Metodología para la estimación de las tarifas de procedimientos médicos o procedimientos sanitarios en las instituciones prestadoras de servicios de salud / Methodology for the estimation of the rates of medical procedures or sanitary procedures in the institutions providing health services

La directiva contiene la finalidad y justificación técnica, ámbito de aplicación, base legal y disposiciones generales y específicas para la metodología de estimación de las tarifas de procedimientos médicos o procedimientos sanitarios en las instituciones prestadoras de servicios de salud.

Lineamientos de política tarifaria del Sector Salud / Tariff policy guidelines of the Health Sector

El documento contiene la finalidad, objetivos, ámbito de aplicación, lineamientos y responsabilidades para la definir la política tarifaría en el sector salud, a fin de contribuir a mejorar el acceso a los servicios de salud a la población residente en el territorio nacional, mediante la regulación de los procesos y procedimientos que facilite la estandarización, determinación y actualización de las tarifas de procedimientos médicos y sanitarios en las Instituciones Prestadoras de los Servicios de Salud - IPRESS, favoreciendo complementariamente la sostenibilidad financiera.

The Global Wicked Problem of Corruption and Its Risks for Access to HIV/AIDS Medicines.

We discuss how corruption affects access to antiretroviral therapies (ARVs) globally. Recent cases of theft of ARVs, collusion, and manipulation in procurement found in countries such as Central African Republic, Bangladesh, Malawi, and Guinea, show there is still much work to be done to reduce the risk of corruption. This includes addressing the structural weaknesses in procurement mechanisms and supply chain management systems of health commodities and medicines.

Schedule for Rating Disabilities: Skin. Final rule.

On August 12, 2016, VA published in the Federal Register the proposed rule for Schedule for Rating Disabilities: Skin. VA received multiple responses during the 60-day comment period. This final rule implements the Secretary's proposed rule with limited revisions.

Nasal Endoscopy Billing Patterns: A Survey of the American Rhinologic Society.

Introduction Nasal endoscopy (NE) is an essential element of office-based clinical rhinology, including the evaluation of chronic rhinosinusitis. Despite the presence of guidelines, variability exists regarding coding and billing for NE especially with regard to inclusion of evaluation and management (E&M) codes and use of the 25 modifier. The goal of this survey was to assess the billing patterns for NE among American Rhinologic Society (ARS) members. Methods An invitation to participate in a web-based survey was electronically sent to all ARS members. Survey participants were queried regarding demographics and billing patterns for NE in several different clinical scenarios using a 5-point Likert-type scale, with a score of 5 representing "always" and a score of 1 representing "never" for billing E&M. Results A total of 93 respondents successfully completed the survey with a range of the number of years since completing training, practice type (50.5% private, 44.1% academic) and completion of a rhinology fellowship (40.9%). Variable responses for billing patterns for distinct clinical scenarios were noted. Higher scores for billing both E&M and NE for the queried clinical scenarios were noted for new patients (mean 4.50) compared to established patients (mean 3.81) and postoperative patients (mean 3.04). Inclusion of a septoplasty as part of the surgery impacted billing an E&M code 28% of the time. Practice type and history of performing a fellowship did not significantly influence billing patterns for NE. Conclusions Significant variability exists among ARS respondents with regard to billing patterns for NE, despite the presence of coding guidelines. Additional teaching of standard coding practices for NE may limit variability among otolaryngologists.

Medicare and Medicaid Programs; CY 2018 Home Health Prospective Payment System Rate Update and CY 2019 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements. Final rule.

This final rule updates the home health prospective payment system (HH PPS) payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor, effective for home health episodes of care ending on or after January 1, 2018. This rule also: Updates the HH PPS case-mix weights using the most current, complete data available at the time of rulemaking; implements the third year of a 3-year phase-in of a reduction to the national, standardized 60-day episode payment to account for estimated case-mix growth unrelated to increases in patient acuity (that is, nominal case-mix growth) between calendar year (CY) 2012 and CY 2014; and discusses our efforts to monitor the potential impacts of the rebasing adjustments that were implemented in CY 2014 through CY 2017. In addition, this rule finalizes changes to the Home Health Value-Based Purchasing (HHVBP) Model and to the Home Health Quality Reporting Program (HH QRP). We are not finalizing the implementation of the Home Health Groupings Model (HHGM) in this final rule.

Risk Adjustment, Reinsurance Improved Financial Outcomes For Individual Market Insurers With The Highest Claims.

The Affordable Care Act (ACA) reformed the individual health insurance market. Because insurers can no longer vary their offers of coverage based on applicants' health status, the ACA established a risk adjustment program to equalize health-related cost differences across plans. The ACA also established a temporary reinsurance program to subsidize high-cost claims. To assess the impact of these programs, we compared revenues to claims costs for insurers in the individual market during the first two years of ACA implementation (2014 and 2015), before and after the inclusion of risk adjustment and reinsurance payments. Before these payments were included, for the 30 percent of insurers with the highest claims costs, claims (not including administrative expenses) exceeded premium revenues by $90-$397 per enrollee per month. The effect was reversed after these payments were included, with revenues exceeding claims costs by $0-$49 per month. The risk adjustment and reinsurance programs were relatively well targeted in the first two years. While there is ongoing discussion regarding the future of the ACA, our findings can shed light on how risk-sharing programs can address risk selection among insurers-a pervasive issue in all health insurance markets.

Improving Health Care for Spanish-Speaking Rural Dairy Farm Workers.

BACKGROUND: Dartmouth Geisel Migrant Health (DGMH) is a medical student group that provides on-site health services for Spanish-speaking dairy workers in rural Vermont and New Hampshire in conjunction with a federally qualified health center (FQHC). STUDY OBJECTIVE: This project was undertaken to evaluate and improve the services provided by DGMH and the FQHC and to refine understanding of the target population. METHODS: We surveyed 25 workers at 6 collaborating dairy farms to identify health priorities and concerns and perceived barriers and facilitators to health care for these workers. Surveys were administered over 2 weeks in July 2015. Interpreter-mediated appointment and sliding-fee-scale data from a period 7 months that spanned survey administration were also assessed. RESULTS: Diabetes and hypertension were the most common health concerns. Thirty-two percent of participants reported 10 or more days of depressed mood in the past month. Insurance and language were the most common barriers to health care and employers and on-site clinics were the most common facilitators. Appointments most often addressed women's health, gastrointestinal problems, health maintenance, diabetes, and back pain. Thirty FQHC sliding-fee-scale applications were completed by workers. CONCLUSIONS: These Spanish-speaking dairy-farm workers have many health concerns and perceive substantial barriers to health care. Collaboration between medical students, a rural FQHC, and farm employers provides important services that facilitate health care access among this population.

[Calculating Ratios Based on Statutory Health Care Data at the District Level - An Empirical Estimation Based on the Microcensus]. / Ratenbildung bei KV-Daten mit GKV-Versicherten auf Kreisebene ­ ein empirisches Schätzmodell auf der Basis des Mikrozensus.

Background: In Germany, data of the statutory health insurance system are used, amongst others, in health monitoring and health care research at the district level. For the calculation of exact ratios, the number of those covered by statutory health insurance is needed as denominator. For some federal states, however, this number is not available on a district level. Therefore, ratios based on statutory health care data are calculated using a surrogate defined in terms of visits to the doctor. This leads to uncertainties that limit small area comparisons. Therefore, the aim of the present study was to develop a superior estimation model for the number of those covered by statutory health insurance on a district level. Methods: The proportion of those covered by statutory health insurance in the Bavarian districts is estimated by a multiple linear regression model. The model relates data on determinants of the insurance status (income, proportions of civil servants and of self-employed persons) available on district level to data on the number of those covered by statutory health insurance obtained from microcensus on a regional level. The proportion of those covered by statutory health insurance estimated by this model is compared to the surrogate. As an example for practical application, small area estimations for diabetes prevalence are compared to data provided by the Bavarian Association of Statutory Health Insurance Physicians. Results: The proportion of those covered by the statutory health insurance in the Bavarian districts as estimated by the regression model varies between 74.7 and 91.6%. The difference to the currently used surrogate reaches up to 18.6 percentage points. This is also reflected in treatment prevalence, shown here using the example of diabetes mellitus. Conclusion: The present analysis shows the uncertainties of ratios and consequences for small area comparisons based on statutory healthcare data. Providing valid data for the denominator in accordance with the data transparency regulation in the Social Insurance Code (SGB) V should be attempted.

Racial and Ethnic Differences in End-of-Life Medicare Expenditures.

OBJECTIVES: To determine to what extent demographic, social support, socioeconomic, geographic, medical, and End-of-Life (EOL) planning factors explain racial and ethnic variation in Medicare spending during the last 6 months of life. DESIGN: Retrospective cohort study. SETTING: Health and Retirement Study (HRS). PARTICIPANTS: Decedents who participated in HRS between 1998 and 2012 and previously consented to survey linkage with Medicare claims (N = 7,105). MEASUREMENTS: Total Medicare expenditures in the last 180 days of life according to race and ethnicity, controlling for demographic factors, social supports, geography, illness burden, and EOL planning factors, including presence of advance directives, discussion of EOL treatment preferences, and whether death had been expected. RESULTS: The analysis included 5,548 (78.1%) non-Hispanic white, 1,030 (14.5%) non-Hispanic black, and 331 (4.7%) Hispanic adults and 196 (2.8%) adults of other race or ethnicity. Unadjusted results suggest that average EOL Medicare expenditures were $13,522 (35%, P < .001) more for black decedents and $16,341 (42%, P < .001) more for Hispanics than for whites. Controlling for demographic, socioeconomic, geographic, medical, and EOL-specific factors, the Medicare expenditure difference between groups fell to $8,047 (22%, P < .001) more for black and $6,855 (19%, P < .001) more for Hispanic decedents than expenditures for non-Hispanic whites. The expenditure differences between groups remained statistically significant in all models. CONCLUSION: Individuals-level factors, including EOL planning factors do not fully explain racial and ethnic differences in Medicare spending in the last 6 months of life. Future research should focus on broader systemic, organizational, and provider-level factors to explain these differences.

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017. Final rule.

This final rule sets forth payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost-sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges. It also provides additional amendments regarding the annual open enrollment period for the individual market for the 2017 and 2018 benefit years; essential health benefits; cost sharing; qualified health plans; Exchange consumer assistance programs; network adequacy; patient safety; the Small Business Health Options Program; stand-alone dental plans; third-party payments to qualified health plans; the definitions of large employer and small employer; fair health insurance premiums; student health insurance coverage; the rate review program; the medical loss ratio program; eligibility and enrollment; exemptions and appeals; and other related topics.

Basic Health Program; Federal Funding Methodology for Program Years 2017 and 2018. Final methodology.

This document provides the methodology and data sources necessary to determine Federal payment amounts made in program years 2017 and 2018 to states that elect to establish a Basic Health Program under the Affordable Care Act to offer health benefits coverage to low-income individuals otherwise eligible to purchase coverage through Affordable Insurance Exchanges (hereinafter referred to as the Exchanges).

Combining Review Text Content and Reviewer-Item Rating Matrix to Predict Review Rating.

E-commerce develops rapidly. Learning and taking good advantage of the myriad reviews from online customers has become crucial to the success in this game, which calls for increasingly more accuracy in sentiment classification of these reviews. Therefore the finer-grained review rating prediction is preferred over the rough binary sentiment classification. There are mainly two types of method in current review rating prediction. One includes methods based on review text content which focus almost exclusively on textual content and seldom relate to those reviewers and items remarked in other relevant reviews. The other one contains methods based on collaborative filtering which extract information from previous records in the reviewer-item rating matrix, however, ignoring review textual content. Here we proposed a framework for review rating prediction which shows the effective combination of the two. Then we further proposed three specific methods under this framework. Experiments on two movie review datasets demonstrate that our review rating prediction framework has better performance than those previous methods.

Implementing the Affordable Care Act: Promoting Competition in the Individual Marketplaces.

A main goal of the Affordable Care Act is to provide Americans with access to affordable coverage in the individual market, achieved in part by pro­moting competition among insurers on premium price and value. One primary mechanism for meeting that goal is the establishment of new individual health insurance marketplaces where consumers can shop for, compare, and purchase plans, with subsidies if they are eligible. In this issue brief, we explore how the Affordable Care Act is influencing competition in the individual marketplaces in four states--Kansas, Nevada, Rhode Island, and Washington. Strategies include: educating consumers and providing coverage information in one place to ease decision-making; promoting competition among insurers; and ensuring a level playing field for premium rate development through the rate review process.