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Value based reimbursement

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 The MACRA effectively repealed the Centers for Medicare and Medicaid Services (CMS) sustainable growth rate (SGR) formula while combining several CMS quality-reporting programs.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
Amanda N Fader, Tim Xu, Brian J Dunkin, Martin A Makary
BACKGROUND: Surgery is one of the highest priced services in health care, and complications from surgery can be serious and costly. Recently, advances in surgical techniques have allowed surgeons to perform many common operations using minimally invasive methods that result in fewer complications. Despite this, the rates of open surgery remain high across multiple surgical disciplines. METHODS: This is an expert commentary and review of the contemporary literature regarding minimally invasive surgery practices nationwide, the benefits of less invasive approaches, and how minimally invasive compared with open procedures are differentially reimbursed in the United States...
October 17, 2016: Surgical Endoscopy
Madhumita Sinha, Dan Quan, Fred W McDonald, André Valdez
OBJECTIVE: Scorpion antivenom was recently approved for use in patients with clinically significant scorpion envenomation in the United States; no formal economic analysis on its impact on cost of management has been performed. METHODS: Three different strategies of management of scorpion envenomation with systemic neurotoxic symptoms in children were compared for cost minimization from a societal perspective. In strategy I, patients were managed with supportive care only without antivenom...
October 4, 2016: Pediatric Emergency Care
Georgi Iskrov, Tsonka Miteva-Katrandzhieva, Rumen Stefanov
BACKGROUND: Limited resources and expanding expectations push all countries and types of health systems to adopt new approaches in priority setting and resources allocation. Despite best efforts, it is difficult to reconcile all competing interests, and trade-offs are inevitable. This is why multi-criteria decision analysis (MCDA) has played a major role in recent uptake of value-based reimbursement. MCDA framework enables exploration of stakeholders' preferences, as well as explicit organization of broad range of criteria on which real-world decisions are made...
2016: Frontiers in Public Health
Bryan P Nowak
With the implementation of the Affordable Care Act (ACA) the US Government committed to a transition in payment policy for healthcare services linking reimbursement to improved health outcomes rather than the volume of services provided. To accomplish this goal the Department of Health and Human Services (HHS) is designing and implementing new payment models intended to improve the quality of healthcare while reducing its cost. Collectively these novel payment models and programs have been characterized under the moniker of Value-Based Purchasing (VBP) and while many of these models retain a fundamental fee-for-service (FFS) structure they are seen as essential tools in the evolution away from volume based healthcare financing towards a health system that provides "better care, smarter spending, and healthier people"...
September 30, 2016: Journal of Pain and Symptom Management
Yangyang R Yu, Paulette I Abbas, Carolyn M Smith, Kathleen E Carberry, Hui Ren, Binita Patel, Jed G Nuchtern, Monica E Lopez
PURPOSE: As reimbursement programs shift to value-based payment models emphasizing quality and efficient healthcare delivery, there exists a need to better understand process management to unearth true costs of patient care. We sought to identify cost-reduction opportunities in simple appendicitis management by applying a time-driven activity-based costing (TDABC) methodology to this high-volume surgical condition. METHODS: Process maps were created using medical record time stamps...
September 15, 2016: Journal of Pediatric Surgery
Omer Ben-Aharon, Oren Shavit, Racheli Magnezi
BACKGROUND: Increasing health costs in developed countries are a major concern for decision makers. A variety of cost containment tools are used to control this trend, including maximum price regulation and reimbursement methods for health technologies. Information regarding expenditure-related outcomes of these tools is not available. OBJECTIVE: To evaluate the association between different cost-regulating mechanisms and national health expenditures in selected countries...
September 30, 2016: European Journal of Health Economics: HEPAC: Health Economics in Prevention and Care
Kosj Yamoah, Peter As Johnstone
Proton beam therapy has recently become available to a broader population base. There remains much controversy about its routine use in prostate cancer. We provide an analysis of the existing literature regarding efficacy and toxicity of the technique. Currently, the use of proton beam therapy for prostate cancer is largely dependent on continued reimbursement for the practice. While there are potential benefits supporting the use of protons in prostate cancer, the low risk of toxicity using existing techniques and the high cost of protons contribute to lower the value of the technique...
2016: OncoTargets and Therapy
Betty Jo Rocchio
The reimbursement structure of the US health care system is shifting from a volume-based system to a value-based system. Adopting a comprehensive data analytics platform has become important to health care facilities, in part to navigate this shift. Hospitals generate plenty of data, but actionable analytics are necessary to help personnel interpret and apply data to improve practice. Perioperative services is an important revenue-generating department for hospitals, and each perioperative service line requires a tailored approach to be successful in managing outcomes and controlling costs...
October 2016: AORN Journal
Tammie R Jones, Lola Coke
This study, implemented on 2 medical-surgical units, evaluated the impact of a standardized, evidence-based new medication education program. Outcomes evaluated included patient postdischarge knowledge of new medication purpose and side effects, patient satisfaction with new medication, and Medicare reimbursement earn-back potential. As a result, knowledge scores for new medication purpose and side effects were high post intervention. Patient satisfaction with new medication education increased. Value-based purchasing reimbursement earn-back potential improved...
October 2016: Journal of Nursing Administration
Hans-Joerg Fugel, Mark Nuijten, Maarten Postma
RATIONALE: Stratified Medicine (SM) is becoming a natural result of advances in biomedical science and a promising path for the innovation-based biopharmaceutical industry to create new investment opportunities. While the use of biomarkers to improve R&D efficiency and productivity is very much acknowledged by industry, much work remains to be done to understand the drivers and conditions that favour using a stratified approach to create economically viable products and to justify the investment in SM interventions as a stratification option...
December 25, 2016: New Biotechnology
Anand K Narayan, Susan C Harvey, Daniel J Durand
: Purpose To evaluate the impact of accountable care organizations (ACOs) on use of screening mammography in the Medicare Shared Savings Program (MSSP), the largest value-based reimbursement program in U.S. HISTORY: Materials and Methods Institutional review board approval was waived, as the study used publicly available unidentifiable data. Medicare data were retrospectively obtained for participating ACOs from 2012 to 2014. Baseline information and the ACO-20 measure (percentage of women aged 40-69 years who underwent screening mammography within 24 months) were obtained...
September 20, 2016: Radiology
Steven Thompson, Stephen Varvel, Maciek Sasinowski, James P Burke
Big data and advances in analytical processes represent an opportunity for the healthcare industry to make better evidence-based decisions on the value generated by various tests, procedures, and interventions. Value-based reimbursement is the process of identifying and compensating healthcare providers based on whether their services improve quality of care without increasing cost of care or maintain quality of care while decreasing costs. In this article, we motivate and illustrate the potential opportunities for payers and providers to collaborate and evaluate the clinical and economic efficacy of different healthcare services...
September 2016: Big Data
Afshin A Anoushiravani, Zain Sayeed, Mouhanad M El-Othmani, Peter K Wong, Khaled J Saleh
As health care reimbursement models shift from volume-based to value-based models, orthopedic surgeons must provide patients with highly reliable care, while consciously minimizing cost, maintaining quality, and providing timely interventions. An established means of achieving these goals is by implementing a highly reliable care model; however, before such a model can be initiated, a safety culture, robust improvement strategies, and committed leadership are needed. This article discusses interdependent and critical changes required to implement a highly reliable care system...
October 2016: Orthopedic Clinics of North America
Marc N Elliott, Megan K Beckett, William G Lehrman, Paul Cleary, Christopher W Cohea, Laura A Giordano, Elizabeth H Goldstein, Cheryl L Damberg
In 2015 the Medicare Hospital Value-Based Purchasing (VBP) program paid hospitals $1.4 billion in performance-based incentives; 30 percent of a hospital's VBP Total Performance Score was based on performance on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures of the patient experience of care. Hospitals receive patient experience points based on three components: achievement, improvement, and consistency. For 2015 we examined how the three components affected reimbursement for 3,152 hospitals, including their impact on low-performing and high-minority hospitals...
September 1, 2016: Health Affairs
Rishin J Kadakia, Briggs M Ahearn, Shay Tenenbaum, Jason T Bariteau
: Introduction Ankle fractures are the third most common orthopaedic injury seen in the geriatric patient. Studies have identified mortality benefits with operative management, but treatment must be considered on a case-by-case basis. In the era of value-based analysis, a thorough of understanding of outcomes and costs of treatment is required. The purpose of this study was to analyze the inpatient and readmission costs associated with operative and nonoperative management of geriatric ankle fractures...
September 7, 2016: Foot & Ankle Specialist
Randall F Holcombe, Michelle Evangelista, Frances Cartwright
A comprehensive quality improvement program is critically important for participation in value-based reimbursement models. Seven essential characteristics must be addressed in the development of a cancer-focused quality program. These include leadership, environment, engagement, ethos, metrics, accountability, and sustainability (Q=LE(3)MAS). This article describes how to address each essential characteristic and provides examples from the experience at Mount Sinai Hospital, a large, urban, academic hospital/health system in New York City...
September 6, 2016: Journal of Oncology Practice
Camille Haycock, Michelle L Edwards, Christopher S Stanley
The Centers for Medicare & Medicaid Services (CMS) has released a proposed rule that details a consolidated pay-for-performance provider payment system within the Medicare Access and CHIP Reauthorization Act. This proposed rule establishes policy for the new provider Merit-Based Incentive System and Alternative Payment Models. While the rule is extremely complex, and not yet finalized, there are significant implications for nursing and advanced practice providers. This proposed rule intends to drastically change the current provider payment system and reward providers who demonstrate better quality outcomes at a lower cost...
October 2016: Nursing Administration Quarterly
Mondher Toumi, Szymon Jarosławski, Toyohiro Sawada, Åsa Kornfeld
The high cost of novel treatments is the major driver of negative or restricted reimbursement decisions by healthcare payers in many countries. Costly drugs can be subject to Market Access Agreements (MAAs), which are financial (Commercial Agreements [CAs]) or outcomes-based (Payment for Performance Agreements [P4Ps] or Coverage with Evidence Development agreements [CEDs]). Outcomes in outcomes-based MAAs are assessed through changes in surrogate endpoints (SEPs) or patient-relevant endpoints (PEPs). In May 2015, we reviewed published and grey literature on MAAs between manufacturers and large, institutionalised payers from all geographical areas, and classified the schemes into CAs, P4Ps and CEDs, as well as by therapeutic area and country...
August 31, 2016: Applied Health Economics and Health Policy
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