Search

Introduction:As physician reimbursement models transition from fee-for-service to value-based purchasing, patient satisfaction is becoming an important payment modifier. Studies have shown correlat...

Introduction:Patient satisfaction scores play an ever increasing role in physician reimbursement. Positive scores contribute to a physician earning up to 9% reimbursement bonuses, while neg...

Perception of physician reimbursement for surgical procedures is not well studied. The few existing studies illustrate that patients believe compensation to be higher than in reality. These studies focus on patient perceptions and have not assessed health-care workers’ views. Our study examined health-care workers’ perception of reimbursement for complex surgical oncology procedures. An anonymous online survey was distributed to employees at our cancer center with descriptions and illustrations of three oncology procedures—hepatectomy, gastrectomy, and pancreaticoduodenectomy. Participants estimated the Medicare fee and gave their perceived value of each procedure. Participants recorded their perception of surgeon compensation overall, both before and after revealing the Medicare fee schedule. Most of the 113 participants were physicians (33.6%) and nurses (28.3%). When blinded to the Medicare fee schedules, most felt that reimbursements were too low for all procedures (60–64%) and that surgeons were overall undercompensated (57%). Value predictions for each procedure were discordant from actual Medicare fee schedules, with overestimates up to 374 per cent. After revealing the Medicare fee schedules, 55 per cent of respondents felt that surgeons were undercompensated. Even among health-care workers, a large discrepancy exists between perceived and actual reimbursement. Revealing actual reimbursements did not alter perception on overall surgeon compensation.

Fewer than 60% of Americans diagnosed with HIV are retained in care, with racial disparities. Addressing structural barriers to care may improve outcomes along the HIV care continuum, such as retention, and promote health equity. We examined the relationship between physician reimbursement and retention in HIV care, including racial differences. Data included person-level demographic information and administrative claims (Medicaid Analytic eXtract, 2008-12), state Medicaid-to-Medicare fee ratios (Urban Institute, 2008, 2012), and county characteristics for 15 Southern states plus District of Columbia. The fee ratio is a standardized measure of physician reimbursement capturing state variation in Medicaid relative to Medicare physician reimbursement, which is largely consistent across states. We used generalized estimating equations to assess the association between physician reimbursement ratio and retention in HIV care (≥2 claims for physician visits, antiretroviral prescriptions, or CD4 or HIV RNA viral load tests ≥90 days apart in a calendar-year). We also evaluated an increase in the fee ratio to parity, where Medicaid and Medicare physician reimbursement are equal. Stratified analysis assessed racial differences. The sample included 55,237 adult Medicaid enrollees living with HIV (179,002 enrollee-years). Enrollees were retained in HIV care for approximately three-quarters (76.8%) of their enrollment-years, with retention lower among non-Hispanic Black (76.2%) versus non-Hispanic White (81.3%, p

Background Although pay-for-performance (P4P) among primary care physicians for enhanced chronic disease management is increasingly common, the evidence base is fragmented in terms of socially equitable impacts in achieving the quadruple aim for healthcare improvement: better population health, reduced healthcare costs, and enhanced patient and provider experiences. This study aimed to assess the literature from a systematic review on how P4P for diabetes services impacts on gender equity in patient outcomes and the physician workforce. Methods A gender-based analysis was performed of studies retrieved through a systematic search of 10 abstract and citation databases plus grey literature sources for P4P impact assessments in multiple languages over the period January 2000 to April 2018, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study was restricted to single-payer national health systems to minimize the risk of physicians sorting out of health organizations with a strong performance pay component. Two reviewers scored and synthesized the integration of sex and gender in assessing patient- and provider-oriented outcomes as well as the quality of the evidence. Findings Of the 2218 identified records, 39 studies covering eight P4P interventions in seven countries were included for analysis. Most (79%) of the studies reported having considered sex/gender in the design, but only 28% presented sex-disaggregated patient data in the results of the P4P assessment models, and none (0%) assessed the interaction of patients’ sex with the policy intervention. Few (15%) of the studies controlled for the provider’s sex, and none (0%) discussed impacts of P4P on the work life of providers from a gender perspective (e.g., pay equity). Conclusions There is a dearth of evidence on gender-based outcomes of publicly funded incentivizing physician payment schemes for chronic disease care. As the popularity of P4P to achieve health system goals continues to grow, so does the risk of unintended consequences. There is a critical need for research integrating gender concerns to help inform performance-based health workforce financing policy options in the era of the Sustainable Development Goals.

Objectives To assess subjects' perception of healthcare costs and physician reimbursement. Background The lack of transparency in healthcare reimbursement leaves patients and physicians unaware of the distribution of health care dollars. Methods Anonymous survey-based study by means of convenience sampling. Participants were asked to estimate the total hospital cost and physician fee for one of the six medical procedures (n = 250). Results On the average for all 6 procedures, patients estimated the total cost was $36,177, ∼1,540% more than the actual Medicare rate of $7,333. Similarly, patients estimated the physician fee was $7,694, 1,474% more the actual Medicare rate of $589. Conclusion Patients' perception of the total cost and physician fee are significantly higher than Medicare rates for all 6 procedures. This lack of insight may have widespread negative implications on the patient-physician relationship, on political trends to reduce physician reimbursement, and on a physician's desire to continue practicing medicine.

“If you always do what you’ve always done, you always get what you’ve always gotten.”—Jessie Potter [(1)][1] The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is considered to be one of the largest changes to Medicare physician reimbursement since its launch in 1965.

The relative value unit (RVU) is an important measuring tool for the work performed by physicians, and is currently used in the United States to calculate physician reimbursement. An understanding of radiology RVUs and current procedural terminology codes is important for radiologists, trainees, radiology managers, and administrators, as this knowledge would help them to understand better their current productivity and reimbursement, as well as controversies regarding reimbursement, and permit them to adapt to reimbursement changes that may occur in the future. This article reviews the components of the RVU and how radiology payment is calculated, highlights trends in RVUs and resultant payment for diagnostic and therapeutic imaging and examinations, and discusses current issues involving RVU and current procedural terminology codes.

Importance Physicians face pressure to improve clinical efficiency, particularly with electronic health record (EHR) adoption and gradual shifts toward value-based reimbursement models. These pressures are especially pronounced in academic medical centers, where delivery of care must be balanced with medical education. However, the association of the presence of trainees with clinical efficiency in outpatient ophthalmology clinics is not known. Objective To quantify the association of the presence of trainees (residents and fellows) and efficiency in an outpatient ophthalmology clinic. Design, Setting, and Participants This single-center cohort study was conducted from January 1 through December 31, 2014, at an academic department of ophthalmology. Participants included 49 448 patient appointments with 33 attending physicians and 40 trainees. Exposures Presence vs absence of trainees in an appointment or clinic session, as determined by review of the EHR audit log. Main Outcomes and Measures Patient appointment time, as determined by time stamps in the EHR clinical data warehouse. Linear mixed models were developed to analyze variability among clinicians and patients. Results Among the 33 study physicians (13 women [39%] and 20 men [61%]; median age, 44 years [interquartile range, 39-53 years]), appointments with trainees were significantly longer than appointments in clinic sessions without trainees (mean [SD], 105.0 [55.7] vs 80.3 [45.4] minutes; P

Physician reimbursement and the coding to support it are critically important to the sustained health of any physician's practice. This article reviews the recent history of physician reimbursement from the government and third-party payers and physician coding to support reimbursement. Explanations of terminology and documentation requirements are included.

This study analyses the effect of a change in the remuneration system for physicians on the treatment lengths as measured by the number of doctor visits using data from the German Socio-Economic Panel over the period 1995-2002. Specifically, I analyse the introduction of a remuneration cap (so called practice budgets) for physicians who treat publicly insured patients in 1997. I find evidence that the reform of 1997 did not change the extensive margin of doctor visits but strongly affected the intensive margin. The conditional number of doctor visits among publicly insured decreased while it increased among privately insured. This can be seen as evidence that physicians respond to the change in incentives induced by the reform by altering their patient mix.

STUDY DESIGN Anonymous patient survey. OBJECTIVE To determine what patients think surgeons should be paid to perform elective spine surgical procedures, and gauge awareness of actual Medicare reimbursement. SUMMARY OF BACKGROUND DATA With increasing transparency, the public may become aware of physician reimbursements and may be a part of the debate regarding appropriate reimbursement. It is unknown what patients perceive that spinal surgeons deserve to be, or are actually, paid to perform spinal procedures. METHODS Two hundred anonymous surveys were given to consecutive patients in an outpatient office setting by means of convenience sampling. Patients were asked how much they think physicians are and should be reimbursed for typical spine procedures; and they were asked about their opinions of the actual reimbursement amount for these procedures. It was made explicit that the fee in question included only the surgeon's reimbursement and not that of the hospital. Data were tabulated, statistical comparisons were made, and results were correlated with demographic information. RESULTS On average, respondents thought that surgeons should be paid $21,299 for performing a lumbar discectomy and estimated that Medicare actually pays $12,336 (actual average reimbursement $971). Similar disparities were seen for the other procedures.The vast majority of respondents thought that the average Medicare reimbursement for spine procedures was too low. For example, 92.2% of patients thought that $971 for a lumbar discectomy was "too low," 6.1% thought it was "about right," and only 1.6% thought that $971 was "too high." CONCLUSION Patients think that orthopedic spine surgeons should be compensated over 10 to 20 times more than current Medicare reimbursement rates. Patients overestimate the actual amount that Medicare reimburses by a factor of approximately 7 to 10. Less than 10% of patients think that the current Medicare payment is about right, and less than 2% think that surgeons are overpaid.

Background: The incidence of cancer and the cost of its treatment continue to rise. The effect of these dual forces is a major burden on the system of health care financing. One cost containment approach involves changing the way physicians are paid. Payers are testing reimbursement methods such as capitation and prospective payment while also evaluating how the changes impact health outcomes, resource utilization, and quality of care. The purpose of this study is to identify evidence related to physician payment methods’ impacts, with a focus on cancer control. Methods: We conducted a rapid review. This involved defining eligibility criteria, identifying a search strategy, performing study selection according to the eligibility criteria, and abstracting data from included studies. This process was accompanied by a gray literature search for special topics. Results: The incentives in fee-for-service payment systems generally lead to health care services being applied inconsistently because providers practice independently with few systems in place for developing treatment protocols and practice reviews. This inconsistency is pronounced in cancer care because much of the total per patient spending occurs in the last month of life. Some insurers are predicting that this variation can be reduced through the use of prospective or bundled payments combined with decision support systems. Workload, recruitment, and retention are all affected by changes to physician payment models; effects seem to be magnified in the specialist context as their several extra years of training lower their overall supply. Conclusions: Experimentation with physician payment methods has tended to neglect cancer care providers. Policymakers designing cancer-focused physician reimbursement pilot programs should incorporate quality measurement since very ill patients may receive too little treatment when payment models do not cover oncologists’ total costs, e.g., fee-for-service systems whose prices do not account for the possible presence of other diseases.

Objectives: Healthcare policy changes and decreases in Medicare physician reimbursement continue to change the landscape of healthcare. Historically, patient perceptions of surgeon reimbursement have been exaggerated compared to actual reimbursement. Currently there is limited evidence for patient perception for arthroscopic meniscectomy and ACL reconstruction. The purpose of this study was to evaluate patient perception of physician reimbursement for arthroscopic meniscectomy and ACL reconstruction and to compare health care perceptions between urban and suburban clinics. Methods: Surveys were given to 231 consecutive patients, 127 in an urban clinic and 104 in a suburban clinic. Patients were asked their estimation of reasonable reimbursement for arthroscopic meniscectomy and ACL reconstruction as well as their perception on actual Medicare reimbursement to physicians. They were also asked how much would they be willing to pay out of pocket for the procedures. After revealing actual reimbursement rates, patients were asked if reimbursement levels were appropriate, whether surgeon subspecialty training was important, and if additional compensation should be associated with subspecialty training. Survey responses were compared with respondents in an urban versus a suburban setting as well as amongst income and education level. Results: Patients on average reported surgeons should receive $8,096 for a meniscectomy and $11,794 for an ACL reconstruction, 14 times and 11 times as much as actually reimbursed, respectively. Patients estimated that Medicare paid physicians $5,442 for a meniscectomy and $6,667 for an ACL reconstruction. Patients were willing to pay $2,286 out of pocket for a meniscectomy and $11,793 for an ACL reconstruction. Sixty five percent of patients believed reimbursement for meniscectomy was too low and 57% of patients believe reimbursement for ACL reconstruction was too low. Less than 2% of patients believed physician salaries should be cut, whereas 75% believed physicians should be paid extra for sub-specialty training. There were no differences in payment perception between urban and suburban settings. Conclusion: Patients perceived the values of meniscectomy and ACL reconstruction were substantially higher than current Medicare reimbursement. Majority of patients believed that the current reimbursement is too low and patients on average would be willing to pay more out of pocket than is currently reimbursed.

Public perception on physician reimbursement may be that considerable payments are received for procedures: a direct contrast to the actual decline. We aim to investigate patient perceptions toward plastic surgeon reimbursements from insurance companies.A survey of 4 common, single-staged procedures was administered to 140 patients. Patients were asked for their opinion on current insurance company reimbursement fees and what they believed the reimbursement fee should be.Eighty-four patients completed the survey. Patients estimated physician's reimbursements at 472% to 1061% more for breast reduction, 347% to 770% for abdominal hernia reconstruction, 372% to 787% for panniculectomy, and 290% to 628% for mandibular fracture repair. Despite these perceived higher-than-actual-fee payments, 87% of patients thought reimbursements should still be higher.Patients surveyed overestimated plastic surgery procedure fees by 290% to 1061%. Patients should be informed and educated regarding current fee schedules to plastic surgeons to correct current misconceptions.

Although uncompensated care for hospital-based care has fallen dramatically since the implementation of the Affordable Care Act and Medicaid expansion, the changes in hospital physician reimbursement are not known. We evaluated if payer mix and physician reimbursement by encounter changed between 2013 and 2014 in an academic hospitalist practice in a Medicaid expansion state. This was a retrospective cohort study of all general medicine inpatient admissions to an academic hospitalist group in 2013 and 2014. The proportion of encounters by payer and reimbursement/inpatient encounter were compared in 2013 versus 2014. A sensitivity analysis determined the relative contribution of different factors to the change in reimbursement/encounter. Among 37 540 and 40 397 general medicine inpatient encounters in 2013 and 2014, respectively, Medicaid encounters increased (17.3% to 30.0%, P < .001), uninsured encounters decreased (18.4% to 6.3%, P < 0.001), and private payer encounters also decreased (14.1% to 13.3%, P = .001). The median reimbursement/encounter increased 4.2% from $79.98/encounter in 2013 to $83.36/encounter in 2014 ( P < .001). In a sensitivity analysis, changes in length of stay, proportions in encounter type by payer, payer mix, and reimbursement for encounter type by payer accounted for −0.7%, 0.8%, 2.0%, and 2.3% of the reimbursement change, respectively. From 2013 to 2014, Medicaid encounters increased, and uninsured and private payer encounters decreased within our hospitalist practice. Reimbursement/encounter also increased, much of which could be attributed to a change in payer mix. Further analyses of physician reimbursement in Medicaid expansion and non-expansion states would further delineate reimbursement changes that are directly attributable to Medicaid expansion.

Background The purpose of this study is to evaluate patient's perceptions of physician reimbursement for the most commonly performed surgery on the hand, a carpal tunnel release (CTR). Methods Anonymous physician reimbursement surveys were given to patients and non-patients in the waiting rooms of orthopaedic hand physicians' offices and certified hand therapist's offices. The survey consisted of 13 questions. Respondents were asked (1) what they thought a surgeon should be paid to perform a carpal tunnel release, (2) to estimate how much Medicare reimburses the surgeon, and (3) about how health care dollars should be divided among the surgeon, the anesthesiologist, and the hospital or surgery center. Descriptive subject data included age, gender, income, educational background, and insurance type. Results Patients thought that hand surgeons should receive $5030 for performing a CTR and the percentage of health care funds should be distributed primarily to the hand surgeon (56 %), followed by the anesthesiologist (23 %) and then the hospital/surgery center (21 %). They estimated that Medicare reimburses the hand surgeon $2685 for a CTR. Most patients (86 %) stated that Medicare reimbursement was “lower” or “much lower” than what it should be. Conclusion Respondents believed that hand surgeons should be reimbursed greater than 12 times the Medicare reimbursement rate of approximately $412 and that the physicians (surgeons and anesthesiologist) should command most of the health care funds allocated to this treatment. This study highlights the discrepancy between patient's perceptions and actual physician reimbursement as it relates to federal health care. Efforts should be made to educate patients on this discrepancy.

© 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2015.01.007 Over recent years, we have warned American Gastroenterological Association (AGA) members that physician reimbursement is in turbulent times. While this remains the case, we scored a point for fairness and transparency in the 2015 Medicare Physician Fee Schedule Final Rule. The AGA Governing Board asked reimbursement expert Dr Dawn Francis to reflect on policy issues in the 2015 rule and outline the challenges we face in the future.

Background It has been documented that children insured by Medicaid in California have significantly less access to orthopedic care than children with private insurance. Low Medicaid physician reimbursement rates have been hypothesized to be a major factor. The first objective of this study was to examine whether children insured by Medicaid have limited access to orthopedic care in a national sample. The second objective was to determine if state variations in Medicaid physician reimbursement rates correlate with access to orthopedic care. Methods Two-hundred fifty orthopedic surgeon's offices, 5 randomly chosen in each of 50 states, were telephoned. Each office called was asked to answer questions to an anonymous, disclosed survey. The survey asked whether the office accepted pediatric patients, whether they accepted children with Medicaid, and whether they limited the number of children that they accepted with Medicaid, and if so why. Each state sets its own rate of physician reimbursement rates that were collected from individual state Medicaid agencies for 3 different CPT codes. The relationship between acceptance of patients with Medicaid and the individual state's Medicaid reimbursement rate was examined. Results Children with Medicaid insurance had limited access to orthopedic care in 88 of 230 (38%) offices that treat children, and 18% (41/230) of offices would not see a child with Medicaid under any circumstances. Reimbursement rates for CPT codes widely varied by state: 99243 for an outpatient consultation (range, $20-$176.38), 99213 for an established follow-up outpatient visit (range, $6-$77.76), and 25560 for global treatment of a nondisplaced radius and ulna shaft fracture without manipulation (range, $50-$403.94). There was a statistically significant relationship between access to medical care for Medicaid patients and physician reimbursement rates for all 3 CPT codes. Conclusions Children insured with Medicaid have limited access to orthopedic care in this nationwide sample. Medicaid physician reimbursement significantly correlates with patient access to medical care. These data may be of value in the ongoing efforts to improve access to medical care for children on Medicaid. The logical inference from this study is that increasing physician reimbursement rates will improve access. In the authors' opinion, reimbursement rates should be made higher than office overhead to effect meaningful change.

To determine patient assumptions and opinions of the billing and reimbursement process in an urban urologic practice. Healthcare policy and physician reimbursement has been discussed in political and economic forums; however, few studies exist that reflect a patient's perspective of reimbursement issues.An anonymous, voluntary 11-question survey was given to 825 patients during a 10-week interval. The instrument measured patient perceptions on the amounts (in percentages) that would, and should, be covered by insurance carriers and collected by their urologist. It also measured the time frames perceived for these events to occur. Our aim was to evaluate their knowledge of office urologic reimbursement.Overall, 532 patients (75%) surveyed believed their insurance would cover 80% to 100% of their bill. A total of 309 patients (49%) thought their urologist would receive 80% to 100% of the bill, and 383 (60%) thought they should receive that level of compensation (P0.0001). Respondents with prior surgical contact thought their urologist would (P = 0.004) and should (P = 0.01) be reimbursed at a greater level than those without prior surgical contact. When asked about the time to reimbursement, 340 (73%) thought their doctor would be paid within 6 weeks compared with 453 (95%) who thought their urologist should be paid within that time (P0.0001).The survey responses demonstrated patients' convictions that their urologists should be reimbursed in a timely manner. Additional studies examining both patient and healthcare provider perspectives are needed to better educate both of these groups on the medical billing and reimbursement process.

Background. There is concern that commercial health insurance reimbursement levels for immunizations and well-child visits may not be meeting the delivery and practice overhead costs within some areas of the country. There is also concern that insufficient physician reimbursement levels may negatively affect the quality of children’s health care.Objective. We examined the relationships between commercial health insurance reimbursement levels to physicians for pediatric services and rates of immunization and well visits for children and adolescents.Design. Quality of care was measured by examining state-level immunization and well-visit rates for 2002, which were obtained from the National Committee for Quality Assurance, Health Plan Employer Data and Information Set (HEDIS). Reimbursement data were obtained from the American Academy of Pediatrics Medical Cost Model. Variations in the child and adolescent HEDIS measures were examined as a function of physician reimbursement levels for pediatric services across states. HEDIS data were available for a total of 32 states. Partial correlations controlled for pediatrician concentration, as collected from the US Bureau of the Census and the American Medical Association Physician Masterfile data.Results. Compliance with HEDIS immunization rates for all recommended vaccines was 60% for children and 24% for adolescents. By excluding the varicella vaccine, these rates increased to 70% for children and 44% for adolescents. Adherence rates for well visits were also higher for infants (60%) and children (59%) than for adolescents (34%). Physician reimbursement levels for pediatric services varied from $16.88 per member per month to $32.06 per member per month across states. Statistically significant positive correlations for reimbursement levels were found for 8 of the 16 HEDIS measures examined. Correlations with reimbursement levels were found for childhood immunizations (r = 0.42), infant well visits (r = 0.44), childhood well visits (r = 0.46), and adolescent well visits (r = 0.42). Reimbursement levels were especially strongly related to the rates of adolescent varicella vaccination (r = 0.53). When partial correlations were examined to control for pediatrician concentration, the correlations were reduced by 0.09 on average, suggesting that pediatrician supply may serve as an intermediary of the reimbursement relationship.Conclusions. Immunization and well-visit rates for infants, children, and adolescents were positively linked with physician reimbursement rates for those services. Although methodologic limitations suggest caution when interpreting these findings, more attention should be given to physician reimbursement levels as a possible predictor of immunization and well-visit rates as measures of quality of care and to the importance of reimbursement levels for pediatrician recruitment.

Payment for physician services in the United States is directly tied to the payment system implemented in the Medicare system. The use of a code to categorize medical and surgical services, as well as a relative value system to assess physician services and reimburse them accordingly, is now well established. In light of this, it is important for physicians to possess knowledge of how this coding and reimbursement system was established, how it is updated, what means are available to modify it, and how it is used in practice. The author addresses these issues, offering a primer for the neurosurgeon on the Medicare system as it relates to physician payment.

Importance Nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, yet little is known about the prices that MA plans pay for physician services. Medicare Advantage insurers typically also sell commercial plans, and the extent to which MA physician reimbursement reflects traditional Medicare (TM) rates vs negotiated commercial prices is unclear. Objective To compare prices paid for physician and other health care services in MA, traditional Medicare, and commercial plans. Design, Setting, and Participants Retrospective analysis of claims data evaluating MA prices paid to physicians and for laboratory services and durable medical equipment between 2007 and 2012 in 348 US core-based statistical areas. The study population included all MA and commercial enrollees with a large national health insurer operating in both markets, as well as a 20% sample of TM beneficiaries. Exposures Enrollment in an MA plan. Main Outcomes and Measures Mean reimbursement paid to physicians, laboratories, and durable medical equipment suppliers for MA and commercial enrollees relative to TM rates for 11 Healthcare Common Procedure Coding Systems (HCPCS) codes spanning 7 sites of care. Results The sample consisted of 144 million claims. Physician reimbursement in MA was more strongly tied to TM rates than commercial prices, although MA plans tended to pay physicians less than TM. For a mid-level office visit with an established patient ( Current Procedural Terminology [ CPT ] code 99213), the mean MA price was 96.9% (95% CI, 96.7%-97.2%) of TM. Across the common physician services we evaluated, mean MA reimbursement ranged from 91.3% of TM for cataract removal in an ambulatory surgery center ( CPT 66984; 95% CI, 90.7%-91.9%) to 102.3% of TM for complex evaluation and management of a patient in the emergency department ( CPT 99285; 95% CI, 102.1%-102.6%). However, for laboratory services and durable medical equipment, where commercial prices are lower than TM rates, MA plans take advantage of these lower commercial prices, ranging from 67.4% for a walker (HCPCS code E0143; 95% CI, 66.3%-68.5%) to 75.8% for a complete blood cell count ( CPT 85025; 95% CI, 75.0%-76.6%). Conclusions and Relevance Traditional Medicare’s administratively set rates act as a strong anchor for physician reimbursement in the MA market, although MA plans succeed in negotiating lower prices for other health care services for which TM overpays. Reforms that transition the Medicare program toward some premium support models could substantially affect how physicians and other clinicians are paid.

In 2010, the Centers for Medicare and Medicaid Services (CMS) simplified the coding of urodynamics by eliminating several Current Procedural Terminology (CPT) codes. One effect of this was a decrease in the reimbursement for urodynamics to physicians. In addition, CMS has also placed more emphasis on pairing the urodynamic CPT codes with an appropriate International Classification of Diseases-9th Revision Clinical Modification (ICD-9-CM) code. If coded correctly, urodynamic evaluation can still be reimbursed fairly. This chapter attempts to explain the reimbursement for urodynamics, basic coding terminology and provides a step-by-step explanation of how urodynamics should be properly coded.

In this paper, we investigate in a controlled laboratory experiment physician behavior in the case of payment heterogeneity. In the experiment, each physician provides medical care to patients whose treatments are paid for either under fee-for-service (FFS) or capitation (CAP). We observe that physicians customize care in response to the payment system. A FFS patient receives considerably more medical care than the corresponding CAP patient with the same illness and treatment preference. Physicians over-serve FFS patients and under-serve CAP patients. After a CAP payment reduction in the experiment we observe neither a quantity reduction under CAP nor a spillover into the treatment of FFS patients.

BACKGROUND: Endoscopy accounts for a significant proportion of income for physicians practicing gastroenterology. Fees are set provincially, and the consistency with regard to compensation for colonoscopy and gastroscopy across the provinces has yet to be established.OBJECTIVE: To compare and contrast provincial endoscopy fees across Canada and internationally.METHODS: Provincial and territorial ministries responsible for health care were contacted for their most current fee schedule. This was reviewed, and the billing amounts for colonoscopy and endoscopy collected. International contacts were made with regard to rates outside of Canada.RESULTS: The mean (± SD) national fee for gastroscopy was $114.19±$31.47 per procedure, with a range of $52.50 to $156.10. Physician billing nationally averaged $170.99±$33.49 per colonoscopy procedure, with a range of $105.00 to $223.00. The province of Quebec provided the least amount of compensation for both procedures, and the province of Nova Scotia provided the most for both procedures.CONCLUSION: Physician fees for gastroscopy and colonoscopy vary widely among the provinces, and, on average, seem to be less than international rates.

The study aim was to understand patient impressions of reimbursement to orthopedic spine surgeons. Our findings revealed that the majority of patients significantly overestimate the amount surgeons are reimbursed per procedure. Despite this, most feel that surgeons are appropriately compensated. Additionally, many patients are unaware of the global billing period.

It is found that health maintenance organizations (HMOs) initially increase, but will eventually significantly decrease, a population's health care costs. Thus, HMOs appear to require a significant amount of time to control effectively physician and patient behaviour and achieve reductions in costs. Unlike health care costs, HMOs are found to have no significant impact on a population's aggregate health in either the short- or the long-run. Thus, HMOs are found to achieve savings in health care costs in the long-fun and they apparently do so with no resultant decline in health. The paper also has important implications for the National Health Service (NHS) in Great Britain given the similarities that exist between HMO physician reimbursement and NHS funding of its general practitioners.

In response to a reader's question, Dr. Philipsen examines the possibilities of conflict of interest in various methods of physician reimbursement.

This article assesses the situation that led to the development of the Resource-Based Relative-Value Scale (RBRVS), describes the scale and how it might be applied, and compares it to other reimbursement schemes. Potential weaknesses of the RBRVS are also discussed.

As Medicaid reaches its 40th birthday, the future of the program is less certain than it has been for years. Congress recently passed the Budget Reconciliation Act, which could signal the beginning of a restructuring and retrenchment of the Medicaid program. Under this act, individual states will have the option of reducing benefits and imposing significant costs on Medicaid recipients, including copayments. New procedural barriers such as a rigid demand for a birth certificate to establish eligibility will make it harder for eligible people to access the program. These provisions will likely result in fewer enrollees. Yet, at the same time that Congress is allowing or requiring states to make these changes that may result in drastic reductions in their Medicaid programs, Illinois has enacted the All Kids program, which is a major expansion of Illinois' publicly supported health coverage programs. Under All Kids, Illinois will offer Medicaid-type benefits to all children who are currently uninsured. Illinois is bucking the trend by increasing its eligible populations but not increasing its spending. Illinois' All Kids program is designed to expand access to health care while offsetting the costs of expansion through cost savings. Illinois intends to generate those cost savings by implementing primary care case management and disease management programs, all based on physician payment on a fee-for-service basis. Illinois will also require that families who are currently uninsured and not currently covered by a public program make … Address correspondence to Mark Rosenberg, MD, MA, Children's Healthcare Associates, 2835 N Sheffield Ave, #501, Chicago, IL 60657. E-mail: markrosenbergmd{at}aol.com

The Medicare program, enacted in 1965, is a federally funded health care coverage plan for people aged 65 years and older, for those who are disabled, and for those needing renal dialysis or kidney transplants for the treatment of end-stage renal disease. Today, nearly 40 million Americans rely on Medicare for their health care services. The purpose of the Medicare program is to increase access to quality care for the elderly while maintaining a financially viable federal fund from which health care reimbursements can be appropriately and efficiently allocated to health care providers. This paper has three main objectives: (1) introduce the functioning of the Medicare payment system, (2) explain in more detail how the program currently reimburses physicians, and (3) discuss the current challenges facing the physician reimbursement system.

A cross-sectional anonymous postal survey was carried out in a Department of Internal Medicine in order to assess physicians' knowledge about and attitudes towards clinical practice guidelines and to evaluate the role of age in determining their use and opinions. The study took place in a Swiss University Hospital where exposure to guidelines had been limited. The questionnaire was sent to the 174 physicians of the Department. The response rate was 67% (116/174). The spontaneous definitions of guidelines were heterogeneous and referred to information of uncertain validity. Most participants, especially the younger groups of junior and senior residents, reported using guidelines and were favourable to their development. Less favourable attitudes were observed among senior staff physicians and consultants. For instance, the latter more often held the opinion that guidelines are too rigid to apply to individual patients, were likely to decrease physician reimbursement and to hamper research (respectively, 32% vs 24%, 50% vs 31% and 18% vs 7% when compared with the opinions of residents). In conclusion, in a non-prescriptive hospital setting, where the development, dissemination and implementation of guidelines are emerging, the concept of 'guideline' was heterogeneous. Despite generally positive attitudes towards guidelines, the opinion of senior staff physicians constitute a barrier to their dissemination and implementation.

✓ The President of the American Association of Neurological Surgeons (AANS) discusses the present socioeconomic milieu, which has created anxiety in the neurosurgical community. The underlying factors are technological advances, hospital-physician relationships, medical liability, quality assurance reviews, and physician reimbursement. It is proposed that neurosurgeons be proactive in the development of health-care reform.

Physician payment under Medicaid has been a cause of growing concern among physicians because of the low levels of reimbursement in relation to private payors and the Medicare program in many states. This is particularly important to physicians caring for children because of the growing dependence of poor children on Medicaid and the evolution of Medicaid policies since the mid 1980s. Beginning in the mid 1980s Congress began legislating a series of laws that expanded Medicaid eligibility for poor and near poor children. This series of legislation culminated with the Omnibus Budget Reconciliation Acts of 1989 and 1990. These acts required all states to establish minimum Medicaid income eligibility thresholds at 133% of the federal poverty level for children less than 6 years of age and then subsequently to phase-in coverage, 1 year at a time, for all children through 18 years of age with family incomes less than 100% of poverty level.