A systematic review on reporting quality of economic evaluations for negotiated glucose-lowering drugs in China national reimbursement drug list.

BACKGROUND: This study aimed to examine the reporting quality of existing economic evaluations for negotiated glucose-lowering drugs (GLDs) included in China National Reimbursement Drug List (NRDL) using the Consolidated Health Economic Evaluation Reporting Standards 2013 (CHEERS 2013). METHODS: We performed a systematic literature research through 7 databases to identify published economic evaluations for GLDs included in the China NRDL up to March 2021. Reporting quality of identified studies was assessed by two independent reviewers based on the CHEERS checklist. The Kruskal-Wallis test and Mann-Whitney U test were performed to examine the association between reporting quality and characteristics of the identified studies. RESULTS: We have identified 24 studies, which evaluated six GLDs types. The average score rate of the included studies was 77.41% (SD:13.23%, Range 47.62%-91.67%). Among all the required reporting items, characterizing heterogeneity (score rate = 4.17%) was the least satisfied item. Among six parts of CHEERS, results part scored least at 0.55 (score rate = 54.79%) because of the incompleteness of characterizing uncertainty. Results from the Kruskal-Wallis test and Mann-Whitney U test showed that model choice, journal type, type of economic evaluations, and study perspective were associated with the reporting quality of the studies. CONCLUSIONS: There remains room to improve the reporting quality of economic evaluations for GLDs in NRDL. Checklists such as CHEERS should be widely used to improve the reporting quality of economic researches in China.

Reported Variation in Hospital Billing Quality.

This study examines how US hospitals perform on billing quality measures, including legal actions taken by a hospital to collect medical debt, the timeliness of sending patients an itemized billing statement, and patient access to a qualified billing representative.

Skilled Nursing Facility Participation in a Voluntary Medicare Bundled Payment Program: Association With Facility Financial Performance.

IMPORTANCE: Model 3 of the Bundled Payments for Care Improvement (BPCI) is an alternative payment model in which an entity takes accountability for the episode costs. It is unclear how BPCI affected the overall skilled nursing facility (SNF) financial performance and the differences between facilities with differing racial/ethnic and socioeconomic status (SES) composition of the residents. OBJECTIVE: The objective of this study was to determine associations between BPCI participation and SNF finances and across-facility differences in SNF financial performance. DESIGN, SETTING, AND PARTICIPANTS: A longitudinal study spanning 2010-2017, based on difference-in-differences analyses for 575 persistent-participation SNFs, 496 dropout SNFs, and 13,630 eligible nonparticipating SNFs. MAIN OUTCOME MEASURES: Inflation-adjusted operating expenses, revenues, profit, and profit margin. RESULTS: BPCI was associated with reductions of $0.63 million in operating expenses and $0.57 million in operating revenues for the persistent-participation group but had no impact on the dropout group compared with nonparticipating SNFs. Among persistent-participation SNFs, the BPCI-related declines were $0.74 million in operating expenses and $0.52 million in operating revenues for majority-serving SNFs; and $1.33 and $0.82 million in operating expenses and revenues, respectively, for non-Medicaid-dependent SNFs. The between-facility SES gaps in operating expenses were reduced (differential difference-in-differences estimate=$1.09 million). Among dropout SNFs, BPCI showed mixed effects on across-facility SES and racial/ethnic differences in operating expenses and revenues. The BPCI program showed no effect on operating profit measures. CONCLUSIONS: BPCI led to reduced operating expenses and revenues for SNFs that participated and remained in the program but had no effect on operating profit indicators and mixed effects on SES and racial/ethnic differences across SNFs.

Dermatologists' Perspectives on Defining Moderate Psoriasis: The Canadian Moderate Psoriasis Survey.

BACKGROUND: Psoriasis is commonly classified as either mild or moderate to severe, without specific parameters to differentiate moderate versus severe disease. This may lead to patients with moderate psoriasis being underrecognized and undertreated. OBJECTIVE: An online survey was conducted to assess Canadian dermatologists’ perspectives on the definition and treatment of psoriasis. METHOD: Dermatologists included in the survey were regional and national leaders with expertise in psoriasis. Questions were developed based on feedback from a steering committee of Canadian dermatologists. RESULTS: Of 88 dermatologists contacted, 69 responded; 42.0% were in practice for >20 years. Most dermatologists reported using the percentage of psoriasis-affected body surface area (BSA) to describe disease severity (90.8% for moderate and 87.5% for severe psoriasis). The lower and upper median cutoffs for moderate psoriasis were reported as 5.0% and 10.0% for BSA and 7.0 and 11.5 for the Dermatology Life Quality Index. Most dermatologists also consider psoriasis location (eg, palms, scalp, genital area, face) as an important indicator of disease severity. The majority of Canadian dermatologists (87.5%) identified access to treatment as one of the biggest challenges for patients with moderate psoriasis. Most dermatologists estimated that ≤40% of their patients with moderate plaque psoriasis were being treated with traditional oral systemics, targeted oral systemics, or biologics. CONCLUSIONS: This is the first survey of Canadian dermatologists on moderate psoriasis. Efforts are needed to implement a clinically useful definition of moderate plaque psoriasis to improve patient care and to raise awareness of the definition among regulatory agencies and reimbursement authorities. J Drugs Dermatol. 2021;20(2):126-132. doi:10.36849/JDD.5531.

Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients.

IMPORTANCE: The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown. OBJECTIVE: To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs. MAIN OUTCOME MEASURES: Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident. RESULTS: The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities. CONCLUSIONS: The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.

Challenges and Adverse Outcomes of Implementing Reimbursement Mechanisms Based on the Diagnosis-Related Group Classification System: A systematic review.

In health insurance, a reimbursement mechanism refers to a method of third-party repayment to offset the use of medical services and equipment. This systematic review aimed to identify challenges and adverse outcomes generated by the implementation of reimbursement mechanisms based on the diagnosis-related group (DRG) classification system. All articles published between 1983 and 2017 and indexed in various databases were reviewed. Of the 1,475 articles identified, 36 were relevant and were included in the analysis. Overall, the most frequent challenges were increased costs (especially for severe diseases and specialised services), a lack of adequate supervision and technical infrastructure and the complexity of the method. Adverse outcomes included reduced length of patient stay, early patient discharge, decreased admissions, increased re-admissions and reduced services. Moreover, DRG-based reimbursement mechanisms often resulted in the referral of patients to other institutions, thus transferring costs to other sectors.

The impact of global budget payment reform on systemic overuse in Maryland.

BACKGROUND: Medical overuse is a leading contributor to the high cost of the US health care system and is a definitive misuse of resources. Elimination of overuse could improve health care efficiency. In 2014, the State of Maryland placed the majority of its hospitals under an all-payer, annual, global budget for inpatient and outpatient hospital services. This program aims to control hospital use and spending. OBJECTIVE: To assess whether the Maryland global budget program was associated with a reduction in the broad overuse of health care services. METHODS: We conducted a retrospective analysis of deidentified claims for 18-64 year old adults from the IBM MarketScan® Commercial Claims and Encounters Database. We matched 2 Maryland Metropolitan Statistical Areas (MSAs) to 6 out-of-state comparison MSAs. In a difference-in-differences analysis, we compared changes in systemic overuse in Maryland vs the comparison MSAs before (2011-2013) and after implementation (2014-2015) of the global budget program. Systemic overuse was measured using a semiannual Johns Hopkins Overuse Index. RESULTS: Global budgets were not associated with a reduction in systemic overuse. Over the first 1.5 years of the program, we estimated a nonsignificant differential change of -0.002 points (95%CI, -0.372 to 0.369; p = 0.993) relative to the comparison group. This result was robust to multiple model assumptions and sensitivity analyses. CONCLUSIONS: We did not find evidence that Maryland hospitals met their revenue targets by reducing systemic overuse. Global budgets alone may be too blunt of an instrument to selectively reduce low-value care.

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.

Patient Perception of Orthopedic Surgeon Reimbursement.

Significant attention has been directed at evaluating reimbursement rates to orthopedic surgeons for various surgical procedures. To evaluate patients' understanding of the surgeon reimbursement process, studies using patient surveys have been conducted to determine patients' perceptions of orthopedic surgeon compensation. To date, there has been no systematic review to consolidate the data of these studies. This study aimed to synthesize the findings of these individual studies across multiple subspecialties of orthopedic surgery to evaluate the potential discrepancy between how much patients believe orthopedic surgeons are reimbursed and the actual reimbursement rate. We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies that report findings of patient perceptions of orthopedic surgeon reimbursement for various procedures. Searches were conducted using MEDLINE through PubMed, Embase, and Scopus. Summary estimates of reimbursement discrepancies across subspecialties and overall were reported as unweighted averages of the individual study results within each group. Twelve studies were identified that met inclusion criteria, constituting 4309 surveys. These survey studies measured patients' perceptions of how much orthopedic surgeons are reimbursed for common procedures, including anterior cruciate ligament reconstruction, arthroscopic meniscectomy, carpal tunnel release, rotator cuff repair, multiple spine procedures and total shoulder, hip, and knee arthroplasty. It was found that patients reported reasonable surgeon's fees to be 11.2 times more than actual Medicare reimbursement. Among individual studies, the largest discrepancies were seen in total hip arthroplasty (26 times), whereas the smallest difference was in anterior cruciate ligament reconstruction (1.6 times). On average, patients estimated Medicare reimbursement rates to be 5.9 times higher than the actual surgeon reimbursement. Patients consistently overestimate how much orthopedic surgeons are reimbursed for common orthopedic procedures. The results of this systematic review suggest that patients may value these procedures more than what Medicare reimburses. Such information may help educate the public, direct policy, and increase transparency between orthopedic surgeons and patients.

A call for harmonization of European kidney care: dialysis reimbursement and distribution of kidney replacement therapies.

BACKGROUND: We compare reimbursement for haemodialysis (HD) and peritoneal dialysis (PD) in European countries to assess the impact on government healthcare budgets. We discuss strategies to reduce costs by promoting sustainable dialysis and kidney transplantation. METHODS: This was a cross-sectional survey among nephrologists conducted online July-December 2016. European countries were categorized by tertiles of gross domestic product per capita (GDP). Reimbursement data were matched to kidney replacement therapy (KRT) data. RESULTS: The prevalence per million population of patients being treated with long-term dialysis was not significantly different across tertiles of GDP (P = 0.22). The percentage of PD increased with GDP across tertiles (4.9, 8.2, 13.4%; P < 0.001). The HD-to-PD reimbursement ratio was higher in countries with the highest tertile of GDP (0.7, 1.0 versus 1.7; P = 0.007). Home HD was mainly reimbursed in countries with the highest tertile of GDP (15, 15 versus 69%; P = 0.005). The percentage of public health expenditure for reimbursement of dialysis decreased across tertiles of GDP (3.3, 1.5, 0.7%; P < 0.001). Transplantation as a proportion of all KRT increased across tertiles of GDP (18.5, 39.5, 56.0%; P < 0.001). CONCLUSIONS: In Europe, dialysis has a disproportionately high impact on public health expenditure, especially in countries with a lower GDP. In these countries, the cost difference between PD and HD is smaller, and home dialysis and transplantation are less frequently provided than in countries with a higher GDP. In-depth evaluation and analysis of influential economic and political measures are needed to steer optimized reimbursement strategies for KRT.

What Do Doctors Think About Value-Based Healthcare? A Survey of Practicing Physicians in a Private Healthcare Provider in Brazil.

OBJECTIVES: As health systems start to discuss alternative payment models for fostering value in healthcare, there is increased interest in understanding how physicians will cope with different remuneration schemes. We conducted a survey of physicians practicing at Hospital Israelita Albert Einstein, a nonprofit private healthcare provider in Brazil, aimed at capturing their awareness of value-based healthcare (VBHC). METHODS: Our study uses data from a survey administered to doctors practicing at Einstein between September and November 2018. Descriptive statistics and adjusted multivariate logistic regression analyses were used to describe physicians' characteristics associated with their views on VBHC. RESULTS: A total of 1000 physicians completed the survey (response rate: 13%). Although only 25% knew the value equation, 67% defined value in health according to Porter's-the outcomes that matter to patients in relation to the costs of offering such outcomes. Most participants identified increased healthcare costs as the main reason for the discussions over new financing models. Only 27% of physicians rated their awareness of VBHC as high or very high. In the multivariate analysis, awareness of VBHC was associated with holding a management position, scoring high in the hospital's physician segmentation program, being familiar with the value equation, and attributing high importance to developing new VBHC financing models for health system transformation. CONCLUSIONS: Physician awareness of key VBHC concepts is still heterogeneous in our clinical setting. Promoting opportunities for involving physicians in the discussion of VBHC is key for a successful value-driven transformation of healthcare.

Work Relative Value Units Do Not Adequately Support the Burden of Infection Management in Revision Knee Arthroplasty.

BACKGROUND: Revision total knee arthroplasty for infection is challenging. Septic revisions, whether 1-stage or 2-stage, may require more time and effort than comparable aseptic revisions. However, the burden of infection may not be reflected by the relative value units (RVUs) assigned to septic revision compared with aseptic revision. The purposes of this study were to compare the RVUs of aseptic and septic revision total knee arthroplasties and to calculate the RVU per minute for work effort. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was analyzed for the years 2006 to 2017. The Current Procedural Terminology (CPT) code 27487 and the International Classification of Diseases, Ninth Revision (ICD-9) code 996.XX, excluding 996.6X, were used to identify all aseptic revision total knee arthroplasties (n = 12,907). The CPT code 27487 and the ICD-9 code 996.6X were used to determine all 1-stage septic revision total knee arthroplasties (n = 891). The CPT codes 27488 and 11981 were used to identify the first stage of a 2-stage revision (n = 293). The CPT codes 27447 and 11982 were used to identify the second stage of a 2-stage revision (n = 279). After 4:1 propensity score matching, 274 cases were identified per septic cohort (aseptic single-stage: n = 1,096). The RVU-to-dollar conversion factor was provided by the U.S. Centers for Medicare & Medicaid Services (CMS), and RVU dollar valuations were calculated. RESULTS: The septic second-stage revision was used as the control group for comparisons. The RVU per minute for the aseptic 2-component revision was 0.215, from a mean operative time of 148.95 minutes. The RVU per minute for the septic, 2-component, 1-stage revision was 0.199, from a mean operative time of 160.6 minutes. For septic, 2-stage revisions, the first-stage RVU per minute was 0.157, from a mean operative time of 138.1 minutes. The second-stage RVU per minute was 0.144, from a mean operative time of 170.0 minutes. Two-component aseptic revision total knee arthroplasty was valued the highest. CONCLUSIONS: Despite the increased complexity and worse postoperative outcomes associated with revision total knee arthroplasties for infection, the current physician reimbursement does not account for these challenges. This inadequate compensation may discourage providers from performing these operations and, in turn, make it more difficult for patients with periprosthetic joint infection to receive the necessary treatment. Therefore, the CPT code revaluation may be warranted for these procedures.

Inpatient teledermatology: Current state and practice gaps.

BACKGROUND: Inpatient dermatology care can be challenging for dermatologists. Currently teledermatology is widely used in the outpatient setting but is not common in the inpatient setting, although it has the potential to reduce wait times and improve access to care. OBJECTIVE: To review the available literature on inpatient teledermatology, assess how teledermatology is currently being used in the inpatient setting, and recommend best practice use of inpatient teledermatology. METHODS: A literature review was performed and dermatology attending physicians were surveyed at the Society for Dermatology Hospitalists annual meeting about their current use of inpatient teledermatology. RESULTS: The majority of attending physicians (80.8%, n = 21/26) responded that their institution uses some form of teledermatology. Approximately half of those using teledermatology used it for both inpatient and outpatient consultations (55%, n = 11/20). For institutions with inpatient teledermatology, attending physicians used teledermatology to remotely staff inpatient consultations (81.8%, n = 9/11), triage consultations (63.6%, n = 7/11), and answer curbside questions from primary teams (18.2%, n = 2/11). LIMITATIONS: The limitations of this study include a limited sample size from a single meeting. CONCLUSION: Inpatient teledermatology is currently under-utilized has the potential to increase access to dermatology care and may be best used for triaging and remote staffing. Additionally, standardization of platforms and reimbursement would allow for increased use of inpatient teledermatology.

Use of Reimbursed Psychology Videoconference Services in Australia: An Investigation Using Administrative Data.

BACKGROUND: In November 2017, the Australian government approved reimbursement for psychology consultations conducted by videoconference under the Better Access initiative to address inequitable access of mental health services across regions in Australia. OBJECTIVE: This project uses publically available activity data from the Medicare Benefits Scheme to quantify the uptake of videoconference for psychology resulting from the initiative change. METHODS: Data were extracted from the Medicare Benefits Schedule item reports using the item codes for standard consultations and the new item codes for videoconference consultations. Activity data from 2 years before and the first year of the change to the Better Access initiative were compared to examine the uptake of videoconference for psychology. Data were stratified by allied health profession, sex, age and state jurisdiction. RESULTS: In the 1-year period after the introduction of reimbursed videoconference consultations, approximately 5.7 million in-person consultations and 4141 videoconference consultations were funded by Medicare in Australia. Videoconference consultations comprised 0.07% of the total consultations performed in that 1-year period and showed an increased trajectory. The results can guide future research into evaluating the clinical outcomes of patients via both in-person and videoconference delivery modes. CONCLUSIONS: Videoconference mental health services were used in the first year that they were available, although they only accounted for a small percentage of all mental health consultations provided by allied health professionals. This finding lays the foundation for future work which could examine the effectiveness of the scheme in reducing inequity and investigating the economic benefits of the expanded initiative to the government and society.

Practice Variation in Vena Cava Filter Use Among Trauma Centers in the National Trauma Database.

BACKGROUND: Agreement regarding indications for vena cava filter (VCF) utilization in trauma patients has been in flux since the filter's introduction. As VCF technology and practice guidelines have evolved, the use of VCF in trauma patients has changed. This study examines variation in VCF placement among trauma centers. MATERIALS AND METHODS: A retrospective study was performed using data from the National Trauma Data Bank (2005-2014). Trauma centers were grouped according to whether they placed VCFs during the study period (VCF+/VCF-). A multivariable probit regression model was fit to predict the number of VCFs used among the VCF+ centers (the expected [E] number of VCF per center). The ratio of observed VCF placement (O) to expected VCFs (O:E) was computed and rank ordered to compare interfacility practice variation. RESULTS: In total, 65,482 VCFs were placed by 448 centers. Twenty centers (4.3%) placed no VCFs. The greatest predictors of VCF placement were deep vein thrombosis, spinal cord paralysis, and major procedure. The strongest negative predictor of VCF placement was admission during the year 2014. Among the VCF+ centers, O:E varied by nearly 500%. One hundred fifty centers had an O:E greater than one. One hundred sixty-nine centers had an O:E less than one. CONCLUSIONS: Substantial variation in practice is present in VCF placement. This variation cannot be explained only by the characteristics of the patients treated at these centers but could be also due to conflicting guidelines, changing evidence, decreasing reimbursement rates, or the culture of trauma centers.

The implementation of HTA in medicine pricing and reimbursement policies in Indonesia: Insights from multiple stakeholders.

OBJECTIVES: This study aimed to identify the barriers and facilitators to improve the use of health technology assessment (HTA) for the selection of medicines listed in the e-Catalogue and the national formulary in Indonesia. METHODS: Semi-structured interviews were conducted to collect qualitative data. Purposive sampling was used to recruit the stakeholders consisting of policymakers, a pharmaceutical industry representative, healthcare providers, and patients. The data were analyzed using directed content analysis and following the COnsolidated criteria for REporting Qualitative studies (COREQ). RESULTS: The twenty-five participants interviewed agreed with the use of HTA for supporting the e-Catalogue and the national formulary and perceived the advantages of HTA implementation outweighed the disadvantages. Barriers mentioned were a lack of capability of local human resources, financial incentives, a clear framework and insufficient data. Strategies suggested to overcome the barriers were establishing (inter)national networks to build up capacity, setting up departments of HTA in several universities in Indonesia, and introducing a clear HTA framework. Facilitators mentioned were the ambition to achieve universal health coverage, the presence of legal frameworks to implement HTA in the e-Catalogue and the national formulary, and the demands for appropriate medicine policies. CONCLUSIONS: Several barriers are currently hampering broad implementation of HTA in medicine pricing and reimbursement policy in Indonesia. Solutions to these issues appear feasible and important facilitators exist.

Use of Advance Care Planning Billing Codes in a Tertiary Care Center Setting.

INTRODUCTION: The Centers for Medicare and Medicaid Services released the final payment rules for reimbursement of advance care planning (ACP) effective January 2016. In its first year, 23,000 providers nationwide submitted 624,000 claims using the Current Procedural Terminology codes 99497 and 99498. The objectives of our study were to 1) assess the frequency of ACP codes used at a single academic tertiary care center in Iowa, 2) determine when and by whom the codes were used, and 3) summarize ACP clinical notes. METHODS: Using the electronic medical record data warehouse from a single tertiary teaching hospital and affiliated clinics, date of service, department where service was provided, provider name and type, patient medical record number, date of birth, and gender linked to the ACP codes 99497 and 99498 were collected. The content of ACP clinical notes were reviewed and summarized. Study period was from January 1, 2016 through September 19, 2018. RESULTS: During the 33 months, code 99497 was used 17 times and code 99498 was never used. Code 99497 was successfully reimbursed 4 times. DISCUSSION: Charges were not reimbursed if the ACP visits did not meet the minimum time requirement or were conducted by an individual not considered a qualified health care professional per Medicare rules. CONCLUSION: ACP codes 99497 and 99498 were very rarely used at this tertiary care center during the initial 33-months after the Medicare rules went into effect. Interventions are needed to promote the use of ACP codes, so the time spent in important ACP discussions are properly compensated.

Association of the Mandatory Medicare Bundled Payment With Joint Replacement Outcomes in Hospitals With Disadvantaged Patients.

Importance: Medicare's Comprehensive Care for Joint Replacement (CJR) model rewards or penalizes hospitals on the basis of meeting spending benchmarks that do not account for patients' preexisting social and medical complexity or high expenses associated with serving disadvantaged populations such as dual-eligible patients (ie, those enrolled in both Medicare and Medicaid). The CJR model may have different implications for hospitals serving a high percentage of dual-eligible patients (termed high-dual) and hospitals serving a low percentage of dual-eligible patients (termed low-dual). Objective: To examine changes associated with the CJR model among high-dual or low-dual hospitals in 2016 to 2017. Design, Setting, and Participants: This cohort study comprised 3 analyses of high-dual or low-dual hospitals (n = 1165) serving patients with hip or knee joint replacements (n = 768 224) in 67 treatment metropolitan statistical areas (MSAs) selected for CJR participation and 103 control MSAs. The study used Medicare claims data and public reports from 2012 to 2017. Data analysis was conducted from February 1, 2019, to August 31, 2019. Exposures: The CJR model holds participating hospitals accountable for the spending and quality of care during care episodes for patients with hip or knee joint replacement, including hospitalization and 90 days after discharge. Main Outcomes and Measures: The primary outcomes were total episode spending, discharge to institutional postacute care facility, and readmission within the 90-day postdischarge period; bonus and penalty payments for each hospital; and reductions in per-episode spending required to receive a bonus for each hospital. Results: In total, 1165 hospitals (291 high-dual and 874 low-dual) and 768 224 patients with joint replacement (494 013 women [64.3%]; mean [SD] age, 76 [7] years) were included. An episode-level triple-difference analysis indicated that total spending under the CJR model decreased at high-dual hospitals (by $851; 95% CI, -$1556 to -$146; P = .02) and low-dual hospitals (by $567; 95% CI, -$933 to -$202; P = .003). The size of decreases did not differ between the 2 groups (difference, -$284; 95% CI, -$981 to $413; P = .42). Discharge to institutional postacute care settings and readmission did not change among both hospital groups. High-dual hospitals were less likely to receive a bonus compared with low-dual hospitals (40.3% vs 59.1% in 2016; 56.9% vs 76.0% in 2017). To receive a bonus, high-dual hospitals would be required to reduce spending by $887 to $2231 per episode, compared with only $89 to $215 for low-dual hospitals. Conclusions and Relevance: The study found that high- and low-dual hospitals made changes in care after CJR implementation, and the magnitude of these changes did not differ between the 2 groups. However, high-dual hospitals were less likely to receive a bonus for spending cuts. Spending benchmarks for CJR would require high-dual hospitals to reduce spending more substantially to receive a financial incentive.