to OBCs. METHODS: The Academy of Managed Care Pharmacy (AMCP) and Xcenda conducted an online survey with AMCP payer and manufacturer members. Participants were asked a series of questions regarding their use of OBCs, barriers to implementation, and elements required in establishing successful OBCs. The importance and urgency of specific impediments to successful OBC implementation were also assessed. RESULTS: The survey was fielded May 12, 2017, to June 7, 2017, yielding 65 responses (35 payers/30 manufacturers). While a minority of payers/manufacturers had at least 1 OBC in place (20%/33%), a majority had interest in future OBC use (71%/63%). Among those with at least 1 OBC in place, 86%/80% of payers/manufacturers had renewed at least 1 OBC in the past 5 years. All payers and 60% of manufacturers with OBCs included compliance measures. Improvement in clinical outcomes was also common (71%/70%) (e.g., reaching set laboratory values goals), and 71%/60% included avoidance of unnecessary medical resource use (e.g., hospitalization and emergency department visit). The barrier most frequently identified by payers in implementing OBCs was evidence that OBCs reduced pharmacy spending (60%), while manufacturers identified the inability to obtain accurate data/outcome measures (73%) as a major limiting factor. Payers/manufacturers endorsed the use of easily measurable outcomes (91%/100%) as most important in establishing successful OBCs. Manufacturers, and to a lesser extent payers, indicated that regulations and legal issues need to be addressed to make progress in OBC implementation (e.g., safe harbor for preapproval health care economic information [77%/46%] and exemption of OBCs for best-price requirements [83%/51%]). The only exception was the clarification of regulations for discussing information outside of an FDA-approved label, in which both manufacturers and payers indicated a very strong need (100%) to be addressed. CONCLUSIONS: Surveyed AMCP members are interested in OBCs and recognize their alignment to societal health goals and health care affordability, although actual use of these contracts has been somewhat limited to date. Results from this survey indicate that there is potential for OBC use to increase as barriers and limitations are addressed. DISCLOSURES: This research was sponsored by the Academy of Managed Care Pharmacy and Xcenda. Duhig, Kaufman, and Hughes are employed by Xcenda. Saha is employed by the Academy of Managed Care Pharmacy. Smith has nothing disclose. Study concept and design were contributed by Duhig, Kaufman, Saha, and Hughes. Kaufman and Hughes collected the data, and data interpretation was performed by all the authors. The manuscript was written by Saha, Smith, and Duhig, along with Kaufman and Hughes.

[Reimbursement of health apps by the German statutory health insurance]. / Erstattung von Health-Apps durch die gesetzliche Krankenversicherung.

A reimbursement category for "apps" does not exist in German statutory health insurance. Nevertheless different ways for reimbursement of digital health care products or processes exist. This article provides an overview and a description of the most relevant finance and reimbursement categories for apps in German statutory health insurance. The legal qualifications and preconditions of reimbursement in the context of single contracts with one health insurance fund will be discussed as well as collective contracts with national statutory health insurance funds. The benefit of a general outline appeals especially in respect to the numerous new players and products in the health care market. The article will highlight that health apps can challenge existing legal market access and reimbursement criteria and paths. At the same time, these criteria and paths exist. In terms of a learning system, they need to be met and followed.

Outcomes-Based Pharmaceutical Contracts: An Answer to High U.S. Drug Spending?

Issue: Brand-name prescription drug prices are increasing in the United States, putting pressure on payers and patients. Some manufacturers have responded by offering outcomes-based contracts, in which rebate levels are tied to a specified outcome in the target population. Goal: To assess the expected benefits and limitations of outcomes-based pharmaceutical contracts in the U.S., including their potential impact on prescription drug spending. Methods: Semistructured interviews with payers, manufacturers, and policy experts. Key Findings: Pharmaceutical manufacturers and some private payers are increasingly interested in outcomes-based contracts for high-cost brand-name drugs. But the power of these contracts to curb spending is questionable, largely because their applicability is restricted to a small subset of drugs and meaningful metrics to evaluate their impact are limited. There is no evidence that these contracts have resulted in less spending or better quality. Conclusions: Outcomes-based contracts are intended to shift pharmaceutical spending toward more effective drugs, but their impact is unclear. Voluntary testing and rigorous evaluation of such contracts in the Medicare and Medicaid programs could increase understanding of this new model.