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Background Bounceback policies for readmitted patients are commonly used by hospitals in the U.S., but to date there have been no studies of their impact on patient care or outcomes. In July 2011, a large, tertiary-care, academic medical center introduced a stronger bounceback policy for readmitted patients cared for by the resident service. The primary objective of this study was to determine the impact of the policy on readmission rates, length of stay (LOS), and LOS index. The secondary objective was to assess the effect of time within clinical rotations on the same outcomes. Methods This retrospective cohort study included patients admitted to the resident and hospitalist medicine services from 6/15/09 to 6/16/13. Total number of hospitalizations analyzed was 66,118. Measures included 30-day readmission rates, LOS, and adjusted LOS index. Covariates included time within clinical rotation and patient-level characteristics. The hospitalist service was used as a control group. Results After the policy was implemented, the resident service had an 8% lower relative risk ratio of 30-day readmission compared to the hospitalist service (p =.05). There was no significant different in LOS or LOS index. LOS for patients on the resident service exhibited a weekly pattern, with LOS lowest on Mondays and increasing throughout the week. Conclusions A stronger bounceback policy resulted in a small decrease in 30-day readmission rates without increasing LOS. Implications Bounceback policies may be an effective and low-cost tool to reduce readmissions by leveraging non-financial incentives to change physicians’ behavior.

Heidi A. Krantz, RN, BSN is the Director of Value Analysis at Johns Hopkins Bayview Medical Center in the Johns Hopkins Health System. Barbara Strain, MA, CVAHP is the Director of Value Management at the University of Virginia Health System. Jane Torzewski RN, MAN, MBA is a Senior Category Manager for the Mayo Clinic Physician Preference Contracting team. She previously was a Senior Clinical Value Analyst on the Mayo Clinic Value Analysis team.

Endobronchial ultrasonography (EBUS) has become an invaluable tool in the diagnosis of patients with a variety of thoracic abnormalities. The majority of EBUS procedures are used to diagnose and stage mediastinal and hilar abnormalities, as well as peripheral pulmonary targets, with a probe-based technology. Nearly 1,000 articles have been written about its use and utility. New Current Procedural Terminology (CPT) codes have been introduced in 2016 to better capture the work and clinical use associated with the various types of EBUS procedures. The existing 31620 code has been deleted and replaced by three new codes: 31652, 31653, and 31654. These new codes have been through the valuation process, and the new rule for reimbursement has been active since January 1, 2016 with National Correct Coding Initiative correction as of April 1, 2016. The impact of these new codes will result in a net reduction in professional and technical reimbursement. This article describes the current use of EBUS and explains the current codes and professional reimbursement.

Resume Objectif de l’etude L’irradiation du sein apres tumorectomie est le standard pour le cancer du sein invasif. Des etudes randomisees montrent que la radiotherapie hypofractionnee est equivalente chez des patients selectionnes. Cette etude s’est interessee a l’evolution des pratiques dans un centre de lutte contre le cancer et analyse son impact economique. Materiel et methode Toutes les prescriptions pour cancer du sein invasif entre janvier 2010 et juin 2014 ont ete analysees. Les patientes d’au moins 60 ans, atteintes de cancer classe pN0, n’ayant pas ete irradiees dans les aires ganglionnaires, sans indication de boost, ont ete incluses dans l’etude economique. L’etude des pratiques a exclu celles incluses dans des essais cliniques, ou atteintes de tumeur de haut grade. Le cout des transports a ete estime grâce aux donnees de la Caisse primaire d’assurance maladie (CPAM) Resultats Deux mille trente et une patientes ont recu un traitement, 399 etaient eligibles pour l’etude economique (20 %) et 282 pour celle des pratiques (14 %). La proportion de traitement en 25 fractions a diminue de 90 % a 16 % au premier semestre 2014. A contrario, les traitements en 15 ou 16 fractions ont augmente de 6 % en 2010 a 68 % debut 2014. La proportion de traitements hypofractionnes est passee de 100 % de 42,5 Gy en 16 seances en 2010 a 100 % de 40 Gy en 15 seances en 2014, s’adaptant a l’actualisation des essais Standardisation of Breast Radiotherapy (START) britanniques. Le traitement en cinq seances etait stable autour de 7 % (4 a 16 %), reserve pour les patientes de plus de 80 ans (p Conclusion L’hypofractionnement peut concerner environ 20 % des patients. Cela permettrait de diminuer l’investissement personnel du patient dans son traitement et d’epargner 2327 € par traitement pour la societe.

Objectives Belgium, and especially the northern region called Flanders, has been a centre of expertise in cochlear implants and early hearing screening for many years. Cochlear implants are reimbursed by the Belgian National Institute for Health and Disability (BNIHD) Insurance in adults and in children since October 1994. More than 20 years later, we would like to measure the prevalence of cochlear implants in adults and in children till now. Materials and methods Based on scientific research data on the prevalence of severe to profound hearing loss in adults and in children and on the number of implantations from the data of the BNIHD, we could measure the percentages of paediatric and adult CI users in comparing to the number of CI candidates. Results The degree of utilisation of cochlear implantation varies considerably between the paediatric and the adult population. On average, 78% of deaf children are receiving cochlear implants, but in adults only 6.6% of CI candidates are receiving one. Conclusion There are big differences in Belgium in utilisation of cochlear implants between adults and children. Because of the underutilisation of cochlear implants, especially in adults, we have to work on raising the general awareness of the benefits of cochlear implants, and its improvement in quality of life, based on cost-effectiveness data and on guidelines for good clinical practice.

La Presse Medicale - In Press.Proof corrected by the author Available online since samedi 15 avril 2017

OBJECTIVES: Nutritional services are a critical component of cancer care, yet Registered Dietitian Nutritionist (RDN) staffing patterns in outpatient cancer centers are poorly documented. The objective of this study was to inform availability of nutrition services by examining RDN staffing and utilization in outpatient cancer centers nationwide. METHODS: An online questionnaire was developed and approved by the Oncology Nutrition Dietetic Practice Group (a practice group of the Academy of Nutrition and Dietetics) and The Ohio State University Institutional Review Board. The deidentified survey was intended for RDNs who practice at outpatient oncology centers and distributed via Academy email in fall 2017. To avoid duplication, each respondent was prompted to submit one survey per center. Annual analytic cases, representing unique new patients diagnosed and treated at each center, were collected. Data on RDN staffing patterns, reimbursement for services, and malnutrition screening practices were analyzed. RESULTS: Over one year, 310 surveys were submitted and 206 provided usable data. Of those, 82% of the centers reported at least one dedicated RDN on staff with an average of 1.7 RDN full-time equivalents. The mean annual analytic cases reported were 2043, representing a RDN-to-patient ratio of 1:1202. During this time, RDNs evaluated an average of 7.5 patients per day, yet 48% of centers did not bill for nutrition services. Over half (54%) of the participating facilities screened for malnutrition using a validated or adapted screening tool, such as the Malnutrition Screening Tool. CONCLUSIONS: This is the first comprehensive, national study to inform nutrition care provider-to-patient ratio in cancer centers which have at least one dedicated RDN. Screening for malnutrition and billing for nutritional evaluations were not widely practiced in the participating facilities. Our findings indicate that the majority of cancer centers nationally are providing inadequate RDN coverage and have low utilization of nutrition services. FUNDING SOURCES: N/A.

Surgical resection is currently the gold standard in operable patients with early-stage lung cancer. Video-assisted thoracoscopic surgery (VATS) lobectomy is a technique that has technically evolved and grown increasingly popular over the past two decades. This article presents the evolution, definition, current application, and some of the controversies surrounding VATS lobectomy.

The key to improving ambulatory endoscopy center (AEC) performance revolves around implementing certain key activities while at the same time consistently measuring and reporting specific mission-critical metrics throughout the organization. Although many of these key activities could be described as “business fundamentals,” the impact of health care reform will be driven home within the AEC environment as reimbursement transforms from the purely fee-for-service model to other alternate reimbursement arrangements. Although other contributions to this issue focus on potential future reimbursement models in more detail, a focus on quality and cost-effectiveness is a common theme in most potential new reimbursement mechanisms. In the historical AEC environment, procedural volume has always been King; his Queen is room utilization. These factors are undoubtedly the two key drivers of performance within the center today and will remain so in the future. However, all kingdoms need their knights of the round table and this article focuses on those elements that assist in driving financial, operational, and clinical performance. These same elements will prove critical in tomorrow's AEC reimbursement environment that transforms as the result of various health care reform initiatives.

Recent decades have witnessed striking growth in the number of older adults both in the United States and throughout much of the world, largely due to improved public health, nutrition, and medical care. Between 2000 and 2030, the proportion of the world's population age 65 years and older is

Although innovation marches forward and places new therapeutic options at our doorsteps, the regulatory and payer environment must be considered if any of these new opportunities will be available in the clinical mainstream. Endolumenal treatment of bariatric disease will face many of the same challenges as those the endolumenal treatment of gastroesophageal reflux has faced over the last decade. In an era of shrinking health care dollars, the challenge of reimbursement will be significant. Strategies for the implementation of endolumenal therapies for the treatment of obesity must include a data-driven approach that addresses not only regulatory but also financial concerns to be successful.

rn a , the This new imum 07 ttles elinrers sitive c r of o b ical a entifi ll of o e s for t ral ( comp we d view t spect Medic the r mat summ volu for t all s are s this s tor w onth p This r sion p tal P his c for t n is a ount, a the q units s o by w ur industry has seen changes in the way w business. First, we faced the paramou change in the manner of payment for che herapy and adjunct drugs under the Medicare syst or years, Medicare reimbursed on an average wh ale price (AWP) payment methodology. The dr ere adjudicated at a certain percentage of AWP; h ver, we saw the percentage incrementally decre hrough the years. Then the hammer was evo edicare, after their General Accounting Office (GA ndings of wide discrepancies in the cost of acqu rugs relative to the payment physicians were rec ng, decided to develop what we know as AS 6 Average Sales Price). This is important to rehash ause subsequent to the restructuring of the drug ent changes, it prompted our practices to analyze mpact to our bottom lines. In addition, it cre remendous concerns on how effective care for can atients would be sought. The voice of our indu as partially heard. Medicare decided to create a ad of additional CPT codes for the administratio hemotherapy and therapeutic/prophylactic/diagnos ic procedures. This was to accurately reimburse he “complexities” associated with certain administ ions, as well as the adverse effects and the onsumption in the delivery and preparation for a ient. In the field, we were left with the dubious t oding these new procedures accurately. To further complicate matters, we needed to lea emporary set of G-Codes for 2005. Then, in 2006 MA published standard CPT codes for use. rompted us to insure that all the applicable staff k ow to use and apply the new codes so that max eimbursement could be captured. Fortunately, 20 aw fewer changes; however, we still face uphill ba very day with regards to understanding coding d ations not only for Medicare, but for private insu s well. Moreover, once we think we are in po

Objectives: Pricing polices used in many countries are often viewed in the United States as a mechanism of price constraint. Support for this contention has arisen from pricing studies which demonstrate that the United States pays higher prices for many pharmaceutical products. No study to date, however, has examined the prices paid for pharmaceuticals that provide significant health gain, which might be expected to be lower where price constraints were operating. This study aimed to examine prices paid by federal government programs and agencies in Australia and the United States for pharmaceutical products that provide significant health gain. Methods: Products identified by the US Food and Drug Administration and the Canadian Patented Medicines Prices Review Board as likely to confer significant health gains between 1999 and 2004 were identified. Australian and US federal government prices ($US) and US average manufacturer prices (AMP), which do not include discounts or rebates, during the second quarter of 2006 were compared. Results: Of 22 products for which comparisons were possible, Australian prices were higher than the US Federal Supply Schedule (FSS) prices for 14 (64%) products. When compared with AMP, Australian prices were higher for eight of the 22 products. Overall, Australian prices were higher on average by 4.2% when compared with the FSS and lower by 14.4% when compared with the AMP. Conclusion: These results suggest that Australian prices for medicines representing significant advances in therapy are similar to those paid under key US programs despite fundamental differences in policy contexts.

Restrictive reimbursement mechanisms are leading larger numbers of specialty patients to primary care practices for routine monitoring and management. Thus, primary care providers are often required to expand the skills they have in treating problems such as seizures. Based on expert experience, this article presents a simple approach to sorting out the questions that the provider must answer in caring for the patient with seizures.

Regulatory and reimbursement authorities face uncertain choices when considering the adoption of health-care technologies. In this Viewpoint, we present an analytic framework that separates the issue of whether a technology should be adopted on the basis of existing evidence from whether more research should be demanded to support future decisions. We show the application of this framework to the assessment of heath-care technologies using a published analysis of a new drug treatment for Alzheimer's disease. The results of the analysis show that the amount and type of evidence required to support the adoption of a health technology will differ substantially between technologies with different characteristics. Additionally, the analysis can be used to aid the efficient design of research. We discuss the implications of adoption of this new framework for regulatory and reimbursement decisions.

Although most health care professionals would wish it otherwise, documentation will never be eliminated completely. It can be ignored and complained about, but documentation will always be there to remind us, “If it wasn't documented, it wasn't done.” Home care providers need to be cognizant of the imperative for effective documentation. Corporate compliance initiatives, fraud and abuse issues, and changes in reimbursement mechanisms make documentation more important than ever. Home care providers must create an environment conducive to effective documentation practices.

Contractual relations encompass the contractual terms within a governing relationship; typically this comprises: the relationship, the risk apportionment, the division of responsibilities and the reimbursement mechanism. In the Western construction industry these have traditionally surrounded arms-length/adversarial discrete contracts. Recent moves to foster collaboration have confused the ‘end’ with the ‘means’ and thus will not maximize the business objectives. This article considers a range of ‘fit-for-purpose’ contractual relations which, when appropriate, can be linked with positive measures to foster collaboration. Consequently this effects the risks and responsibilities prescribed in the contract which, when appropriately aligned, will ensure business success.

Bulgaria is in the process of re-structuring its health care system from one based on command and control to one founded on pluralism. This paper explores the way this transformation is taking place from the comparative perspective of the health care reforms being implemented in Britain and elsewhere. It draws out the lessons that there may be for Bulgaria based on western European experience and concludes with an assessment of the applicability and desirability of relying on the experience of other countries as a precursor for policy development and formulation in another.

In this paper, the radiotherapy reimbursement systems actually used in the EU countries are compared. From this overview, it is concluded that up to date health care policy makers have not yet tapped all opportunities to encourage efficient, accessible radiotherapy delivery of high quality, through the reimbursement system. Therefore, some recommendations are given on how the reimbursement system can be designed in order to promote efficiency, accessibility and/or quality.