Examining the use of psychiatric collaborative care and behavioral health integration codes at federally qualified health centers: A mixed-methods study.

INTRODUCTION: Despite evidence to support the integration of behavioral health and physical health care, the adoption of Integrated Behavioral Health (IBH) has been stymied by a lack of reliable and sustainable financing mechanisms. This study aimed to provide information on the use of Psychiatric Collaborative Care Model (CoCM) and behavioral health integration (BHI) codes and the implementation of IBH in federally qualified health centers (FQHCs). METHOD: This cross-sectional, mixed-methods study involved an electronic survey of administrators and follow-up qualitative interviews from a subset of survey respondents. Quantitative data were analyzed using descriptive analysis and thematic coding was used to analyze qualitative data to identify salient themes. RESULTS: Administrators (N = 52) from 11 states completed the survey. Use of CoCM (13%) or BHI codes (17.4%) was low. Most administrators were not aware that CoCM (72%) or BHI codes (70%) existed. Qualitative interviews (n = 9) described barriers that further complicate IBH and code use like workforce shortages and insufficient reimbursement for the cost to deliver CoCM services. DISCUSSION: Although FQHCs are working to meet the needs of the communities they serve, a lack of billing clarity and awareness and workforce issues hinder the adoption of the CoCM. FQHCs face many demands to provide care to safety net populations, yet are not fully equipped with the resources, workflows, staffing, and payment structures to support CoCM/BHI billing. Increased financial and logistical support to build practice infrastructure is needed to reduce the administrative complexity and inadequate reimbursement mechanisms that currently hinder the implementation of the CoCM and integrated care delivery. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

How Can a Bundled Payment Model Incentivize the Transition from Single-Disease Management to Person-Centred and Integrated Care for Chronic Diseases in the Netherlands?

To stimulate the integration of chronic care across disciplines, the Netherlands has implemented single-disease management programmes (SDMPs) in primary care since 2010; for example, for COPD, type 2 diabetes mellitus, and cardiovascular diseases. These disease-specific chronic care programmes are funded by bundled payments. For chronically ill patients with multimorbidity or with problems in other domains of health, this approach was shown to be less fit for purpose. As a result, we are currently witnessing several initiatives to broaden the scope of these programmes, aiming to provide truly person-centred integrated care (PC-IC). This raises the question if it is possible to design a payment model that would support this transition. We present an alternative payment model that combines a person-centred bundled payment with a shared savings model and pay-for-performance elements. Based on theoretical reasoning and results of previous evaluation studies, we expect the proposed payment model to stimulate integration of person-centred care between primary healthcare providers, secondary healthcare providers, and the social care domain. We also expect it to incentivise cost-conscious provider-behaviour, while safeguarding the quality of care, provided that adequate risk-mitigating actions, such as case-mix adjustment and cost-capping, are taken.

Hospital Responses to Incentives in Episode-Based Payment for Joint Surgery: A Controlled Population-Based Study.

Importance: Medicare's Comprehensive Care for Joint Replacement (CJR) model, initiated in 2016, is a national episode-based payment model for lower-extremity joint replacement (LEJR). Metropolitan statistical areas (MSAs) were randomly assigned to participation. In the third year of the program, Medicare made hospital participation voluntary in half of the MSAs and enabled LEJRs for knees to be performed in the outpatient setting without being subject to episode-based payment. How these changes affected program savings is unclear. Objective: To estimate savings from the CJR program over time and assess how responses by hospitals to changing incentives were associated with those savings. Design, Participants, and Setting: This controlled population-based study used Medicare claims data from January 1, 2014, to December 31, 2019, to analyze the spending for beneficiaries who received LEJR in 171 MSAs randomized to CJR vs typical payment. One-quarter of beneficiaries before and after the April 1, 2016, start date were excluded as a 6-month washout period (January 1 to June 30, 2016) to allow time in the evaluation period for hospitals to respond to the program rules. Main Outcomes and Measures: The main outcomes were episode spending and, starting in year 3 of the program, the hospitals' decision to no longer participate in CJR and perform LEJRs in the outpatient setting. Results: Data from 1 087 177 patients (mean [SD] age, 74.4 [8.4] years; 692 604 women [63.7%]; 980 635 non-Hispanic White patients [90.2%]) were analyzed. Over the first 4 years of CJR, 321 038 LEJR episodes were performed at 702 CJR hospitals, and 456 792 episodes were performed at 826 control hospitals. From the second to the fourth year of the program, savings in CJR vs control MSAs diminished from -$976 per LEJR episode (95% CI, -$1340 to -$612) to -$331 (95% CI, -$792 to $130). In MSAs where hospital participation was made voluntary in the third year, more hospitals in the highest quartile of baseline spending dropped out compared with the lowest quartile (56 of 60 [93.3%] vs 29 of 56 [51.8%]). In MSAs where participation remained mandatory, CJR hospitals shifted fewer knee replacements to the outpatient setting in years 3 to 4 than controls (12 571 of 59 182 [21.2%] vs 21 650 of 68 722 [31.5%] of knee LEJRs). In these mandatory MSAs, 75% of the reduction in savings per episode from years 1 to 2 to years 3 to 4 of the program ($455; 95% CI, $137-$722) was attributable to CJR hospitals' decision on which patients would undergo surgery or whether the surgical procedure would occur in the outpatient setting. Conclusions and Relevance: This controlled population-based study found that savings observed in the second year of CJR largely dissipated by the fourth year owing to a combination of responses among hospitals to changes in the program. These results suggest a need for caution regarding the design of new alternative payment models.

Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement.

Importance: The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective: To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants: This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures: Implementation of the CJR model in 2016. Main Outcomes and Measures: Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results: The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance: Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.

Association of Medicare Mandatory Bundled Payment Program With the Receipt of Elective Hip and Knee Replacement in White, Black, and Hispanic Beneficiaries.

Importance: The Comprehensive Care for Joint Replacement (CJR) model was designed to reduce the cost and improve the quality of hip or knee replacement among Medicare beneficiaries. Yet whether this model may exacerbate existing racial/ethnic disparities in access to the surgery is unclear. Objective: To examine the association of the CJR model with the receipt of elective hip or knee replacement across White, Black, and Hispanic Medicare beneficiaries. Design, Setting, and Participants: Retrospective cohort study of Medicare claims from 2013 through 2017 among White, Black, and Hispanic Medicare beneficiaries undergoing elective joint replacement in 65 treatment (selected for CJR participation) and 101 control metropolitan statistical areas (MSAs). Exposures: Starting in April 2016, hospitals in the treatment MSAs were required to participate in the CJR model and were accountable for expenditures occurring during patients' hospitalization for hip or knee replacement and 90 days after the hospital discharge. Main Outcomes and Measures: Beneficiary-level elective hip or knee replacement receipt in a given year. Results: Among 17 243 304 patients, 9 839 996 (57%) were women; 2 107 425 (12%) were age 85 years or older. Of the final sample, 14 632 434 (85%) were White beneficiaries, 1 518 629 (9%) were Black beneficiaries, and 1 092 241 (6%) were Hispanic beneficiaries. The CJR model was associated with an increase of 1.6 elective hip or knee replacements per 1000 beneficiary-years for Hispanic beneficiaries (95% CI, 0.06-2.05) and a decrease of 0.64 replacements for Black beneficiaries (95% CI, -1.25 to -0.02). No evidence was found for any changes for White beneficiaries per 1000 beneficiary-years (0.04 replacements, 95% CI, -0.35 to 0.42 replacements). The Black-White difference in the rate of elective hip or knee replacement per 1000 beneficiary-years further widened by 0.68 replacements (-0.68, 95% CI, -1.20 to -0.15). Conclusions and Relevance: In this cohort study, the CJR model was associated with increased receipt of elective hip or knee replacement among Hispanic beneficiaries, decreased receipt among Black beneficiaries, and no change in receipt among White beneficiaries. The decreased receipt of elective hip or knee replacement among Black beneficiaries may suggest that value-based payment models, including the CJR model, could be monitored for unintended consequences. However, the lack of similar findings among Hispanic beneficiaries suggests that payment models may have differential impacts across racial/ethnic groups.

Telehealth During the COVID-19 Pandemic: A Cross-Sectional Survey of Registered Dietitian Nutritionists.

During the current coronavirus disease 2019 (COVID-19) pandemic, health care practices have shifted to minimize virus transmission, with unprecedented expansion of telehealth. This study describes self-reported changes in registered dietitian nutritionist (RDN) practice related to delivery of nutrition care via telehealth shortly after the onset of the COVID-19 pandemic in the United States. This cross-sectional, anonymous online survey was administered from mid-April to mid-May 2020 to RDNs in the United States providing face-to-face nutrition care prior to the COVID-19 pandemic. This survey included 54 questions about practitioner demographics and experience and current practices providing nutrition care via telehealth, including billing procedures, and was completed by 2016 RDNs with a median (interquartile range) of 15 (6-27) years of experience in dietetics practice. Although 37% of respondents reported that they provided nutrition care via telehealth prior to the COVID-19 pandemic, this proportion was 78% at the time of the survey. Respondents reported spending a median (interquartile range) of 30 (20-45) minutes in direct contact with the individual/group per telehealth session. The most frequently reported barriers to delivering nutrition care via telehealth were lack of client interest (29%) and Internet access (26%) and inability to conduct or evaluate typical nutrition assessment or monitoring/evaluation activities (28%). Frequently reported benefits included promoting compliance with social distancing (66%) and scheduling flexibility (50%). About half of RDNs or their employers sometimes or always bill for telehealth services, and of those, 61% are sometimes or always reimbursed. Based on RDN needs, the Academy of Nutrition and Dietetics continues to advocate and provide resources for providing effective telehealth and receiving reimbursement via appropriate coding and billing. Moving forward, it will be important for RDNs to participate fully in health care delivered by telehealth and telehealth research both during and after the COVID-19 public health emergency.

The current state of patient access to new drugs in South Korea under the positive list system: evaluation of the changes since the new review pathways.

Objective: This study aims to provide an up-to-date analysis of the current state of patient access to new drugs in South Korea, focusing on the effect of new review pathways for reimbursement. Methods: We analyzed patients' access to new drugs, listing rate and lead time until listing from marketing authorization. New pathways were defined as 'price negotiation waiver,' 'risk-sharing agreements,' and 'pharmacoeconomic evaluation exemption.' Results: The listing rate for drugs increased after the introduction of the new pathways (93.7% vs. 77.9%, p < 0.001). Before the new pathways, the median lead time for listing was 21.0 months (95% CI: 16.9-25.0), while afterward it was shortened to 10.9 months (95% CI: 10.2-11.7) (p < 0.001). Conclusion: Although it has strengthened national health insurance coverage by positively impacting the rate and lead time, the lead time for the oncology and orphan drugs is substantially longer as compared to other drugs. Expanding the eligibility criteria to include non-life-threatening but rare or intractable diseases, and resolving the system's operational issues are still necessary.

Spillover effects of mandatory hip and knee replacement surgery bundles in medicare.

BACKGROUND: Medicare used the Comprehensive Care for Joint Replacement (CJR) Model to mandate that hospitals in certain health care markets accept bundled payments for lower extremity joint replacement surgery. CJR has reduced spending with stable quality as intended among Medicare fee-for-service patients, but benefits could "spill over" to individuals insured through private health plans. Definitive evidence of spillovers remains lacking. OBJECTIVE: To evaluate the association between CJR participation and changes in outcomes among privately insured individuals. DESIGN, SETTING, PARTICIPANTS: We used 2013-2017 Health Care Cost Institute claims for 418,016 privately insured individuals undergoing joint replacement in 75 CJR and 121 Non-CJR markets. Multivariable generalized linear models with hospital and market random effects and time fixed effects were used to analyze the association between CJR participation and changes in outcomes. MAIN OUTCOMES AND MEASURES: Total episode spending, discharge to institutional post-acute care, and quality (e.g., surgical complications, readmissions). RESULTS: Patients in CJR and Non-CJR markets did not differ in total episode spending (difference of -$157, 95% CI -$1043 to $728, p = 0.73) or discharge to institutional post-acute care (difference of -1.1%, 95% CI -3.2%-1.0%, p = 0.31). Similarly, patients in the two groups did not differ in quality or other utilization outcomes. Findings were generally similar in stratified and sensitivity analyses. CONCLUSIONS: There was a lack of evidence of cost or utilization spillovers from CJR to privately insured individuals. There may be limits in the ability of certain value-based payment reforms to drive broad changes in care delivery and patient outcomes.

Recommendations to Improve Payment Policies for Comprehensive Dementia Care.

Access to comprehensive dementia care is limited. Recent changes in billing for professional services, including new physician fee schedule codes, encourage clinicians to provide new services; however, current reimbursement does not cover costs for all needed elements of dementia care. The Payment Model for Comprehensive Dementia Care Conference convened more than 50 national experts from diverse perspectives to review promising strategies for payment reform including ways to accelerate their adoption. Recommendations for reform included payments for services to family caregivers; new research to determine success metrics; education for consumers, providers, and policymakers; and advancing a population health model approach to tier coverage based on risk and need within a health system.

Association of Medicare Mandatory Bundled Payment System for Hip and Knee Joint Replacement With Racial/Ethnic Difference in Joint Replacement Care.

Importance: There are marked racial/ethnic differences in hip and knee joint replacement care as well as concerns that value-based payments may exacerbate existing racial/ethnic disparities in care. Objective: To examine changes in joint replacement care associated with Medicare's Comprehensive Care for Joint Replacement (CJR) model among White, Black, and Hispanic patients. Design, Setting, and Participants: Retrospective cohort study of Medicare claims from 2013 through 2017 among White, Black, and Hispanic patients undergoing joint replacement in 67 treatment (selected for CJR participation) and 103 control metropolitan statistical areas. Exposures: The CJR model holds hospitals accountable for spending and quality of joint replacement care during care episodes (index hospitalization through 90 days after discharge). Main Outcomes and Measures: The primary outcomes were spending, discharge to institutional postacute care, and readmission during care episodes. Results: Among 688 346 patients, 442 163 (64.2%) were women, and 87 286 (12.7%) were 85 years or older. Under CJR, spending decreased by $439 for White patients (95% CI, -$718 to -$161; from pre-CJR spending in treatment metropolitan statistical areas of $25 264) but did not change for Black patients and Hispanic patients. Discharges to institutional postacute care decreased for all groups (-2.5 percentage points; 95% CI, -4.7 to -0.4, from pre-CJR risk of 46.2% for White patients; -6.0 percentage points; 95% CI, -9.8 to -2.2, from pre-CJR risk of 59.5% for Black patients; and -4.3 percentage points; 95% CI, -7.6 to -1.0, from pre-CJR risk of 54.3% for Hispanic patients). Readmission risk decreased for Black patients by 3.1 percentage points (95% CI, -5.9 to -0.4, from pre-CJR risk of 21.8%) and did not change for White patients and Hispanic patients. Under CJR, Black-White differences in discharges to institutional postacute care decreased by 3.4 percentage points (95% CI, -6.4 to -0.5, from the pre-CJR Black-White difference of 13.3 percentage points). No evidence was found demonstrating that Black-White differences changed for other outcomes or that Hispanic-White differences changed for any outcomes under CJR. Conclusions and Relevance: In this cohort study of patients receiving joint replacements, CJR was associated with decreased readmissions for Black patients. Furthermore, Black patients experienced a greater decrease in discharges to institutional postacute care relative to White patients, representing relative improvements despite concerns that value-based payment models may exacerbate existing disparities. Nonetheless, differences between White and Black patients in joint replacement care still persisted even after these changes.

Relative value units in health care: Friend, foe, or necessary evil?

The purpose of this article is to describe this use of relative value units (RVUs) among nurse practitioners (NP), including the challenges NPs may experience. Relative value units were developed as a means to determine reimbursement for health care based on time spent with the patient and skills required to complete the interaction, while addressing any disparities of reimbursement based on geography or insurance. Increasingly, providers such as NPs are being evaluated based in large part on how many RVUs they generate, which seems to prioritize productivity and may overlook many nonbillable aspects of the NP role such as emotional support or patient education. Nurse practitioners working in settings that require more invasive procedures may seem to be more productive on paper, regardless of the number of patients seen. Relative value units may not adequately reflect the skill and time taken to care for patients with chronic illness. Gender differences have been noted, both in terms of the number of RVUs generated for care of male or female patients, and those generated by male or female providers. If NPs are evaluated primarily based on productivity as measured by RVUs, we must consider how this might minimize or even invalidate the therapeutic relationship and holistic approach to patient care. Relative value units may negatively affect the willingness of NPs to serve as preceptors. Finally, as NPs experience less face-to-face time with patients and more demands for productivity, there may be a loss of quality care and professional integrity, which raises the risk of burnout among NPs.

AMCP Partnership Forum: What's Next for Specialty Medication Benefit Design and Reimbursement.

Rising specialty drug costs present a challenge for patients and payers. High-cost products, such as gene therapies or immunotherapies, can significantly affect the budget of a payer that does not have the ability to spread risk across a large population. Stakeholders are considering new reimbursement and benefit designs for specialty medications to improve efficiencies and better manage costs. The potential effect of changes to specialty medication benefit designs and reimbursement systems on patient care, access to medications, and the overall health care system are important considerations when assessing the benefits and challenges associated with reform proposals. Options to better manage the affordability of specialty medications are needed to ensure that patients can continue to access medications, while allowing payers to remain good stewards of health care dollars and supporting marketplace competition and incentives to stimulate innovation. New benefit designs that address these needs, while also supporting marketplace competition and providing incentives that stimulate innovation, have been considered. To explore options, AMCP convened a multidisciplinary stakeholder forum on December 10-11, 2019, in Alexandria, VA. Health care leaders representing academia, health plans, integrated delivery systems, industry leaders, pharmaceutical manufacturers, pharmacy benefit managers, employers, federal government agencies, national health care provider organizations, and patient advocacy organizations participated in the forum. The forum was designed for stakeholders to discuss strategies for the following: (a) reduce costs for beneficiaries while maintaining or improving access to prescription drugs; (b) support marketplace competition and incentives for biopharmaceutical innovation; (c) minimize physicians' financial risk associated with managing drug inventories; (d) remove adverse reimbursement incentives for prescribing higher priced drugs; (e) consider the cost-effectiveness of treatments and services across the health care continuum; and (f) support quality measurement and program evaluation metrics. Recommendations emerging from the forum included creation of novel payment models for the most expensive therapies that allow for larger risk pools, while maintaining the sustainability of the reinsurance market remains. Simplification and standardization were cited as goals for system reform and technological innovations that allow health care providers to view cost-effectiveness information at the point of prescribing, combined with value-based contracting were also recommended. Finally, ensuring that plans remain patient-centric and are designed to address patient needs holistically was stressed as an important goal. DISCLOSURES: This partnership forum was sponsored by Amgen, AstraZeneca, Bayer, GSK, Merck, Pfizer, PhRMA, Takeda, and Xcenda. These proceedings were prepared as a summary of the forum to represent common themes; they are not necessarily endorsed by all attendees nor should they be construed as reflecting group consensus.

Development of transferability guidance for integrated care models with special focus on Central and Eastern European countries.

AIM: To develop pragmatic recommendations for Central and Eastern European (CEE) policymakers about transferability assessment of integrated care models established in higher income European Union (EU) countries. METHODS: Draft recommendations were developed based on Horizon 2020-funded SELFIE project deliverables related to 17 promising integrated care models for multimorbid patients throughout Europe, as well as on an online survey among CEE stakeholders on the relevance of implementation barriers. Draft recommendations were discussed at the SELFIE transferability workshop and finalized together with 22 experts from 12 CEE countries. RESULTS: Thirteen transferability recommendations are provided in three areas. Feasibility of local implementation covers the identification and prioritization of implementation barriers and proposals for potential solutions. Performance measurement of potentially transferable models focuses on the selection of models with proven benefits and assurance of performance monitoring. Transferability of financing methods for integrated care explores the relevance of financing methodologies and planning of adequate initial and long-term financing. CONCLUSIONS: Implementation of international integrated care models cannot be recommended without evidence on its local feasibility or scientifically sound and locally relevant performance assessment in the country of origin. However, if the original financing method is not transferable to the target region, development of a locally relevant alternative financing method can be considered.

Can vertically integrated health systems provide greater value: The case of hospitals under the comprehensive care for joint replacement model?

OBJECTIVE: We aim to assess whether system providers perform better than nonsystem providers under an alternative payment model that incentivizes high-quality, cost-efficient care. We posit that the payment environment and the incentives it provides can affect the relative performance of vertically integrated health systems. To examine this potential influence, we compare system and nonsystem hospitals participating in Medicare's Comprehensive Care for Joint Replacement (CJR) model. DATA SOURCES: We used hospital cost and quality data from the Centers for Medicare & Medicaid Services linked to data from the Agency for Healthcare Research and Quality's Compendium of US Health Systems and hospital characteristics from secondary sources. The data include 706 hospitals in 67 metropolitan areas. STUDY DESIGN: We estimated regressions that compared system and nonsystem hospitals' 2017 cost and quality performance providing lower joint replacements among hospitals required to participate in CJR. PRINCIPAL FINDINGS: Among CJR hospitals, system hospitals that provided comprehensive services in their local market had 5.8 percent ($1612) lower episode costs (P = .01) than nonsystem hospitals. System hospitals that did not provide such services had 3.5 percent ($967) lower episode costs (P = .14). Quality differences between system hospitals and nonsystem hospitals were mostly small and statistically insignificant. CONCLUSIONS: When operating under alternative payment model incentives, vertical integration may enable hospitals to lower costs with similar quality scores.

Moving from Volume to Value with Hospital Funding Policies in Canada.

Canada's two most populous provinces are moving toward activity-based funding (ABF) of hospitals. Although ABF may encourage greater value by improving cost-efficiency, it may decrease value in other respects. To address this trade-off, many jurisdictions have implemented value-based payment programs that modify ABF payments based on hospital performance on other aspects of value, such as outcomes and patient experience. In this article, the design and implementation of two value-based programs are reviewed: Australia's Pricing for Safety and Quality Program and Medicare's Hospital Value-Based Purchasing Program. The contrasts of these programs highlight key questions facing provincial payers in Canada to increase value from hospital spending.

Analysing criteria for price and reimbursement of orphan drugs in Spain.

OBJECTIVE: There are differences between countries regarding data requirements for orphan drug evaluation and it  is also unknown which criteria might determine the price and reimbursement decision. This study aimed to identify the key  criteria for price and reimbursement of orphan drugs in Spain, approved by the European Commission, between January 2012 and June 2018. METHOD: A descriptive analysis of the orphan drugs and its characteristics was performed. Outcomes criteria assessed  were: therapeutic area, existence of alternative treatment, rarity of the disease, clinical trial outcomes and therapeutic  positioning report assessment. Hypotheses for each variable regarding Spanish pricing and reimbursement were made  and tested with two regression analyses. RESULTS: Out of 78 orphan drugs approved by the European Commission, 82.1% asked pricing and reimbursement in  Spain. From this, 43.8% had pricing and reimbursement approved and 20.3% rejected. Mean time from Spanish  marketing authorisation approval to pricing and reimbursement approval was 12.1 ± 5.1 months. Having a positive  therapeutic positioning report and no therapeutic alternatives would be associated with a positive pricing and  reimbursement in Spain. CONCLUSIONS: It remains challenging to establish which are the driving criteria for pricing and reimbursement approval  of orphan drugs in Spain. Further research should be done including other variables that might influence the pricing and  reimbursement final decision in Spain.

Objetivo: Los requisitos para la evaluación de los medicamentos huérfanos difieren entre los países  miembros de la Unión Europea y tampoco se sabe qué criterios influyen en la decisión final sobre  precio y financiación. Este estudio ha tenido como objetivo identificar los criterios clave para establecer el precio y la financiación de los medicamentos huérfanos en España, una vez  aprobados por la Comisión Europea, entre enero de 2012 hasta junio de 2018.Método: Se realizó un análisis descriptivo de los medicamentos huérfanos y sus características. Los  criterios evaluados fueron: área terapéutica, existencia de tratamientos alternativos, rareza de la  enfermedad, tipo de resultados de los ensayos clínicos e informe de posicionamiento terapéutico. Para  cada variable se estableció una hipótesis con respecto a la aprobación de precio y  financiación y se analizaron con dos análisis de regresión.Resultados: De las 78 aprobaciones de medicamentos huérfanos realizadas por la Comisión Europea,  el 82,1% solicitaron precio y financiación en España. De estas, el 43,8% fueron aprobadas  y el 20,3% fueron rechazadas. El tiempo medio desde la aprobación de la autorización de comercialización en España hasta la aprobación del precio y la financiación fue de 12,1 ± 5,1  meses. Un informe de posicionamiento positivo y la falta de alternativas terapéuticas se asociaría con  una aprobación de precio y financiación.Conclusiones: Sigue siendo un reto establecer cuáles son los criterios clave para la aprobación de los  medicamentos huérfanos en España. Los próximos estudios deberían incluir un mayor número de  variables que puedan influir en el precio y la decisión de financiación.