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Objectives The criteria for the reimbursement of fluoroquinolones changed in Belgium on 1 May 2018. This study aims to quantify the difference in fluoroquinolone use after this change, and to assess the timing and persistence of this effect, both in terms of total reimbursed fluoroquinolone use and its relative proportion. Methods Longitudinal reimbursement data on fluoroquinolone use in the Belgian community from January 2017 to November 2018 were analysed to identify a change in reimbursed fluoroquinolone use expressed in DDD per 1000 inhabitants per day (DID), using a set of non-linear mixed models including change-points. In addition, longitudinal data on the relative proportion of prescribed fluoroquinolones from January 2017 to December 2018 were analysed to identify a change in the relative proportion of prescribed fluoroquinolones using generalized estimation equations including change-points. Results Fluoroquinolone use dropped significantly immediately after the change in reimbursement criteria, from 2.21 DID (95% CI: 2.03–2.38) to 0.52 DID (95% CI: 0.48–0.56) and from 9.14% (95% CI: 8.75%–9.56%) to 6.52% (95% CI: 6.04%–7.04%). The observed decrease in fluoroquinolone use persisted over time. Conclusions While fluoroquinolone use was still above the target of 5% after the change in reimbursement criteria, its implementation helped to lower fluoroquinolone use in Belgium.

A Hidden Opportunity Coverage of the “routine costs” associated with clinical trial participation will soon be guaranteed for Medicaid beneficiaries for the first time, which could help reduce ineq...

Background Studies of medical conditions in the Bundled Payments for Care Improvement (BPCI) initiative did not show reductions in Medicare payments for the majority of conditions, but this could mask heterogeneity. Objective To determine whether earlier enrollment and/or longer participation in BPCI were associated with performance. Design We divided BPCI hospitals into wave 1 (joined 10/1/13, 1/1/14, or 4/1/14), wave 2 (joined 7/1/14, 10/1/14, 1/1/15, or 4/1/15), and wave 3 (joined 7/1/15, 10/1/15, or 1/1/16) and compared changes in Medicare payments for acute myocardial infarction, heart failure, pneumonia, sepsis, and chronic obstructive pulmonary disease between BPCI and matched controls in 6-month increments. Subjects US hospitals. Measures Medicare payments. Results There were 120 hospital-condition pairs in wave 1, 264 in wave 2, and 300 in wave 3. Wave 1 hospitals had similar savings to controls early in the program (0-6 mo difference in differences -$10, P=0.976; 6-12 mo +$295, P=0.441; 12-18 mo -$540, P=0.218; 18-24 mo -$485, P=0.259) but had greater savings than controls at 24-30 months (difference in differences -$663, P=0.035). Wave 2 (0-6 mo +$193, P=0.524; 6-12 mo -$183, P=0.489; 12-18 mo -$162, P=0.618) and wave 3 hospitals (0-6 mo +$79, P=0.753; 6-12 mo -$32, P=0.876) did not achieve significant savings at any time interval. There were no differential changes in patient outcomes over time. Conclusions Hospitals that joined BPCI earliest began to achieve savings at roughly 2 years of participation. These findings have implications for this and other alternative payment models.

Introduction: The purpose of this systematic review was investigating the implementation outcomes of the diagnosis-related groups. Methods: In this study, articles evaluating the effect of DRG impl...

Aims The aim of this study was to analyze the true costs associated with preoperative CT scans performed for robotic-assisted total knee arthroplasty (RATKA) planning and to determine the value of a formal radiologist’s report of these studies. Methods We reviewed 194 CT reports of 176 sequential patients who underwent primary RATKA by a single surgeon at a suburban teaching hospital. CT radiology reports were reviewed for the presence of incidental findings that might change the management of the patient. Payments for the scans, including the technical and professional components, for 330 patients at two hospitals were also recorded and compared. Results There were 82 incidental findings in 61 CT studies, one of which led to a recommendation for additional testing. Across both institutions, the mean total payment for a preoperative scan was $446 ($8 to $3,870). The mean patient payment was $71 ($0 to $2,690). There was wide variation in payments between the institutions. In Institution A, the mean total payment was $258 ($168 to $264), with a mean patient payment of $57 ($0 to $100). The mean technical payment in this institution was $211 ($8 to $856), while the mean professional payment was $48 ($0 to $66). In Institution B, the mean total payment was $636 ($37 to $3,870), with a mean patient payment of $85 ($0 to $2,690). Conclusion The total cost of a CT scan is low and a minimal part of the overall cost of the RATKA. No incidental findings identified on imaging led to a change in management, suggesting that the professional component could be eliminated to reduce costs. Further studies need to take into account the patient perspective and the wide variation in total costs and patient payments across institutions and insurances. Cite this article: Bone Joint J 2020;102-B(6 Supple A):79–84.

Zusammenfassung Hintergrund Die pädiatrisch-onkologische Versorgungsstruktur nimmt in Deutschland eine Sonderrolle ein. An Krebs erkrankte Kinder und Jugendliche werden bundesweit einheitlich in Therapiestudien und Registern sektorenübergreifend an Zentren behandelt, die eine interdisziplinäre und multiprofessionelle Versorgung sicherstellen können. Für die Abrechnung der nicht-vollstationären Leistungen verwenden die Zentren heterogene Abrechnungsmodalitäten, die den erforderlichen Versorgungsaufwand monetär überwiegend nicht decken. Methode Es wurde deutschlandweit eine Umfrage aller Zentren der Gesellschaft für Pädiatrische Hämatologie und Onkologie (GPOH) durchgeführt. In der Umfrage wurde standardisiert abgefragt, über welche Versorgungsarten der nicht-vollstationäre Bereich in der Kinderonkologie finanziert wird und ob eine Kostendeckung erreicht werden kann. Ergebnisse Von 58 kinderonkologischen Zentren beteiligten sich insgesamt 18 (33%) an der Umfrage, darunter 8 (44%) Universitätsklinika. Die Inanspruchnahme verfügbarer Abrechnungsarten erwies sich als sehr heterogen. Im Mittel werden 3,33±1,49 Abrechnungsarten pro Zentrum angewandt. 17 der 18 teilnehmenden Zentren gaben an, mit den Erlösen die Kosten für die nicht-vollstationäre Versorgung nicht decken zu können. Diskussion und Schlussfolgerung Kinderonkologische Zentren in Deutschland können eine kostendeckende Versorgung im nicht-vollstationären Setting nicht erreichen. Für die nicht-vollstationäre Versorgung an Krebs erkrankter Kinder und Jugendlicher wird eine bundeseinheitliche und leistungsgerechte Versorgungsform dringend benötigt. Drei verschiedene Modelle, die einen adäquaten Handlungsrahmen bieten, wurden erarbeitet und vorgestellt.

Work-related musculoskeletal disorders (WRMSDs) are a costly problem within the sonography profession, affecting health care organization bottom lines, sonographer satisfaction, and the patient experience. There is limited evidence regarding the limits of exposure to sonography examinations that would reduce on-the-job injury. This case study demonstrates the use of examination schedules that incorporate demand, length and difficulty level of examinations, staffing resources, and equipment availability, which may help to determine appropriate or maximum workloads for sonographers within their respective workplace. Developing a culture of prevention is a critical and cost-effective component of reducing WRMSDs.

The purpose of this study is to evaluate monetary trends from 2000 to 2018 in Medicare reimbursement rates for the most common general surgery procedures.A complete understanding of financial trends in general surgery in the United States is lacking. As such, an evaluation of trends in reimbursement rates in general surgery is important for defining the specialty's current and future financial health.The Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services was queried for each of the 20 top codes top in general surgery. The total raw percent change in Medicare reimbursement rate for each procedure from 2000 to 2018 was calculated and averaged. All data was corrected for inflation. Both average annual and total percentage change were calculated based on these adjusted trends. Compound annual growth rate was calculated using the adjusted data.After adjusting all data for inflation, the reimbursement rate for all included procedures decreased by an average of 24.4% throughout the study period. During this time, the adjusted reimbursement rate decreased by an average of 1.4% each year with an average compound annual growth rate of -1.6%.After adjusting for inflation, Medicare reimbursement rates in general surgery have steadily decreased from 2000 to 2018. It is important that these trends are understood and considered by surgeons, healthcare administrators, and policy-makers in order to develop and implement agreeable models of reimbursement while ensuring access to quality general surgery care in the United States.

Background GEMINI trials and real-world studies in Western population have demonstrated the effectiveness and safety of vedolizumab (VDZ) for IBD. However, long-term real-world evidence of VDZ in Asian populations remains limited. This study aimed to investigate the effectiveness and safety of VDZ in Taiwan CD and UC patients, and the IBD relapse after VDZ discontinuation. Methods Data were prospectively collected (January 2018-May 2020) from the Taiwan Society of IBD (TSIBD) registry, one of the largest real-world Asian IBD cohorts. Patients (>18 years old) receiving ≥1 dose of VDZ with up to a 1-year follow-up period were analyzed. Effectiveness at 6 month and 1 year including clinical response (CRS), clinical remission (CRM), steroid-free remission (SRM) and mucosal healing (MH);and safety outcome were analyzed descriptively. IBD relapse after VDZ treatment discontinuation was assessed since the reimbursement period in Taiwan is limited due to drug holiday required by government. Results A total of 274 patients (CD:127, UC:147) were included. At VDZ initiation, average [SD] age (year): 33.4 [14.6] in CD and 42.4 [14.3] in UC; median disease duration (years): 3.1 in CD and 3.9 in UC; 50.4% of CD and 70.7% of UC patients were biologics (bio)-naïve. Treatment effectiveness was analyzed (Figure 1-4). At 6 months, effectiveness in the CD bio-naïve group was significantly higher than the bio-exposed patients in CRS (67.4% vs 43.9%, p=0.047), CRM (62.8% vs 39.0%, p=0.025), and SRM (43.3% vs 4.3%, p=0.001), respectively. At 1 year, the CD bio-naïve group had higher CRS (82.1% vs 60.7%, p=0.026) than the bio-exposed group. There was no difference in effectiveness between bio-naïve and bio-exposed groups in UC at both 6 months and 1 year. Three patients (1.1%) reported serious infections (respiratory infection, intractable infection with underlying myelodysplastic syndrome and intestinal perforation due to endoscopy) and two (0.7%) had infusion-related reactions. No malignancies or hepatic injuries were reported. After limited treatment up to one year due to reimbursement, 58% (54/93) of patients had IBD relapse (CD: 27 [62.8%], UC: 27 [54%]). After cessation of VDZ, the mean [SD] time to IBD relapse was 5.5 [4.0] months in CD, and 5.8 [5.7] months for UC. Conclusion This study has shown the effectiveness and safety of VDZ therapy for Taiwan IBD patients. Better outcomes were observed in bio-naïve CD patients, whereas bio-naïve and bio-exposed UC patients have comparable outcomes. After a limited VDZ treatment duration, over one-half of patients had IBD relapse, with the majority occurring within 5 months of VDZ discontinuation. These data suggest that continued VDZ therapy would benefit the majority of IBD patients in Taiwan.

IMPORTANCE: Women cardiologists receive lower salaries than men; however, it is unknown whether US Centers for Medicare & Medicaid Services (CMS) reimbursement also differs by gender and contributes to the lower salaries. OBJECTIVE: To determine whether gender differences exist in the reimbursements, charges, and reimbursement per charge from CMS. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional analysis used the CMS database to obtain 2016 reimbursement data for US cardiologists. These included reimbursements to cardiologists, charges submitted, and unique billing codes. Gender differences in reimbursement for evaluation and management and procedural charges from both inpatient and outpatient settings were also assessed. Analysis took place between April 2019 and December 2020. MAIN OUTCOMES AND MEASURES: Outcomes included median CMS payments received and median charges submitted in the inpatient and outpatient settings in 2016. RESULTS: In 2016, 17 524 cardiologists (2312 women [13%] and 15 212 men [87%]) received CMS payments in the inpatient setting, and 16 929 cardiologists (2151 women [13%] and 14 778 men [87%]) received CMS payments in the outpatient setting. Men received higher median payments in the inpatient (median [interquartile range], $62 897 [$30 904-$104 267] vs $45 288 [$21 371-$73 191]; P

This cross-sectional study assesses the use of Medicare's cognitive assessment and care planning codes in the first 2 years of their introduction.

Background In vitro fertilisation (IVF) treatment is one of the most expensive infertility treatments. Cost has been described as a substantial barrier to access. In France all infertility treatments, including IVF, are fully reimbursed, but are there other barriers to access? Methods Based on the French national health insurance database that exhaustively records reimbursed healthcare, this cohort study included all women aged 18–49 years unsuccessfully treated with ovarian induction (first-line infertility treatment) between January–August 2016. Outcome was IVF access within 24 months of starting first-line treatment. Univariate and multivariate regressions explored age, disadvantaged social status, driving time to nearest IVF centre, and deprivation index of area of residence. Results Over 20,000 women unsuccessfully received first-line treatment. Almost 80% did not access IVF within 24 months. After age 34, probability of access decreased. Disadvantaged social status and living in a disadvantaged area were associated with lower probability of accessing IVF. Driving time to the nearest IVF centre was not significantly associated with access. Conclusions Socio-economic barriers to access IVF exist despite full treatment reimbursement in France. To reduce health inequalities, we need to better understand the nature and patterns of these barriers among less socially advantaged people. Key messages After failure of first-line infertility treatment, only 20% of women access IVF although it is fully reimbursed in France. Age, but most importantly socio-economic status, is a key determinant of access to IVF treatment. Distance from nearest IVF centre does not appear significant in explaining access to treatment in France.

Study question What is the probability that patients will receive assisted reproductive technology (ART) treatment based on their out-of-pocket payment and income class? Summary answer Higher-income patients opted for ART even at a higher cost, whereas an out-of-pocket payment was the most influential determinant in all income groups. What is known already Economic disparities affect access to ART treatment in many countries. At the time of this survey, Japan provided partial reimbursement for ART treatment exclusively for those in low- or middle-income classes due to limited governmental budgets. However, the optimal financial support by income class is unknown. Study design, size, duration We conducted a discrete choice experiment (DCE) in Japan in January 2020 including 824 women with fertility problems who were recruited via an online social research panel. Participants/materials, setting, methods Participants included women aged 25–44 years undergoing fertility diagnosis or treatment. They completed a DCE questionnaire including 16 hypothetical scenarios, created by orthogonal design, to measure six relevant ART attributes (pregnancy rate, risk of adverse effects, number of visits to outpatient clinics, consultation hours, kindness of staff, and out-of-pocket expense) and their relation to treatment choice. We used mixed-effect logistic regression models to estimate the probability of receiving ART treatment for each attribute. Main results and the role of chance Of the 1,247 eligible women recruited, 824 completed the survey (66% participation rate). All six attributes significantly influenced treatment preference, with participants valuing out-of-pocket payment the most, followed by pregnancy rates and kindness of staff. The odds ratios of each attribute to receiving ART treatment were 0.58 (95% confidence interval [CI]: 0.57 − 0.59) for out-of-pocket payments per additional 100,000 Japanese yen (JPY; i.e., 800 euros), 1.47 (95% CI: 1.43 − 1.53) for pregnancy rates per additional 5%, and 4.16 (95% CI: 3.73 − 4.64) for kindness of staff, after adjusting for clinical and socioeconomic factors. Significant interactions occurred between high household income (≥8 million JPY) and high out-of-pocket payment (≥500,000 JPY). However, the mean predicted probability of the highest-income patients (i.e., ≥10 million JPY) to receive ART treatment at the average cost without public funding (i.e., 400,000 JPY) was 47% (interquartile range: 18%−76%), whereas that of middle-income patients (i.e., 6–8 million JPY) to receive ART at the average subsidized cost (i.e., 100,000 JPY) was 60% (interquartile range: 33%–88%). Limitations, reasons for caution Other attributes not included in our DCE scenarios might be relevant in real-life settings. Choices made in a DCE would not wholly match the actual treatment choices. Wider implications of the findings: The present DCE suggested that out-of-pocket payment was the primary determinant in patients’ ART decisions. High-income patients were more likely to receive ART treatment even at a high cost, but their ineligibility for government financial support due to their high income might discourage them from receiving treatment. Trial registration number NA

This cross-sectional study compares cost and payer reimbursement for hospital admissions of children and assesses associations of underpayment by patients’ demographic and clinical characteristics.

Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Helsinki and Uusimaa Hospital district Finnish foundation for cardiovascular research Introduction Atrial fibrillation (AF) is a major cause of ischemic stroke. The risk of stroke is strongly associated with age, sex and comorbidities of the patients. Therefore, it is crucial that the comorbidities are consistently recorded in medical records as well as health care registries. Purpose This study aims to evaluate the prevalence of the comorbidities related to AF stroke risk in Finnish nationwide population registries, and assess how the use and combination of these registries affect the calculated CHA2DS2-VASc risk score. The comorbidities evaluated were Hypertension, Diabetes, Stroke or TIA, Heart Failure, and Vascular Disease. Methods The Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study collected data on all Finnish AF patients from 1st January 2004 to 31st December 2018. Due to the initiation of the national primary care register in 2012, this substudy uses the data of patients with a new AF diagnosis during 2012-2018 (n = 168 353). Using a unique personal identification code, individual patient data were linked from the Finnish national health care registries "AvoHILMO" (primary care) and "HILMO" (secondary and tertiary care), National Prescription Register (ATC codes of purchased medication) and the National Reimbursement Register for reimbursed medication upheld by the Social Insurance Institute (KELA). Results The average CHA2DS2-VASc risk score when entering the cohort, and including information from all registries, equaled 2.91 for men (mean age 70.0 years) and 4.42 for women (mean age 76.9 years). The highest prevalence of diabetes and hypertension were found based on the National Reimbursement Register (ATC codes). Stroke or TIA and heart failure were identified almost exclusively based on secondary and tertiary hospital records. The table represents our results. Conclusion Comprehensive registry analysis of AF patients requires the inclusion of both hospital and medication data. The role of primary care information was limited. Comorbidity and CHA2DS2-VASc weight Total Prevalence Primary care ICD-10 codes Primary care ICPC-2 codes Secondary and tertiary care ICD-10 codes ATCcodes Medication reimbursement codes Hypertension 1 82%137 317 28%47 337 13%21 427 39%66 252 77%130 400 7%10 957 Diabetes 1 24%41 017 13%22 666 13%22 547 14%23 793 21%35 942 12%20 295 Stroke or TIA 2 17%28 653 4%6 254 1%1 968 16%27 379 - - Heart Failure 1 18%29 827 5%7 630 1%1 398 16%26 366 - 1%1 908 Vascular Disease1 28%47 420 12%19 581 2%3 265 25%41 647 - 7%11 802 Average CHA2DS2-VASc contribution 1.86 0.65 0.31 1.26 0.99 0.26 The prevalence of the comorbidities and average CHA2DS2-VASc risk score contribution by registry and combined.

Funding Acknowledgements Type of funding sources: None. Introduction Home-based Cardiac Rehabilitation (CR-HB) models have been shown to be effective, however, there is a large variation of protocols and minimal evidence of effectiveness in higher risk populations, in which exercise at distance might be concerning. In addition, lack of reimbursement models has discouraged the widespread adoption of CR-HB. During the coronavirus 2019 (COVID-19) pandemic, an even greater gap in CR care has emerged due to the decreased availability of on-site services. Purpose Evaluation of the safety of a CR-HB program during COVID-19 pandemic. Methods Prospective cohort study which included patients (pts) who were participating in a centre-based CR program and accepted to participate in a CR-HB after the centre-based CR program closure due to COVID-19. The CR-HB consisted in a multidisciplinary digital CR program, including: 1.pts regular clinical and exercise risk assessment; 2.psychological tele-appointments and group sessions; 3. online exercise training sessions, which consisted of recorded videos and real time online exercise training sessions (each session recommended 3 times per week, during 60 minutes); 4.structured online educational program for pts and family members/caregivers, including educational videos and webinars; 5. follow-up fortnightly questionnaire to evaluate risk factors control and need for appointments or directing to hospital; 6. nutrition tele-appointments; 7. physician tele-appointments, scheduled according to follow-up questionnaire or at patients request (e-mail or telephone) to avoid unnecessary exposure and overload in the hospital. Minor and major adverse events such as hospitalizations due to cardiac event or other non CV reason, cardiac or noncardiac death, during or immediately after the exercise sessions, were collected. Results 116 cardiovascular disease (CVD) pts (62.6 ± 8.9 years, 95 males) who were attending a Centre-based CR program were included in a CR-HB program. Almost 90% (n = 103) of the participants had coronary artery disease; 13.8% pts had heart failure. The mean LVEF was 52 ± 11%; 31,1% of the population had at least moderate risk. Regarding risk factors, obesity was the most common risk factor (74.7%) followed by hypertension (59.6%), family history (41.8%), dyslipidaemia (37.9%), diabetes (18.1%), and smoking (12.9%). 98 CVD pts (85.5%) successfully completed all the online assessments. Three male participants dropped out for hospitalization due to knee surgery, pacemaker implantation and in-stent restenosis without relation to exercise sessions. No major events were registered during the exercise training sessions and only one minor adverse event, sprained ankle, was reported during the training sessions. Conclusions This CR-HB program, originated by the need of social distancing during COVID-19 pandemic, revealed to be a valuable and safe strategy to reach at distance most patients previously in a Centre-based CR program.

INTRODUCTION: Telehealth is gaining more attention in multiple specialties, including urology. Video visits in particular have shown high satisfaction and cost-saving for patients. However, there has been little investigation into how video visits compare to traditional clinic visits on measures of clinical efficiency and reimbursement. METHODS: Our dataset included 250 video visits of established patients at Michigan Medicine Department of Urology and 250 in-person clinic visits with the same providers completed between July 2016 and July 2017. Information on visit completion and cancellation rates; cycle time (time from check in to check out); reimbursement; and patient out-of-pocket expenses was collected using the electronic medical record and billing data. RESULTS: Completion rates were similar between video and clinic visits (58% versus 61%, respectively; p=0.24). Average cycle time for video visits was significantly shorter compared to clinic visits (24 min vs 80 min, respectively; p

This cohort study describes recent trends in use and payment rates and in overall expenditure for skin cancer procedures in the Medicare Part B population in the United States.

Background 2019 ESC/EAS dyslipidaemia guidelines recommend a 50% lowering in untreated LDL-C and use of PCSK9 inhibitors (PCSK9i) for patients at very-high cardiovascular (CV) risk when LDL-C target goals of Purpose This observational study describes a cohort of patients initiating evolocumab across 10 EU countries. Methods Patients are followed from evolocumab initiation (baseline). Demographic/clinical characteristics, lipid modifying therapy (LLT) and lipid values were collected from medical records (6 months prior to evolocumab initiation through 30 months post initiation). We report interim data from patients initiating evolocumab from August 2015 with follow-up through October 2019. Results 1896 patients initiated on evolocumab as per local reimbursement criteria were included in this interim analysis (planned sample size: N=2,000). Most (1663 [88%]) had 12 months follow-up, 665 (35%) had 18 months follow-up; mean follow-up, 16.3 months. Mean (SD) age was 60.0 (10.8) years; 85% of patients had a history of CV disease (CVD), 44% had a diagnosis of familial hypercholesterolemia (FH), 19% had type 2 diabetes, 66% were hypertensive, 7% had renal impairment and half (51%) were prior or current smokers. The majority (60%) reported statin intolerance and 42% were not receiving any LLT at evolocumab initiation. Fewer than half (805 [43%]) were receiving a statin (±ezetimibe) at evolocumab initiation; of these, most were on a high/moderate intensity (68%/22%). 12% of patients were receiving statin monotherapy. Median (Q1, Q3) baseline LDL-C was 3.98 (3.16, 5.06) mmol/L. Within 3 months of evolocumab initiation median LDL-C fell by 58% to 1.62 mmol/L. This reduction was maintained over time (Figure). Overall, 58% of patients achieved at least one LDL-C Conclusion In Europe, patients initiated on evolocumab had baseline LDL-C levels almost 3 times higher than the present threshold for PCSK9i use, reflecting local reimbursement criteria. Evolocumab resulted in a more than 50% reduction in LDL-C; however, only approximately half of all patients achieved an LDL-C LDL-C levels after evolocumab initiation Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Amgen

From a smartphone ping signifying the start of a fertile window to controlling a breast pump with a few clicks in a mobile app, “femtech” has readily integrated into women's daily lives. Femtech, a term coined to describe the realm of technology catering to female health needs, encompasses a range of digital technology addressing women's health, including fertility tracking, pregnancy and nursing counseling, and online contraception provision. While femtech puts autonomy and information in the hands of its users, access to the technology is not yet equitably distributed. As insurance reimbursement can increase and equitize that access, this research examines what legal duties exist for increasing access to femtech. In analyzing how insurance schemes have integrated femtech, this research compares how select femtech products fare across reimbursement systems, using fertility algorithm, smart breast pump, and pelvic floor trainer case studies in the U.S, U.K, and Sweden. Insights reveal a duty to promote access to femtech, as well as varying degrees of integration in respective health systems. Insights also reveal which elements of the female life course are overlooked in reimbursement schemes. Key messages Femtech has the power to put agency and information in the hands of millions of women. Yet, access is not equitable given significant financial and regulatory barriers. Comparative studies of fertility algorithms, smart breast pumps, and pelvic floor trainers in international health systems demand increased advocacy to realize the duty to enable femtech access.

Background Financial accessibility to healthcare is a cornerstone in the Belgian health care system. A whole range of financial protectives measures are applied to ensure accessibility to all residents by minimizing the medical costs including a higher reimbursement for vulnerable population groups and protective measures for people with high health expenses due to chronic diseases. This study examines the effectiveness of such protective measures on the use of dental care among a representative sample of Belgian adults. Methods Data from the participants of the Belgian health interview survey (BHIS) 2013 aged 18 years and over were individually linked with data from the Belgian compulsory health insurance data (BCHI), (n = 8,668). Multivariate logistic regression was applied to assess the impact of the financial measures on the use of dental care. Results Five percent of the population reported having delayed dental care in the past 12 months due to financial barriers. Results from the multivariate model show that irrespective of gender, age, and educational level, individuals who have preferential reimbursement are more likely to postpone their dental care (OR = 3.32, 95% CI: 1.87-5.92), while those who can account on measures for high health expenses due to chronic diseases are less likely to do so (but not significantly). Conclusions Findings suggest that vulnerable people have more postponement despite the fact that they have a preferential reimbursement and, high expenses as a result of chronic diseases are not associated with more postponement of dental care. More targeted financial interventions should be necessary to reduce postponement of dental service utilization. Key messages Current health interventions are not yet effective for vulnerable people in dental care use. High expenses as a result of chronic diseases are not associated with more postponement of dental care.

Aims The purpose of this study was to determine the impact of the removal of total knee arthroplasty (TKA) from the Medicare Inpatient Only (IPO) list on our Bundled Payments for Care Improvement (BPCI) Initiative in 2018. Methods We examined our institutional database to identify all Medicare patients who underwent primary TKA from 2017 to 2018. Hospital inpatient or outpatient status was cross-referenced with Centers for Medicare & Medicaid Services (CMS) claims data. Demographics, comorbidities, and outcomes were compared between patients classified as ‘outpatient’ and ‘inpatient’ TKA. Episode-of-care BPCI costs were then compared from 2017 to 2018. Results Of the 2,135 primary TKA patients in 2018, 908 (43%) were classified as an outpatient and were excluded from BPCI. Inpatient classified patients had longer mean length of stay (1.9 (SD 1.4) vs 1.4 (SD 1.7) days, p < 0.001) and higher rates of discharge to rehabilitation (17% vs 3%, p < 0.001). Post-acute care costs increased when comparing the BPCI patients from 2017 to 2018, ($5,037 (SD $7,792) vs $5793 (SD $8,311), p = 0.010). The removal of TKA from the IPO list turned a net savings of $53,805 in 2017 into a loss of $219,747 in 2018 for our BPCI programme. Conclusions Following the removal of TKA from the IPO list, nearly half of the patients at our institution were inappropriately classified as an outpatient. Our target price was increased and our institution realized a substantial loss in 2018 BPCI despite strong quality metrics. CMS should address its negative implications on bundled payment programmes. Cite this article: Bone Joint J 2020;102-B(6 Supple A):19–23.

Background and Aims A living-donor kidney transplant (LDKT) is one of the best treatments for kidney failure, yet in the UK there is evidence of ethnic inequity in access. We designed this questionnaire-based mixed-methods study to investigate the patient-reported reasons that family members of Black, Asian and Minority Ethnic group (BAME) individuals were not able to become living kidney donors. Method This questionnaire-based case-control study included 14 UK hospitals. Participants were adults transplanted between 1/4/13-31/3/17. Participants provided data on all relatives aged >18 years who could have been potential living kidney donors. Participants were asked for the reasons why relatives could not donate: individuals were asked to tick all options that applied from a list of reasons (Age; Health; Weight; Location; Financial/Cost; Job; Blood group; No-one to care for them after donation), and a box was provided for free-text entries following the option of ‘Other – please give details’. Multivariable logistic regression was used to analyse the association between the likelihood of selecting each reason for non-donation and the participant’s ethnicity (binary variable White versus BAME). 56/171 BAME respondents provided free text responses and all were analysed. Qualitative responses were analysed using thematic analysis. Results 1,240 questionnaires were returned from 3,103 patients (40% response). There was strong evidence that after adjustment for potential confounders sex, age and socioeconomic position, BAME individuals were more likely than White respondents to indicate that family members lived too far away to donate (adjusted odds ratio (aOR) 3.14 [95% CI 2.10-4.70]), were prevented from donating by financial concerns (aOR 2.25 [95% CI 1.49-3.39]), were not able to take time off work (aOR 2.05 [95% CI 1.36-3.09]), and were not the right blood group (aOR 1.47 [95% CI 1.12-1.94]). Four qualitative themes were identified from free-text responses from BAME participants: i) Burden of disease within the family ii) ‘Unorthodox’ religious beliefs iii) Specific geographical concerns (healthcare provision, visa difficulties) iv) Knowledge handling. The theme ‘Knowledge Handling’ incorporated three subthemes: a) Need for more detailed knowledge, b) Protected disclosure of health status, and c) Recipient assumptions about potential donor knowledge. Conclusion We have identified multiple barriers to living kidney donation in the UK BAME population, which should be further investigated and addressed. BAME transplant recipients were more likely to report that potential donors were not the right blood group to donate: work should be undertaken to ascertain if this reflects true ABO-incompatibility or perceived incompatibility. Potential donors living outside the UK is a major barrier, related to difficulties with accessing visa and concerns about a specific country’s healthcare system’s capacity for longer-term post-donation care. The financial barriers reported may disproportionately affect overseas donors who, although entitled to reimbursement for travel, accommodation and visa costs, may incur large “up-front” costs which may be prohibitive. No respondents reported that a major religion’s position on living donation was a barrier to donation. However, there were several references to family members holding beliefs that were described as ‘distorted’ religious beliefs: this highlights the need to understand the beliefs of potential donors who belong to non-mainstream religions, which may be out of the remit of denominational faith leaders.

The Centers for Medicare and Medicaid Services should immediately update current policies to include reimbursement for Medicare patients receiving intravenous antibiotics at home. The majority of these patients are over the age of 65 and at increased risk for severe illness due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Requiring them to travel to an infusion center, stay in a skilled nursing facility or remain in the hospital longer than necessary to receive treatment results in avoidable risk of exposure amidst a pandemic. Current policy has significant implications for increased cost and harm to both these patients and the US healthcare system.

Background Quota payment for specific diseases under global budget is one of the most typical modes of provider payment system reform in rural China. This study aimed to assess this reform mode from aspects of the total fee, structure of the fee and enrollees’ benefits. Methods A total of 127,491 inpatient records from 2014 to 2016 were extracted from the New Rural Cooperative Medical Scheme (NRCMS) database in Weiyuan County, Gansu Province. Total fee, actual compensation ratio, out-of-pocket ratio, constituent ratio of the treatment fee, constituent ratio of the inspection and laboratory fee, and length of stay were selected as dependent variables. Both generalized additive models (GAMs) and multiple linear regression models were used to measure the change in dependent variables along with year. Results Prior to the adjustment of the compensation type, out-of-pocket ratio and length of stay decreased, while total fee, actual compensation ratio, constituent ratio of the treatment fee, and constituent ratio of the inspection and laboratory fee increased. After the compensation type was adjusted, the mean of the total fee increased rapidly in 2015 and remained stable in 2016. The mean length of stay increased in 2015 but decreased in 2016. A comparison of inpatients suffering from diseases covered by quota payments and those suffering from general diseases revealed that total fee, out-of-pocket ratio, and length of stay decreased and actual compensation ratio increased for the former, whereas the opposite was true for the latter. Constituent ratio of the treatment fee and constituent ratio of the inspection and laboratory fee increased for both samples, except for the constituent ratio of the inspection and laboratory fee of quota payment diseases in 2016, which did not change. Conclusions Quota payment for specific diseases under global budget had obviously positive effects on cost control in Weiyuan, Gansu. Considering the limited coverage of quota payment for diseases, the long-term effect of this reform mode and its replicability awaits further evaluation.

The Center for Medicare and Medicaid Innovation (CMMI) launched the Bundled Payments for Care Improvement (BPCI) initiative in 2013. A subsequent study showed that the initiative was associated with reductions in Medicare payments for total joint replacement, but little is known about the effect of BPCI on medical conditions.We used Medicare claims from 2013 through 2015 to identify admissions for the five most commonly selected medical conditions in BPCI: congestive heart failure (CHF), pneumonia, chronic obstructive pulmonary disease (COPD), sepsis, and acute myocardial infarction (AMI). We used difference-in-differences analyses to assess changes in standardized Medicare payments per episode of care (defined as the hospitalization plus 90 days after discharge) for these conditions at BPCI hospitals and matched control hospitals.A total of 125 hospitals participated in BPCI for CHF, 105 hospitals for pneumonia, 101 hospitals for COPD, 88 hospitals for sepsis, and 73 hospitals for AMI. At baseline, the average Medicare payment per episode of care across the five conditions at BPCI hospitals was $24,280, which decreased to $23,993 during the intervention period (difference, -$286; P=0.41). Control hospitals had an average payment for all episodes of $23,901, which decreased to $23,503 during the intervention period (difference, -$398; P=0.08; difference in differences, $112; P=0.79). Changes from baseline to the intervention period in clinical complexity, length of stay, emergency department use or readmission within 30 or 90 days after hospital discharge, or death within 30 or 90 days after admission did not differ significantly between the intervention and control hospitals.Hospital participation in five common medical bundles under BPCI was not associated with significant changes in Medicare payments, clinical complexity, length of stay, emergency department use, hospital readmission, or mortality. (Funded by the Commonwealth Fund.).

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.

In an era of mandatory bundled payments for total joint replacement, accurate analysis of the cost of procedures is essential for orthopaedic surgeons and their institutions to maintain viable practices. The purpose of this study was to compare traditional accounting and time-driven activity-based costing (TDABC) methods for estimating the total costs of total hip and knee arthroplasty care cycles.We calculated the overall costs of elective primary total hip and total knee replacement care cycles at our academic medical center using traditional and TDABC accounting methods. We compared the methods with respect to the overall costs of hip and knee replacement and the costs for each major cost category.The traditional accounting method resulted in higher cost estimates. The total cost per hip replacement was $22,076 (2014 USD) using traditional accounting and was $12,957 using TDABC. The total cost per knee replacement was $29,488 using traditional accounting and was $16,981 using TDABC. With respect to cost categories, estimates using traditional accounting were greater for hip and knee replacement, respectively, by $3,432 and $5,486 for personnel, by $3,398 and $3,664 for space and equipment, and by $2,289 and $3,357 for indirect costs. Implants and consumables were derived from the actual hospital purchase price; accordingly, both methods produced equivalent results.Substantial cost differences exist between accounting methods. The focus of TDABC only on resources used directly by the patient contrasts with the allocation of all operating costs, including all indirect costs and unused capacity, with traditional accounting. We expect that the true costs of hip and knee replacement care cycles are likely somewhere between estimates derived from traditional accounting methods and TDABC. TDABC offers patient-level granular cost information that better serves in the redesign of care pathways and may lead to more strategic resource-allocation decisions to optimize actual operating margins.

Wie in vielen anderen Bereichen drangen auch im Gesundheitssektor innovative digitale Produkte auf den Markt. Wenn es sich bei diesen Digitalprodukten, wie z. B. Apps, um Medizinprodukte handelt, sind Start-up-Unternehmen oft mit unvertrauten, teilweise als schwerfallig empfundenen Rahmenbedingungen und Ablaufen konfrontiert. Bei der Zertifizierung als Medizinprodukt sowie ggf. Einzug in die Kostenerstattung konnen Probleme auftreten. Um besser zu verstehen, welche Erfahrungen Start-ups bereits in diesem Bereich gemacht haben, welche Hurden sie sehen und welcher Bedarf fur spezifische Unterstutzungsangebote besteht, haben der Digitalverband Bitkom e. V. und das Bundesinstitut fur Arzneimittel und Medizinprodukte (BfArM) gemeinsam eine webbasierte Umfrage mit insgesamt 23 Fragen zu funf Themenkomplexen durchgefuhrt. Die Fragen betrafen u. a. die Zusammensetzung des Teams, Produktplanung, Vertrautheit mit regulatorischen Vorgaben, Erfahrungen mit Institutionen und Informationsangeboten sowie die Einschatzung zu Herausforderungen und resultierendem Unterstutzungsbedarf. Auf der Basis von 18 vollstandig eingegangenen Antworten zeigt sich, dass diese Teams u. a. Produkte mit Dokumentations- und Kommunikationselementen, aber auch mit diagnostischen und therapeutischen Funktionen, also Medizinprodukteigenschaften, planen. Mit den diesbezuglichen regulatorischen Rahmenbedingungen sehen sie sich insgesamt relativ gut vertraut. Die grosten Probleme werden im Hinblick auf Rahmenbedingungen sowie zeitlichen und finanziellen Aufwand zur Erreichung einer Kostenerstattung gesehen. Insbesondere in diesem Bereich, aber auch im Hinblick auf die Zertifizierung digitaler Medizinprodukte wird ein groser Bedarf fur niedrigschwellige, kostengunstige Beratungsangebote sowie eine Vereinfachung und Beschleunigung entsprechender Verfahren gesehen.