Rising Prices and Lower Medicare Reimbursement Rates Create Outrage Among Clinicians.

In a recent Hot Topics article, reimbursement rates for Medicare physicians are discussed, and how it will impact their practice.

Rising Prices and Lower Medicare Reimbursement Rates Create Outrage Among Clinicians.

In a recent Hot Topics article, reimbursement rates for Medicare physicians are discussed, and how it will impact their practice.

The best of both worlds? The economic effects of a hybrid fee-for-service and prospective payment reimbursement system.

Countries seeking to move away from a purely fee-for-service (FFS) system may consider a hybrid approach whereby only some procedures are paid by FFS while others are paid prospectively. Yet little evidence exists whether such a hybrid payment system contains overall costs without adverse influences on health outcomes. In 2003, Japan experienced a reform from FFS to a hybrid payment system in which only some inpatient procedures were paid prospectively. We exploit this reform to test how such a hybrid system affects overall costs and health outcomes. Briefly, we find that healthcare providers responded opportunistically to the reform, moving some procedures out of the bundled inpatient setting to FFS services, leading to no reduction in cost. There was some evidence of a moderate deterioration in health outcomes, in terms of a decline in the probability of symptoms being cured at discharge. In sum, our results suggest that in some cases, a hybrid payment system can be non-superior to either FFS or prospective payment system.

What Doctors Want: A Comment on the Financial Preferences of Organized Medicine.

Organized medicine's persistent demand for high payments is one factor that contributes to the rising costs of health care. The profession's long-standing preference for private and fee-for-service practice has pressured payers to increase reimbursement rates in fee-based systems; and it has stalled, thwarted, or otherwise co-opted attempts to contain costs in other payment systems. Yet what doctors want in fact varies. This article revisits classic comparative studies of organized medicine in advanced democracies to highlight two underemphasized findings: (1) physicians' financial preferences can deviate from traditional expectations, and (2) the structure of the organizations that represent doctors can shape whether and how those preferences are expressed. These findings remain relevant today as a discussion of contemporary American health politics illustrates.

Gender variation in Medicare utilization and payments in gynecologic oncology.

OBJECTIVES: The Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (POSPUF) and Medicare Physician and Other Supplier National Provider Identifier (POS NPI) Aggregate Report are publicly available files from the Center for Medicare and Medicaid Services that include payments to providers who care for fee-for-service Medicare recipients. The aim of this study was to analyze variability in gynecologic oncologists' Medicare reimbursements, with attention to differences in provider gender and time in practice. METHODS: The 2015 POSPUF and POS NPI were analyzed with respect to gynecologic oncologists. We searched external publicly available data sources to confirm subspecialty and to determine each provider's number of years in practice. Evaluation and management (E&M) and procedure/surgery codes were analyzed; drug delivery codes were excluded due to variability in billing by facility/hospital. RESULTS: The POS NPI file included 733 gynecologic oncologist providers receiving $55,626,739 in total payments. Female providers comprised 39% of gynecologic oncologists and received 31% of reimbursements (30% of E&M reimbursements and 24% of surgical reimbursements). During the first ten years in practice, female providers comprised 58% of providers and accounted for 52% of reimbursed services, compared to 38% of providers/26% of reimbursed services (11-20 years), and 18% of providers/19% of reimbursed services (>20 years). CONCLUSION: Male gynecologic oncologists perform more Medicare services than their female counterparts. There is a comparable number of services performed between genders among both the most senior and the most junior providers, with a gender gap in services and reimbursements among mid-career providers.

The pharmacist's role in shaping the future of value-based payment models in state Medicaid programs.

OBJECTIVES: To describe roles for pharmacists to facilitate payer-initiated value-based contracts within state Medicaid programs. SUMMARY: According to the Centers for Medicare and Medicaid Services, prescription drug expenditures are expected to see the fastest annual growth in the health care sector over the next decade owing to a greater number of costly specialty medications and overall higher drug prices. Increased prescription costs make value-based contracts particularly compelling opportunities for payers. Pharmacists, as formulary subject-matter experts, have unique skills that are beneficial to value-based contract designs. Much like their role in formulary development, pharmacists' clinical knowledge of evidence-based medicine and cost-effective medication use ensures that contract negotiations are both clinically appropriate and address cost-savings components. Well designed value-based contracts can potentially improve the quality of care without increasing overall health care expenditures. Other potential benefits of value-based contracts include reducing waste, achieving cost predictability, and achieving fiscal responsibility for high-cost drugs while supporting patient access.

An unintended consequence of provider payment reform: The case of capitation grants in the National Health Insurance reform of Indonesia.

One of the most important components of the ambitious 2014 National Health Insurance reform in Indonesia is the implementation of prospective payment system known as capitation grants, paid monthly to the primary health providers based on the enrolment rate. This has ushered in additional financial resources for the health managers in resource allocations, especially in the hiring of manpower. Drawing data from the Indonesia Family Life Survey (1993-2015), this paper uses difference-in-differences method to evaluate the effects of the payment method reform on the allocation of human resources for health among the primary health providers. To our surprise, there was no statistically significant change in the total number of full-time staff among the capitated facilities after the reform. However, capitation grants caused an increase in the number of full-time equivalent and part-time equivalent contract staff, but a significant decline in the number of full-time permanent staff among the urban capitated facilities. It is likely that more contract health workers were hired at the expense of full-time permanent staff among the capitated facilities in the urban regions. This unintended consequence shed light on the need to develop nuanced and contextual understanding of payment reforms in developing countries.

Leap of Faith--Medicare's New Physician Payment System.

Medicare's new payment system reflects the movement toward value-based payment, which is built on the view that we can contain costs only by eliminating fee-for-service payment. But there are important problems with this belief and the reforms it inspires.

Physician Payment after the SGR--The New Meritocracy.

With the Merit-Based Incentive Payment System, Medicare shifts from payment based on macroeconomic indicators to relying on physician- or group-level indicators of cost and quality--and could create a large fee differential between high- and low-performing physicians.

What characteristics of provider payment mechanisms influence health care providers' behaviour? A literature review.

BACKGROUND: Provider payment mechanisms (PPMs) create incentives or signals that influence the behaviour of health care providers. Understanding the characteristics of PPMs that influence health care providers' behaviour is essential for aligning PPM reforms for improving access, quality, and efficiency of health care services. We reviewed empirical literature that examined the characteristics of PPMs that influence the behaviour of health care providers. METHODS: We systematically searched for empirical literature in PubMed, Web of Science, and Google Scholar databases and complemented these with physical searching of the references of selected papers for further relevant studies. A total of 16 studies that met our inclusion and exclusion criteria were identified. We analysed data using thematic review. RESULTS: We identified seven major characteristics of PPMs that influence health care providers' behaviour. Of these characteristics, payment rate, the sufficiency of payment rate to cover the cost of services, timeliness of payment, payment schedule, performance requirements, and accountability mechanisms were the most important. CONCLUSIONS: Our review found that health care providers' behaviour is influenced by the characteristics of PPMs. Provider payment mechanism reforms that optimally structure these characteristics can elicit required incentives for access, equity, quality, and efficiency in service delivery among health care providers towards achieving universal health coverage.

Medicare Physician Payment in Need of Major Repair.

This Viewpoint examines Medicare physician payment flaws and needed reforms, including changes implemented by Congress, CMS, commercial payers, and physician employers.

No Permanent Fix: MACRA, MIPS, and the Politics of Physician Payment Reform.

Organized medicine long yearned for the demise of Medicare's Sustainable Growth Rate (SGR) formula for updating physician fees. Congress finally obliged in 2015, repealing the SGR as part of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA established value-based metrics for physician payment and financial incentives for doctors to join alternative delivery models like patient-centered medical homes. Throughout the law's initial implementation, the politics of accommodation prevailed, with federal officials crafting final rules that made MACRA more favorable for physicians. However, the era of accommodation could be short-lived. The discretion that the Centers for Medicare and Medicaid Services had during the first two years of implementation is ending. Additionally, euphoria over the SGR's repeal has given way to concerns over the new program's value-based purchasing arrangements and uncertainty over their sustainability. MACRA eliminated the SGR, but not the politics of physician payment.

Payment system of urban family physician programme in the Islamic Republic of Iran: is it appropriate?

BACKGROUND: The payment system is pivotal in implementing policies in the health sector. Equitable access to healthcare is the main principle of the payment system. AIMS: This study aimed to investigate aspects of the payment system in the urban family physician programme (FPP) in the Islamic Republic of Iran. METHODS: This was a qualitative study. We obtained data from key informants and both formal and grey literature. We used content analysis for data analysis. RESULTS: A range of concepts was explored related to the payment system of the FPP. By merging similar expressions, we categorized the findings into four main themes including: payment method, payment criteria and incentives, payment process and amount of payment. CONCLUSIONS: FPP is required to follow convenient implementation methods. The mechanisms of payment in the health sector are weak and have no transparency. A blurred combination of criteria makes an unclear process for determining the payment mechanisms. It is recommended that the opinions of key stakeholders be taken into consideration prior to developing payment mechanisms and financial incentives.

Door Is Open for HRAs to Make a Comeback.

For four years, businesses that wanted to reimburse employees for their health insurance premiums rather than buying their coverage for them were told that that was no longer allowed under the ACA. But the health reimbursement arrangement (HRA) is back, brought back to life by provisions tucked into last year's 21st Century Cure Act.

A Look at MACRA: What to Expect in 2017.

The Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015 fundamentally changes how physicians who care for Medicare patients will be paid. Although physicians won't see changes in their payments in 2017, they need to understand that their performance in 2017 will be the basis for the payments made to them starting in 2019. This article summarizes the two paths for determining future Medicare payments established by the law: the merit-based incentive payment system and advanced alternative payment models.

Many changes in payment, practice are only paving the road to further physician discontent.

We live in challenging times for physicians, who are required to do things that are wearing them out and making them feel bad about their jobs.