Prices for Physicians' Services in Medicare Advantage and Commercial Plans.

The prices that insurers pay physicians ultimately affect beneficiaries' health insurance premiums. Using 2014 claims data from three major insurers, we analyzed the prices insurers paid in their Medicare Advantage (MA) and commercial plans for 20 physician services, in and out of network, and compared those prices with estimated amounts that Medicare's fee-for-service (FFS) program would pay for the same service. MA prices paid by those insurers were close to Medicare FFS prices, varied minimally, and were similar in and out of network. In contrast, commercial prices paid by the same insurers were substantially higher than FFS, varied widely, and were up to three times higher out of network than in network. Those results suggest that insurers can use statutory limits on out-of-network charges in MA to negotiate lower in-network prices in those plans. In contrast, without those limits on out-of-network prices, in-network prices in commercial plans are much higher.

The Impact of the Affordable Care Act (ACA) Medicaid Expansion on Visit Rates for Diabetes in Safety Net Health Centers.

OBJECTIVE: To (1) compare clinic-level uninsured, Medicaid-insured, and privately insured visit rates within and between expansion and nonexpansion states before and after the Affordable Care Act (ACA) Medicaid expansion among the 3 cohorts of patient populations; and (2) assess whether there was a change in clinic-level overall, primary care visits, preventive care visits, and diabetes screening rates in expansion versus nonexpansion states from pre-ACA to post-ACA Medicaid expansion. METHODS: Electronic health record data on nonpregnant patients aged 19 to 64 years, with ≥1 ambulatory visit between 01/01/2012 and 12/31/2015 (n = 483,912 in expansion states; n = 388,466 in nonexpansion states) from 198 primary care community health centers were analyzed. Using a difference-in-difference methodology, we assessed changes in visit rates pre-ACA versus post-ACA among a cohort of patients with diabetes, prediabetes, and no diabetes. RESULTS: Rates of uninsured visits decreased for all cohorts in expansion and nonexpansion states. For all cohorts, Medicaid-insured visit rates increased significantly more in expansion compared with nonexpansion states, especially among prediabetic patients (+71%). In nonexpansion states, privately insured visit rates more than tripled for the prediabetes cohort and doubled for the diabetes and no diabetes cohorts. Rates for glycosylated hemoglobin screenings increased in all groups, with the largest changes among no diabetes (rate ratio, 2.26; 95% CI, 1.97-2.56) and prediabetes cohorts (rate ratio, 2.00; 95% CI, 1.80-2.19) in expansion states. CONCLUSION: The ACA reduced uninsurance and increased access to preventive care for vulnerable patients, especially those with prediabetes. These findings are important to consider when making decisions regarding altering the ACA.

Physician Reimbursement in Medicare Advantage Compared With Traditional Medicare and Commercial Health Insurance.

Importance: Nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, yet little is known about the prices that MA plans pay for physician services. Medicare Advantage insurers typically also sell commercial plans, and the extent to which MA physician reimbursement reflects traditional Medicare (TM) rates vs negotiated commercial prices is unclear. Objective: To compare prices paid for physician and other health care services in MA, traditional Medicare, and commercial plans. Design, Setting, and Participants: Retrospective analysis of claims data evaluating MA prices paid to physicians and for laboratory services and durable medical equipment between 2007 and 2012 in 348 US core-based statistical areas. The study population included all MA and commercial enrollees with a large national health insurer operating in both markets, as well as a 20% sample of TM beneficiaries. Exposures: Enrollment in an MA plan. Main Outcomes and Measures: Mean reimbursement paid to physicians, laboratories, and durable medical equipment suppliers for MA and commercial enrollees relative to TM rates for 11 Healthcare Common Procedure Coding Systems (HCPCS) codes spanning 7 sites of care. Results: The sample consisted of 144 million claims. Physician reimbursement in MA was more strongly tied to TM rates than commercial prices, although MA plans tended to pay physicians less than TM. For a mid-level office visit with an established patient (Current Procedural Terminology [CPT] code 99213), the mean MA price was 96.9% (95% CI, 96.7%-97.2%) of TM. Across the common physician services we evaluated, mean MA reimbursement ranged from 91.3% of TM for cataract removal in an ambulatory surgery center (CPT 66984; 95% CI, 90.7%-91.9%) to 102.3% of TM for complex evaluation and management of a patient in the emergency department (CPT 99285; 95% CI, 102.1%-102.6%). However, for laboratory services and durable medical equipment, where commercial prices are lower than TM rates, MA plans take advantage of these lower commercial prices, ranging from 67.4% for a walker (HCPCS code E0143; 95% CI, 66.3%-68.5%) to 75.8% for a complete blood cell count (CPT 85025; 95% CI, 75.0%-76.6%). Conclusions and Relevance: Traditional Medicare's administratively set rates act as a strong anchor for physician reimbursement in the MA market, although MA plans succeed in negotiating lower prices for other health care services for which TM overpays. Reforms that transition the Medicare program toward some premium support models could substantially affect how physicians and other clinicians are paid.

Gatekeeping and the utilization of physician services in France: Evidence on the Médecin traitant reform.

In 2005, France implemented a gatekeeping reform designed to improve care coordination and to reduce utilization of specialists' services. Under this policy, patients designate a médecin traitant, typically a general practitioner, who will be their first point of contact during an episode of care and who will provide referrals to specialists. A key element of the policy is that patients who self-refer to a specialist face higher cost sharing than if they received a referral from their médecin traitant. We consider the effect of this policy on the utilization of physician services. Our analysis of administrative claims data spanning the years 2000-2008 indicates that visits to specialists, which were increasing in the years prior to the implementation of the reform, fell after the policy was in place. Additional evidence from the administrative claims as well as survey data suggest that this decline arose from a reduction in self-referrals, which is consistent with the objectives of the policy. Visits fell significantly both for specialties targeted by the policy and specialties for which self-referrals are still allowed for certain treatments. This apparent spillover effect may suggest that, at least initially, patients did not understand the subtleties of the policy.

Return to Work after a Work Accident: Is Coordination between the Occupational Physician and the Insurance Physician Possible? / Retour à l'emploi après un accident de travail : une coordination entre médecin du travail et médecin-conseil d'assurance est-elle possible ?

Occupational physicians and insurance physicians each have their own roles in managing the consequences of work accidents and their interaction is pivotal in the administrative and clinical process of return to work. We wanted to analyse the barriers and facilitators of this collaboration in Belgium.A qualitative study was conducted based on individual interviews of a sample of insurance physicians and occupational physicians working in French-speaking Belgium. This sample was selected to represent all insurance companies and most prevention and protection services operating on the territory. The interview scheme was designed to explore the various dimensions of the RDIC model (Resource Dependence Institutional Collaboration) of collaboration between professionals.This study highlighted certain obstacles to collaboration, related to the mutual perception of the 2 professions, ignorance of the other profession's work context, lack of independent resources blocking the willingness to cooperate (sufficient time, fees). Some facilitating factors were also identified : occupational physicians' willingness to cooperate, a positive attitude towards the ability to cooperate, as well as proposals for immediate improvement of some factors. Collaboration between these 2 professions has rarely been studied and the results of the present study provide tracks for improvement that can be applied in the short or medium term to enable those two categories of physicians to be better organized and more efficient in managing disability consequences of work accidents.

A retrospective cohort study of long-term immediate-release hydrocodone/acetaminophen use and acetaminophen dosing above the Food and Drug Administration recommended maximum daily limit among commercially insured individuals in the United States (2008-2013).

UNLABELLED: Immediate-release (IR) hydrocodone/acetaminophen is the most prescribed opioid in the United States; however, patterns of use, including long-term treatment and dose, are not well described. Duration of use, including the percentage of patients on long-term treatment (>90 days of continuous use), was assessed for patients newly prescribed IR hydrocodone/acetaminophen compared to other opioid analgesics in a national commercial insurance database (January 2008-September 2013). Though only a small percentage of IR hydrocodone/acetaminophen patients continued treatment long-term (1.7%), the number was large (104,839) and was nearly 5 times the number receiving extended-release (ER) morphine (n = 22,338) and nearly 4 times the number receiving ER oxycodone (n = 26,946) long-term. Using a less conservative allowable gap in treatment increased the number of patients meeting the criteria for long-term use (approximately 160,000 for IR hydrocodone/acetaminophen vs <30,000 for ER morphine and ER oxycodone). Most patients meeting these criteria received IR hydrocodone doses between >20 and ≤60 mg/d (n = 56,220, 53.6%) in month 4; 5.5% (n = 5,743) received doses >60 mg/d. Moreover, approximately 15% of IR hydrocodone/acetaminophen patients (n > 900,000) were prescribed total daily acetaminophen doses exceeding 4 g (the limit recommended by the U.S. Food and Drug Administration) at their initial IR hydrocodone/acetaminophen prescription or any time during therapy. PERSPECTIVE: Although most patients were prescribed IR hydrocodone/acetaminophen for acute pain, the number of patients prescribed long-term therapy exceeds the number of patients prescribed ER opioids. It is important to consider the benefits and risks inherent with long-term opioid therapy, whether with IR or ER opioids, to ensure safe use of these products.

Análisis del impacto del aumento del coseguro en un servicio de emergencias

Definimos como coseguro a la participación directa del paciente en un porcentaje del costo de los servicios sanitarios en el momento de utilizarlos. Con el pago del coseguro además de contener el uso de los servicios se puede obtener una financiación adicional para el sistema. Los Servicios de Emergencias tienen como complemento la atención domiciliaria no urgente o consultas. En los cuales el coseguro, se utiliza como método de racionalización del uso del servicio. De esta manera, se busca que sea utilizado de la forma más efectiva posible. Se ha descripto como influencian el copago en la atención primaria pero poco se ha planteado en la atención pre hospitalaria. Por este motivo, debemos valorar si el aumento del coseguro es efectivo para restringir el uso del servicio y si el mismo trae consecuencias sobre la salud de las personas. Se realizó un estudio retrospectivo, de Cohorte longitudinal, donde se recolectaron los datos de la asistencia médica de un Servicio de Emergencias comprendidos entre Setiembre 2011 hasta abril 2013 en la ciudad de Córdoba Capital. Los datos surgidos fueron analizados en dos periodos, los cuales se denominaron: periodo 1 que incluye aquellas consultas con coseguro realizadas desde Septiembre de 2011 a Septiembre de 2012. El período 2, que incluye aquellas consultas con coseguro realizadas entre Septiembre de 2012 a Septiembre de 2013. En este período se realizó un aumento del 100% del coseguro. Todas las prestaciones serán dominadas “auxilios”, y serán clasificados en Grado 1, 2 y 3, dependiendo de su complejidad. Los mismos son registrados desde el Despacho del Servicio de Emergencias Médicas y registrados por el sistema DTM 26 Socorro Medico ®, posteriormente se exportaran los datos a planilla Excel 2010®. comparando los dos períodos mes a mes no se encuentran diferencias significativas en las consultas o Grado 3 (p= 0,19)...

We define as co-insurance to the direct participation of the patient in a percentage of the cost of health services at the time of use. With the payment of the co-insurance in addition to containing the use of the services you can get an additional funding for the system. The Emergency Services have as a complement the home care not urgent or medical consultations. In which the co-insurance, is used as a method of rationalization of the use of the service. In this way, are looking to be used in the most effective way possible. Has been described as influence the copayment in primary care but little has been raised in the attention pre-hospital care. For this reason, we must assess whether the increase in the Co-insurance is effective to restrict the use of the service and if the same brings consequences on the health of the people. A retrospective study was performed of longitudinal cohort, where data were collected from the medical assistance of an Emergency Service between September 2011 to April 2013 in the city of Cordoba Capital. The data were analyzed in two periods, which were termed: period 1 that includes those consultations with coinsurance carried out from September 2011 to September 2012. The period 2 this includes those consultations with coinsurance undertaken between September 2012 to September 2013. In this period was an increase of 100 per cent of the co-insurance. All the benefits shall be dominated "aid", and shall be classified in grade 1, 2 and 3, depending on its complexity. The same are recorded from the Office of the Medical Emergency Service and registered by the DTM 26 Medical Relief ®, subsequently exported data to Excel 2010®. Comparing both periods , month by month, no significant differences are found in the consultations or Grade 3 (p= 0.19)...

Patients' preferences explain a small but significant share of regional variation in medicare spending.

This study assessed the extent to which differences in patients' preferences across geographic areas explained differences in traditional fee-for-service Medicare spending across Dartmouth Atlas of Health Care Hospital Referral Regions (HRRs). Preference measures were based on results of a survey that asked patients questions about their physicians, their own health status, and the care they would want in their last six months of life. We found that patients' preferences explained 5 percent of the variation across HRRs in total Medicare spending. In comparison, supply factors, such as the number of physicians, specialists, and hospital beds, explained 23 percent, and patients' health and income explained 12 percent. We also explored the relative importance of preferences in determining three components of total spending: spending at the end of life, inpatient spending, and spending on physician services. Relative to supply factors, health, and income, patients' preferences explained the largest share of variation in end-of-life spending and the smallest share of variation in spending on physician services. We conclude that variation in preferences contributes to differences across areas in Medicare spending. Medicare policy must consider both supply factors and patients' preferences in deciding how much to accommodate area variation in spending and the extent to which that variation should be subsidized by taxpayers.

Value-based purchasing for physician services.

Growth in Medicare expenditures has forced legislators and policymakers to look for ways to slow spending and get more value for their money. This article reviews previous federal efforts to control Medicare costs as well as current ones required by the Patient Protection and Affordable Care Act. It also describes a proposal for value-based purchasing that the authors developed under contract to the Centers for Medicare and Medicaid Services. This approach uses two measurement systems-one for physicians who practice primarily in outpatient settings and one for physicians who practice primarily in the hospital.

Impact of once-daily versus twice-daily dosing frequency on adherence to chronic medications among patients with venous thromboembolism.

BACKGROUND: Multiple daily dosing may be negatively associated with patient medication adherence; however, adherence-related data are lacking in a patient population with venous thromboembolism (VTE). OBJECTIVE: To assess the adherence rates between once-daily (OD) and twice-daily (BID) dosing regimens of chronic medications in patients with VTE. METHODS: We analyzed the PharMetrics Integrated Claims database (claims of commercial insurers in the US) from 1 January 2004, through 31 December 2009. Adult patients with continuous insurance coverage, newly initiated on diabetes mellitus or hypertension medication, and having at least one VTE diagnosis were included. Adherence to OD and BID therapies was calculated by using two measures: medication possession ratio (MPR) and proportion of days covered (PDC). Adherence was defined as an MPR or PDC ≥0.8. Multivariate logistic regressions were conducted to compare the probability of adherence between the OD and BID groups adjusting for baseline confounders. RESULTS: A total of 4,867 OD and 1,069 BID patients were identified. Mean duration of exposure to therapy for OD and BID patients was 386 and 356 days (p = 0.011), respectively. Based on MPR, 69 % of OD and 62 % of BID patients were adherent (p < 0.001). For PDC at 12 months, the proportion of adherent patients for the OD and BID groups was 45 and 36 % (p < 0.001), respectively. Adjusted odds ratios (95 % CI) of adherence for the OD relative to BID group were 1.61 (1.37-1.89) based on MPR (p < 0.001) and 1.46 (1.16-1.83) based on PDC at 12 months (p = 0.001). CONCLUSIONS: This study demonstrates that VTE patients treated with chronic medications on OD dosing regimens were associated with an approximately 39-61 % higher likelihood of adherence compared with subjects on BID dosing regimens.

Physician reimbursement for critical care services integrating palliative care for patients who are critically ill.

Patients with advanced illness often spend time in an ICU, while nearly one-third of patients with advanced cancer who receive Medicare die in hospitals, often with failed ICU care. For most, death occurs following the withdrawal or withholding of life-sustaining treatments. The integration of palliative care is essential for high-quality critical care. Although palliative care specialists are becoming increasingly available, intensivists and other physicians are also expected to provide basic palliative care, including symptom treatment and communication about goals of care. Patients who are critically ill are often unable to make decisions about their care. In these situations, physicians must meet with family members or other surrogates to determine appropriate medical treatments. These meetings require clinical expertise to ensure that patient values are explored for medical decision making about therapeutic options, including palliative care. Meetings with families take time. Issues related to the disease process, prognosis, and treatment plan are complex, and decisions about the use or limitation of intensive care therapies have life-or-death implications. Inadequate reimbursement for physician services may be a barrier to the optimal delivery of high-quality palliative care, including effective communication. Appropriate documentation of time spent integrating palliative and critical care for patients who are critically ill can be consistent with the Current Procedural Terminology codes (99291 and 99292) for critical care services. The purpose of this article is to help intensivists and other providers understand the circumstances in which integration of palliative and critical care meets the definition of critical care services for billing purposes.

Hospital quality and the cost of inpatient surgery in the United States.

CONTEXT: Payers, policy makers, and professional organizations have launched a variety of initiatives aimed at improving hospital quality with inpatient surgery. Despite their obvious benefits for patients, the likely impact of these efforts on health care costs is uncertain. In this context, we examined relationships between hospital outcomes and expenditures in the US Medicare population. METHODS: Using the 100% national claims files, we identified all US hospitals performing coronary artery bypass graft, total hip replacement, abdominal aortic aneurysm repair, or colectomy procedures between 2005 and 2007. For each procedure, we ranked hospitals by their risk- and reliability-adjusted outcomes (complication and mortality rates, respectively) and sorted them into quintiles. We then examined relationships between hospital outcomes and risk-adjusted, 30-day episode payments. RESULTS: There was a strong, positive correlation between hospital complication rates and episode payments for all procedures. With coronary artery bypass graft, for example, hospitals in the highest complication quintile had average payments that were $5353 per patient higher than at hospitals in the lowest quintile ($46,024 vs $40,671, P < 0.001). Payments to hospitals with high complication rates were also higher for colectomy ($2719 per patient), abdominal aortic aneurysm repair ($5279), and hip replacement ($2436). Higher episode payments at lower-quality hospitals were attributable in large part to higher payments for the index hospitalization, although 30-day readmissions, physician services, and postdischarge ancillary care also contributed. Despite the strong association between hospital complication rates and payments, hospital mortality was not associated with expenditures. CONCLUSIONS: Medicare payments around episodes of inpatient surgery are substantially higher at hospitals with high complications. These findings suggest that local, regional, and national efforts aimed at improving surgical quality may ultimately reduce costs and improve outcomes.

[An international comparison of physician control systems].

This study compares physicians' regulations set by the United Kingdom, the United States, Canada and Germany which have typical healthcare systems. Physicians' regulations are defined in this study as four aspects: physicians' training and qualifications, career pathways, payment methods and behavior regulations. Strict access rules, practicing with freedom, different training models between general and special practitioners, health services priced by negotiations and regulations by professional organizations are the common features of physicians' regulations in these four western countries. Three aspects--introducing contract mechanism, enhancing the roles of professional organizations and extending physicians' practice space should be taken into account in China's future reform of physicians' regulations.

Herpes zoster incidence among insured persons in the United States, 1993-2006: evaluation of impact of varicella vaccination.

BACKGROUND: herpes zoster (HZ) is caused by reactivation of latent varicella zoster virus and is often associated with substantial pain and disability. Baseline incidence of HZ prior to introduction of HZ vaccine is not well described, and it is unclear whether introduction of the varicella vaccination program in 1995 has altered the epidemiology of HZ. We examined trends in the incidence of HZ and impact of varicella vaccination on HZ trends using a large medical claims database. METHODS: medical claims data from the MarketScan databases were obtained for 1993-2006. We calculated HZ incidence using all persons with a first outpatient service associated with a 053.xx code (HZ ICD-9 code) as the numerator, and total MarketScan enrollment as the denominator; HZ incidence was stratified by age and sex. We used statewide varicella vaccination coverage in children aged 19-35 months to explore the impact of varicella vaccination on HZ incidence. RESULTS: HZ incidence increased for the entire study period and for all age groups, with greater rates of increase 1993-1996 (P < .001). HZ rates were higher for females than males throughout the study period (P < .001) and for all age groups (P < .001). HZ incidence did not vary by state varicella vaccination coverage. CONCLUSIONS: HZ incidence has been increasing from 1993-2006. We found no evidence to attribute the increase to the varicella vaccine program.

Effect of physician remuneration fees on glaucoma procedure rates in Canada.

PURPOSE: Earlier studies have reported wide regional variability in glaucoma procedure rates, suggesting nonclinical factors influencing procedure rates. This study was designed to investigate the possible influence of fees on procedure rates. METHODS: Databases were accessed to obtain yearly provincial population, procedure and ophthalmologist numbers, and physician fees for trabeculoplasties, trabeculectomies, and glaucoma drainage device (GDD) implantations from 1992 to 2007. Regression models using generalized estimating equation methods were used to evaluate the influence of fees on procedure rates after adjusting for temporal trends and the number of ophthalmologists per 1000 persons with glaucoma. RESULTS: Trends in glaucoma procedure rates and fees varied widely among provinces: decrease of 98% to an increase of 380% for trabeculoplasties, decrease of 72% to an increase of 42% for trabeculectomies, and decrease of 32% to an increase of 1292% for GDD. In 2007, provincial remuneration varied from $125 to $553 for trabeculoplasties, $370 to $748 for trabeculectomies, and $426 to $956 for GDD. The regression models found for every 1000 persons with glaucoma, a $100 increase in fee was associated with 0.68 more trabeculoplasties (P=0.94), 1.2 fewer trabeculectomies (P=0.17), and 0.18 more GDD implantations (P=0.18); and for every additional ophthalmologist per 1000 persons with glaucoma, 53.8 more trabeculoplasties (P=0.24), 0.34 more trabeculectomies (P=0.86), and 0.79 more GDD implantations (P=0.0004). A regression model examining procedure substitution effect did not find any association between relative remuneration and procedure rate. CONCLUSION: Our analysis did not show an influence of physician remuneration fee on procedure rates in Canada during the study period.