Preferences of healthcare providers for capitation payment in Kenya: a discrete choice experiment.

Provider payment mechanisms (PPMs) are important to the universal health coverage (UHC) agenda as they can influence healthcare provider behaviour and create incentives for health service delivery, quality and efficiency. Therefore, when designing PPMs, it is important to consider providers' preferences for PPM characteristics. We set out to uncover senior health facility managers' preferences for the attributes of a capitation payment mechanism in Kenya. We use a discrete choice experiment and focus on four capitation attributes, namely, payment schedule, timeliness of payments, capitation rate per individual per year and services to be paid by the capitation rate. Using a Bayesian efficient experimental design, choice data were collected from 233 senior health facility managers across 98 health facilities in seven Kenyan counties. Panel mixed multinomial logit and latent class models were used in the analysis. We found that capitation arrangements with frequent payment schedules, timelier disbursements, higher payment rates per individual per year and those that paid for a limited set of health services were preferred. The capitation rate per individual per year was the most important attribute. Respondents were willing to accept an increase in the capitation rate to compensate for bundling a broader set of health services under the capitation payment. In addition, we found preference heterogeneity across respondents and latent classes. In conclusion, these attributes can be used as potential targets for interventions aimed at configuring capitation to achieve UHC.

Include Payers in Your Product Development and Clinical Use Processes.

Wound/ulcer management scientists, researchers, manufacturers, professionals, and providers cannot assume that clearance or approval by the Food and Drug Administration (FDA) will guarantee reimbursement for medical devices they develop or wish to use in their practices. Even if a relative code and a published payment rate for the code exist, if the payers do not provide coverage for the technology, the devices may not be able to be sold and used in all settings throughout the continuum of care. Unfortunately, reimbursement (particularly coverage) is often an after-thought once FDA clearance or approval is achieved. This article describes two new Medicare coverage processes that should encourage all stakeholders to educate payers early and often why important medical devices should be covered for their patients with wounds/ulcers.

Physician-initiated payment reform: a new path toward value.

OBJECTIVES: In the move toward value-based payment, new payment models have largely been designed by payers and focused on the role of primary care providers. We examine a new phase of payment reform wherein providers, mostly specialists, are designing alternative payment models (APMs) for their own practices through a task force, called the Physician-Focused Payment Model Technical Advisory Committee, created by the Medicare Access and CHIP Reauthorization Act of 2015. Although it is a potentially notable shift in payment reform, little is known about the content of these proposals to date. STUDY DESIGN: Qualitative systematic review of physician-focused payment model proposals submitted to CMS. METHODS: We analyzed the first wave of new payment models proposed. For each of the 24 proposals submitted by physicians and physician groups, we assessed the models on their 10 key dimensions and evaluated underlying themes across all or many of the models to gain insights into what providers are looking for in APMs within the constraints of the rules established by the HHS secretary. RESULTS: Key features of the models and our analysis include bearing financial risk, a reliance on case management, embrace of new technologies, and consideration of legal barriers. CONCLUSIONS: We discuss how specialists may help lead in the evolving payment landscape and recommend how these models might be improved. Payers and policy makers could benefit from our findings, which reflect how providers view financial risk in APMs and provide guidance on the types of payment reforms that they may embrace in the journey toward value.

Back to the Future: Impact of a Paper-Based Admission H&P on Clinical Documentation Improvement at a Level 1 Trauma Center.

The Medicare Severity Diagnosis Related Group (MS-DRG) weight, as derived from the MS-DRG assigned at discharge, is in part determined by the physician-documented diagnoses. However, the terminology associated with MS-DRG determination is often not aligned with typical physician language, leading to inaccurate coding and decreased hospital reimbursements. The goal of this study was to evaluate the impact of a diagnosis picklist within a paper-based history and physical examination (H&P) on the average MS-DRG weight and the Case-mix index (CMI). Our trauma center implemented a paper H&P form for trauma patients featuring picklist diagnoses aligned with the MS-DRG terminology and arranged by the physiologic system. To evaluate its impact, we conducted a cohort study using data from our trauma registry between July 2015 and November 2017. Our cohort included 442 (26.0%) paper and 1,261 (74.0%) dictated H&Ps. Average CMI (2.56 vs 2.15) and expected patients ($25,057 vs $19,825) were higher for the paper group (P < 0.001, P = 0.002). Adjusted regression models demonstrated paper coding to be associated with 0.265 CMI points, translating to an average increase in expected payment of 6.5 per cent per patient. Utilization of a standardized, paper-based H&P template with picklist diagnoses was associated with a higher trauma service CMI and higher expected payments. Preprinted diagnoses that align with the MS-DRG terminology lead to clinical documentation improvement.

Don't Try This at Work: Security Risk Analysis Is Not a Do-It-Yourself Project.

Medicare's Merit-Based Incentive Payment System (MIPS) requires practices to conduct a security risk analysis at least once a year. HIPAA requires at least one analysis, and annual check-ups are considered a best practice. Many physicians find out through these reports that their practices have a lot of work to do to keep patient records safe.

United Healthcare Cuts Consults.

United Healthcare is eliminating payment for consults in two phases - one that took effect June 1 for certain services, and their complete elimination starting in October. The change is an effort to align with the Centers for Medicare & Medicaid Services policy that eliminated payment for most consults in 2010, but it's going to make it more difficult for many specialists to get compensated for the extra time and work those services require.

Demonstrating advanced practice provider value: Implementing a new advanced practice provider billing algorithm.

BACKGROUND: Rapid changes in health care are driving the adjustment of work flow by which providers serve patients in team-based care. Specifically, there is a need to develop more effective and efficient utilization with accurate attribution of advanced practice providers' (APPs) productivity. LOCAL PROBLEM: The Directors of the APP-Best Practice Center conducted assessments of each clinical area at MUSC Health, a large academic medical center. A knowledge gap was identified, not only regarding billing practices of the APPs (nurse practitioners/physician assistants) but also in the utilization of APPs to practice to the fullest extent of their license, education, and experience. METHODS: By substantiating APPs' contribution margin through the process of implementing a new standardized APP billing algorithm, a change in practice was accepted by senior leadership and a new APP billing algorithm was built while following updated practice laws, compliance/legal standards, and hospital bylaws/regulations. INTERVENTIONS: A new billing algorithm was implemented on July 1, 2017, and outcomes were evaluated 12 months after implementation. RESULTS: This project uncovered the work already performed by APPs while increasing relative value units, collections, and overall patient encounters by the APP/physician team. Findings suggest improved utilization and appropriate attribution of productivity. CONCLUSIONS: With the APP work force growing, the implementation of electronic medical record systems, and today's health care financial constraints, it is imperative that health care systems standardize their billing practices. The APP billing algorithm is a critical tool that will help to meet this demand.

Time-Driven Activity-Based Costing in Fracture Care: Is This a More Accurate Way to Prepare for Alternative Payment Models?

OBJECTIVES: To use surgical treatment of isolated ankle fractures as a model to compare time-driven activity-based costing (TDABC) and our institution's traditional cost accounting (TCA) method to measure true cost expenditure around a specific episode of care. METHODS: Level I trauma center ankle fractures treated between 2012 and 2016 were identified through a registry. Inclusion criteria were age greater than 18 years and same-day ankle fracture operation. Exclusion criteria were pilon fractures, vascular injuries, soft-tissue coverage, and external fixation. Time for each phase of care was determined through repeated observations. The TCA method at our institution uses all hospital costs and allocates them to surgeries using a relative value method. RESULTS: A total of 35 patients met the inclusion/exclusion criteria, 18 were men and 17 were women. Age at time of surgery was 47 ± 15 years. Time from injury to surgery was 10 ± 4 days. Operative time was 86 ± 30 minutes, Post-anesthesia care unit (PACU) time was 87 ± 27 minutes, and secondary recovery time was 100 ± 56 minutes. Average cost was significantly lower for the TDABC method ($2792 ± 734) than the TCA method ($5782 ± 1348) (P < 0.001). There was no difference between methods for implant cost ($882 ± 507 for Traditional Accounting (TA) and $957 ± 651 for TDABC, P = 0.593). TCA produced a significantly greater cost (P < 0.01) in every other category. CONCLUSIONS: As orthopaedics transitions to alternative payment models, accurate costing will become critical to maintaining a successful practice. TDABC may provide a better estimate of the cost of the resources necessary to treat a patient.

Effects of a new medical insurance payment system for hospice patients in palliative care programs in Korea.

BACKGROUND: This study investigates the effects of a new medical insurance payment system for hospice patients in palliative care programs and analyzes length of survival (LoS) determinants. METHOD: At the Pusan National University Hospital hospice center, between January 2015 and April 2016, 276 patients were hospitalized with several diagnosed types of terminal stage cancer. This study separated patients into two groups, "old" and "new," by admission date, considering the new system has been applied from July 15, 2015. The study subsequently compared LoS, total cost, and out-of-pocket expenses for the two groups. RESULTS: Overall, 142 patients applied to the new medical insurance payment system group, while the old medical insurance payment system included 134 patients. The results do not show a significantly negative difference in LoS for the new system group (p = 0.054). Total cost is higher within the new group (p <  0.001); however, the new system registers lower patient out-of-pocket expenses (p <  0.001). CONCLUSION: The novelty of this study is proving that the new medical insurance payment system is not inferior to the classic one in terms of LoS. The total cost of the new system increased due to a multidisciplinary approach toward palliative care. However, out-of-pocket expenses for patients overall decreased, easing their financial burden.

Harnessing electronic healthcare data for wound care research: Standards for reporting observational registry data obtained directly from electronic health records.

The United States Food and Drug Administration will consider the expansion of coverage indications for some drugs and devices based on real-world data. Real-world data accrual in patient registries has historically been via manual data entry from the medical chart at a time distant from patient care, which is fraught with systematic error. The efficient automated transmission of data directly from electronic health records is replacing this labor-intensive paradigm. However, real-world data collection is unfamiliar. The potential sources of bias arising from the source of data and data accrual, documentation, and aggregation have not been well defined. Furthermore, the technological aspects of data acquisition and transmission are less transparent. We explore opportunities for harnessing direct-from-electronic health record registry reporting and propose the ABCs of Registries (Analysis of Bias Criteria of Registries), which are an evaluation framework for publications to minimize potential bias of real-world data obtained directly from an electronic health record method. These standards are based on a point-of-care data documentation process using a common definitional framework and data dictionaries. By way of example, we describe a wound registry obtained directly from electronic health records. This qualified clinical data registry minimizes bias by ensuring complete and accurate point-of-care data capture, standardizes usual care linked to quality reporting, and prevents post-hoc vetting of outcomes. The resulting data are of high quality and integrity and can be used for comparative effectiveness research in wound care. In this way, the effort needed to succeed with the Quality Payment Program is leveraged to obtain the real-world data needed for comparative effectiveness research.

Current State of Value-Based Purchasing Programs.

The US healthcare system is rapidly moving toward rewarding value. Recent legislation, such as the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act, solidified the role of value-based payment in Medicare. Many private insurers are following Medicare's lead. Much of the policy attention has been on programs such as accountable care organizations and bundled payments; yet, value-based purchasing (VBP) or pay-for-performance, defined as providers being paid fee-for-service with payment adjustments up or down based on value metrics, remains a core element of value payment in Medicare Access and CHIP Reauthorization Act and will likely remain so for the foreseeable future. This review article summarizes the current state of VBP programs and provides analysis of the strengths, weaknesses, and opportunities for the future. Multiple inpatient and outpatient VBP programs have been implemented and evaluated; the impact of those programs has been marginal. Opportunities to enhance the performance of VBP programs include improving the quality measurement science, strengthening both the size and design of incentives, reducing health disparities, establishing broad outcome measurement, choosing appropriate comparison targets, and determining the optimal role of VBP relative to alternative payment models. VBP programs will play a significant role in healthcare delivery for years to come, and they serve as an opportunity for providers to build the infrastructure needed for value-oriented care.