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Abstract Background The duration of treatment (DOT) of the initial intervention and subsequent treatment is the key to determining the accuracy of anticancer-drug budget impact analysis (BIA) calculations. However, existing studies only use simple assumptions as a proxy for DOT, resulting in a high degree of bias. Objectives To enhance the accuracy and reliability of anticancer-drug BIA and solve the problem regarding DOT, we propose an alternative individual patient data (IPD)-based approach that reconstructs IPD from the published Kaplan Meier survival curves to estimate DOT. Methods We developed a four-step methodological framework for this new approach, taking the use of pembrolizumab in treating microsatellite-instability–high (MSI-H) advanced colorectal cancer as an example: (1) reconstructing the IPD; (2) calculating the total DOT of the initial intervention and subsequent treatment for each patient; (3) assigning a randomized time and DOT; and (4) multiple replacement sampling and calculation of the mean value. Results Using this approach, the average DOT for the initial intervention and subsequent treatment in each year of the BIA time horizon can be calculated and used to calculate the resources consumed and costs in each year. In our example, the average DOT for the initial intervention with pembrolizumab from the first to the fourth year was 4.90, 6.60, 5.24, and 5.06 months, respectively, while the average DOT for subsequent treatment was 0.75, 2.84, 2.99, and 2.50 months, respectively. Conclusions The reconstructed IPD-based approach can improve the accuracy and reliability of anticancer-drug BIA compared with conventional methods, and can be widely used, especially for anticancer drugs with excellent efficacy.

Background: Policymakers and payers are reevaluating the temporary telehealth flexibilities granted during the COVID-19 public health emergency, which will shape future teledermatology utilization. Objective: To summarize the recently expanded telehealth flexibilities in the United States, projected changes, and corresponding implications for dermatologists. Methods: Narrative review of the literature, United States policies and regulations, and white paper reports. Results: Key telehealth flexibilities included expansion of payment parity, relaxation of originating site requirements, loosening of state licensure requirements, and HIPAA (Health Insurance Portability and Accountability Act of 1996) enforcement discretion. These changes enabled widespread accessibility and adoption of teledermatology, which enhanced high-quality and cost-effective dermatologic care. Most waivers will end 151 days following the end of the public health emergency declaration. Notably, asynchronous telehealth was not included in the reimbursement expansion. Limitations: Only policies and regulations through December 2022 are included. Conclusion: It will be important for the field of dermatology to stay abreast of the upcoming changes in telemedicine policies and reimbursement, to demonstrate teledermatology’s value through evidence-based studies and to advocate for enduring policies that will promote the accessibility of teledermatology for patients.

Introduction: Over the preceding decade, an increasing number of drugs have been approved by the European Medicines Agency (EMA) with limited knowledge of their relative efficacy. This is due to the utilization of non-randomized, single-arm studies, surrogate endpoints, and shorter follow-up time. The impact of this trend on the accessibility and affordability of newly approved drugs in Europe remains uncertain. The primary objective of this study is to provide insights into the issues of accessibility and affordability of new drugs in the Norwegian healthcare system.Method: The presented study entails an analysis of all reimbursement decisions for hospital drugs in Norway spanning 2021–2022. The included drugs were approved by the EMA between 2014 and 2022, with the majority (91%) receiving approval between 2018 and 2022. The drugs were categorized based on the level of documentation of relative efficacy. Approval rates and costs (confidential net-prices) were compared.Results: A total of 35% (70/199) of the reimbursement decisions were characterized by limited certainty regarding relative efficacy and as a consequence the Norwegian Health Technology Assessment (HTA) body did not present an incremental cost-effectiveness ratio (ICER) in the HTA report. Within this category, a lower percentage of drugs (47%) gained reimbursement approval compared to those with a higher certainty level, which were presented with an ICER (58%). On average, drugs with an established relative efficacy were accepted with a 4.4-fold higher cost (confidential net-prices). These trends persisted when specifically examining oncology drugs.Conclusion: Our study underscores that a substantial number of recently introduced drugs receive reimbursement regardless of the level of certainty concerning relative efficacy. However, the results suggest that payers prioritize documented over potential efficacy. Given that updated information on relative efficacy may emerge post-market access, a potential solution to address challenges related to accessibility and affordability in Europe could involve an increased adoption of market entry agreements. These agreements could allow for price adjustments after the presentation of new knowledge regarding relative efficacy, potentially resolving some of the current challenges.

In this latest update we highlight: a publication from the US FDA regarding the definitions of real-world data (RWD) and real-world evidence (RWE); a publication from academic researchers on a demonstration project for target trial emulation; a publication from the National Institute of Health and Care Excellence (NICE) on the 1 year anniversary of their RWE framework; and a publication from NICE and Flatiron Health on the utility of US RWD for initial UK health technology assessment decision making.

Next-generation sequencing (NGS) and liquid biopsy (LB) showed positive results in the fight against different cancer types. This paper aims to assess the uptake of advanced molecular diagnostics/NGS for quick and efficient genetic profiles of tumour cells. For that purpose, the European Alliance for Personalised Medicine conducted a series of expert interviews to ascertain the current status across member states. One stakeholder meeting was additionally conducted to prioritize relevant factors by stakeholders. Seven common pillars were identified, and twenty-five measures were defined based on these pillars. Results showed that a multi-faceted approach is necessary for successful NGS implementation and that regional differences may be influenced by healthcare policies, resources, and infrastructure. It is important to consider different correlations when interpreting the results and to use them as a starting point for further discussion.

Background: Hepatitis C Virus (HCV) remains a challenging health problem worldwide, with increasing incidence despite being curable with Direct Acting Antiviral (DAA) agents. Objective: This study aimed to describe the utilization, reimbursement, and price trends of HCV treatments and evaluate the influence of treatment guidelines and policies. Methods: A retrospective, descriptive drug utilization study conducted using the outpatient pharmacy data extracted from the Centers for Medicaid and Medicare Services State Drug Utilization Data between 2001 and 2021. All HCV treatments approved in the US were included, conventional therapy (CT), and DAA agents. The annual secular trends were calculated for each medication's total number of prescriptions, reimbursements, and prices. The average reimbursement per prescription was calculated and utilized as a proxy of prices. The HCV treatment guideline and policies and legislation were evaluated overtime to measure the impact on the trends. Results: Despite CT having a higher total utilization, DAA agents commanded significantly greater reimbursements, with 4.1 billion USD for CT and 19.45 billion USD for DAA agents. CT utilization increased rapidly and dominated the market until 2011, peaking at 379,696 prescriptions in 2003 but declining afterward. DAA agents' utilization increased rapidly in their first year: i.e., sofosbuvir reached 50,377 prescriptions with 1.3 billion USD in 2014, while ledipasvir/sofosbuvir reached 79,387 prescriptions with 2 billion USD in 2015. The average price per prescription was high for the DAA agents, like 24,992 USD for sofosbuvir and 22,787 USD for ledipasvir/sofosbuvir, compared to CT medications ribavirin, around 500 USD, and pegINF, around 3000 USD. The new DAA agents replaced CT, and initiating market competition among DAA agents. Conclusion: The introduction of multiple DAA agents slightly changed their prescription prices but remained high during the study period. The recent increase in HCV incidence cases indicates accessibility issues for costly and effective DAA agents, with treatment guidelines and policies playing a critical role in shaping these trends.

ABSTRACTObjectives In this paper, we outline and compare pharmaceutical pricing and reimbursement policies for in-patent prescription medicines in three Maghreb countries, Algeria, Morocco, and Tunisia, and explore possible improvements in their pricing and reimbursement systems.Methods The evidence informing this study comes from both an extensive literature review and a primary data collection from experts in the three studied countries.Key findings Twenty-six local experts where interviewed Intervieweesincluded ministry officials, representatives of national regulatory authorities, health insurance organizations, pharmaceutical procurement departments and agencies, academics, private pharmaceutical-sector actors, and associations. Results show that External Reference Pricing (ERP) is the dominant pricing method for in-patent medicines in the studied countries. Value-based pricing through Health Technology Assessment (HTA) is a new concept, recently used in Tunisia to help the reimbursement decision of some in-patent medicines but not yet used in the pricing of innovative medicines in the studied countries. Reimbursement decision is mainly based on negotiations set on Internal Reference Pricing (IRP).Conclusion Whereas each country has its specific regulations, there are many similarities in the pricing and reimbursement policies of in-patent medicines in Algeria, Morocco, and Tunisia. The ERP was found to be the dominant method to inform pricing and reimbursement decisions of in-patent medicines. Countries in the region can focus on the development of explicit value assessment systems and minimize their dependence on ERP over the longer-term. In this context, HTA will rely on local assessment of the evidence.

ABSTRACTBackground and objectives: Multiple reforms aimed at improving the Chinese population’s health have been introduced in recent years, including several designed to improve access to innovative drugs. We sought to review current factors affecting access to innovative drugs in China and to anticipate future trends.Methods: Targeted reviews of published literature and statistics on the Chinese healthcare system, medical insurance and reimbursement processes were conducted, as well as interviews with five Chinese experts involved in the reimbursement of innovative drugs.Results: Drug reimbursement in China is becoming increasingly centralized due to the removal of provincial pathways, the establishment of the National Healthcare Security Administration and the implementation of the National Reimbursement Drug List (NRDL), which is now the main route for drug reimbursement in China. There is also an increasing number of other channels via which patients may access innovative treatments, including various types of commercial insurance and special access. Health technology assessment (HTA) and health economic evidence are becoming pivotal elements of the NRDL decision-making process. Alongside the optimization of HTA decision making, innovative risk-sharing agreements are anticipated to be increasingly leveraged in the future to optimize access to highly specialized technologies and encourage innovation while safeguarding limited healthcare funds.Conclusions: Drug public reimbursement in China continues to align more closely with approaches widely used in Europe in terms of HTA, health economics and pricing. Centralization of decision-making processes for public reimbursement of innovative drugs allows consistency in assessment and access, which optimizes the improvement of the Chinese population’s health.

Background: Transparency in physician billing practices in the United States is lacking. Often, charges may vary substantially between providers and excess charges may be passed on to the patient. In this study, we evaluate Medicare charges and payments for minimally invasive lobectomy to obtain a sense of national billing practices and evaluate for predictors of higher charges. Methods: The 2018 Medicare Provider Utilization Data was queried to identify surgeons submitting charges for Video-Assisted Thoracoscopic Lobectomy. Excess charges were determined by each provider. Additional demographic variables were collected including geographic region for general surgery and cardiothoracic surgery training, years in practice, and current practice setting. A multivariate gamma regression was utilized to determine predictors of high billing practices. Results: A total of 307 unique providers submitted charges ranging from $1,104 to $25,128 with a median of $4,265. The average Medicare Payment amount ranged from $163 to $1,409, with a median of $1,056. Male surgeons were estimated to charge 1.3 times more than female surgeons, while those in an academic setting were estimated to charge 1.4 times more than private practice (p < 0.01). Surgeons practicing in the South or West were estimated to charge 0.76 and 0.81 times as much as those practicing in the Northeast (p < 0.01). Conclusions: Billing practices vary widely across the United States. Charges submitted to Medicare likely represent a provider's charges across all payers. In today's healthcare economy, it is important for patients to understand the true cost of care and for providers to be mindful of reasonable and appropriate charges. [ABSTRACT FROM AUTHOR]

Background:Telehealth and in-person behavioral health services have previously shown equal effectiveness, but cost studies have largely been limited to travel savings for telehealth cohorts. The purpose of this analysis was to compare telehealth and in-person cohorts, who received behavioral health services in a large multisite study of usual care treatment approaches to examine relative value units (RVUs) and payment. Methods:We used current procedural terminology codes for each encounter to identify RVUs and Medicare payment rates. Mixed linear regression models compared telehealth and in-person cohorts on RVUs, per-encounter payment rates, and total-episode payment rates. Results:We found the behavioral health services provided by telehealth to have modest, but statistically significantly lower RVUs (i.e., less provider work in time spent and case complexity), per-encounter payments, and total episode payments than the in-person cohort. Despite Medicare rates discounting payments for nonphysician providers and the in-person cohort using clinical social workers more frequently, the services provided by the telehealth cohort still had lower payments. Thus, the differences observed are due to the in-person cohort receiving higher payment RVU services than the telehealth cohort, which was more likely to receive briefer therapy sessions and other less expensive services. Conclusions:Behavioral health services provided by telehealth used services with lower RVUs than behavioral health services provided in-person, on average, even after adjusting for patient demographics and diagnosis. Observed differences in Medicare payments resulted from the provider type and services used by the two cohorts; thus, costs and insurance reimbursements may vary for others. [ABSTRACT FROM AUTHOR]

Total knee arthroplasty (TKA) is commonly considered to address symptomatically limiting knee osteoarthritis. With increasing utilization, understanding the variability and related drivers may help the healthcare system optimize delivery to the large numbers of patient to whom it is offered. A total of 1,066,327 TKA patients who underwent primary TKA were isolated from a 2010 to 2021 PearlDiver national dataset. Exclusion criteria included patients less than 18 years old and traumatic, infectious, or oncologic indications. Overall, 90-day reimbursements and variables associated with the patient, surgical procedure, region, and perioperative period were abstracted. Multivariable linear regressions were performed to determine independent drivers of reimbursement. The 90-day postoperative reimbursements had an average (standard deviation) of $11,212.99 ($15,000.62), a median (interquartile range) of $4,472.00 ($13,101.00), and a total of $11,946,962,912. Variables independently associated with the greatest increase in overall 90-day reimbursement were related to admission (in-patient index-procedure [+$5,695.26] or hospital readmission [+$18,495.03]). Further drivers were region (Midwest +$8,826.21, West +$4,578.55, South +$3,709.40; relative to Northeast), insurance (commercial +$4,492.34, Medicaid +$1,187.65; relative to Medicare), postoperative emergency department visits (+$3,574.57), postoperative adverse events (+$1,309.35), (P <.0001 for each). The current study assessed over a million TKA patients and found large variations in reimbursement/cost. The largest increases in reimbursement were associated with admission (readmission or index procedure). This was followed by region, insurance, and other postoperative events. These results underscore the necessity to balance performing out-patient surgeries in appropriate patients versus the risk of readmissions and defined other areas for cost containment strategies. [ABSTRACT FROM AUTHOR]

Access to specialty and private practice providers has been a divisive policy issue over the last decade, complicated by the conflict between a reduction in government-funded health care reimbursement and the need for health care providers to sustain a financially sound practice. This study evaluates the orthopedic spine consult service at an academic tertiary care center at 2 separate time points over a 5-year period to better understand the impact of decreasing orthopedic reimbursement rates and the increasing prevalence of federally supported medical insurance on the access to specialty care. In total 500 patients in 2017 and 480 patients in 2021 were included for the final analysis. A higher percentage of consults in 2021 came from the emergency department (74.0% versus 60.4%, P < 0.001); however, the emergency department saw fewer spinal cord injuries (11.9% versus 21.4%, P < 0.001), and the spinal cord injuries were less severe (3.1% versus 6.2% Association Impairment Scale A or B, P = 0.034). A smaller percentage of patients in 2021 went on to receive orthopedic spine surgery following consultation (35.2% versus 43.8%, P = 0.007), and those receiving surgery had an operation performed farther out from the initial consultation (4.73 versus 4.09 days, P < 0.001). Additionally, fewer patients with Medicare insurance (23.5% versus 30.8%) and more patients with Medicaid insurance (20.2% versus 12.4%) were seen in 2021 compared with 2017 (P = 0.003). Overall, this study found an increased proportion of Medicaid patients seen by the spine consult service but a decrease in the acuity of consults. Measures to improve access to health insurance under the Affordable Care Act have revealed the complexity of this issue in health care. This study's findings have demonstrated that while more patients did have insurance coverage following the Affordable Care Act, they still face a barrier to accessing outpatient orthopedic spine providers. [ABSTRACT FROM AUTHOR]

This article discusses the notary's responsibility for the loss of land certificates due to the notary's negligence. The purpose of this study is to find out Notary Responsibility for Loss of Land Title Due to Notary Negligence. This research uses normative or literature research methods by analyzing relevant laws and regulations regarding the authority and responsibilities of notaries. The research results show that notaries have civil liability for losses caused by negligence or deliberate action in carrying out their duties. This civil liability includes reimbursement of costs, compensation and interest to the party who feels aggrieved. Notaries also have a professional code of ethics that regulates their duties and responsibilities, including the obligation to safeguard the interests of related parties and act with integrity. In the case of loss of a land title certificate, the notary must be responsible for the documents entrusted and may be subject to civil sanctions if negligence occurs. [ABSTRACT FROM AUTHOR]

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Hospitals throughout the developed world are reimbursed based on diagnosis-related groups (DRGs). Under this scheme, patients are divided into clinically meaningful groups, and hospitals receive a fixed fee per patient episode tied to the patient DRG. The fee is based on the average cost of providing care to patients who belong to the same DRG across all hospitals. This scheme, sometimes referred to as "yardstick competition," provides incentives for cost reduction, as no hospital wants to operate at a higher cost than average, and can be implemented using accounting data alone. Nevertheless, if costs within a DRG are heterogeneous, this scheme may give rise to cherry-picking incentives, where providers "drop" patients who are more expensive to treat than average. To address this problem, regulators have tried to reduce within-DRG cost heterogeneity by expanding the number of DRG classes. In this paper, we show that even if cost heterogeneity is eliminated, such expansion will fail to completely eliminate patient cherry picking. In equilibrium, the market will bifurcate into two groups, one of which will continue to cherry-pick patients and underinvest in cost reduction, whereas the other group treats all patients. Furthermore, we show that DRG expansion is particularly problematic if hospitals are also able to "upcode" patients, that is, intentionally assign patients to a more resource-intensive DRG than needed to increase income. Upcoding increases within-DRG cost heterogeneity and amplifies cherry-picking incentives. We examine potential solutions involving yardstick competition based on input statistics. This paper was accepted by Carri Chan, healthcare management. Supplemental Material: The online appendices are available at https://doi.org/10.1287/mnsc.2023.4752. [ABSTRACT FROM AUTHOR]

The collaborative care model (CoCM) is an effective strategy to manage common mental disorders in primary care. Despite the growing adoption of newer CoCM billing codes to support these programs, few studies have investigated the use of these codes. This column evaluated the implementation of CoCM billing codes by comparing clinics using different billing strategies and assessed the impact of CoCM code implementation on revenue and on clinical and process-of-care outcomes. Qualitative data were obtained to understand provider perspectives. The results indicate that CoCM billing code implementation is operationally feasible, does not adversely affect the delivery of patient care or revenue, and is acceptable to providers. [ABSTRACT FROM AUTHOR]

Aim: To evaluate healthcare provider awareness and uptake of the Centers for Medicare & Medicaid Services (CMS) billing for coronavirus disease 2019 (COVID‐19) prevention counselling and the delivery of prevention counselling to patients awaiting severe acute respiratory syndrome coronavirus 2 test results. Design: Cross sectional survey of US‐based healthcare providers in February 2021. Methods: Analysis of associations with healthcare provider‐reported awareness of CMS prevention counselling guidance and billing with provider type, specialty, and work setting. Results: A total of 1919 healthcare providers responded to the survey. Overall, 38% (726/1919) of providers reported awareness of available CMS reimbursement for COVID‐19 patient counselling and 29% (465/1614) of CMS billing‐eligible providers reported billing for this counselling. Among physicians, those aware of CMS guidance were significantly more likely to bill (58%) versus those unaware (10%). Among RNSights respondents eligible for CMS billing (n = 114), 31% of those aware of the guidance reported billing as compared to 0% of those not aware. [ABSTRACT FROM AUTHOR]

Purpose: Inconsistent results have been found on the impact of using crosswalks versus EQ-5D value sets on reimbursement decisions. We sought to further investigate this issue in a simulation study. Methods: Trial-based economic evaluation data were simulated for different conditions (depression, low back pain, osteoarthritis, cancer), severity levels (mild, moderate, severe), and effect sizes (small, medium, large). For all 36 scenarios, utilities were calculated using 3L and 5L value sets and crosswalks (3L to 5L and 5L to 3L crosswalks) for the Netherlands, the United States, and Japan. Utilities, quality-adjusted life years (QALYs), incremental QALYs, incremental cost-effectiveness ratios (ICERs), and probabilities of cost-effectiveness (pCE) obtained from values sets and crosswalks were compared. Results: Differences between value sets and crosswalks ranged from −0.33 to 0.13 for utilities, from −0.18 to 0.13 for QALYs, and from −0.01 to 0.08 for incremental QALYs, resulting in different ICERs. For small effect sizes, at a willingness-to-pay of €20,000/QALY, the largest pCE difference was found for moderate cancer between the Japanese 5L value set and 5L to 3L crosswalk (difference = 0.63). For medium effect sizes, the largest difference was found for mild cancer between the Japanese 3L value set and 3L to 5L crosswalk (difference = 0.06). For large effect sizes, the largest difference was found for mild osteoarthritis between the Japanese 3L value set and 3L to 5L crosswalk (difference = 0.08). Conclusion: The use of crosswalks instead of EQ-5D value sets can impact cost–utility outcomes to such an extent that this may influence reimbursement decisions. [ABSTRACT FROM AUTHOR]

Introduction: Our objective was to analyze and compare systematically and structurally reimbursement systems in Poland and other countries. Methods: The systems were selected based on recommendations issued by the Polish Agency for Health Technology Assessment and Tariffication (AHTAPol), which explicitly referred to other countries and agencies). Consequently, apart from Poland, the countries included in the analysis were England, Scotland, Wales, Ireland, France, Netherlands, Germany, Norway, Sweden, Canada, Australia and New Zealand. Relevant information and data were collected through a systematic search of PubMed (Medline), Embase and The Cochrane Library as well as competent authority websites and grey literature sources. Results and discussion: In most of the countries, the submission of a reimbursement application is initiated by a pharmaceutical company, and only a few countries allow it before a product is approved for marketing. All of the agencies analyzed are independent and some have regulatory function of reimbursement decision making body. A key criterion differentiating the various agencies in terms of HTA is the cost-effectiveness threshold. Most of the countries have specific mechanisms to improve access to expensive specialty drugs, including cancer drugs and those used for rare diseases. Reimbursement systems often lack consistency in appreciating the same stages, leading to heterogeneous decision-making processes. The analysis of recommendations issued in different countries for the same medicinal product will allow a better understanding of the relations between the reimbursement system, HTA assessment, stakeholders involvement and decision on reimbursement of innovative drugs. [ABSTRACT FROM AUTHOR]

Community pharmacists form a vital part of the health system all around the globe. Pharmacy remuneration models are aimed to ensure that pharmacies are sustained, and pharmacists could provide cost-effective services to the patients. This review summarizes the pharmacy services remuneration systems from different parts of the globe. Some countries have well-established reimbursement systems that recognize and compensate community pharmacies for their services, others are in the process of expanding the scope of reimbursable services. It further concludes by highlighting the ongoing efforts to incorporate pharmacist-provided services into reimbursement schemes and the need for standardized and consistent approaches to pharmacy remuneration globally. [ABSTRACT FROM AUTHOR]

Many interventional radiologists express concern about communicating their practice needs to their radiology department chairs. As a result, they may have difficulty getting support for hiring of additional physicians and staff, capital investments in equipment, and marketing of IR services. Some perceive that chairs have a preference for diagnostic radiology initiatives over interventional and want to know why. More importantly, they want to know how to approach their chair and succeed in their advocacy for IR. The key to success is understanding the perspective of the chair and the pressures and demands they face. That understanding allows the IR to propose their initiatives in a form that helps address some of the chair's needs and thus eases their path to success. [ABSTRACT FROM AUTHOR]

This article explores the complex issue of medical marijuana reimbursement in workers' compensation claims. Despite marijuana being federally illegal, many states have legalized it for medical or adult use. The article discusses the varying approaches of different states regarding reimbursement, with some allowing it, some disallowing it, and others being undecided. The U.S. Supreme Court recently declined to review the issue, leaving it up to individual states to decide. The article provides examples of states that permit reimbursement and highlights the importance of state legislation and interpretation in determining whether reimbursement is allowed. It also notes the growing trend of states permitting reimbursement for medical marijuana in workers' compensation cases. [Extracted from the article]

Background: In April 2020, pharmacists were added as medical providers under Idaho Medicaid in response to recent scope expansion for pharmacists and to increase beneficiaries' access to coronavirus disease 2019 (COVID-19) testing and services. The COVID-19 pandemic prompted expedited Medicaid enrollment for pharmacists but did not address coverage of medical services provided to privately insured individuals for pharmacy-based testing services. Objective: This study aimed to describe processes used by independently owned, community-based pharmacies in Idaho to credential with private insurers and report outcomes. Methods: Relevant information and forms required to credential with the four major payers in the state of Idaho were collected. Packets were obtained via medical insurers' websites and by direct contact. Questions that arose from community pharmacists during the submission process were collected and answered on a shared spreadsheet, and insurance representatives were contacted directly to resolve questions. Results: Eight out of 13 participating pharmacies submitted an average of three credentialing packets for their facilities. Thirty-five pharmacists also submitted an average of four credentialing packets for themselves. As of mid-May 2021, nearly 20 weeks after submission, only 67 out of 129 pharmacists had received word regarding the status of their applications. Less than half of all pharmacist applications were approved (after their first attempt). Conclusion: Efforts to support the education of both pharmacists and medical insurers may streamline the credentialing processes in the future. [ABSTRACT FROM AUTHOR]

Access to biomolecular technologies has become an essential requirement to ensure optimal and timely treatment of patients with cancer. This study sought to provide a comprehensive overview of the availability and accessibility of biomolecular technologies to patients, the status of their use and prescription, barriers to access, and potential economic issues related to cost and reimbursement. A total of 201 field reporters from 48 European countries submitted data through an electronic survey tool between July and December 2021. The survey methodology mirrored that from previous ESMO studies addressing the availability and accessibility of antineoplastic medicines, in Europe and worldwide. The preliminary data were posted on the ESMO website for open peer-review, and amendments were incorporated into the final report. Overall, basic single-gene techniques are widely available, whereas access to advanced biomolecular technologies, including large next-generation sequencing panels and complete genomic profiles, is highly heterogeneous. In most countries, advanced biomolecular technologies remain largely inaccessible in clinical practice, are limited to clinical trials or basic research, and associated with progressively increasing cost as the technique becomes more advanced. Differences also exist regarding national sequencing initiatives or molecular tumour boards. The most important barriers to multiple versus single-gene sequencing techniques are the reimbursement of the test (59% versus 24%), and the availability of a suitable medicine, either through reimbursement of treatment (48% versus 30%), off-label treatment (52% versus 35%), or clinical trial enrolment (53% versus 39%). Cost and availability of both treatment and test are the two main factors limiting patients' access to advanced biomolecular technologies and as a consequence to innovative anticancer strategies. In the era of precision medicine, tackling the accessibility to biomolecular technologies is a key step to reduce inequalities to transformative cancer care. • Access to biomolecular technologies is essential to ensure optimal and timely treatment of patients with cancer. • Challenges to access to biomolecular technologies limit patient access to targeted and innovative medicines. • This study provides an overview of availability, accessibility, and costs of genomic testing in oncology in Europe. • It highlights existing disparities in access to biomolecular technologies across countries in Europe. • ESMO aims at reducing inequalities and increasing access to cost-effective biomolecular technologies and relevant therapies. [ABSTRACT FROM AUTHOR]

Aim: The aim of the manuscript is to discuss and assess the implications and opportunities as well as dangers of "outpatientization" of surgical and inpatient services for general and abdominal surgery. Method: Narrative overview with literature reference based on a PubMed search with the search terms: outpatient operations and inpatient interventions, AOP catalog, hybrid DRG, outpatient hernia surgery, outpatient proctological surgery, selective sector-equal reimbursement and day-care forms of care. Results (key points): – In the Anglo-American area, the treatment of inguinal hernias is predominantly carried out on an outpatient clinic basis. In the USA, Sweden and Denmark, for example, over 70% of all hernias are treated in an outpatient clinic setting, in Germany it is only 20%. In Germany, the catalog of operations that can be performed on an outpatient basis and other department-replacing interventions in hospitals defines outpatient interventions in accordance with § 115b Social Security Code (SGB) V (Germany). – The conversion from inpatient to outpatient hernia surgery has also failed so far due to an enormous difference in revenues. According to the will of the Federal Ministry of Health, the planned forms of semistationary care are intended to relieve the nursing staff in the hospitals and thus relieve the tense situation of nursing professionals. By the end of March 2023, a special industry-specific reimbursement, so-called hybrid DRGs, is to be agreed, which applies regardless of whether a paid service is provided on an outpatient or inpatient basis. – According to § 115b SGB V, whether a hernia can be performed under inpatient or outpatient conditions is also decided according to the location of the hernia. In the new AOP catalog, frailty is operationalized in the context factors via the degree of care and the Barthel index. If one compares the number of encryption procedures for the 5‑530 procedure (closure of an inguinal hernia) in 2005 (184,679) with the pre-corona year 2019 (179,851), it can be seen that the proportion of hernias treated in hospital remained approximately the same over a period of 14 years. – Most elective proctological procedures can be performed on an outpatient basis. For reasons of safety (bleeding) and practicality (pain management, dressing change of large abscesses), inpatient surgery is preferred: extensive hemorrhoidectomy in the case of massive findings, large abscesses, extensive perianal fistula corrections, particularly high transsphincteric or suprasphincteric fistulas. – Guidelines based on the British Guidelines for Ambulant Surgery should be required for comprehensive outpatient treatment in surgery. The introduction of corresponding hybrid DRGs seems to be the right way to cover the costs of outpatient surgery in hospitals. Conclusion: The restructuring of the hospital landscape and the nationwide expansion of outpatient operations is an unavoidable requirement in view of rising costs in the healthcare system and impending financing bottlenecks, which will pose challenges for the surgical disciplines in the years to come. Outpatient surgery is already practiced in many areas but has not become established due to the different remuneration. The flat rates for the same branches can be a starting point here. Furthermore, evidence-based framework conditions must be created along the lines of the British Guidelines for Ambulant Surgery. [ABSTRACT FROM AUTHOR]

In 2016, Minnesota implemented a new pay-for-performance reimbursement scheme for Medicaid residents in nursing homes, known as Value-Based Reimbursement (VBR). This study seeks to understand whether there is an association between VBR and quality improvement. We use data from 2013 to 2019 including Centers for Medicare and Medicaid Services, Nursing Home Compare, and Long-term care Facts in the US. Using multivariate regression with commuting zone fixed effects, we compare five long-stay and two short-stay clinical quality metrics in Minnesota nursing homes to nursing homes bordering states, before and after VBR was implemented. We find minimal significant changes in quality in Minnesota nursing homes after VBR. Minnesota should reconsider its pay-for-performance efforts. [ABSTRACT FROM AUTHOR]

Bundled payment models require risk adjustment to ensure appropriate targets are set. While this may be standardized for many services, spine fusions demonstrate significant variability in approach, invasiveness, and use of implants, that may require further risk adjustment. To evaluate variability in costs of spinal fusion episodes in a private insurer bundle payment program and identify whether current procedural terminology (CPT) code modifications are necessary for sustainable implementation. Retrospective single-institution cohort study. A total of 542 lumbar fusion episodes in a private insurer bundled payment program from October 2018 to December 2020. A total of 120-day episode of care net surplus/deficit, 90-day readmissions, discharge disposition, and length of hospital stay. A review was conducted of all lumbar fusions in a single institution's payer database. Surgical characteristics (approach [posterior lumbar decompression and fusion (PLDF), transforaminal lumbar interbody fusion (TLIF), and circumferential fusion], levels fused, and primary vs revision) were collected from manual chart review. Episode of care cost data were collected as net surplus or deficit with respect to target prices. A multivariate linear regression model was constructed to measure the independent effects of primary versus revision, levels fused, and approach on the net cost savings. Most procedures were PLDFs (N=312, 57.6%), single-level (N=416, 76.8%) and primary fusions (N=477, 88.0%). Overall, 197 (36.3%) resulted in a deficit, and were more likely to be three levels (7.11% vs 2.03%, p=.005), revisions (18.8% vs 8.12%, p<.001), and TLIF (47.7% vs 35.1%, p<.001) or circumferential fusions (p<.001). One-level PLDFs resulted in the greatest cost savings per episode ($6,883). Across both PLDFs and TLIFs, 3-level procedures resulted in significant deficit of −$23,040 and −$18,887, respectively. For circumferential fusions, 1-level fusions resulted in deficit of −$17,169 per case which rose to −$64,485 and −$49,222 for 2- and 3-level fusions. All 2- and 3-level circumferential spinal fusions resulted in a deficit. On multivariable regression, TLIF and circumferential fusions were independently associated with a deficit of −$7,378 (p=.004) and −$42,185 (p<.001), respectively. Three-level fusions were independently associated with an additional −$26,003 deficit compared to single-level fusions (p<.001). Interbody fusions, especially circumferential fusions, and multi-level procedures are not adequately risk adjusted by current bundled payment models. Health systems may not be able to financially support these alternative payment models with improved procedure-specific risk adjustment. [ABSTRACT FROM AUTHOR]

One of the biggest hurdles to widespread adoption of new procedures and technology such as artificial intelligence (AI) algorithms is payment and coverage policy. Noninvasive assessment of coronary fractional flow reserve is one AI imaging algorithm that will successfully achieve reimbursement through multiple pathways of CMS payment mechanisms in 2024. CMS is the largest provider of health care in the United States. Understanding how this AI algorithm is paid through the different fee schedules will help to understand the challenges CMS has in paying for new services and innovation in the United States. [ABSTRACT FROM AUTHOR]

The Medicare program, by law, must remain budget neutral. Increases in volume or relative value units (RVUs) for individual services necessitate declines in either the conversion factor or assigned RVUs for other services for budget neutrality. This study aimed to assess the contribution of budget neutrality on reimbursement trends per Medicare fee-for-service beneficiary for services provided by radiologists. The study used aggregated 100% of Medicare Part B claims from 2005 to 2021. We computed the percentage change in reimbursement per beneficiary, actual and inflation adjusted, to radiologists. These trends were then adjusted by separately holding constant RVUs per beneficiary and the conversion factor to demonstrate the impact of budget neutrality. Unadjusted reimbursement to radiologists per beneficiary increased 4.2% between 2005 and 2021, but when adjusted for inflation, it declined 24.9%. Over this period, the conversion factor declined 7.9%. Without this decline, the reimbursement per beneficiary would have been 9 percentage points higher in 2021 compared with actual. RVUs per beneficiary performed by radiologists increased 13.1%. Keeping RVUs per beneficiary at 2005 levels, reimbursement per beneficiary would have been 12.1 percentage points lower than observed in 2021. Given budget neutrality, a substantial decline has occurred in inflation-adjusted reimbursement to radiologists per Medicare beneficiary. Decreases due to both inflation and the decline in conversion factor are only partially offset by increased RVUs per beneficiary, meaning more services per patient with less overall pay, an equation likely to heighten access challenges for Medicare beneficiaries and shortages of radiologists. [ABSTRACT FROM AUTHOR]

The Bureau of National Health Insurance in Taiwan implemented a new reimbursement scheme incorporating bone mineral density (BMD) criteria on Jan. 1, 2011. This study aimed to investigate a real-life 11-year secular trend of adherence in new AOMs users and evaluated the change of adherence to AOMs therapy in different urbanization areas after reimbursement criteria were restrained. We used Taiwan's National Health Insurance Research Database to identify new AOMs users as our study population. The AOMs in this study included denosumab, zoledronate, ibandronate, alendronate, raloxifene, and risedronate. The first prescription date of AOMs was defined as the cohort entry date. The adherence rates within one year after initiation were assessed. High adherence (≥75%) in the first year increased markedly after the new reimbursement scheme in 2011, changing from 31.8% in 2008, and 41.7% in 2011 to 54.2% in 2018. On the other hand, low adherence (<25%) decreased from 38.8% in 2008 to 14.6% in 2018. In addition, the switchers increased from 5.9% in 2008 to 9.3% in 2018, indicating a more flexible choice of AOMs. The proportion of high adherence to AOMs was highest in high-urbanization areas, and the proportion increased about two times from 30% in 2008 to 60% in 2018. The implementation of new reimbursement criteria in 2011 was associated with increased adherence to AOMs and the increase was most apparent in high-urbanization areas. [ABSTRACT FROM AUTHOR]

This study aims to identify and classify the costing methods used in hospitals in recent decades and to analyze the research carried out in this area, to identify and characterize the main lines of research and the research paradigms used. To this end, a systematic literature review was carried out, mapping 1067 articles collected from the ISI Web of Science and Scopus databases. The articles were selected by two independent researchers. To ensure the quality of the SLR, AMSTAR 2 was used as well as matrices for quantitative studies, and for qualitative articles. Additionally, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review process was followed to systematize the article selection process. Of the 1067 articles screened, 172 articles met the inclusion criteria. The results point to a growing interest among researchers and a predominance of the positive paradigm, albeit with an increase in interpretative research. There is a growing production of descriptive analyses of hospital processes and the costing of pathologies, with a predominance of the ABC method and analyses of costs and reimbursements for diagnosis-related groups. As a contribution, a conceptual model is proposed that aims to help the performance of hospital institutions, as well as a proposal for a future agenda based on this model. [ABSTRACT FROM AUTHOR]

As a result of an increasing focus on patient-centered care within oncology and more pressure on the sustainability of health-care systems, the discussion on what exactly constitutes value re-appears. Policymakers seek to improve patient values; however, funding all values is not sustainable. We collect available evidence from scientific literature and reflect on the concept of value, the possible incorporation of a wide spectrum of values in reimbursement decisions, and alternative strategies to increase value in oncological care. We state that value holds many different aspects. For reimbursement decisions, we argue that it is simply not feasible to incorporate all patient values because of the need for efficient resource allocation. We argue that we should shift the value debate from the individual perspective of patients to creating value for the cancer population at large. The different strategies we address are as follows: (1) shared decision-making; (2) biomarkers and molecular diagnostics; (3) appropriate evaluation, payment and use of drugs; (4) supportive care; (5) cancer prevention and screening; (6) monitoring late effect; (7) concentration of care and oncological networking; and (8) management of comorbidities. Important preconditions to support these strategies are strategic planning, consistent cancer policies and data availability. [ABSTRACT FROM AUTHOR]

This article provides a discussion of the proposed Medicare physician fee schedule (MPFS) published by the Centers for Medicare & Medicaid Services (CMS) in July 2023, which will negatively impact dermatology practices starting in 2024. An overview of physician payment policy, legislative updates affecting dermatology, and the overall outlook for 2024 for dermatologists also is presented. [ABSTRACT FROM AUTHOR]

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Self-directed care (SDC) is a treatment model in which recipients self-manage funds designated for provision of services. The model is designed to cost no more than traditional services while achieving superior participant outcomes. The authors examined the model's impact on outcomes, service costs, and user satisfaction among medically uninsured, low-income individuals with serious mental illness. Adults in the public mental health system (N=42) were randomly assigned (1:1) to receive SDC or services as usual and were assessed at baseline and 6- and 12-month follow-ups. Outcomes included perceived competence for mental health self-management, met and unmet needs, degree of autonomy support, self-perceived recovery, and employment. Mixed-effects random regression analysis tested for differences in longitudinal changes in outcomes between the two study conditions. Differences in service costs were analyzed with negative binomial regression models. Compared with individuals in the control condition, SDC participants reported greater improvement in perceived competence, met and unmet needs, autonomy support, recovery from symptom domination, and employment. No differences were found between the two groups in total per-person service costs or costs for individual services. The most frequent nontraditional purchases were for medical, dental, and vision services (33%) and health and wellness supports (33%). Satisfaction with SDC services was high. Mental health SDC services achieved participant outcomes superior to treatment as usual, with equivalent service use and costs and high user satisfaction. This model may be well suited to the needs of uninsured adults with low income who receive public behavioral health care. [ABSTRACT FROM AUTHOR]

This article discusses a recent decision by the Austrian Supreme Court regarding the European Works Council's ability to hire experts for support. The court clarified that the European Works Council is not required to obtain free legal advice from interest groups and has the right to choose the expert it commissions. The court emphasized that the costs incurred must be proportionate and appropriate. The article also includes comments from legal experts in Germany and Ireland, highlighting the importance of communication and agreement between the parties before engaging an expert. [Extracted from the article]

Background: Affordability and accessibility of hospital care are under pressure. Research on hospital care financing focuses primarily on incentives in the financial system outside the hospital. It is notable that little is known about (incentives in) internal funding in hospitals. Therefore, our study focuses on the budget allocation in hospitals: the distribution model. Based on our hypothesis that the reimbursement and distribution models in hospitals might interact, we gain knowledge about-, and insight into, the interaction of different reimbursement and distribution models used in Dutch hospitals, and how they affect the financial output of hospital care. Methods: An online survey with 22 questions was conducted among financial senior management as an expert group in 49 Dutch hospitals. Results: Ultimately, 38 of 49 approached experts fully completed the survey, which amounts to 78% of the hospitals we approached and 60% of all Dutch hospitals. The results on the reimbursement model indicate price * volume with adjusted prices above a maximum cap as the most common dominant contract type. On the internal distribution model, 75–80% of the experts reported incremental budgeting as the dominant budgeting method. Results on the interaction between the reimbursement and the distribution model show that both general and specific changes in contract agreements are only partially incorporated in hospital budgets. In 28 out of 31 hospitals with self-employed medical specialists, a relation is reported between the reimbursement model and the contracts with the Medical Consultant Group(s) in which the medical specialists are united. Conclusions: Our results in Dutch setting indicate a limited interaction between the reimbursement model and the distribution model. This lack of congruence between both models might limit the desired effects of incentives in contractual agreements aimed at the financial output. This applies to different reimbursement and distribution models. Further research into the various interactions and incentives, as visualized in our conceptual framework, could result in evidence-based advice for achieving affordable and accessible hospital care. [ABSTRACT FROM AUTHOR]

Introduction: Pathogen inactivation (PI) utilizing amotosalen and UVA light (INTERCEPT® Blood System) is a well-established method for the production of safer platelet concentrates (PCs). While many studies describe clinical and logistical benefits of PI, the implications and potential challenges from a hospital management perspective have not yet been analyzed – health economic analyses considering reimbursement of PI are lacking. The objective of this analysis was to examine the real-life inpatient treatment costs from a hospital perspective and to assess the economic impact of PI-PC versus conventional PC (CONV-PC) administration in Germany. Methods: Real-life cost data for inpatient cancer cases from 2020 of the University Hospital Cologne were identified by operating and procedure codes. The German diagnosis-related groups, extra fees, case mix index (CMI), length of stay (LOS), and average resource consumption of PC were evaluated from a micro-management perspective. The potential economic impact of implementing PI-treated PCs was modeled retrospectively. Results: In total, 951 inpatient cases were analyzed (CMI [median 4.7–9.9], LOS [median 26 days], number of cases in intensive care units [38%]). The median DRG fee was between EUR 13,800 and EUR 26,400. According to our model, the use of PI-PC compared to CONV-PC would result in savings between EUR 184 and EUR 306 per case. Conclusion: From a hospital management perspective, oncological cases requiring PC transfusion are associated with a high CMI (reimbursement per DRG flat fee) and moderate costs with sufficient add-on payment for PI on a case level. Investment and process costs for PI implementation can be analyzed for site-specific scenarios. [ABSTRACT FROM AUTHOR]

This paper reviews the main pricing policies in Latin American countries, discussing their shortcomings. It also gives an overview of the most common pricing and reimbursement policies in Europe and describes in detail three well-established approaches — international price referencing, value-based pricing, including setting up of health technology assessment, and generic and biosimilar policies — building on country examples. [ABSTRACT FROM AUTHOR]

Pharmaceutical systems are frequently characterized by fragmentation, and competences for outpatient and inpatient sectors sit with different authorities, payers, and purchasers. This fragmentation of responsibilities can incentivize shifting expensive therapies and thus patients from one sector to the other. Reimbursement and procurement policies in Europe addressing unwanted consequences of this fragmentation were identified through literature reviews and surveys with policy-makers. Good practice examples include cross-sectorial reimbursement lists managed by committees with representatives from the outpatient and hospital sectors, specific funding mechanisms, joint procurement involving purchasers from both sectors, actions against procurement contracts prohibiting generic competition, and an extension of Health Technology Assessment to the hospital sector. Recognizing fragmentation as a major challenge for pharmaceutical systems, policy-makers in some countries reacted by implementing policies to support cross-sectorial collaboration. However, only a handful of good practice examples exist for reimbursement and procurement policies in Europe. Though robust evaluations are lacking, there are indications that pharmaceutical policies which ensure collaboration at the interface of the outpatient and inpatient sectors would likely result in efficiency gains and better use of public budgets and may serve as lever to improve access to medicines. In several European countries, the decision which medicines are funded by public money (reimbursement) and purchased by public institutions (public procurement) is taken independently for the outpatient sector and the hospital sector. There are different payers and procurers per sector, and even within a sector. Patients may be transferred between the sectors for financial reasons because one payer aims to shift the financial burden for the medication to the other sector. Policy-makers have understood the importance of better collaboration between the sectors, and some European countries introduced policies addressing the issue. The article presents examples of how reimbursement and procurement policies can be designed to improve the collaboration between the outpatient and hospital sectors. Committees that decide whether or not a medicine should be covered may contain representatives from both sectors; they may be mandated to take decisions that apply to medicines for outpatient use and administered in hospitals. Purchasers of both sectors may procure jointly a medicine. Supporting tools, such as the assessment of a medicine to support the decision on coverage and the price, may be used in both sectors. Financing solutions can reduce the incentive for one sector to shift a medicine to the other sector. These measures can help that patients gain improved access to affordable medicines. However, despite the introduction of such interface policies in some countries, policy-makers still need to continue working on overcoming the fragmentation in the pharmaceutical system. [ABSTRACT FROM AUTHOR]

Community pharmacists' roles have expanded in recent years to include offering test and treat programs where they perform testing on Clinical Laboratory Improvement Amendment (CLIA)‐waived point‐of‐care testing (POCT) devices to diagnose specific acute infectious conditions, such as influenza and group A streptococcus (GAS) pharyngitis, and then potentially prescribe and dispense appropriate antimicrobials. Availability of these services in pharmacies has several benefits, including increased access to care, decreased overutilization of other health care services, and decreased antimicrobial resistance. States have different requirements for collaborative practice agreements and reimbursement for these clinical services in community pharmacies. Several studies have looked at outcomes related to community pharmacies implementing test and treat programs for influenza and/or GAS. Other studies looked at outcomes related to implementing testing for SARS‐CoV‐2 and referring for treatment. Most studies described successful implementation and barriers to integration of these programs into pharmacy workflow. Some studies showed that patients want these services to be offered in community pharmacies and are willing to pay for the services. Data show that these services are cost effective compared to physician provider‐based treatment. Newer CLIA‐waived POCT technology may increase implementation of these services, but studies are needed to evaluate their utility in community pharmacies. Pharmacy schools should implement widespread training on these devices, and research should continue in this area to test the use of newer technology (i.e., multiplexed devices) and their economic impact. [ABSTRACT FROM AUTHOR]

The Certified Community Behavioral Health Clinic (CCBHC) demonstration is designed to increase access to comprehensive ambulatory care and crisis services, which may reduce emergency department (ED) visits and hospitalizations. This study examined whether the demonstration had an impact on ED visits and hospitalizations in Missouri, Oklahoma, and Pennsylvania. This difference-in-differences analysis used Medicaid claims data from 2015 to 2019 to examine service use during a 12-month baseline period and the first 24 months of the demonstration for beneficiaries who received care from CCBHCs and beneficiaries who received care from other behavioral health clinics in the same state, representing care as usual. Propensity score methods were used to develop treatment and comparison groups with similar characteristics. In Pennsylvania and Oklahoma, beneficiaries who received care from CCBHCs had a statistically significant reduction in the average number of behavioral health ED visits, relative to the comparison group (13% and 11% reductions, respectively); no impact on ED visits in Missouri was observed. The demonstration was associated with a statistically significant reduction in all-cause hospitalizations in Oklahoma, when the analysis used a 2-year rather than a 1-year baseline period, and also in Pennsylvania, when hospitalizations were truncated at the 98th percentile to exclude beneficiaries with outlier hospitalization rates. The CCBHC demonstration reduced behavioral health ED visits in two states, and the study also revealed some evidence of reductions in hospitalizations. [ABSTRACT FROM AUTHOR]

Managed entry agreements are applied in almost all European countries in order to improve patients' access to therapy. The current study aims to evaluate the changes in the affordability of biological medicines for patients in Bulgaria during 2019–2022. The study is a top-down macroeconomic analysis of the key economic indicators and reimbursed costs of biologic therapies. Affordability was determined as the number of working hours needed to pay for monthly therapy. The average NHIF budget for pharmaceuticals increased significantly along with inflation in the healthcare sector. Bulgarian patients had to devote a large part of their income to buying medicines if a co-payment existed. The percentage of the monthly income of pensioners needed for therapy co-payment varied between 10% and 280%. The hours of work required to purchase a package of biologicals varied between 7 and 137 working hours. The global economic crisis has affected Bulgaria and led to worsening economic parameters. There are still no well-established practices to control public spending, as the measures taken to reduce the final cost of medicines mainly affect the pharmaceutical companies. This type of cost-containment policy provides an opportunity for innovative treatment with biologicals for patients with inflammatory diseases. Most of the therapies cost more than the patients' monthly income. [ABSTRACT FROM AUTHOR]

The rapid growth of Lifestyle Medicine (LM) and Value-Based Care (VBC) are occurring simultaneously yet are not fully aligned in the minds of key stakeholders. Both focus on bending the healthcare cost curve by improving patient outcomes, providing greater access to chronic disease risk reduction services and in the case of LM, driving toward chronic disease remission and reversal. Both require strong physician engagement to be effective and will greatly benefit from thoughtful use of digital health technologies. In this review, key focus areas will be highlighted as foundational aspects in which LM is synonymous with high-value care. Continued efforts in these key areas will ensure that LM becomes the foundation for VBC. [ABSTRACT FROM AUTHOR]