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Interventions: Targeted therapies have been proven to provide clinical benefits to patients with metastatic non-small cell lung cancer (NSCLC). Gefitinib was initially approved and reimbursed as a third-line therapy for patients with advanced NSCLC by the Taiwan National Health Insurance (NHI) in 2004; subsequently it became a second-line therapy (in 2007) and further a first-line therapy (in 2011) for patients with epidermal growth factor receptor mutation-positive advanced NSCLC. Another targeted therapy, erlotinib, was initially approved as a third-line therapy in 2007, and it became a second-line therapy in 2008., Objectives: This study is aimed towards an exploration of the impacts of the Taiwan NHI reimbursement policies (removing reimbursement restrictions) related to accessibility of targeted therapies., Setting: We retrieved 2004-2013 claims data for all patients with lung cancer diagnoses from the NHI Research Database., Design and Outcome Measures: Using an interrupted time series design and segmented regression, we estimated changes in the monthly prescribing rate by patient number and market shares by cost following each modification of the reimbursement policy for gefitinib and erlotinib for NSCLC treatment., Results: Totally 92 220 patients with NSCLC were identified. The prescribing rate of the targeted therapies increased by 15.58%, decreased by 10.98% and increased by 6.31% following the introduction of gefitinib as a second-line treatment in 2007, erlotinib as a second-line treatment in 2008 and gefitinib as as first line treatment in 2011, respectively. The average time to prescription reduced by 65.84% and 41.59% following coverage of erlotinib by insurance and gefitinib/erlotinib as second-line treatments in 2007-2008 and following gefitinib as the first-line treatment in 2011., Conclusions: The changes in reimbursement policies had a significant impact on the accessibility of targeted therapies for NSCLC treatment. Removing reimbursement restrictions can significantly increase the level and the speed of drug accessibility., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Current Medicare MIP measures encourage radiologists not to recommend follow-up for ≤ 1 cm adrenal nodules. However, a radiologist may be the first to discover a small, subclinical pheochromocytoma. As such, recognition of the enhancement pattern of pheochromocytoma is important to ensure detection and properly guide management, which begins with clinical and laboratory assessment for elevated catecholamines.

Two major forms of physician reimbursement include Medicare (MCR; federally funded) and Medicaid (MCD; state funded). The only oversight provided to individual states for setting MCD reimbursement is that it must provide a standard payment that does not negatively affect patient care. The goals of this study were to determine the variability of MCD reimbursement for patients who require orthopedic procedures and to assess how this compares with regional MCR reimbursement. Medicaid reimbursement rates from each state were obtained for total knee arthroplasty, total hip arthroplasty, anterior cruciate ligament repair, rotator cuff repair, anterior cervical decompression and fusion, posterior lumbar decompression, carpal tunnel release, distal radius open reduction and internal fixation, proximal femur open reduction and internal fixation, and ankle open reduction and internal fixation. Discrepancy in reimbursement for these procedures and overall differences in MCD vs MCR reimbursement were determined. Average MCD reimbursement was 81.9% of MCR reimbursement. There was significant variation between states (37.7% to 147% of MCR reimbursement for all 10 procedures). Twenty and 40 states provided less than 75% and 100% of MCR reimbursements, respectively. Medicaid valued knee arthroplasty (91.4% of MCR reimbursement) over other common procedures. Conversely, carpal tunnel release (74.1% of MCR reimbursement; P=.004) had the lowest reimbursements. The most interstate variation was noted for anterior cruciate ligament reimbursement, ranging from 20.6% to 229% of local MCR reimbursement. Disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to understand the impact of these significant differences. It is likely that these discrepancies lead to suboptimal access to necessary orthopedic care. [Orthopedics. 2019; 42(2):e193-e196.]., (Copyright 2018, SLACK Incorporated.)

Medicare's Bundle Payment for Care Improvement (BPCI) Model 2 groups reimbursement for valve surgery into 90-day episodes of care, which include operative costs, inpatient stay, physician fees, postacute care, and readmissions up to 90 days postprocedure. We analyzed our BPCI patients' 90-day outcomes to understand the late financial risks and implications of the bundle payment system for valve patients. All BPCI valve patients from October 2013 (start of risk-sharing phase) to December 2015 were included. Readmissions were categorized as early (≤30 days) or late (31-90 days). Data were collected from institutional databases as well as Medicare claims. Analysis included 376 BPCI valve patients: 202 open and 174 transcatheter aortic valves (TAVR). TAVR patients were older (83.6 vs 73.8 years; P = 0.001) and had higher Society of Thoracic Surgery predicted risk (7.1% vs 2.8%; P = 0.001). Overall, 18.6% of patients (70/376) had one-or-more 90-day readmission, and total claim was on average 51% greater for these patients. Overall readmissions were more common among TAVR patients (22.4% (39/174) vs 15.3% (31/202), P = 0.052) as was late readmission. TAVR patients had significantly higher late readmission claims, and early readmission was predictive of late readmission for TAVR patients only (P = 0.04). Bundled claims for a 90-day episode of care are significantly increased in patients with readmissions. TAVR patients represent a high-risk group for late readmission, possibly a reflection of their chronic disease processes. Being able to identify patients at highest risk for 90-day readmission and the associated claims will be valuable as we enter into risk-bearing episodes of care agreements with Medicare., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: The accuracy of cost savings and reimbursement predictions for medications added to an academic medical center formulary was assessed., Methods: Formulary changes over a 5-year period were reviewed by the investigators. Medications were included if the medication was added to formulary and the monograph included cost savings or reimbursement data that indicated a positive net margin. The primary endpoints were percent predicted cost savings and net margin per medication based on medication cost only. Secondary endpoints included the percent of medications with at least 100% predicted cost savings or net margin and evaluation of median percent predicted savings or net margin individually., Results: The pharmacy and therapeutics committee reviewed 558 formulary agenda items, 184 of which were selected for further analysis. In total, 19 medications were identified as having a predicted monetary advantage. The endpoints of percent predicted cost savings and net margin yielded a median of 76.5% (range 72.9-188.71%) (n = 3) and 148.2% (IQR 108.9-543.3%) (n = 16), respectively. For 13 (68%) of 19 medications, the percent predicted cost savings or net margin was at least 100%., Conclusion: Economic predictions utilized for formulary management at an academic medical center generated net positive monetary value for medications where predicted cost savings or reimbursement factored into the decision to add a medication to the formulary.

Background: The U.S. health care system's transition to a value-based reimbursement model holds important implications for medical innovation, care delivery, and value-based assessments of therapeutic interventions. This transition has been especially noteworthy in oncology, with substantial ongoing changes to payer reimbursement and the provider landscape, as well as the introduction of value frameworks to guide drug treatment decision making. The implications of these changes for provider assessments of drug value and evidence needs remain unclear., Objectives: To understand provider perspectives on drug value assessment and the utility of existing oncology value frameworks by identifying (a) key value-based trends in the evolving oncology landscape, (b) provider definitions of drug value, (c) the role of existing value frameworks in provider decision making, and (d) future provider evidence needs for making value-based treatment decisions., Methods: We conducted a literature review to identify existing oncology value frameworks and definitions of drug treatment value in oncology. Using a structured discussion guide informed by this literature review, we conducted 12 telephone-based in-depth interviews in November and December 2017 with U.S. oncology providers involved in organizational drug treatment and formulary decision making within their practices. Responses to interview questions were analyzed and reported as averages and percentages across participants., Results: Of 293 publications identified by keyword searches, 35 relevant articles were identified. Among these, the literature review identified no common definition for providers to assess drug value. Interview research participants described large ongoing changes in the oncology provider landscape, with economic pressures from payers as the foremost leading factor. Although 5 value frameworks were found in the literature, interviews found that in practice few providers consider these value frameworks to be key influences when evaluating treatment or formulary decisions. Furthermore, while 83% of participants' organizations employed some form of internal clinical pathways, only the minority (25%) with pathways integrated in their electronic medical record (EMR) systems saw these pathways as significantly affecting clinicians' drug treatment decision making. To aid the ongoing shift from volume-based to value-based care, we found that, rather than value frameworks, providers are looking for patient-level tools to make more appropriate drug decisions., Conclusions: Payer reimbursement pressures are leading to radical changes in the oncology provider landscape, and there is a need for improved guidance for providers in assessing drug value. In particular, this study identifies the need for a timely and multifaceted summary of information required to assess the value of alternative treatment options for a given patient. Manufacturers also need to make significant strides to help generate and improve the dissemination of evidence to support the value of their therapies., Disclosures: Funding for this work was provided by Novartis Pharmaceuticals. The study sponsor was involved in study design, data interpretation, and data review. All authors contributed to the development of the manuscript and maintained control over the final content. Sasane, Howe, Wong, and Zacker were employees of Novartis at the time of this study. Frois, Jarvis, and Grice are or have been employed by Analysis Group, which received a grant from Novartis for this research. At the time of this study, Analysis Group received funding from multiple manufacturers with oncology products in their portfolio during this time period, including, but not limited to, Astellas and Genentech.

Background: Since 2012, the pharmaceutical reimbursement legislation in Germany has been applying external reference pricing that uses country-specific economic weights for foreign prices. However, the law does not specify technical details. Therefore, we develop a proposal on how national income weights can be taken into consideration., Areas Covered: We develop weighting schemes that draw on gross domestic product per capita and adjust for purchasing power parities and exchange rates. In a second step, we populate the weighting schemes with economic data as well as with the price data for a pharmaceutical product (abiraterone acetate). Weighting the price of abiraterone acetate by gross domestic product per capita indicates potential price differentials of up to 43 percentage points across European prices in the German basket., Expert Commentary: The weighting of foreign pharmaceutical prices by economic indicators, i.e. gross domestic product per capita, can capture economic differences across countries. It would also allow for differential Ramsey pricing which might foster innovation.

Introduction: Health Technologies Assessment requires that evidence about clinical, economic, social, and organizational aspects be considered and weighted in the selection of drugs for reimbursement. We investigate how evidence is balanced by committee members in Canada, where neither explicit weighing schemes nor thresholds are provided., Methods: Thirty-six past and present members of cancer drug appraisal committees participated in an online stated preferences experiment. The experiment included a ranking of drug attributes, a discrete choice experiment asking to vote in favor or against the funding of drugs described using five attributes, and a best-worst scaling experiment using the same drug descriptions., Results: Respondents focused on the clinical attributes of drugs, particularly on the survival benefit relative to a comparator. As a second criterion, respondents either consider economic attributes or they consider patient relevant attributes, depending on how questions are framed. The small sample size is a limitation to generalizability., Conclusion: Understanding how individuals involved in HTA weigh evidence is important to the development of policy guidelines for the drug selection process. Our pilot results suggest that non-clinical criteria can become marginalized in the appraisal process in the absence of clear guidelines to their use. Avenues for further research are discussed.

Background: Innovative health care reimbursement models are gaining attention as a way to move away from a payment system that rewards quantity of service over quality of care. One such alternative payment model is episode-based payment, such as the Oncology Care Model (OCM) being piloted by the Center for Medicare & Medicaid Innovation., Objective: To adapt the OCM methodology to a commercially insured population to understand the challenges and potential implications of implementing an episode-based payment model in a commercial health plan., Methods: Administrative claims databases from 3 regional commercial health plans were used to identify continually eligible patients (aged ≥ 18 years) with breast cancer, lung cancer, melanoma, or chronic myelogenous leukemia (CML). Episode triggers were identified using the OCM methodology. In calculating the episode-based payments, adjustments to the OCM methodology were necessary to adapt the methodology to a commercial population, since not all Medicare data elements used in the OCM algorithm are available in commercial claims data., Results: The adapted OCM-like model was applied to data from 39,967 patients with 1 of 4 cancer types. Approximately 13% of patients had at least 1 episode per year and the average number of episodes per patient per year for patients with at least 1 episode ranged from 1.42 for patients with melanoma to 1.94 for patients with CML. The percentage of total annual costs included in episodes was 49%, 60%, 34%, and 52% for breast cancer, lung cancer, melanoma, and CML, respectively., Conclusions: As health care financing shifts to alternative payment models, insurers may look to adopt episode-based payments for oncology, similar to the OCM. This study shows that implementing an OCM-like model in a commercial health plan is feasible but will require adjustments to the OCM algorithm to make it implementable and applicable to populations beyond Medicare., Disclosures: This study was conducted by Magellan Rx Management with funding contributed by Novartis. Zacker is an employee of Novartis. The other authors are employed by Magellan Rx Management and have nothing to disclose.

Objectives: To evaluate the ability of claims-based risk adjustment and incremental components of clinical data to identify 90-day episode costs among lower extremity joint replacement (LEJR) patients according to the Centers for Medicare & Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) program provisions., Data Sources: Medicare fee-for-service (FFS) data for qualifying CJR episodes in the United States, and FFS data linked with clinical data from CJR-qualifying LEJR episodes performed at High Value Healthcare Collaborative (HVHC) and Mayo Clinic in 2013. HVHC and Mayo Clinic populations are subsets of the total FFS population to assess the additive value of additional pieces of clinical data in correctly assigning patients to cost groups., Study Design: Multivariable logistic models identified high-cost episodes., Data Collection/extraction Methods: Clinical data from participating health care systems merged with Medicare FFS data., Principal Findings: Our three populations consisted of 363 621 patients in the CMS population, 4881 in the HVHC population, and 918 in the Mayo population. When modeling per CJR specifications, we observed low to moderate model performance (CMS C-Stat = 0.714; HVHC C-Stat = 0.628; Mayo C-Stat = 0.587). Adding CMS-HCC categories improved identification of patients in the top 20% of episode costs (CMS C-Stat = 0.758, HVHC C-Stat = 0.692, Mayo C-Stat = 0.677). Clinical variables, particularly functional status in the population for which this was available (Mayo C-Stat = 0.783), improved ability to identify patients within cost groups., Conclusions: Policy makers could use these findings to improve payment adjustments for bundled LEJR procedures and in consideration of new data elements for reimbursement., (© Health Research and Educational Trust.)

Alternative Payment Models (APMs) can address the limitations inherent in fee-for-service payment to support new approaches to health care delivery that produce greater value. But the models being tested are directly layered on top of fee-for-service architecture, specifically the Medicare Physician Fee Schedule. Shoring up that architecture to produce greater value, in combination with APMs, should be considered an integral part of the movement to value-based payment. We propose ending the split within the Centers for Medicare and Medicaid Services between the people managing the Medicare Physician Fee Schedule and those creating and testing APMs, with both groups advised by a revamped Physician-Focused Payment Model Technical Advisory Committee that covers both dimensions of creating greater value.

Background: Cost-effectiveness in healthcare is being increasingly scrutinized. Data regarding claims variability for vascular operations are lacking. Herein, we aim to describe variability in charges and payments for aortoiliac (AI) and infrainguinal (II) revascularizations., Methods: We analyzed 2012-2014 claims data from a statewide claims database for procedures grouped by Current Procedural Terminology codes into II-open (II-O), II-endovascular (II-E), AI-open (AI-O), and AI-endovascular interventions (AI-E). We compared charges and payments in urban (≥50,000 people, UAs) versus rural areas (<50,000 people, RAs). Amounts are reported in $US as median with interquartile range. Cost-to-charge ratios (CCRs) as a measure of reimbursement were calculated as the percentage of the charges covered by the payments. Wilcoxon rank-sum tests were performed to determine significant differences., Results: A total of 5,239 persons had complete claims data. There were 7,239 UA and 6,891 RA claims, and 1,057 AI claims (AI-E = 879, AI-O = 178) and 4,182 II claims (II-E = 3,012, II-0 = 1,170). Median charges were $5,357 for AI [$1,846-$27,107] and $2,955 for II [$1,484-$9,338.5] (P < 0.0001). Median plan payment was $454 for AI [$0-$1,380] and $454 for II [$54-$1,060] (P = 0.67). For AI and II, charges were significantly higher for UA than RA (AI: UA $9,875 [$2,489-$34,427], RA $3,732 [$1,450-$20,595], P < 0.0001; II: UA $3,596 [$1,700-$21,664], RA $2,534 [$1,298-$6,169], P < 0.0001). AI-E charges were higher than AI-O (AI-E $7,960 [$1,699-$32,507], AI-O $4,774 [$2,636-$7,147], P < 0.0001), but AI-O payments were higher (AI-E $424 [$0-$1,270], AI-O $869 [$164-$1,435], P = 0.0067). II-E charges were higher (II-E $2,994 [$1,552-$22,164], II-O $2,873 [$1,108-$5,345], P < 0.0001), but II-O payments were higher (II-E $427 [$50-$907], II-O $596 [$73-$1,299], P < 0.0001). CCRs were highest for II operations and UAs., Conclusions: Wide variability in claim charges and payments exists for vascular operations. AI procedures had higher charges than II, without any difference in payments. UA charged more than RA for both AI and II operations, but RA had higher payments and CCRs. Endovascular procedures had higher charges, while open procedures had higher payments. Charge differences may be related to endovascular device costs, and further research is necessary to determine the reasons behind consistent claims variability between UA and RA., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The Medicare Access and CHIP Reauthorization Act of 2015 was signed into law on April 16, 2015, fundamentally altering the way clinicians are reimbursed for the treatment of Medicare patients starting in 2017. Under this new pay-for-performance model, reimbursement will be tied to multiple metrics related to quality and cost of care. A scaled scoring system will require providers to compete for positive reimbursement adjustments, while also penalizing poor performers with negative adjustments. A firm understanding of this new system will be essential for all physicians looking to maximize their reimbursement, particularly diagnostic radiologists and members of other highly focused fields where special considerations lead to alterations in the scoring system., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objectives: To describe roles for pharmacists to facilitate payer-initiated value-based contracts within state Medicaid programs., Summary: According to the Centers for Medicare and Medicaid Services, prescription drug expenditures are expected to see the fastest annual growth in the health care sector over the next decade owing to a greater number of costly specialty medications and overall higher drug prices. Increased prescription costs make value-based contracts particularly compelling opportunities for payers. Pharmacists, as formulary subject-matter experts, have unique skills that are beneficial to value-based contract designs. Much like their role in formulary development, pharmacists' clinical knowledge of evidence-based medicine and cost-effective medication use ensures that contract negotiations are both clinically appropriate and address cost-savings components. Well designed value-based contracts can potentially improve the quality of care without increasing overall health care expenditures. Other potential benefits of value-based contracts include reducing waste, achieving cost predictability, and achieving fiscal responsibility for high-cost drugs while supporting patient access., (Copyright © 2019 American Pharmacists Association®. All rights reserved.)

Objectives: The aim of the study was to investigate the direct inpatient cost and analyse influencing factors for patients with rectal cancer with low anterior resection in Beijing, China., Design: A retrospective observational study., Setting: The study was conducted at a three-tertiary oncology institution., Participants: A total of 448 patients who underwent low anterior resection and were diagnosed with rectal cancer from January 2015 to December 2016 at Peking University Cancer Hospital were retrospectively identified. Demographic, clinical and cost data were determined., Results: The median inpatient cost was￥89 064, with a wide range (￥46 711-￥191 329) due to considerable differences in consumables. The material cost accounted for 52.19% and was the highest among all the cost components. Colostomy (OR 4.17; 95% CI 1.79 to 9.71), complications of hypertension (OR 5.30; 95% CI 1.94 to 14.42) and combined with other tumours (OR 2.92; 95% CI 1.12 to 7.60) were risk factors for higher cost, while clinical pathway (OR 0.10; 95% CI 0.03 to 0.35), real-time settlement (OR 0.26; 95% CI 0.10 to 0.68) and combined with cardiovascular disease (OR 0.09; 95% CI 0.02 to 0.52) were protective determinants., Conclusions: This approach is an effective way to relieve the economic burden of patients with cancer by promoting the clinical pathway, optimising the payment scheme and controlling the complication. Further research focused on the full-cost investigation in different stages of rectal cancer based on a longitudinal design is necessary., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Liquid biopsies (LBs) are referred to as the sampling and analysis of non-solid tissue, primarily blood, as a diagnostic and monitoring tool for cancer. Because LBs are largely non-invasive, they are a less-costly alternative for serial analysis of tumor progression and heterogeneity to facilitate clinical management. Although a variety of tumor markers are proposed (e.g., free-circulating DNA), the clinical evidence for Circulating Tumor Cells (CTCs) is currently the most developed. Areas covered: This paper presents a health economic perspective of LBs in cancer management. We first briefly introduce the requirements in biomarker development and validation, illustrated for CTCs. Second, we discuss the state-of-art on the clinical utility of LBs in breast cancer in more detail. We conclude with a future perspective on the clinical use and reimbursement of LBs Expert commentary: A significant increase in clinical research on LBs can be observed and the results suggest a rapid change of cancer management. In addition to studies evaluating clinical utility of LBs, a smooth translation into clinical practice requires systematic assessment of the health economic benefits. This paper argues that (early stage) health economic research is required to facilitate its clinical use and to prioritize further evidence development.

Objective: To determine whether Medicare's Nonpayment Program was associated with decline in venous thromboembolism (VTE) following hip and knee replacements; and whether the decline was greater among hospitals at risk of larger financial losses from the Program., Data Sources: State Inpatient Database for New York (NY) from 2005 to 2013., Study Design: The primary outcome was an occurrence of VTE. Medicare Utilization Ratio (MUR), which is the proportion of inpatient days in a hospital that is financed by Medicare, represented a hospital's financial sensitivity. We used hierarchical logistic regressions with difference-in-differences estimation to study the Program effects., Principal Findings: A total of 98,729 hip replacement and 111,361 knee replacement stays were identified. For hip replacement, the Program was associated with significant reduction (Range: 44% to 53%) in VTE incidence among hospitals in MUR quartiles 2 to 4. For knee replacement, the Program was associated with significant reduction (47%) in VTE incidence only among quartile 2 hospitals., Conclusion: Implementation of the Program was associated with a reduction in VTE, especially for hip replacements, in higher MUR hospitals. Payment reforms such as Medicare's Nonpayment Program that withhold payments for complications are effective and should be continued., (© Health Research and Educational Trust.)

Reforming the payment system of public health insurance from fee-for-service to more efficient alternative schemes has become an urgent policy issue in developing countries. Using a large sample of administrative data drawn from China, we examine a variety of econometric models for predicting the medical expenditures of individuals. We show that the standard ordinary least squares model performs relatively well compared with other models. We then propose two alternative payment schemes on risk-adjusted capitation. The first is a prospective capitation model and the second incorporates both prospective and retrospective features. We simulate the corresponding payments based on model predictions and evaluate the payment/cost ratios for health care providers. The results show that the prospective capitation method generates smaller financial fluctuation, suggesting that policymakers may prefer this method to achieve a smooth transition., (© 2018 John Wiley & Sons, Ltd.)

Organized medicine long yearned for the demise of Medicare's Sustainable Growth Rate (SGR) formula for updating physician fees. Congress finally obliged in 2015, repealing the SGR as part of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA established value-based metrics for physician payment and financial incentives for doctors to join alternative delivery models like patient-centered medical homes. Throughout the law's initial implementation, the politics of accommodation prevailed, with federal officials crafting final rules that made MACRA more favorable for physicians. However, the era of accommodation could be short-lived. The discretion that the Centers for Medicare and Medicaid Services had during the first two years of implementation is ending. Additionally, euphoria over the SGR's repeal has given way to concerns over the new program's value-based purchasing arrangements and uncertainty over their sustainability. MACRA eliminated the SGR, but not the politics of physician payment., (Copyright © 2018 by Duke University Press.)

Objective: Medicare reimbursements are standardized nationwide on the basis of resource-dependent inputs of physicians' time, intensity, practice costs, and malpractice costs, whereas Medicaid payments vary and are determined by individual states. Our objectives were to determine Medicaid reimbursement to physicians for common vascular procedures for the seven states in the Northeast that compose the New England Society for Vascular Surgery and to compare Medicaid payments with Medicare., Methods: Using publicly available data, we obtained Medicaid physician payments in Connecticut, Massachusetts, Maine, New Hampshire, New York, Rhode Island, and Vermont for 10 commonly performed vascular surgery procedures. For comparison, Medicare physician payments for these procedures were adjusted for regional differences using Medicare geographic payment cost indices. Descriptive statistics were calculated by state; Wilcoxon signed rank test was used to compare fees, and one-way analysis of variance was used to compare variance., Results: Medicaid payments varied widely by state. Within individual states (except Vermont), there was no relationship between Medicaid and Medicare payments. Medicaid reimbursement for common vascular procedures ranged from 25% to 91% of Medicare rates and had up to a threefold variation in payment among states for a single procedure. The mean Medicaid payment was 60% of Medicare payment. The greatest state-to-state variance in payment was for open abdominal aortic repair (standard deviation, $227.31); the least was for femoral artery exposure (standard deviation, $31.86). For a Medicaid-based, frequency-weighted analysis of services, New Hampshire exhibited the lowest payments (43% Medicare) and Vermont the highest (80% Medicare)., Conclusions: Among the seven Northeast states considered, with the exception of Vermont, there is no logical relationship between Medicaid and Medicare payments. Because Medicare payments are determined by the Centers for Medicare and Medicaid Services with consideration of resource-based inputs, we conclude that in six of the seven states, Medicaid payments bear no relationship to resource utilization. With Medicaid expansion, access to vascular procedures may be limited by payments insufficient to meet resource needs., (Copyright © 2018. Published by Elsevier Inc.)

Telehealth services have the potential to improve access to care, especially in rural or urban areas with scarce health care resources. Despite the potential benefits, telehealth has not been fully adopted by health centers. This study examined factors associated with and barriers to telehealth use by federally funded health centers. We analyzed data for 2016 from the Uniform Data System using a mixed-methods approach. Our findings suggest that rural location, operational factors, patient demographic characteristics, and reimbursement policies influence health centers' decisions about using telehealth. Cost, reimbursement, and technical issues were described as major barriers. Medicaid reimbursement policies promoting live video and store-and-forward services were associated with a greater likelihood of telehealth adoption. Many health centers were implementing telehealth or exploring its use. Our findings identified areas that policy makers can address to achieve greater telehealth adoption by health centers.

Issue: Delivery system reform has been a focus of regulatory and legislative policy to date, but it is unclear how policymakers will integrate reforms into their plans for 2020 and beyond., Goal: To present and evaluate options for integrating delivery system reform into upcoming legislative proposals., Methods: Literature review., Findings and Conclusions: Policymakers should integrate delivery system reform into their 2020 plans to continue driving value in the health care system. Several options exist for promoting delivery system reform either through a state-based block grant approach or federal public plan approach. We identify three main principles that are critical for success of reform efforts: information sharing and infrastructure, flexibility to innovate, and alignment and stability of efforts.

This article examines the work and leadership of the American Geriatrics Society in making payment for services provided under new, innovative payment codes a reality for geriatrics healthcare professionals. We examine more than a decade of work spanning from a proposal to pay for comprehensive geriatric assessments in 2003 to the multiyear effort that led to Medicare coverage for transitional care management (2013), chronic care management (2015, 2017), and assessment and care planning for cognitive impairment (2017). We review the forces that created an environment for change and the concurrent work of the American Medical Association and the Centers for Medicare and Medicaid Services that made this possible. We highlight opportunities seized that led to seats on crucial panels and legislative victories that helped us make our case for improved payment for geriatrics care. Finally, we address lessons learned and address opportunities where we are currently active. J Am Geriatr Soc 66:2059-2064, 2018., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

The economics of heart failure (HF) touches all patients with HF, their families, and the physicians and health systems that care for them. HF is specifically targeted by cost-reduction and care quality initiatives from the Centers for Medicare and Medicaid Services (CMS). The changing quality assessment and payment landscape is, and will continue to be, challenging for hospitals and HF specialists as they provide care for patients with this debilitating disease. Quality-based payment systems with evolving performance metrics are replacing traditional volume-based fee-for-service models. A critical objective of quality-based models is to improve care and reduce cost, but there are few data to support decision-making on how to improve. CMS payment programs and their implications for health systems treating HF were reviewed at a symposium at the Heart Failure Society of America conference in Nashville, Tennessee on September 15, 2018. This article constitutes the proceedings from that symposium., (Copyright © 2018 Elsevier Inc. All rights reserved.)

This brief highlights key regulatory changes to the Merit-based Incentive Payment System (MIPS) in 2018. We discuss the importance of these changes, particularly as they affect small and rural practices.

Background: Growing numbers of patients in orthopaedic and trauma surgery are obese. The risks involved are e.g. surgical complications, higher costs for longer hospital stays or special operating tables. It is a moot point whether revenues in the German DRG system cover the individual costs in relation to patients' body mass index (BMI) and in which area of hospital care potentially higher costs occur., Material and Methods: Data related to BMI, individual costs and revenues were extracted from the hospital information system for 13,833 patients of a large hospital who were operated in 2007 to 2010 on their upper or lower extremities. We analysed differences in cost revenue relations dependent on patients' BMI and surgical site, and differences in the distribution of hospital cost areas in relation to patients' BMI by t and U tests., Results: Individual costs of morbidly obese (BMI ≥ 40) and underweight patients (BMI < 18.5) significantly (p < 0.05) exceeded individual DRG revenues. Significantly higher cost revenue relations were detected for all operations on the lower and upper extremities except for ankle joint surgeries in which arthroscopical procedures predominate. Most of the incremental costs resulted from higher spending for nursing care, medication and special appliances. Costs for doctors and medical ancillary staff did not increase in relation to patients' BMI., Conclusion: To avoid BMI related patient discrimination, supplementary fees to cover extra costs for morbidly obese or underweight patients with upper or lower extremities operations should raise DRG revenues. Moreover, hospitals should be organisationally prepared for these patients., Competing Interests: Der Erstautor ist in verantwortlicher Position in der untersuchten Klinik tätig. Auf die wissenschaftlichen Analysen dieser Arbeit, die nicht im Rahmen der regulären Arbeitstätigkeit stattfanden, wurde kein Einfluss genommen. Der Zweitautor gibt keinen Interessenkonflikt an., (Georg Thieme Verlag KG Stuttgart · New York.)

A review of the evidence shows that bundled payments for surgical procedures can generate savings without adversely affecting patient outcomes. Less is known about the effect of bundled payments for chronic medical conditions, but early evidence suggests that cost and quality improvements may be small or non-existent. There is little evidence that bundles reduce access and equity, but continued monitoring is required.

As financing mental health care is becoming more challenging, governments are progressively introducing new remuneration systems. At the beginning of 2018, Switzerland introduced TARPSY, a new tariff system based on diagnosis-related psychiatric cost groups that takes into consideration ratings of severity and complexity. TARPSY is expected to provide incentives for medically and economically meaningful treatment, increase transparency, and improve the quality of the provided services by triggering competition between hospitals. Yet some fear that TARPSY will lead to an economization of mental health, encouraging a reduction in length of stay and medically indicated treatment.

Background: Innovative technologies challenge healthcare systems, as evidence on costs and benefits frequently usually are slow to reflect new technology. We investigated these dynamics for Germany, using the emergence of transcatheter aortic valve implementation (TAVI) as an alternative to conventional aortic valve replacements (CAVR)., Objective: We focused on the role of patient co-morbidity-which would be a medical explanation for adopting TAVI-and hospital ownership status, hypothesizing that for-profit facilities are more likely to capitalize on the favorable reimbursement conditions of TAVI., Methods: The analysis uses claims data from the Techniker Krankenkasse, the largest health insurance fund in Germany, for the years 2009-2015, covering 2892 patients with TAVI and 9523 with CAVR. The decision on TAVI versus CAVR was estimated for patient-level data, that is, socioeconomic data as well as co-morbidity. At the hospital level, we included the ownership type. We also controlled for effects of the respective owner (rather than the type of ownership), including a random intercept., Results: While the co-morbidity score of TAVI patients was much higher in the early years, over time, the score almost converged with that of CAVR patients. This is in agreement with emerging evidence that suggests the use of TAVI also leads to better patient outcomes. Our results indicate that the type of ownership does not drive the switch to TAVI. We found little, if any, effect from the respective owner, regardless of ownership type., Conclusion: Overall, the effects of co-morbidity suggest that providers acted responsibly when adopting TAVI while evidence was still emerging.

Background: The payment system is pivotal in implementing policies in the health sector. Equitable access to healthcare is the main principle of the payment system., Aims: This study aimed to investigate aspects of the payment system in the urban family physician programme (FPP) in the Islamic Republic of Iran., Methods: This was a qualitative study. We obtained data from key informants and both formal and grey literature. We used content analysis for data analysis., Results: A range of concepts was explored related to the payment system of the FPP. By merging similar expressions, we categorized the findings into four main themes including: payment method, payment criteria and incentives, payment process and amount of payment., Conclusions: FPP is required to follow convenient implementation methods. The mechanisms of payment in the health sector are weak and have no transparency. A blurred combination of criteria makes an unclear process for determining the payment mechanisms. It is recommended that the opinions of key stakeholders be taken into consideration prior to developing payment mechanisms and financial incentives., (Copyright © World Health Organization (WHO) 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

US policymakers place high priority on tying Medicare payments to the value of care delivered. A critical part of this effort is the Hospital Value-based Purchasing Program (HVBP), which rewards or penalizes hospitals based on their quality and episode-based costs of care and incentivizes integration between hospitals and post-acute care providers. Within HVBP, each patient affects hospital performance on a variety of quality and spending measures, and performance translates directly to changes in program points and ultimately dollars. In short, hospital revenue from a patient consists not only of the DRG payment, but also of that patient's marginal future reimbursement. We estimate the magnitude of the marginal future reimbursement for individual patients across each type of quality and performance measure. We describe how those incentives differ across hospitals, including integrated and safety-net hospitals. We find evidence that hospitals improved their performance over time in the areas where they have the highest marginal incentives to improve care, and that integrated hospitals responded more than non-integrated hospitals., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: To provide a detailed overview of the recent reforms in pharmaceutical pricing and reimbursement processes as well as in other important areas of the pharmaceutical policy in Greece., Methods: Information was collected via a structured questionnaire. The study used publicly available resources, such as publications, relevant legislation, and statistical data, while health experts were also consulted., Results: Recent pharmaceutical reforms included significant price cuts, increased co-payments and some provisions for vulnerable groups, rebates/clawbacks, mandatory electronic prescribing and prescription by international nonproprietary name, generics substitution, prescription limits and detailed auditing, centralized procurement, as well as changes in the pricing and reimbursement processes, with the introduction of positive and negative lists and an internal price referencing system. Price lists are compiled by the National Organization for Medicines and are issued by the Ministry of Health (MoH). An advisory pricing committee comprising representatives of stakeholder groups was abolished in early 2018. Nevertheless, under the new provisions, a health technology assessment body for the economic evaluation of reimbursed drugs is to be established for the first time in Greece. The committee is to be staffed by experts appointed by a ministerial decision of the MoH. The specific features of the process are yet to be determined., Conclusions: The pricing and reimbursement decision-making processes are centralized under the competence of the MoH. Despite the good intentions of the reformers, there are still some aspects of transparency, equity, and long-term sustainability that remain under question in Greece., (Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Objectives: To examine and compare the use of health technology assessment (HTA) for the reimbursement of new medicines in selected European Union member states with decades of experience in the use of HTA and in countries that have used it regularly since 2000., Methods: The selected countries were categorized into "earlier" adopters (group A: England, Germany, France, and Sweden) and more "recent" adopters (group B: Poland, Bulgaria, Hungary, and Romania). A systematic review of published literature was performed. The analysis and comparison of HTA procedures were done by using an analytical framework., Results: In all countries, the assessment criteria used include effectiveness, safety, relative effectiveness, and economic data. In group A countries, the main objectives are improving quality of care, ensuring equal access, and efficient use of resources. Group B countries have established HTA organizations with official guidelines but often seek the decisions of other developed countries. They place considerable emphasis on the budget impact of new therapies, and HTA is also used as a cost estimation tool for state budgets., Conclusions: HTA organizations have been developed dynamically not only in high-income countries but also in countries with limited resources. The experience and evolution of both can be used by countries that are in the dawn of creating an HTA organization., (Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

The aim of this article was to present a general overview of the health care system as well as pricing and reimbursement environment in Estonia. In Estonia the main stakeholders in the pharmaceutical sector are the Ministry of Social Affairs, the State Agency of Medicine, and the Estonian Health Insurance Fund. The national health insurance scheme is public, and approximately 95% of the population is covered by it. It is a social insurance, and universal and equal access to health care based on national health insurance is granted. The Estonian Health Insurance Fund is financed from social taxes and state budget and is responsible for the reimbursement of pharmaceuticals in the hospital setting. It acts as an advisory body to the Ministry of Social Affairs on the process of reimbursement regarding cost effectiveness. Pharmaceutical products' reimbursement dossiers submission and decisions are dealt with on the state level. Health technology assessment analyses are required by the authorities and the Baltic Guidelines for Economic Evaluations of Pharmaceuticals have to be followed. The reimbursement lists are positive lists only, and the criteria upon which reimbursement decisions are based are officially defined. Revisions of reimbursement are performed depending on the need and they are based on the prices of reference countries., (Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)