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Primary care reimbursement models

William B Weeks, William J Schoellkopf, Lyle S Sorensen, Andrew L Masica, Robert E Nesse, James N Weinstein
BACKGROUND: Broader use of value-based reimbursement models will require providers to transparently demonstrate health care value. We sought to determine and report cost and quality data for episodes of hip and knee arthroplasty surgery among 13 members of the High Value Healthcare Collaborative (HVHC), a consortium of health care systems interested in improving health care value. METHODS: We conducted a retrospective, cross-sectional observational cohort study of 30-day episodes of care for hip and knee arthroplasty in fee-for-service Medicare beneficiaries aged 65 or older who had hip or knee osteoarthritis and used 1 of 13 HVHC member systems for uncomplicated primary hip arthroplasty (N = 8853) or knee arthroplasty (N = 16,434), respectively, in 2012 or 2013...
September 28, 2016: Journal of Arthroplasty
Joseph E Tanenbaum, Vincent J Alentado, Jacob A Miller, Daniel Lubelski, Edward C Benzel, Thomas E Mroz
BACKGROUND CONTEXT: Lumbar fusion is a common and costly procedure in the United States. Reimbursement for surgical procedures is increasingly tied to care quality and patient safety as part of value-based reimbursement programs. The incidence of adverse quality events among lumbar fusion patients is unknown using the definition of care quality (patient safety indicators [PSI]) utilized by the Centers for Medicare and Medicaid Services (CMS). The association between insurance status and the incidence of PSI is similarly unknown in lumbar fusion patients...
October 17, 2016: Spine Journal: Official Journal of the North American Spine Society
Khaled J Saleh, William O Shaffer
In 2015, the US Congress passed legislation entitled the Medicare Access and CHIP [Children's Health Insurance Program] Reauthorization Act (MACRA), which led to the formation of two reimbursement paradigms: the merit-based incentive payment system (MIPS) and alternative payment models (APMs). The MACRA effectively repealed the Centers for Medicare and Medicaid Services (CMS) sustainable growth rate (SGR) formula while combining several CMS quality-reporting programs. As such, MACRA represents an unparalleled acceleration toward reimbursement models that recognize value rather than volume...
November 2016: Journal of the American Academy of Orthopaedic Surgeons
Thomas S Valley, Allan J Walkey, Peter K Lindenauer, Renda Soylemez Wiener, Colin R Cooke
OBJECTIVE: Despite increasing use, evidence is mixed as to the appropriate use of noninvasive ventilation in patients with pneumonia. We aimed to determine the relationship between receipt of noninvasive ventilation and outcomes for patients with pneumonia in a real-world setting. DESIGN, SETTING, PATIENTS: We performed a retrospective cohort study of Medicare beneficiaries (aged > 64 yr) admitted to 2,757 acute-care hospitals in the United States with pneumonia, who received mechanical ventilation from 2010 to 2011...
October 5, 2016: Critical Care Medicine
Soteri Polydorou, Stephen Ross, Peter Coleman, Laura Duncan, Nichole Roxas, Anil Thomas, Sonia Mendoza, Helena Hansen
OBJECTIVES: This report identifies the institutional barriers to, and benefits of, buprenorphine maintenance treatment (BMT) integration in an established hospital-based opioid treatment program (OTP). METHODS: This case study presents the authors' experiences at the clinic, hospital, and corporation levels during efforts to integrate BMT into a hospital-based OTP in New York City and a descriptive quantitative analysis of the characteristics of hospital outpatients treated with buprenorphine from 2006 to 2013 (N=735)...
October 17, 2016: Psychiatric Services: a Journal of the American Psychiatric Association
Irina Odnoletkova, Dirk Ramaekers, Frank Nobels, Geert Goderis, Bert Aertgeerts, Lieven Annemans
BACKGROUND: People with diabetes have a high risk of developing micro- and macrovascular complications associated with diminished life expectancy and elevated treatment costs. Patient education programs can improve diabetes control in the short term, but their cost-effectiveness is uncertain. Our study aimed to analyze the lifelong cost-effectiveness of a nurse-led telecoaching program compared to usual care in people with type 2 diabetes from the perspective of the Belgian healthcare system...
2016: PloS One
János Sándor, Karolina Kósa, Magor Papp, Gergő Fürjes, László Kőrösi, Mihajlo Jakovljevic, Róza Ádány
Mortality caused by non-communicable diseases has been extremely high in Hungary, which can largely be attributed to not performed preventive examinations (PEs) at the level of primary health care (PHC). Both structures and financial incentives are lacking, which could support the provision of legally defined PEs. A Model Programme was launched in Hungary in 2012 to adapt the recommendations for PHC of the World Health Organization. A baseline survey was carried out to describe the occurrence of not performed PEs...
2016: Frontiers in Public Health
Syed K Mehdi, Joseph E Tanenbaum, Vincent J Alentado, Jacob A Miller, Daniel Lubelski, Edward C Benzel, Thomas E Mroz
STUDY DESIGN: Retrospective cohort study. BACKGROUND CONTEXT: CMS defines "adverse quality events" as the incidence of certain complications such as post-surgical hematoma and/or iatrogenic pneumothorax during an inpatient stay. Patient safety indicators (PSI) are a means to measure the incidence of these adverse events. When these occur, reimbursement to the hospital decreases. The incidence of adverse quality events among patients hospitalized for primary spinal neoplasms is unknown...
September 21, 2016: Spine Journal: Official Journal of the North American Spine Society
Job F M van Boven, Dermot Ryan, Michelle N Eakin, Giorgio W Canonica, Aji Barot, Juliet M Foster
Adherence to medication comprises a multiphased temporal process involving (1) initiation of prescribed therapy, (2) implementation as prescribed, and (3) subsequent persistence. Medication adherence remains suboptimal in most patients with long-term respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). Interventions have been shown to effectively improve treatment initiation, implementation, and persistence when delivered at the health care professional level or the system level, but demonstration of the cost-effectiveness of these interventions is necessary to ensure their widespread use...
September 2016: Journal of Allergy and Clinical Immunology in Practice
Janet G Wood
OBJECTIVE: The aim of this study was to evaluate the economic and quality outcomes associated with a collaborative advanced practice nurse and hospitalist physician model of care on the inpatient stroke unit as compared with usual hospitalist physician-led care. BACKGROUND: High functioning collaborative teams are anticipated to be essential under value-based reimbursement. METHODS: Hospitalist nurse practitioners were assigned to the stroke unit in collaboration with hospitalist physicians to implement daily hospital management for patients with stroke and transient ischemic attack...
October 2016: Journal of Neuroscience Nursing: Journal of the American Association of Neuroscience Nurses
Gracelyn Cruden, Kelly Kelleher, Sheppard Kellam, C Hendricks Brown
The delivery of prevention services to children and adolescents through traditional healthcare settings is challenging for a variety of reasons. Parent- and community-focused services are typically not reimbursable in traditional medical settings, and personal healthcare services are often designed for acute and chronic medical treatment rather than prevention. To provide preventive services in a setting that reaches the widest population, those interested in public health and prevention often turn to school settings...
October 2016: American Journal of Preventive Medicine
Joyce C West, Diana E Clarke, Farifteh Firoozmand Duffy, Keila D Barber, Eve K Mościcki, Ramin Mojtabai, Kristin Kroeger Ptakowski, Saul Levin
OBJECTIVE: This study sought to describe the extent to which psychiatrists, prior to insurance expansions under the Affordable Care Act (ACA), reported currently participating or being likely to participate in integrated services delivery models, to assume new roles, to accept new reimbursement structures, and to use electronic health records (EHRs). METHODS: A cross-sectional probability survey of U.S. psychiatrists was fielded from September to December 2013. In total, 2,800 psychiatrists were randomly selected from the AMA Physician Masterfile, and 45% responded...
August 15, 2016: Psychiatric Services: a Journal of the American Psychiatric Association
P Maxwell Courtney, James I Huddleston, Richard Iorio, David C Markel
BACKGROUND: Alternative payment models, such as bundled payments, aim to control rising costs for total knee arthroplasty (TKA) and total hip arthroplasty (THA). Without risk adjustment for patients who may utilize more resources, concerns exist about patient selection and access to care. The purpose of this study was to determine whether lower socioeconomic status (SES) was associated with increased resource utilization following TKA and THA. METHODS: Using the Michigan Arthroplasty Registry Collaborative Quality Initiative database, we reviewed a consecutive series of 4168 primary TKA and THA patients over a 3-year period...
July 16, 2016: Journal of Arthroplasty
Robin M A Clarke, Jessica Jeffrey, Mark Grossman, Thomas Strouse, Michael Gitlin, Samuel A Skootsky
Patients with behavioral health disorders often have worse health outcomes and have higher health care utilization than patients with medical diseases alone. As such, people with behavioral health conditions are important populations for accountable care organizations (ACOs) seeking to improve the efficiency of their delivery systems. However, ACOs have historically faced numerous barriers in implementing behavioral health population-based programs, including acquiring reimbursement, recruiting providers, and integrating new services...
August 1, 2016: Health Affairs
Sumer K Wallace, Melissa J Fazzari, Hui Chen, William A Cliby, Eva Chalas
OBJECTIVE: To compare complications and outcomes after hysterectomy for benign compared with malignant indications in the United States. METHODS: Women who underwent hysterectomy in the United States for either benign or malignant indications from January 2008 to December 2012 were retrospectively identified using the National Surgical Quality Improvement Program database. Patients were excluded if the procedure was not performed for primary gynecologic indications...
September 2016: Obstetrics and Gynecology
Joseph E Tanenbaum, Jacob A Miller, Vincent J Alentado, Daniel Lubelski, Benjamin P Rosenbaum, Edward C Benzel, Thomas E Mroz
BACKGROUND CONTEXT: The incidence of adverse care quality events among patients undergoing cervical fusion surgery is unknown using the definition of care quality employed by the Centers for Medicare and Medicaid Services (CMS). The effect of insurance status on the incidence of these adverse quality events is also unknown. PURPOSE: This study determined the incidence of hospital acquired conditions (HAC) and patient safety indicators (PSI) in cervical spine fusion patients and analyzed the association between primary payer status and these adverse events...
August 4, 2016: Spine Journal: Official Journal of the North American Spine Society
Domino Determann, Mattijs S Lambooij, Esther W de Bekker-Grob, Arthur P Hayen, Marco Varkevisser, Frederik T Schut, G Ardine de Wit
Within a healthcare system with managed competition, health insurers are expected to act as prudent buyers of care on behalf of their customers. To fulfil this role adequately, understanding consumer preferences for health plan characteristics is of vital importance. Little is known, however, about these preferences and how they vary across consumers. Using a discrete choice experiment (DCE) we quantified trade-offs between basic health plan characteristics and analysed whether there are differences in preferences according to age, health status and income...
September 2016: Social Science & Medicine
Verena Schadewaldt, Elizabeth McInnes, Janet E Hiller, Anne Gardner
BACKGROUND: In 2010 policy changes were introduced to the Australian healthcare system that granted nurse practitioners access to the public health insurance scheme (Medicare) subject to a collaborative arrangement with a medical practitioner. These changes facilitated nurse practitioner practice in primary healthcare settings. This study investigated the experiences and perceptions of nurse practitioners and medical practitioners who worked together under the new policies and aimed to identify enablers of collaborative practice models...
2016: BMC Family Practice
John B Kisiel, Gauree G Konijeti, Andrew J Piscitello, Tarun Chandra, Thomas F Goss, David A Ahlquist, Francis A Farraye, Ashwin N Ananthakrishnan
BACKGROUND & AIMS: Patients with chronic ulcerative colitis are at increased risk for colorectal neoplasia (CRN). Surveillance by white-light endoscopy (WLE) or chromoendoscopy may reduce risk of CRN, but these strategies are underused. Analysis of DNA from stool samples (sDNA) can detect CRN with high levels of sensitivity, but it is not clear if this approach is cost-effective. We simulated these strategies for CRN detection to determine which approach is most cost-effective. METHODS: We adapted a previously published Markov model to simulate the clinical course of chronic ulcerative colitis, the incidence of cancer or dysplasia, and costs and benefits of care with 4 surveillance strategies: (1) analysis of sDNA and diagnostic chromoendoscopy for patients with positive results, (2) analysis of sDNA with diagnostic WLE for patients with positive results, (3) chromoendoscopy with targeted collection of biopsies, or (4) WLE with random collection of biopsies...
July 25, 2016: Clinical Gastroenterology and Hepatology
Jack M Colwill, John J Frey, Macaran A Baird, John W Kirk, Walter W Rosser
A group of senior leaders from the early generation of academic family medicine reflect on the meaning of being a personal physician, based on their own clinical experiences and as teachers of residents and students in academic health centers. Recognizing that changes in clinical care and education at national and local systems levels have added extraordinary demands to the role of the personal physician, the senior group offers examples of how the discipline might go forward in changing times. Differently organized care such as the Family Health Team model in Ontario, Canada; value-based payment for populations in large health systems; and federal changes in reimbursement for populations can have positive effects on physician satisfaction...
July 2016: Journal of the American Board of Family Medicine: JABFM
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