Costs saved and avoided from pharmacist interventions to address drug-related problems identified from outpatient clinics in Jordan.

BACKGROUND: The pharmacist plays an essential role in identifying and managing drug-related problems. The aim of this research was to assess the costs avoided by clinical pharmacist interventions to resolve drug-related problems. RESEARCH DESIGN AND METHODS: Clinical pharmacists identified drug-related problems and interventions to address them in consecutive outpatients visiting internal medicine clinics at major teaching and public hospitals in Jordan from September 2012 to December 2013. The costs avoided by each intervention to address drug-related problems were collected from the literature. The collected data were used to calculate the overall cost saved and avoided by the interventions implemented to address the identified drug-related problems, adopting a Jordanian healthcare system perspective. RESULTS: A total of 2747 patients were enrolled in the study. Diagnostic interventions, such as the need for additional diagnostic testing, were employed in 95.07% of the 13935 intervention to address the drug-related problem "Miscellaneous" which was the most frequent drug-related problems. Other common drug-related problems categories included inappropriate knowledge (n = 6972), inappropriate adherence (4447), efficacy-related drug-related problem (3395) and unnecessary drug therapy (1082). The total cost avoided over the research period was JOD 1418720 per month and total cost saved over the study period was JOD 17250.204. Drug-related problems were associated the number of prescription medications (odds ratio = 1.105; 95% confidence interval = 1.069-1.142), prescribed gastrointestinal drugs (3.485; 2.86-4.247), prescribed antimicrobials (3.326; 1.084-10.205), and prescribed musculoskeletal drugs (1.385; 1.011-1.852). CONCLUSIONS: The study revealed that pharmacists have provided cognitive input to rationalize and optimize the medication use and prevent errors, that led to the reported projected avoided and saved expenditures via various interventions to address drug-related problems. This highlights the added economic impact to the clinical impact of drug-related problems on patients and the healthcare system. The high prevalence and cost of drug-related problems offer strong rationale for pharmacists to provide more vigilant intervention to improve patient outcomes while maintaining cost effectiveness.

Value-based comparison of ambulatory children with respiratory diseases in an emergency department and a walk-in clinic: a retrospective cohort study in Québec, Canada.

OBJECTIVE: To compare health outcomes and costs given in the emergency department (ED) and walk-in clinics for ambulatory children presenting with acute respiratory diseases. DESIGN: A retrospective cohort study. SETTING: This study was conducted from April 2016 to March 2017 in one ED and one walk-in clinic. The ED is a paediatric tertiary care centre, and the clinic has access to lab tests and X-rays. PARTICIPANTS: Inclusion criteria were children: (1) aged from 2 to 17 years old and (2) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia or acute asthma. MAIN OUTCOME MEASURES: The primary outcome measure was the proportion of patients returning to any ED or clinic within 3 and 7 days of the index visit. The secondary outcome measures were the mean cost of care estimated using time-driven activity-based costing and the incidence of antibiotic prescription for URTI patients. RESULTS: We included 532 children seen in the ED and 201 seen in the walk-in clinic. The incidence of return visits at 3 and 7 days was 20.7% and 27.3% in the ED vs 6.5% and 11.4% in the clinic (adjusted relative risk at 3 days (aRR) (95% CI) 3.17 (1.77 to 5.66) and aRR at 7 days 2.24 (1.46 to 3.44)). The mean cost (95% CI) of care (CAD) at the index visit was $C96.68 (92.62 to 100.74) in the ED vs $C48.82 (45.47 to 52.16) in the clinic (mean difference (95% CI): 46.15 (41.29 to 51.02)). Antibiotic prescription for URTI was less common in the ED than in the clinic (1.5% vs 16.4%; aRR 0.10 (95% CI 0.03 to 0.32)). CONCLUSIONS: The incidence of return visits and cost of care were significantly higher in the ED, while antibiotic use for URTI was more frequent in the walk-in clinic. These data may help determine which setting offers the highest value to ambulatory children with acute respiratory conditions.

Access to Sudden Sensorineural Hearing Loss Care at Private Equity-Owned Otolaryngology Clinics.

OBJECTIVE: Characterizing access to sudden sensorineural hearing loss (SSNHL) care at private practice otolaryngology clinics of varying ownership models. STUDY DESIGN: Cross-sectional prospective review. SETTING: Private practice otolaryngology clinics. METHODS: We employed a Secret Shopper study design with private equity (PE) owned and non-PE-owned clinics within 15 miles of one another. Using a standardized script, researchers randomly called 50% of each clinic type between October 2021 and January 2022 requesting an appointment on behalf of a family member enrolled in either Medicaid or private insurance (PI) experiencing SSNHL. Access to timely care was assessed between clinic ownership and insurance type. RESULTS: Seventy-eight total PE-owned otolaryngology clinics were identified across the United States. Only 40 non-PE clinics could be matched to the PE clinics; 39 PE and 28 non-PE clinics were called as Medicaid patients; 39 PE and 25 non-PE clinics were called as PI patients; 48.7% of PE and 28.6% of non-PE clinics accepted Medicaid. The mean wait time to new appointment ranged between 9.55 and 13.21 days for all insurance and ownership types but did not vary significantly (P > .480). Telehealth was significantly more likely to be offered for new Medicaid patients at non-PE clinics compared to PE clinics (31.8% vs 0.0%, P = .001). The mean cost for an appointment was significantly greater at PE clinics than at non-PE clinics ($291.18 vs $203.75, P = .004). CONCLUSIONS: Patients seeking SSNHL care at PE-owned otolaryngology clinics are likely to face long wait times prior to obtaining an initial appointment and reduced telehealth options.

Progressive Massive Fibrosis Identified at Federally Funded Black Lung Clinics in the US.

This study of US Black Lung Clinics (established to treat coal miners) reports the prevalence of progressive massive fibrosis identified through June 2023.

Association Between Dialysis Facility Ownership and Access to the Waiting List and Transplant in Pediatric Patients With End-stage Kidney Disease in the US.

Importance: Care of adults at profit vs nonprofit dialysis facilities has been associated with lower access to transplant. Whether profit status is associated with transplant access for pediatric patients with end-stage kidney disease is unknown. Objective: To determine whether profit status of dialysis facilities is associated with placement on the kidney transplant waiting list or receipt of kidney transplant among pediatric patients receiving maintenance dialysis. Design, Setting, and Participants: This retrospective cohort study reviewed the US Renal Data System records of 13 333 patients younger than 18 years who started dialysis from 2000 through 2018 in US dialysis facilities (followed up through June 30, 2019). Exposures: Time-updated profit status of dialysis facilities. Main Outcomes and Measures: Cox models, adjusted for clinical and demographic factors, were used to examine time to wait-listing and receipt of kidney transplant by profit status of dialysis facilities. Results: A total of 13 333 pediatric patients who started receiving maintenance dialysis were included in the analysis (median age, 12 years [IQR, 3-15 years]; 6054 females [45%]; 3321 non-Hispanic Black patients [25%]; 3695 Hispanic patients [28%]). During a median follow-up of 0.87 years (IQR, 0.39-1.85 years), the incidence of wait-listing was lower at profit facilities than at nonprofit facilities, 36.2 vs 49.8 per 100 person-years, respectively (absolute risk difference, -13.6 (95% CI, -15.4 to -11.8 per 100 person-years; adjusted hazard ratio [HR] for wait-listing at profit vs nonprofit facilities, 0.79; 95% CI, 0.75-0.83). During a median follow-up of 1.52 years (IQR, 0.75-2.87 years), the incidence of kidney transplant (living or deceased donor) was also lower at profit facilities than at nonprofit facilities, 21.5 vs 31.3 per 100 person-years, respectively; absolute risk difference, -9.8 (95% CI, -10.9 to -8.6 per 100 person-years) adjusted HR for kidney transplant at profit vs nonprofit facilities, 0.71 (95% CI, 0.67-0.74). Conclusions and Relevance: Among a cohort of pediatric patients receiving dialysis in the US from 2000 through 2018, profit facility status was associated with longer time to wait-listing and longer time to kidney transplant.

Long-run growth of ambulatory surgery centers 1990-2015 and Medicare payment policy.

OBJECTIVE: To examine long-run growth in the ambulatory surgery center (ASC) industry and potential factors influencing its trajectory. DATA SOURCES: National data for all Medicare-certified ASCs (1990-2015) and outpatient discharge records from the state of Florida in 2007. STUDY DESIGN: We documented the number of ASCs in the United States over time and decomposed the trend into underlying ASC market entry and exit behavior. We then examined the plausibility of 2008 Medicare payment reforms to influence the trend changes. DATA EXTRACTION METHODS: Data on ASC openings and closures are obtained from the Centers for Medicare and Medicaid Services Provider of Service files. Secondary data on ASC volume in Florida are obtained from the Florida Agency for Health Care Administration. PRINCIPAL FINDINGS: The number of ASCs in the United States grew 5%-10% annually between 1990 and 2007 but by 1% or less beginning in 2008. This change coincided with substantive reductions in Medicare payments for key ASC services. The annual number of new ASCs was as much as 50% lower following the payment change. CONCLUSIONS: ASCs are an important competitor for outpatient services, but growth has slowed dramatically. Sharp changes in new ASC entry align with less generous Medicare fees.

Characterizing demographics and cost of care for dyshidrotic eczema.

BACKGROUND: Dyshidrotic eczema (DE) is a common form of eczema affecting the hands, feet, or both areas. To date, there has been little research examining demographics and cost burden associated with this disease. OBJECTIVE: This study seeks to characterize the demographics of patients affected and the direct costs of care associated with DE. METHODS: This is a retrospective analysis utilizing insurance claim information from IBM MarketScan. Pertinent data including demographic information, healthcare provider type, medications prescribed, and average cost of care were identified using the ICD 10 code L30.1 for DE for the year 2018. RESULTS: In 2018, 34 932 patients filed claims for DE, with 61% female and an average age of 37 years at first diagnosis. DE was mostly seen in employees from the service industry and the manufacturing of durable goods. The total annual direct cost was US $11 738 985. Average annual costs, however, did vary based on type of treating healthcare provider, level of care, and medications prescribed. CONCLUSIONS: Patients with DE can face an economic burden due to their disease and providers should aim to recognize this disease and its treatments to minimize healthcare costs for patients and improve quality of life.

Celebrating a decade of the minor operations clinic: an approach at a regional New Zealand hospital.

BACKGROUND: A minor operations clinic has been providing a "one-stop shop" at our regional New Zealand hospital for the past decade to service management of skin lesions. This study aims to assess demographics, service characteristics, clinical standards and cost-savings from this setup, and to identify areas for improvement and potentially provide a model for other health units. METHODS: All patients seen between May 2009 and June 2019 were prospectively included. Data includes demographics, waitlist period, referral sources, follow-up destinations, histology including involvement of margins and cost. RESULTS: A total of 4,926 patients were included, with 6,442 procedures overall. Median age was 72 years old. The main source of referrals was primary care. The majority of patients were returned directly to primary care. Median wait-time was 66 days, and this remained static over the decade. 56.6% of excised lesions yielded malignant histology and 90.1% achieved clear margins. There was a calculated saving of NZ$607.00 per patient with our one-stop shop compared to our previous traditional model. A further calculated saving of NZ$452,028.50 was achieved by diverting complex procedures from requiring operating theatre environments. CONCLUSIONS: Our model provides successful, streamlined and cost-effective treatment of skin lesions for our community. This model (or aspects of) may be similarly effective in other regional centres.

Patient Health Outcomes following Dialysis Facility Closures in the United States.

BACKGROUND: Ongoing changes to reimbursement of United States dialysis care may increase the risk of dialysis facility closures. Closures may be particularly detrimental to the health of patients receiving dialysis, who are medically complex and clinically tenuous. METHODS: We used two separate analytic strategies-one using facility-based matching and the other using propensity score matching-to compare health outcomes of patients receiving in-center hemodialysis at United States facilities that closed with outcomes of similar patients who were unaffected. We used negative binomial and Cox regression models to estimate associations of facility closure with hospitalization and mortality in the subsequent 180 days. RESULTS: We identified 8386 patients affected by 521 facility closures from January 2001 through April 2014. In the facility-matched model, closures were associated with 9% higher rates of hospitalization (relative rate ratio [RR], 1.09; 95% confidence interval [95% CI], 1.03 to 1.16), yielding an absolute annual rate difference of 1.69 hospital days per patient-year (95% CI, 0.45 to 2.93). Similarly, in a propensity-matched model, closures were associated with 7% higher rates of hospitalization (RR, 1.07; 95% CI, 1.00 to 1.13; P=0.04), yielding an absolute rate difference of 1.08 hospital days per year (95% CI, 0.04 to 2.12). Closures were associated with nonsignificant increases in mortality (hazard ratio [HR], 1.08; 95% CI, 1.00 to 1.18; P=0.05 for the facility-matched comparison; HR, 1.08; 95% CI, 0.99 to 1.17; P=0.08 for the propensity-matched comparison). CONCLUSIONS: Patients affected by dialysis facility closures experienced increased rates of hospitalization in the subsequent 180 days and may be at increased risk of death. This highlights the need for effective policies that continue to mitigate risk of facility closures.

"Do Their Own Thing": Radical Health Care and the Fair Haven Community Health Center.

Radical health reform movements of the 1960s inspired two widely adopted alternative health care models in the United States: free clinics and community health centers. These groundbreaking institutions attempted to realize bold ideals but faced financial, bureaucratic, and political obstacles. This article examines the history of Fair Haven Community Health Care (FHCHC) in New Haven, Connecticut, an organization that spanned both models and typified innovative aspects of each while resisting the forces that tempered many of its contemporaries' progressive practices. Motivated by a tradition of independence and struggling to address medical neglect in their neighborhood, FHCHC leaders chose not to affiliate with the local academic hospital, a decision that led many disaffected community members to embrace the clinic. The FHCHC also prioritized grant funding over fee-for-service revenue, thus retaining freedom to implement creative programs. Furthermore, the center functioned in an egalitarian manner, enthusiastically employing nurse practitioners and whole-staff meetings, and was largely able to avoid the conflicts that strained other community-controlled organizations. The FHCHC proved unusual among free clinics and health centers and demonstrated strategies similar institutions might employ to overcome common challenges. (Am J Public Health. 2021;111(10): 1806-1814. https://doi.org/10.2105/AJPH.2021.306417).

Outreach physiatry clinics in remote Manitoba communities: an economic cost analysis.

BACKGROUND: One in 5 people in Canada have a disability affecting daily activities, and, for rural patients, accessing lifelong physiatry care to improve function and manage symptoms requires complex and expensive travel. We compared the costs of new outreach physiatry clinics with those of conventional urban clinics in Manitoba. METHODS: Six outreach clinics were held from January 2018 to September 2019 in the remote communities of St. Theresa Point and Churchill, Manitoba. A general physiatry population was seen in these clinics, including patients with musculoskeletal and neurologic conditions seen in consultation and follow-up. We performed a societal cost-minimization analysis comparing outreach clinic costs to estimated costs of standard care at conventional outpatient clinics in Winnipeg. Outcomes of interest included direct costs to government health services and patients, and indirect opportunity cost of travel time. We calculated total costs, average cost per clinic visit and incremental costs for outreach clinics compared to conventional urban clinics. Costs were inflated to 2020 Canadian dollars. RESULTS: Thirty-one patients (48 visits) were seen at the outreach clinics. The total cost of providing outreach clinics, $33 136, was 21% of the estimated cost of standard care, $158 344. When only direct costs were included, outreach clinics cost an estimated 24% of conventional care costs. The average unit cost per outreach visit was $690, compared to $3299 per conventional visit, for an incremental cost of -$2609 per outreach visit. INTERPRETATION: An outreach physiatry visit in Manitoba cost an estimated 21% of a conventional urban outpatient visit, or 24% when only direct costs were included, with costs savings largely related to travel. Outreach physiatry care in this model provides substantial cost savings for the public health care system as the primary payer, and can reduce the travel cost burden for patients who do not have public travel funding.

Billing patterns for in-office computerized tomography scans of the face/sinus by otolaryngologists.

PURPOSE: To evaluate billing trends, Medicare reimbursement, and practice setting for Medicare-billing otolaryngologists (ORLs) performing in-office face computerized tomography (CT) scans. METHODS: This retrospective study included data on Medicare-billing ORLs from Medicare Part B: Provider Utilization and Payment Datafiles (2012-2018). Number of Medicare-billing ORLs performing in-office CT scans, and total sums and medians for Medicare reimbursements, services performed, and number of patients were gathered along with geographic and practice-type distributions. RESULTS: In 2018, roughly 1 in 7 Medicare-billing ORLs was performing in-office CT scans, an increase from 1 in 10 in 2012 (48.2% growth). From 2012 to 2018, there has been near-linear growth in number of in-office CT scans performed (58.2% growth), and number of Medicare fee-for-service (FFS) patients receiving an in-office CT scan (64.8% growth). However, at the median, the number of in-office CT scans performed and number of Medicare FFS patients receiving an in-office CT, per physician, has remained constant, despite a decline of 42.3% (2012: $227.67; 2018: $131.26) in median Medicare reimbursements. CONCLUSION: Though sharp declines have been seen in Medicare reimbursement, a greater proportion of Medicare-billing ORLs have been performing in-office face CT scans, while median number of in-office CT scans per ORL has remained constant. Although further investigation is certainly warranted, this analysis suggests that ORLs, at least in the case of the Medicare FFS population, are utilizing in-office CT imaging for preoperative planning, pathologic diagnosis, and patient convenience, rather than increased revenue streams. Future studies should focus on observing these billing trends among private insurers.

Musculoskeletal Urgent Care Centers Restrict Access for Patients with Medicaid Insurance Based on Policy and Location.

BACKGROUND: As the urgent care landscape evolves, specialized musculoskeletal urgent care centers (MUCCs) are becoming more prevalent. MUCCs have been offered as a convenient, cost-effective option for timely acute orthopaedic care. However, a recent "secret-shopper" study on patient access to MUCCs in Connecticut demonstrated that patients with Medicaid had limited access to these orthopaedic-specific urgent care centers. To investigate how generalizable these regional findings are to the United States, we conducted a nationwide secret-shopper study of MUCCs to identify determinants of patient access. QUESTIONS/PURPOSES: (1) What proportion of MUCCs in the United States provide access for patients with Medicaid insurance? (2) What factors are associated with MUCCs providing access for patients with Medicaid insurance? (3) What barriers exist for patients seeking care at MUCCs? METHODS: An online search of all MUCCs across the United States was conducted in this cross-sectional study. Three separate search modalities were used to gather a complete list. Of the 565 identified, 558 were contacted by phone with investigators posing over the telephone as simulated patients seeking treatment for a sprained ankle. Thirty-nine percent (216 of 558) of centers were located in the South, 13% (71 of 558) in the West, 25% (138 of 558) in the Midwest, and 24% (133 of 558) in New England. This study was given an exemption waiver by our institution's IRB. MUCCs were contacted using a standardized script to assess acceptance of Medicaid insurance and identify barriers to care. Question 1 was answered through determining the percentage of MUCCs that accepted Medicaid insurance. Question 2 considered whether there was an association between Medicaid acceptance and factors such as Medicaid physician reimbursements or MUCC center type. Question 3 sought to characterize the prevalence of any other means of limiting access for Medicaid patients, including requiring a referral for a visit and disallowing continuity of care at that MUCC. RESULTS: Of the MUCCs contacted, 58% (323 of 558) accepted Medicaid insurance. In 16 states, the proportion of MUCCs that accepted Medicaid was equal to or less than 50%. In 22 states, all MUCCs surveyed accepted Medicaid insurance. Academic-affiliated MUCCs accepted Medicaid patients at a higher proportion than centers owned by private practices (odds ratio 14 [95% CI 4.2 to 44]; p < 0.001). States with higher Medicaid physician reimbursements saw proportional increases in the percentage of MUCCs that accepted Medicaid insurance under multivariable analysis (OR 36 [95% CI 14 to 99]; p < 0.001). Barriers to care for Medicaid patients characterized included location restriction and primary care physician referral requirements. CONCLUSION: It is clear that musculoskeletal urgent care at these centers is inaccessible to a large segment of the Medicaid-insured population. This inaccessibility seems to be related to state Medicaid physician fee schedules and a center's affiliation with a private orthopaedic practice, indicating how underlying financial pressures influence private practice policies. Ultimately, the refusal of Medicaid by MUCCs may lead to disparities in which patients with private insurance are cared for at MUCCs, while those with Medicaid may experience delays in care. Going forward, there are three main options to tackle this issue: increasing Medicaid physician reimbursement to provide a financial incentive, establishing stricter standards for MUCCs to operate at the state level, or streamlining administration to reduce costs overall. Further research will be necessary to evaluate which policy intervention will be most effective. LEVEL OF EVIDENCE: Level II, prognostic study.

Dialysis Facility Profit Status and Early Steps in Kidney Transplantation in the Southeastern United States.

BACKGROUND AND OBJECTIVES: Dialysis facilities in the United States play a key role in access to kidney transplantation. Previous studies reported that patients treated at for-profit facilities are less likely to be waitlisted and receive a transplant, but their effect on early steps in the transplant process is unknown. The study's objective was to determine the association between dialysis facility profit status and critical steps in the transplantation process in Georgia, North Carolina, and South Carolina. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective cohort study, we linked referral and evaluation data from all nine transplant centers in the Southeast with United States Renal Data System surveillance data. The cohort study included 33,651 patients with kidney failure initiating dialysis from January 1, 2012 to August 31, 2016. Patients were censored for event (date of referral, evaluation, or waitlisting), death, or end of study (August 31, 2017 for referral and March 1, 2018 for evaluation and waitlisting). The primary exposure was dialysis facility profit status: for profit versus nonprofit. The primary outcome was referral for evaluation at a transplant center after dialysis initiation. Secondary outcomes were start of evaluation at a transplant center after referral and waitlisting. RESULTS: Of the 33,651 patients with incident kidney failure, most received dialysis treatment at a for-profit facility (85%). For-profit (versus nonprofit) facilities had a lower cumulative incidence difference for referral within 1 year of dialysis (-4.5%; 95% confidence interval, -6.0% to -3.2%). In adjusted analyses, for-profit versus nonprofit facilities had lower referral (hazard ratio, 0.84; 95% confidence interval, 0.80 to 0.88). Start of evaluation within 6 months of referral (-1.0%; 95% confidence interval, -3.1% to 1.3%) and waitlisting within 6 months of evaluation (1.0%; 95% confidence interval, -1.2 to 3.3) did not meaningfully differ between groups. CONCLUSIONS: Findings suggest lower access to referral among patients dialyzing in for-profit facilities in the Southeast United States, but no difference in starting the evaluation and waitlisting by facility profit status.

Estimate cost of providing methadone maintenance treatment at a methadone clinic in Nairobi Kenya: direct costs.

Methadone maintenance treatment is reported as cost-effective in treatment of opioid use disorder. Estimated cost of providing methadone varies widely in different regions but there is no data regarding cost of methadone treatment in Kenya. The aim of this study was to estimate the cost of methadone maintenance treatment at a methadone maintenance treatment clinic in Nairobi, Kenya from the perspective of the government, implementing partner and the clients. Data was collected for the period of February 2017 to September 2018 for 700 enrolled clients. The cost of providing methadone treatment was estimated as the sum of salaries, laboratory test, methadone and other commodities costs. The outcome was daily cost of methadone per client. The costs are given in Kenya Shillings (Ksh). The cost of treating one client is approximately Ksh. 149 (US$1.49) per day which amounts to Ksh 4500 (US$ 45) per month. This is from the estimated direct costs such as salaries which accounted for 86.4%, methadone 9.6%, tests and other consumables at 4%. The estimated average dose per patient per day is 60mg.This excludes indirect costs such as capital and set up cost, maintenance cost, training, drug import and distribution and other bills. The findings of this study show that the estimate cost of providing methadone at Nairobi, Kenya is comparable to that in other centers. This can help to inform policy makers on continued provision of methadone treatment in the country.

Cost-Benefit Analysis of Ultrasonography in the Hand Clinic.

BACKGROUND: Despite previous studies demonstrating the benefit of office-based ultrasonography for musculoskeletal evaluation, many hand surgery clinics have yet to adopt this practice. The authors conducted a cost-benefit analysis of establishing an ultrasound machine in a hand clinic. METHODS: The authors used the Medicare Physician Fee Schedule, Physician/Supplier Procedure Summary, and Physician Compare National Downloadable File databases to estimate provider reimbursement and annual frequency of office-based upper extremity-related ultrasound procedures. Ultrasound machine cost, maintenance fees, and consumable supply prices were gleaned from the literature. The primary outcomes were net cost-benefit difference and benefit-cost ratio at 1 year, 5 years, and 10 years after implementation. Sensitivity analyses were performed by varying factors that influence the net cost-benefit difference. RESULTS: The estimated total initial expense to establish ultrasonography in the clinic was $53,985. The overall cost-benefit difference was -$49,530 per practice at the end of the first year (benefit-cost ratio, 0.3), -$1049 after 5 years (benefit-cost ratio, 1.0), and $52,022 after 10 years (benefit-cost ratio, 1.4). Benefits primarily accrued because of physician reimbursements. One-way sensitivity analysis revealed machine price, annual procedure volume, and reimbursement rate as the most influential parameters in determining the benefit-cost ratio. Ultrasonography was cost beneficial when the machine price was less than $46,000 or if the billing frequency exceeded six times per week. A societal perspective analysis demonstrated a large net benefit of $218,162 after 5 years. CONCLUSIONS: Implementation of office-based ultrasound imaging can result in a positive financial return on investment. Ultrasound machine cost and procedural volume were the most critical factors influencing benefit-cost ratio.

Recent Trends in Medicare Utilization and Reimbursement for Orthopaedic Procedures Performed at Ambulatory Surgery Centers.

BACKGROUND: As part of a market-driven response to the increasing costs of hospital-based surgical care, an increasing volume of orthopaedic procedures are being performed in ambulatory surgery centers (ASCs). The purpose of the present study was to identify recent trends in orthopaedic ASC procedure volume, utilization, and reimbursements in the Medicare system between 2012 and 2017. METHODS: This cross-sectional, national study tracked annual Medicare claims and payments and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates, and reimbursement rates, and to identify demographic predictors of ASC utilization. RESULTS: A total of 1,914,905 orthopaedic procedures were performed at ASCs in the Medicare population between 2012 and 2017, with an 8.8% increase in annual procedure volume and a 10.5% increase in average reimbursements per case. ASC orthopaedic procedure utilization, including utilization across all subspecialties, is strongly associated with metropolitan areas compared with rural areas. In addition, orthopaedic procedure utilization, including for sports and hand procedures, was found to be significantly higher in wealthier counties (measured by average household income) and in counties located in the South. CONCLUSIONS: This study demonstrated increasing orthopaedic ASC procedure volume in recent years, driven by increases in hand procedure volume. Medicare reimbursements per case have steadily risen and outpaced the rate of inflation over the study period. However, as orthopaedic practice overhead continues to increase, other Medicare expenditures such as hospital payments and operational and implant costs also must be evaluated. These findings may provide a source of information that can be used by orthopaedic surgeons, policy makers, investors, and other stakeholders to make informed decisions regarding the costs and benefits of the use of ASCs for orthopaedic procedures.

Payment methods for healthcare providers working in outpatient healthcare settings.

BACKGROUND: Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES: To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA: Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes. MAIN RESULTS: We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS: For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.