Patient selection in the Comprehensive Care for Joint Replacement model.

OBJECTIVE: To understand whether the Comprehensive Care for Joint Replacement (CJR) program induces participating hospitals to (1) preferentially select lower risk patients, (2) reduce 90-day episode-of-care costs, (3) improve quality of care, and (4) achieve greater cost reduction during its second year, when downside financial risk was applied. DATA SOURCES: We identified beneficiaries of age 65 years or older undergoing hip or knee joint replacement in the 100% sample of Medicare fee-for-service inpatient (Part A) claims from January 1, 2013 to August 31, 2017. Cases were linked to subsequent outpatient, Part B, home health agency, and skilled nursing facility claims, as well as publicly available participation status for CJR. STUDY DESIGN: We estimated the effect of CJR for hospitals in the 67 metropolitan statistical areas (MSA) selected to participate in CJR (785 hospitals), compared to those in 104 non-CJR MSAs (962 hospitals; maintaining fee-for-service). A difference-in-differences approach was used to detect patient selection, as well as to compare 90-day episode-of-care costs and quality of care between CJR and non-CJR hospitals over the first two performance years. DATA COLLECTION: We excluded 172 hospitals from our analysis due to their preexisting BPCI participation. We focused on elective admissions in the main analysis. PRINCIPAL FINDINGS: While reductions in 90-day episode-of-care costs were greater among CJR hospitals (-$902, 95% CI: -$1305, -$499), largely driven by a 16.8% (p < 0.01) decline in 90-day spending in skilled nursing facilities, CJR hospitals significantly reduced the 90-day readmission rate (-3.9%; p < 0.05) and preferentially avoided patients aged 85 years or older (-5.9%; p < 0.01) and Black (-7.0%; p < 0.01). Cost reduction was greater in 2017 than in 2016, corresponding to the start of downside risk. CONCLUSIONS: Participation in CJR was associated with a modest cost reduction and a reduction in 90-day readmission rates; however, we also observed evidence of preferential avoidance of older patients perceived as being higher risk among CJR hospitals.

The Society for Vascular Surgery Alternative Payment Model Task Force report on opportunities for value-based reimbursement in care for patients with peripheral artery disease.

The Society for Vascular Surgery Alternative Payment Model (APM) Taskforce document explores the drivers and implications for developing objective value-based reimbursement plans for the care of patients with peripheral arterial disease (PAD). The APM is a payment approach that highlights high-quality and cost-efficient care and is a financially incentivized pathway for participation in the Quality Payment Program, which aims to replace the traditional fee-for-service payment method. At present, the participation of vascular specialists in APMs is hampered owing to the absence of dedicated models. The increasing prevalence of PAD diagnosis, technological advances in therapeutic devices, and the increasing cost of care of the affected patients have financial consequences on care delivery models and population health. The document summarizes the existing measurement methods of cost, care processes, and outcomes using payor data, patient-reported outcomes, and registry participation. The document also evaluates the existing challenges in the evaluation of PAD care, including intervention overuse, treatment disparities, varied clinical presentations, and the effects of multiple comorbid conditions on the cost potentially attributable to the vascular interventionalist. Medicare reimbursement data analysis also confirmed the prolonged need for additional healthcare services after vascular interventions. The Society for Vascular Surgery proposes that a PAD APM should provide patients with comprehensive care using a longitudinal approach with integration of multiple key medical and surgical services. It should maintain appropriate access to diagnostic and therapeutic advancements and eliminate unnecessary interventions. It should also decrease the variability in care but must also consider the varying complexity of the presenting PAD conditions. Enhanced quality of care and physician innovation should be rewarded. In addition, provisions should be present within an APM for high-risk patients who carry the risk of exclusion from care because of the naturally associated high costs. Although the document demonstrates clear opportunities for quality improvement and cost savings in PAD care, continued PAD APM development requires the assessment of more granular data for accurate risk adjustment, in addition to largescale testing before public release. Collaboration between payors and physician specialty societies remains key.

Impact of integrated healthcare: Taiwan's Family Doctor Plan.

Integration of health services has been pursued worldwide. Diversity in integration approaches and in the contexts in which integrated programmes operate, however, hinders comparative analysis of care integration in both high-income countries (HICs) and low- and middle-income countries (LMICs). This study evaluates an HIC programme implemented in a delivery system resembling those of LMICs, especially its weak primary care system. The programme, Taiwan's Family Doctor Plan (FDP), targets high-cost and chronic patients, incorporating key elements of integrated care, viz., case management, multidisciplinary teams and care pathways. This study estimates the effects of shifting from usual to integrated care and locates contextual factors that may distort programme implementation. To estimate programme effects, difference-in-differences analysis is applied to a balanced panel comprising >160 000 patients over 2009-13. Because physician participation is voluntary, a propensity score matching method is used to match providers. The research findings reveal that introduction of the FDP has not reoriented the model of care from fragmented towards integrated health services. It reduces continuity of care and has no effect on co-ordination of care. Regarding quality of care, the FDP is shown to have no effect on avoidable admissions and increases drug injections and emergency department visits. Several contextual factors may serve as barriers that impede elements of FDP from generating desirable outcomes. These include absence of registration and gatekeeping systems; limited capacities of clinics; and preponderance of fee-for-service remuneration. These findings suggest that HIC design elements may not be directly transferrable to settings with weak primary care systems, as is typical of LMIC healthcare. Changes at the system level, such as establishing regular sources of care, may be necessary before elements of integrated care are introduced to a weaker primary care system.

Distribution of monetary incentives in health insurance scheme influences acupuncture treatment choices: An experimental study.

BACKGROUND: Understanding how doctors respond to occupational and monetary incentives in health care payment systems is important for determining the effectiveness of such systems. This study examined changes in doctors' behaviors in response to monetary incentives within health care payment systems in a ceteris paribus setting. METHODS: An online experiment was developed to analyze the effect of monetary incentives similar to fee-for-service (FFS) and capitation (CAP) on doctors' prescription patterns. In the first session, no monetary values were presented. In the second session conducted 1 week later, doctors were randomly assigned to one of two monetary incentive groups (FFS group: n = 25, CAP group: n = 25). In all sessions, doctors were presented with 10 cases and asked to determine the type and number of treatments. RESULTS: In the first session with no monetary incentives, there was no significant difference between the FFS and CAP groups in the number of treatments. When monetary incentives were provided, doctors in the CAP group prescribed fewer treatments than the FFS group. The perceived severity of the cases did not change significantly between sessions and between groups. linear mixed-effects regression model indicated the treatment choices were influenced by monetary incentives, but not by the perceived severity of the patient's symptoms. CONCLUSION: The monetary values incentivized the doctors' treatment choices, but not their professional evaluation of patients. Monetary values designed within health care systems influence the doctor's decisions in the form of external rewards, in addition to occupational values, and can thus be adjusted by more effective incentives.

Getting Paid for Clinical Services.

Increasingly, pharmacists are providing advanced, patient-centered clinical services. However, pharmacists are not currently included in key sections of the Social Security Act, which determines eligibility to bill and be reimbursed by Medicare. Many state and private health plans also cite the omission from Medicare as the rationale for excluding reimbursement of pharmacists for clinical services. This has prompted forward-thinking pharmacists to seek opportunities for reimbursement in other ways, allowing them to provide value to the health care system, while carving out unique niches for pharmacists to care for patients.

The exploration of medical resources utilization among inguinal hernia repair in Taiwan diagnosis-related groups.

BACKGROUND: This study centered on differences in medical costs, using the Taiwan diagnosis-related groups (Tw-DRGs) on medical resource utilization in inguinal hernia repair (IHR) in hospitals with different ownership to provide suitable reference information for hospital administrators. METHODS: The 2010-2011 data for three hospitals under different ownership were extracted from the Taiwan National Health Insurance claims database. A retrospective method was applied to analyze the age, sex, length of stay, diagnosis and surgical procedure code, and the change in financial risk of medical costs in IHR cases after introduction of Tw-DRGs. The study calculated the cost using Tw-DRG payment principles, and compared it with estimated inpatient medical costs calculated using the fee-for-service policy. RESULTS: There were 723 IHR cases satisfying the Tw-DRGs criteria. Cost control in the medical care corporation hospital (US$764.2/case) was more efficient than that in the public hospital (US$902.7/case) or nonprofit proprietary hospital (US$817.1/case) surveyed in this study. For IHR, anesthesiologists in the public hospital preferred to use general anesthesia (86%), while those in the two other hospitals tended to administer spinal anesthesia. We also discovered the difference in anesthesia cost was high, at US$80.2/case on average. CONCLUSIONS: Because the Tw-DRG-based reimbursement system produces varying hospital costs, hospital administrators should establish a financial risk assessment system as early as possible to improve healthcare quality and financial management efficiency. This would then benefit the hospital, patient, and Bureau of National Health Insurance.

Payment for Integrated Care: Challenges and Opportunities.

A multidisciplinary team approach to care and robust care coordination services are primary components of almost all integrated care delivery systems. Given that these services have limited reimbursement in fee-for-service payment arrangements, integrating care in a fee-for-service environment is almost impossible. Capitated payment models hold promise for supporting integrated behavioral and physical health services. There are multiple national examples of integrated care delivery systems supported by capitated payment arrangements.

Improving Oncology Quality Measurement in Accountable Care: Filling Gaps with Cross-Cutting Measures.

Payment for health care services, including oncology services, is shifting from volume-based fee-for-service to value-based accountable care. The objective of accountable care is to support providers with flexibility and resources to reform care delivery, accompanied by accountability for maintaining or improving outcomes while lowering costs. These changes depend on health care payers, systems, physicians, and patients having meaningful measures to assess care delivery and outcomes and to balance financial incentives for lowering costs while providing greater value. Gaps in accountable care measure sets may cause missed signals of problems in care and missed opportunities for improvement. Measures to balance financial incentives may be particularly important for oncology, where high cost and increasingly targeted diagnostics and therapeutics intersect with the highly complex and heterogeneous needs and preferences of cancer patients. Moreover, the concept of value in cancer care, defined as the measure of outcomes achieved per costs incurred, is rarely incorporated into performance measurement. This article analyzes gaps in oncology measures in accountable care, discusses challenging measurement issues, and offers strategies for improving oncology measurement. Discern Health analyzed gaps in accountable care measure sets for 10 cancer conditions that were selected based on incidence and prevalence; impact on cost and mortality; a diverse range of high-cost diagnostic procedures and treatment modalities (e.g., genomic tumor testing, molecularly targeted therapies, and stereotactic radiotherapy); and disparities or performance gaps in patient care. We identified gaps by comparing accountable care set measures with high-priority measurement opportunities derived from practice guidelines developed by the National Comprehensive Cancer Network and other oncology specialty societies. We found significant gaps in accountable care measure sets across all 10 conditions. For each gap, we searched for available measures not already being used in programs. Where existing measures did not cover gaps, we recommended refinements to existing measures or proposed measures for development. We shared the results of the measure gap analysis with a roundtable of national experts in cancer care and oncology measurement. During a web meeting and an in-person meeting, the roundtable reviewed the gap analysis and identified priority opportunities for improving measurement. The group determined that overreliance on condition-specific process measures is problematic because of rapidly changing evidence and increasing personalization of cancer care. The group's primary recommendation for enhancing measure sets was to prioritize and develop effective cross-cutting measures that assess clinical and patient-reported outcomes, including shared decision making, care planning, and symptom control. The group also prioritized certain safety and structural measures to complement condition-specific process measures. Further, the group explored strategies for using clinical pathways and devising layered measurement approaches to improve measurement for accountable care. This article presents the roundtable's conclusions and recommendations for next steps. DISCLOSURES: Funding for this project was provided by the National Pharmaceutical Council (NPC). Westrich and Dubois are employees of the NPC. Valuck is a partner with Discern Health. Blaisdell and Dugan are employed by Discern Health. McClellan reports fees for serving on the Johnson & Johnson Board of Directors. Dugan reports consulting fees from the National Committee for Quality Assurance and Pharmacy Quality Alliance. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Study concept and design were contributed by Blaisdell, Valuck, Dugan, and Westrich. Blaisdell took the lead in data collection, along with Valuck and Dugan, and data interpretation was performed by Valuck, Blaisdell, Westrich, and Dubois. The manuscript was written by Blaisdell, along with Valuck and Dugan, and revised by Valuck, Westrich, Miller, and McClellan.

Cross-Sectional Analysis of Per Capita Supply of Doctors of Chiropractic and Opioid Use in Younger Medicare Beneficiaries.

OBJECTIVE: The purpose of this study was to determine whether the per-capita supply of doctors of chiropractic (DCs) or Medicare spending on chiropractic care was associated with opioid use among younger, disabled Medicare beneficiaries. METHODS: Using 2011 data, at the hospital referral region level, we correlated the per-capita supply of DCs and spending on chiropractic manipulative therapy (CMT) with several measures of per-capita opioid use by younger, disabled Medicare beneficiaries. RESULTS: Per-capita supply of DCs and spending on CMT were strongly inversely correlated with the percentage of younger Medicare beneficiaries who had at least 1, as well as with 6 or more, opioid prescription fills. Neither measure was correlated with mean daily morphine equivalents per opioid user or per chronic opioid user. CONCLUSIONS: A higher per-capita supply of DCs and Medicare spending on CMT were inversely associated with younger, disabled Medicare beneficiaries obtaining an opioid prescription. However, neither measure was associated with opioid dosage among patients who obtained opioid prescriptions.

[Introduction of performance- and day-based lump-sum remuneration for stationary psychiatric and psychosomatic treatments in Germany--analysis of incentives of the PEPP system]. / Leistungs- und tagesbezogene pauschale Vergütung in der stationären psychiatrischen und psychosomatischen Versorgung - Eine Analyse der Anreizwirkungen des PEPP-Systems.

PURPOSE: This paper surveys the effects of day-based lump-sum remuneration as defined by the PEPP system on the patients' length of stay and compares its incentives to the mechanisms of the German DRG system and the former remunera-tion system for stationary psychiatric and psychosomatic treatments. METHODS: The analysis identifies the economically optimal length of stay defined as the profit maximising duration of treatment by comparing marginal revenues and marginal costs. Since it is economically optimal to extend the treatment until the marginal costs exceed the marginal revenues, psychiatric and psychosomatic facilities are incentivised to minimise the time gap between average duration of treatment as expected duration of treatment and the economically optimal length of stay. RESULTS: Compared to the German DRG system, which provides a strong incentive to reduce length of stay, the incentives set by the PEPP system imply either a reduction or an extension of treatment duration depending on the underlying cost function. If a degressive cost function is assumed, which is typical for treatments of psychiatric and psychosomatic illnesses, the economically optimal duration of treatment will be at the last upper boundary of the interval of the marginal revenue function in which the average marginal revenues exceed the average marginal costs. It is also feasible that it is economically optimal to treat the patient for as long as possible. The hospital is incentivised to extend or reduce the time of treatment to this point in time. CONCLUSIONS: Psychiatric and psychosomatic hospitals are able to increase their profits by reducing or extending time of treatment. Therefore these facilities have to justify the extent of treatment to the health insurance companies. Since the incentives of the PEPP system and the DRG system diverge, the results of research on supply induced demand in the DRG system cannot be transferred to the discussion about the effects of the introduction of the PEPP system. As long as the average duration of treatment as expected duration of treatment deviates from the economically optimal length of stay, policy makers should consider the options of adaptations, i. e., increase of time intervals or calculating cost weights based on variable costs combined with separate remuneration of fixed costs. The TEPP system and PEPPplus are already being discussed as adaptions or additions.

The financial impact of increasing home-based high dose haemodialysis and peritoneal dialysis.

BACKGROUND: Evidence suggests that high dose haemodialysis (HD) may be associated with better health outcomes and even cost savings (if conducted at home) versus conventional in-centre HD (ICHD). Home-based regimens such as peritoneal dialysis (PD) are also associated with significant cost reductions and are more convenient for patients. However, the financial impact of increasing the use of high dose HD at home with an increased tariff is uncertain. A budget impact analysis was performed to investigate the financial impact of increasing the proportion of patients receiving home-based dialysis modalities from the perspective of the England National Health Service (NHS) payer. METHODS: A Markov model was constructed to investigate the 5 year budget impact of increasing the proportion of dialysis patients receiving home-based dialysis, including both high dose HD at home and PD, under the current reimbursement tariff and a hypothetically increased tariff for home HD (£575/week). Five scenarios were compared with the current England dialysis modality distribution (prevalent patients, 14.1% PD, 82.0% ICHD, 3.9% conventional home HD; incident patients, 22.9% PD, 77.1% ICHD) with all increases coming from the ICHD population. RESULTS: Under the current tariff of £456/week, increasing the proportion of dialysis patients receiving high dose HD at home resulted in a saving of £19.6 million. Conducting high dose HD at home under a hypothetical tariff of £575/week was associated with a budget increase (£19.9 million). The costs of high dose HD at home were totally offset by increasing the usage of PD to 20-25%, generating savings of £40.0 million - £94.5 million over 5 years under the increased tariff. Conversely, having all patients treated in-centre resulted in a £172.6 million increase in dialysis costs over 5 years. CONCLUSION: This analysis shows that performing high dose HD at home could allow the UK healthcare system to capture the clinical and humanistic benefits associated with this therapy while limiting the impact on the dialysis budget. Increasing the usage of PD to 20-25%, the levels observed in 2005-2008, will totally offset the additional costs and generate further savings.

Community oncology in an era of payment reform.

Patients and payers (government and private) are frustrated with the fee-for-service system (FFS) of payment for outpatient health services. FFS rewards volume and highly valued services, including expensive diagnostics and therapeutics, over lesser valued cognitive services. Proposed payment schemes would incent collaboration and coordination of care among providers and reward quality. In oncology, new payment schemes must address the high costs of all services, particularly drugs, while preserving the robust distribution of sites of service available to patients in the United States. Information technology and personalized cancer care are changing the practice of oncology. Twenty-first century oncology will require increasing cognitive work and shared decision making, both of which are not well regarded in the FFS model. A high proportion of health care dollars are consumed in the final months of life. Effective delivery of palliative and end-of-life care must be addressed by practice and by new models of payment. Value-based reimbursement schemes will require oncology practices to change how they are structured. Lessons drawn from the principles of primary care's Patient Centered Medical Home (PCMH) will help oncology practice to prepare for new schemes. PCMH principles place a premium on proactively addressing toxicities of therapies, coordinating care with other providers, and engaging patients in shared decision making, supporting the ideal of value defined in the triple aim-to measurably improve patient experience and quality of care at less cost. Payment reform will be disruptive to all. Oncology must be engaged in policy discussions and guide rational shifts in priorities defined by new payment models.

Getting value from health spending: going beyond payment reform.

It is widely held that fee-for-service (FFS) payment systems reward volume and intensity of services, contributing to overall cost inflation, while doing little to reward quality, efficiency, or care coordination. Recently, The National Commission on Physician Payment Reform (sponsored by SGIM) has recommended that payers "should largely eliminate stand-alone fee-for-service payment to medical practices because of its inherent inefficiencies and problematic financial incentives." As the current and former Chief Medical Officers of a large national insurer, we agree that payment reform is a critical component of health care modernization. But calls to transform payment simultaneously go too far, and don't go far enough. Based on our experience, we believe there are several critical ingredients that are either missing or under-emphasized in most payment reform proposals, including: health care is local so no one size fits all; upgrading performance measures; monitoring/overcoming unintended consequences; using a full toolbox to achieve transformation; and ensuring that the necessary components for successful delivery reform are in place. Thinking holistically and remembering that healthcare is a complex adaptive system are crucial to achieving better results for patients and the health system.

[Hernia repair at the groin - who undergoes which surgical intervention?]. / Leistenhernienreparation - Wo wird wie operiert?

BACKGROUND: Within the Guidelines of the European Hernia Society (EHS), there are disctinct statements about where and how inguinal hernia has to be surgically approached. In ASA-I and -II patients, it is recommended to perform the operation in an outpatient clinic setting. Male patients older than 30 years of age should undergo preferably surgical intervention using a mesh. In this context, there are two basic questions: "Are these recommendations already implemented in daily surgical practice (?)" and "Are these guidelines the road to success (?)", which are to be commented based on i) data from two registries, ii) data obtained in the surgical practice of the first author and iii) a selective literature search. MATERIAL AND METHODS: An analysis was made of prospectively obtained data from two German registries (Herniamed registry [H-med]; Quality Assurance Inguinal Hernia Registry [QIHR]) and a consecutive and representative patient cohort of a single surgical practice [Surg-Pract] specialised in hernia surgery. Main results and concluding remarks are discussed in light of data reported in the literature. RESULTS: Proportions of hernia repair in an outpatient clinic setting were substantially different among the 3 groups (as follows): H-med (22.3 %), QIHR (62.7 %), Surg-Pract (80.5 %) whereas the percentages of ASA-I and -II patients differed only slightly: H-med (83.4 %), QIHR (89.5 %) and Surg-Pract (88.3 %). Recurrency rates after 12 months were 0.6 % (QIHR) and 0.7 % (Surg-Pract), respectively. In Surg-Pract, for 30 % of hernia repairs, "only" suturing for reconstruction was used. CONCLUSION: In ASA-I and -II patients, a substantial proportion of individuals can be surgically treated in an outpatient clinic setting with no disadvantages regarding high surgical quality and favourable outcome. Data from the national H-med indicated a much lower percentage of such patients than internationally reported and, in addition, a disproportionately high rate of endoscopic procedures. Moreover, reimbursement for hernia repair in an outpatient clinic setting is much worse in Germany compared with international standards, and, interestingly, there is by a factor of 1/3 an above average number of hospital beds in Germany compared with the OECD countries.

Paying for quality not quantity: a wisconsin health maintenance organization proposes an incentive model for reimbursement of chiropractic services.

OBJECTIVE: The purpose of this study is to describe a reimbursement model that was developed by one Health Maintenance Organization (HMO) to transition from fee-for-service to add a combination of pay for performance and reporting model of reimbursement for chiropractic care. METHODS: The previous incentive program used by the HMO provided best-practice education and additional reimbursement incentives for achieving the National Committee for Quality Assurance Back Pain Recognition Program (NCQA-BPRP) recognition status. However, this model had not leveled costs between doctors of chiropractic (DCs). Therefore, the HMO management aimed to develop a reimbursement model to incentivize providers to embrace existing best-practice models and report existing quality metrics. The development goals included the following: it should (1) be as financially predictable as the previous system, (2) cost no more on a per-member basis, (3) meet the coverage needs of its members, and (4) be able to be operationalized. The model should also reward DCs who embraced best practices with compensation, not simply tied to providing more procedures, the new program needed to (1) cause little or no disruption in current billing, (2) be grounded achievable and defined expectations for improvement in quality, and (3) be voluntary, without being unduly punitive, should the DC choose not to participate in the program. RESULTS: The generated model was named the Comprehensive Chiropractic Quality Reimbursement Methodology (CCQRM; pronounced "Quorum"). In this hybrid model, additional reimbursement, beyond pay-for-procedures will be based on unique payment interpretations reporting selected, existing Physician Quality Reporting System (PQRS) codes, meaningful use of electronic health records, and achieving NCQA-BPRP recognition. This model aims to compensate providers using pay-for-performance, pay-for-quality reporting, pay-for-procedure methods. CONCLUSION: The CCQRM reimbursement model was developed to address the current needs of one HMO that aims to transition from fee-for-service to a pay-for-performance and quality reporting for reimbursement for chiropractic care. This model is theoretically based on the combination of a fee-for-service payment, pay for participation (NCQA Back Pain Recognition Program payment), meaningful use of electronic health record payment, and pay for reporting (PQRS-BPMG payment). Evaluation of this model needs to be implemented to determine if it will achieve its intended goals.

[Explanation method for health economic value of neurology].

As for the one with value, the reward rises generally. How should we discuss the value of the medicine or the examination in Neurology? I am recognizing that it is a complex and difficult theme. In this lecture, I tried to think about the idea of technology value in Neurology and the evaluation of doctor fee in public health system. It was a purpose to maximize well-being in the society. Medical value is that expressing by the performance of cost-effectiveness is an ideal. On the other hand, the total work and the resource cost with a lot of reports have both merits and demerits respectively. It is necessary to explain the technology of Neurology with combinations by three indexes of the total work and the resource cost and the outcome.