National and Geographic Trends in Medicare Reimbursement for Pain Management 2014-2023.

BACKGROUND: Increasing enrollment in Medicare has coincided with reductions in reimbursement for various procedures, including interventional pain procedures. No previous analysis of state-to-state differences in Medicare reimbursement rates for practicing pain management physicians has been performed. OBJECTIVE: To quantify recent national and geographical trends for interventional pain procedures. STUDY DESIGN: This study used datasets from the Centers for Medicare and Medicaid Services to identify the top 10 highest-grossing Current Procedure Terminology (CPT) codes for pain procedures and for evaluation and management (E/M) from 2014 to 2023. Data analysis took place during May 2023. METHODS: Primary outcomes were calculated inflation-adjusted rates of yearly percent change (YPC) for each CPT code, state, territory, and U.S. Census region. An independent samples t-test compared the national YPC rates of procedure to those of E/M reimbursement. Medicare reimbursements throughout the United States for interventional pain procedures and clinic evaluations were measured from 2014-2023. RESULTS: From 2014 to 2023, inflation-adjusted Medicare reimbursement for interventional pain procedures decreased yearly by an average of 3.63%. In comparison, clinic evaluation reimbursement decreased by only 0.87% yearly and was significantly different from procedure reimbursement (P < 0.001). Pain management procedure reimbursement decreased the most in Illinois (-4.26%), Wyoming (-3.88%), Wisconsin (-3.87%), Nevada (-3.83%) and Kansas (-3.82%). Meanwhile, rates for Puerto Rico (-1.94%), Massachusetts (-3.24%), Washington (-3.31%), New York (-3.39%), and West Virginia (-3.47%) decreased the least. When states were grouped into U.S. Census regions, no significant regional differences in pain management procedure reimbursement changes could be observed. LIMITATIONS: Only the facility prices of the top 10 highest-grossing procedure and E/M CPT codes that had available data for 2014 to 2023 could be included in our analysis; trends for private insurance reimbursement could not be analyzed. CONCLUSIONS: Medicare reimbursement rates for interventional pain procedures have decreased from 2014 to 2023, both nationally and in each region of the U.S. Our analysis suggests that certain states and territories have experienced less favorable reimbursement trends than others. This issue is worthy of attention as larger proportions of the U.S. population become eligible for Medicare coverage; should these trends continue, interventional pain physicians may consider moving their practices to areas that are less affected. Major efforts are required to preserve the quality of care that Medicare beneficiaries receive and to remedy the problem of depreciating reimbursement.

Dental Coverage for Medicare Beneficiaries.

Poor oral health has been associated with various systemic diseases (e.g., endocarditis, pneumonia, cardiovascular disease, and diabetes) and decreased quality of life. When enacted in 1965, Medicare excluded coverage for comprehensive dental services. As of 2023, Medicare has allowed coverage of limited dental services inextricably linked to specific medical conditions. Many Medicare Advantage plans (Medicare Part C) offer dental coverage. Yet in 2019, approximately 24 million Medicare beneficiaries (47% of all Medicare enrollees), lacked dental coverage. Seventy-one percent of traditional Medicare enrollees (those not enrolled in a Medicare Advantage Plan) reported that high cost was the primary reason that they did not obtain dental care. The importance of oral health for the older adults has been the main reason that a national interprofessional consortium, which includes several national nursing organizations, has been advocating for legislation to expand Medicare to include dental coverage. The consortium's efforts have been thwarted by fierce opposition from the American Dental Association and many Republican legislators. Given the vital role that nurses and advanced practice nurses play in caring for the nation's older adults and disabled, nursing's voice needs to be strengthened as leaders in advocating for inclusion of dental benefits in traditional Medicare.

National centralized drug procurement and health care expenditure of households-micro-evidence from CFPS.

Objective: This paper utilizes data from the China Family Panel Studies (CFPS) to evaluate the impact of the "4 + 7" National Centralized Drug Procurement (NCDP) on Per Capita Household Health Care Expenditure (PCHHCE). Methods: The study applies the Differences-in-Differences (DID) methodology to analyze the effects of NCDP. Various robustness tests were conducted, including the Permutation test, Propensity Score Matching, alterations in regression methodologies, and consideration of individual fixed effects. Results: Research indicates that the implementation of NCDP led to a reduction of 10.6% in PCHHCE. The results remained consistent across all robustness tests. Additionally, the research identifies diversity in NCDP effects among various household characteristics, with a more significant impact on households residing in rural regions of China, enrolled in Basic Medical Insurance for urban and rural residents and urban workers, and having an income bracket of 25-75%. Conclusion: These findings carry policy implications for the future expansion and advancement of NCDP in China. The study highlights the effectiveness of NCDP in reducing healthcare expenditures and suggests potential areas for policy improvement and further research.

Skilled Nursing and Home Health Policy: A Primer for the Hospital Clinician.

This paper addresses the increasing challenges faced by hospital clinicians in coordinating and recommending postacute care for patients, focusing on issues related to access to the most common postacute services: skilled nursing facilities (SNFs) and home health agencies (HHAs). In coordinating discharges, hospital clinicians have minimal information on care delivery in these settings. This knowledge gap is exacerbated by the disrupted continuum of patient care between acute care hospitals, SNFs, and HHAs. To address these challenges, hospital clinicians must understand how recent federal policies have impacted SNF and HHA care provision. The paper provides an overview of recent Centers for Medicare and Medicaid Services (CMS) policies and programs affecting SNFs and HHAs, including: (1) fee-for-service reimbursement reform (ie, Patient Driven Payment Model [PDPM] and the Patient Driven Groupings Model [PDGM]); (2) bundled payment programs; (3) accountable care organizations; (4) Medicare Advantage plans. Overall, this paper aims to help hospital clinicians stay informed about the evolving landscape of postacute care delivery by providing relevant information on how recent policy changes have impacted patient care.

'The Emperor's new clothes?' Healthcare professionals' perceptions of the nursing associate role in two UK National Health Service hospitals: A qualitative interview study.

Background: The introduction of nursing associates in England in 2017 as a professional 'bridging' role aimed to mitigate chronic staffing shortages, enable career progression of healthcare assistants and release registered nurses to provide more complex care. Limited evidence exists about the alignment between the identity and purpose of nursing associate roles described by the UK independent regulator, the Nursing & Midwifery Council, and the expectations, obligations, and team dynamics encountered in practice. Purpose: Investigate the perceptions of nursing associate roles through the views and experiences of role holders, registered nurses, and healthcare assistants. Setting: Two British National Health Service (NHS) Hospital Trusts in London, England (UK). Methods: For this registered service evaluation, data were collected via in-person, semi-structured interviews. Verbatim transcripts were coded inductively. An adapted framework analysis method, suitable for use with Excel, was applied to support the identification of cross cutting themes. We used the Standards for Reporting Qualitative Research checklist for reporting this study. Results: Eleven registered nurses, five nursing associates, and five healthcare assistants participated. Their experiences seldom reflected the policy vision of the nursing associate role in practice. Several participants likened the nursing associate role to the fable of the 'Emperor's New Clothes' in which expectations and reality diverge. With this over-arching theme, four sub-themes were identified: (1) preparedness of organisational infrastructure to support this role; (2) credibility of the role in practice; (3) perceived organisational "blindness" to the ambiguities of the role and (4) increasing task orientation and segmentation in care delivery. Conclusion: There is a discrepancy between the identity of the nursing associate role as imagined in the policy agenda and its reality in practice. There is a need for more protected and well-defined training, clear role boundaries, and accessible career progression pathways for nursing associates. Moreover, honest dialogue at an organisational and policy level must continue, so that the challenges and opportunities of the nursing associate role are properly realised. Tweetable abstract: Emperor's new clothes! Experiences and views of new nursing associate roles in NHS (UK) acute hospitals @CarolynSpring3.

Achieving Equity in Transportation for Radiotherapy.

Transportation is a significant social determinant of health and a barrier to treatment for many patients. Cancer patients are disproportionately affected, and it can be especially salient for patients undergoing several weeks of daily radiation treatment. A prospective survey pilot study at our institution examining financial toxicity related to transportation for patients undergoing radiation treatment showed a correlation between high transportation costs and financial stress. Furthermore, those living >10 miles from the radiation center were associated with worse financial toxicity. Previous programs implemented to address the transportation issue in oncology have been mainly inadequate or ineffective. These programs have been set back due to a lack of awareness and low utilization. The Health Equity Achievement in Radiation Therapy (HEART) adjustment from the proposed Radiation Oncology Case Rate (ROCR) payment model for radiation oncology will greatly alleviate transportation barriers for patients undergoing radiation treatment. The $500 per patient can be utilized for those patients at the highest risk, like those living far away from the radiation center.

Evaluating the Population-Based Usage and Benefit of Digitally Collected Patient-Reported Outcomes and Experiences in Patients With Chronic Diseases: The PROMchronic Study Protocol.

BACKGROUND: Chronic diseases are associated with a high disease burden. Under- and overprovision of care as well as quality variation between health care providers persists, while current quality indicators rarely capture the patients' perspective. Capturing patient-reported outcome measures (PROMs) as well as patient-reported experience measures (PREMs) is becoming more and more important to identify gaps in care provision, prioritize services most valuable to patients, and aid patients' self-management. OBJECTIVE: This study aims to measure the potential benefits and effectiveness of using electronic patient-reported outcome measures (ePROMs) and electronic patient-reported experience measures in a structured and population-based manner to enhance health care for chronic disease patients in Germany. METHODS: This prospective cohort study aims to evaluate the potential benefits of PROM usage in patients with chronic diseases. We evaluate whether (1) digitally collected PROMs and PREMs can be used for health system performance assessment by generating a representative response of chronically diseased individuals with asthma, chronic obstructive pulmonary disease, diabetes, and coronary artery disease across Germany, and (2) based on the PROMs and PREMs, low-value care can be identified. As patient-reported outcomes (PROs) are rarely presented back to patients, (3) this study also examines patients' reactions to their PROM scores in the form of digital PRO feedback. For these purposes, randomly selected patients from a nationwide German insurer are digitally surveyed with generic and disease-specific PROMs and PREMs, as well as additional questions on their health-related behavior, 4 times over 1 year. Individual PRO feedback is presented back to patients longitudinally and compared to a peer group after each survey period. Patient-reported data is linked with health insurance data. Response rates, changes in health and experience outcomes over time, self-reported changes in health behavior, and health care system usage will be analyzed. RESULTS: The PROMchronic study explores the usage of PROMs in patients with chronic diseases. Data collection began in October 2023, after the initial invitation letter. All the 200,000 potential patients have been invited to participate in the study. Data have not yet been analyzed. Publication of the interim results is planned for the autumn of 2024, and the results are planned to be published in 2025. CONCLUSIONS: We aim to fill the research gap on the population-based usage of PROMs and PREMs in patients with chronic diseases and add to the current understanding of PROM data-sharing with patients. The study's results can thereby inform whether a health care system-wide approach to collecting PROMs and PREMs can be used to identify low-value care, assess quality variation within and across chronic conditions, and determine whether PRO feedback is helpful and associated with any changes in patients' health behaviors. TRIAL REGISTRATION: German Clinical Trials Register DRKS00031656; https://drks.de/search/en/trial/DRKS00031656. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/56487.

Equity and Inclusion for LGBTQ+ Residents: Lessons Learned from the Initial Long-Term Care Equality Index (LEI).

OBJECTIVES: Most older adults with lesbian, gay, bisexual, queer, questioning, transgender, and related identities (LGBTQ+) are concerned about receiving lower-quality care and/or being mistreated in nursing homes. Older LGBTQ+ veterans may have additional reservations about care in Department of Veterans Affairs (VA) nursing homes (Community Living Centers [CLCs]) because of experience with past discriminatory military policies (eg, bans on participating in military service, Don't Ask Don't Tell). This article describes one of the first VA CLCs to participate in the Human Rights Campaign-developed Long-Term Care Equality Index (LEI). DESIGN: A single-site formative evaluation was completed to support quality improvement and identify opportunities for growth using the LEI. The LEI is a facility benchmarking tool to support more inclusive environments for LGBTQ+ residents and employees. The LEI offers 4 evaluation criteria: (1) Non-Discrimination and Staff Training; (2) LGBTQ+ Resident Services and Support; (3) Employee Benefits and Policies; and (4) Resident and Community Engagement. Facilities receive ratings based on the number of requirements achieved in each category. PARTICIPANTS AND METHODS: Older LGBTQ+ veterans, current CLC residents, interdisciplinary CLC providers and leadership, and national Geriatrics and Extended Care program managers collaborated to pilot the LEI and develop tools and materials to support other VA facilities' participation in the LEI. RESULTS: Qualitative interviews with veterans and CLC residents supported inclusion of gender identity and sexual orientation in resident handbooks, discussions about person-centered care, and opportunities for additional staff training and community engagement (eg, observing Pride Month in June). Resources to support VA long-term care facilities' participation in the LEI were developed. CONCLUSIONS AND IMPLICATIONS: The LEI offers a structured approach to identifying areas for improvement in providing high-quality and equitable care in long-term care settings. Practical suggestions for CLCs and other nursing home settings considering the LEI for the first time are discussed.