[Functional Electrical Stimulation in a Case of Drop Foot and Atactic Gait: Expert Assessment of Contested Medical Aids]. / Funktionelle Elektrostimulation bei Fußheberschwäche und ataktischem Gangbild: Gutachterliches Vorgehen bei streitiger Hilfsmittelversorgung.

Expert medical opinions are necessary in pretrial cases and other legal matters. They act as means of evidence for administrative bodies and courts. It may be necessary to adapt the method of evaluation depending upon the issue or subject matter to be evaluated. We report on a social court case, which needed to answer the question of the medical necessity of a functional electrical stimulation orthosis prescribed to improve the function of a drop foot accompanied by an atactic gait disorder. The claimant suffered from a stroke, which had occurred several years before. Her aids were an ankle-foot-orthosis for foot lift and a wheeled walker. The current treatment was to be augmented by the disputed device. The statutory health insurance declined to meet the costs. They failed to find relevant benefits after analysis of video tapes of the patient's gait while using an electrical stimulation orthosis. The social court requested an expert opinion to answer the question as to whether or not there was a relevant functional benefit to using functional electrical stimulation over the existing orthosis or to an alternative treatment. Video documentation was desired by the court. We used the clinic's gait analysis laboratory, which is equipped with a gait course and the claimed video documentation. Standardised video documentation offers substantial advantages for answering forensic questions such as these. It assures reproducibility and comparability of all tested scenarios, with objectification of the individual advantages or limitations. This gain in both validity and reliability fulfills the scientific requirements placed upon an expert assessment.

Traditional Payment Models in Radiology: Historical Context for Ongoing Reform.

The passage of the Medicare Access and CHIP Reauthorization Act (MACRA) replaces the sustainable growth rate with a payment system based on quality and alternative payment model participation. The general structure of payment under MACRA is included in the statute, but the rules and regulations defining its implementation are yet to be formalized. It is imperative that the radiology profession inform policymakers on their role in health care under MACRA. This will require a detailed understanding of prior legislative and nonlegislative actions that helped shape MACRA. To that end, the authors provide a detailed historical context for payment reform, focusing on the payment quality initiatives and alternative payment model demonstrations that helped provide the foundation of future MACRA-driven payment reform.

Plastic surgery practice models and research aims under the Patient Protection and Affordable Care Act.

As the health care landscape in the United States changes under the Affordable Care Act, providers are set to face numerous new challenges. Although concerns about practice sustainability with declining reimbursement have dominated the dialogue, there are more pressing changes to the health care funding mechanism as a whole that must be addressed. Plastic surgeons, involved in various practice models each with different relationships to hospitals, referring physicians, and payers, must understand these reimbursement changes to dictate adequate compensation in the future. In this article, the authors discuss bundle payments and accountable care organizations, and how plastic surgeons might best engage in these new system designs. In addition, the authors review the value of a focused and driven health-services research agenda in plastic surgery, and the importance of this research in supporting long-term financial stability for the specialty.

[The hospital financing frame regulation, psychiatric OPS figures and new reimbursement ordinance for psychosomatic medicine and psychotherapy as well as psychiatry and psychotherapy]. / Das Krankenhausfinanzierungsrahmengesetz (KHRG), die Psych-OPS-Ziffern und die neue Entgeltregelung für Psychosomatische Medizin und Psychotherapie sowie Psychiatrie und Psychotherapie.

In March 2009 the "Krankenhausfinanzierungsrahmengesetz (KHRG)" (Hospital Finance Law) came into force. For this reason, new procedures covering psychosomatic-psychotherapeutic und psychiatric-psychotherapeutic inpatient treatment had to be developed. This paper presents the new Psych-Procedures (Psych-OPS) together with first instructions on coding procedures.

Naturopathy and the primary care practice.

Naturopathy is a distinct type of primary care medicine that blends age-old healing traditions with scientific advances and current research. Naturopathy is guided by a unique set of principles that recognize the body's innate healing capacity, emphasize disease prevention, and encourage individual responsibility to obtain optimal health. Naturopathic treatment modalities include diet and clinical nutrition, behavioral change, hydrotherapy, homeopathy, botanical medicine, physical medicine, pharmaceuticals, and minor surgery. Naturopathic physicians (NDs) are trained as primary care physicians in 4-year, accredited doctoral-level naturopathic medical schools. At present, there are 15 US states, 2 US territories, and several provinces in Canada, Australia, and New Zealand that recognize licensure for NDs.

Aligning physician and hospital incentives: the approach at hospital for special surgery.

Healthcare administrators and physicians alike are navigating an increasingly complex and highly regulated healthcare environment. Unlike in the past, institutions now require strong collaboration among physician and administrative leaders. As providers and managers are trained and work differently, new methods are needed to provide the infrastructure and resources necessary to create, nurture, and sustain alignment between them. We describe four initiatives by administrators and physicians at Hospital for Special Surgery to work together in mutually beneficial relationships that help us achieve the highest level of patient care, satisfaction and safety. These initiatives include improving management efficiency through an orthopaedic service line structure, helping individual physicians grow their practices through the demand-office-operating room initiative of the Physicians Service Department, controlling costs through the supply effectiveness policy, and promoting teamwork in innovation through the technology transfer program.

Aligning incentives in orthopaedics: opportunities and challenges -- the Case Medical Center experience.

For 30 years, the orthopaedic faculty at Case Western Reserve University worked as an independent private corporation within University Hospitals Case Medical Center (Hospital). However, by 2002, it became progressively obvious to our orthopaedic practice that we needed to modify our business model to better manage the healthcare regulatory changes and decreased reimbursement if we were to continue to attract and retain the best and brightest orthopaedic surgeons to our practice. In 2002, our surgeons created a new entity wholly owned by the parent corporation at the Hospital. As part of this transaction, the parties negotiated a balanced employment model designed to fully integrate the orthopaedic surgeons into the integrated delivery system that included the Hospital. This new faculty practice plan adopted a RVU-based compensation model for the physicians, with components that created incentives both for clinical practice and for academic and administrative service contributions. Over the past 5 years, aligning incentives with the Hospital has substantially increased the clinical productivity of the surgeons and has also benefited the Hospital and our patients. Furthermore, aligned incentives between surgeons and hospitals could be of substantial financial benefit to both, as Medicare moves forward with its bundled project initiative.

Evidence and values: requirements for public reimbursement of drugs for rare diseases--a case study in oncology.

INTRODUCTION: Doubts have been expressed about whether standard methods of health technology assessment are suitable for the evaluation of drugs for rare diseases. Under conditions of rarity, it may be more difficult to conduct large randomized trials in order to gather adequate evidence on efficacy, and the standard methods of economic evaluation may not adequately reflect societal preferences for the treatment of serious and/or life-threatening rare diseases. METHODS: A roundtable was held at the University of Toronto Joint Centre for Bioethics on February 18, 2008 to address these issues. While the focus was on evaluation and reimbursement decision-making for rare cancers, the discussion was broadened to consider the place of evidence and values in considering public reimbursement of drugs prescribed for rare disorders more generally. DISCUSSION: This paper explores the relevant issues in more detail, using the example of a new drug for treatment of renal cell carcinoma. CONCLUSION: There should be a greater commitment by reimbursement agencies to a fair and transparent decision-making process with appropriate community input. Criteria should be developed to validate surrogate markers for rare diseases. It should also be acknowledged that the traditional measures of benefit in economic studies do not incorporate all elements of social value. The need should be recognized to balance equity with an efficient use of resources.

[Competition in healthcare--a health systems' perspective]. / Wettbewerb im Gesundheitswesen--eine Gesundheitssystemperspektive.

That "more competition in healthcare primarily produces more needs-based equity, better quality, higher efficiency, reduced costs and less bureaucracy" is a familiar claim. But is it correct? Three types of competition can be identified within a triangle: (1) competition among third-party-payers for insured individuals/customers, (2) competition among providers for patients, and (3) competition among third-party payers for contracts with providers--and vice versa. German and international evidence for these three types of competition demonstrates that many expectations--e.g., that patients can be steered based on quality information--are wishful thinking. Instead of market and competition, regulation is needed (e.g., in the form of an effective risk-based allocation mechanism) to ensure high-quality care for those 5% of the population incurring 50% of the healthcare expenditures (i.e., the seriously ill patients), while at the same time competition based on selective contracts does not pay off for the majority of the population due to high transaction costs.

Pricing and reimbursement of pharmaceuticals in the Czech Republic and Sweden.

OBJECTIVES: To describe and compare price regulation and reimbursement in the Czech Republic and Sweden. METHODS: Legal documents, government reports, statutory information, annual reports and scientific articles were searched using the keywords: pharmaceutical market regulation, drug policy, drug pricing, drug reimbursement and patients' participation in costs concerning both countries. Approaches to regulation and regulatory steps concerning prices were compared between the countries. MAIN OUTCOME MEASURE: (i) Institutional responsibilities in pricing and reimbursement of pharmaceuticals; (ii) principles of patients' participation in costs on pharmaceuticals. RESULTS: Substantial differences were found in terms of pricing. In the Czech Republic, the Ministry of Finance sets maximal prices for pharmaceuticals whereas in Sweden there is a process of price regulation combined with reimbursement decisions taken by the Pharmaceutical Benefits Board. Together with a system of state-owned pharmacies, this ensures that drug prices in Sweden are fixed at the same level throughout the country. In the Czech Republic, prices may differ, since only maximal price levels are set. In both countries, decisions about reimbursement are taken at the national or state level whereas insurance funds or county councils are responsible for covering costs. The private share of pharmaceutical expenditures is substantially lower in the Czech Republic, even though there is no maximal level for patient's co-payment, as there is in Sweden. CONCLUSION: Differences in price setting and some other regulations of the pharmaceutical market were found. Both systems are designed to promote rational use of pharmaceuticals; and are based on social solidarity.