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Objective: To determine if Medicare Shared Savings Program Accountable Care Organizations (ACOs) using cost reduction measures in specialist compensation demonstrated better performance., Data Sources: National, cross-sectional survey data on ACOs (2013-2015) linked to public-use data on ACO performance (2014-2016)., Study Design: We compared characteristics of ACOs that did and did not report use of cost reduction measures in specialist compensation and determined the association between using this approach and ACO savings, outpatient spending, and specialist visit rates., Principal Findings: Of 160 ACOs surveyed, 26 percent reported using cost reduction measures to help determine specialist compensation. ACOs using cost reduction in specialist compensation were more often physician-led (68.3 vs 49.6 percent) and served higher-risk patients (mean Hierarchical Condition Category score 1.09 vs 1.05). These ACOs had similar savings per beneficiary year (adjusted difference $82.6 [95% CI -77.9, 243.1]), outpatient spending per beneficiary year (-24.0 [95% CI -248.9, 200.8]), and specialist visits per 1000 beneficiary years (369.7 [95% CI -9.3, 748.7])., Conclusion: Incentivizing specialists on cost reduction was not associated with ACO savings in the short term. Further work is needed to determine the most effective approach to engage specialists in ACO efforts., (© Health Research and Educational Trust.)

Background: External reference pricing (ERP) is widely used to regulate pharmaceutical prices and help determine reimbursement. Its implementation varies substantially across countries, making it difficult to study and understand its impact on key policy objectives., Objectives: To assess the evidence on ERP in different settings and its impact on key health policy objectives, notably, cost-containment, pharmaceutical price levels, drug use, equity, efficiency, availability, affordability and industrial policy; and second, to critically assess the quality of evidence on ERP., Methods: Primary and secondary data collection through a survey of leading experts and a systematic literature review, respectively, over the 2000-2017 period., Results: Forty five studies were included in the systematic review (January 2000-December 2016). Primary evidence was gathered via survey distribution to experts in 21 countries (January-July 2017). ERP contributes to cost-containment, but this is a short-term effect highly dependent on the way ERP is designed and implemented. Low prices, as a result of ERP, can undermine the availability of medicines and lead to launch delays or product withdrawals. Downward price convergence can hamper investment in innovation. ERP does not seem to promote efficiency in achieving health system goals. As evidence is weak, results need to be interpreted with caution., Conclusions: ERP has not regulated prices efficiently and has unintended consequences that reduce the benefits arising from it. If ERP is carefully designed with minimal price revisions, prudent selection of basket size and countries, and consideration of transaction prices, it could be a more effective mechanism enhancing welfare, equitable access to medicines within countries and help promote industry innovation.

In 2012, China's first diagnosis-related group (DRG) payment system was piloted in Beijing. This study explored whether this payment pilot improved quality and reduced costs of acute myocardial infarction (AMI) care in hospitals implementing DRG payment as compared to control hospitals. A difference-in-difference study design was used with regression and considered several quality indicators including aspirin at arrival, aspirin at discharge, β-blocker at arrival, β-blocker at discharge, statin at discharge, in-hospital mortality, and 30-day readmission rates. DRG payment mechanisms without specific mechanisms to promote care quality did not improve quality of AMI care. Future studies should study the impact of cost control mechanisms together with quality improvement efforts to assess how quality of care may be improved within the Chinese healthcare system. These lessons would be helpful to share with lower-middle-income countries undergoing rapid development that are transitioning to a significantly higher burden of non-communicable diseases., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Preoperative testing before low-risk procedures remains overutilised. Few studies have looked at factors leading to increased testing. We hypothesised that consultation to a cardiologist prior to a low-risk procedure leads to increased cardiac testing., Methods and Results: 907 consecutive patients who underwent inpatient endoscopy/colonoscopy at a single academic centre were identified. Of those patients, 79 patients (8.7%) received preoperative consultation from a board certified cardiologist. 158 control patients who did not receive consultation from a cardiologist were matched by age and gender. Clinical and financial data were obtained from chart review and hospital billing. Logistic and linear regression models were constructed to compare the groups. Patients evaluated by a cardiologist were more likely to receive preoperative testing than patients who did not undergo evaluation with a cardiologist (OR 47.5, (95% CI 6.49 to 347.65). Specifically, patients seen by a cardiologist received more echocardiograms (60.8% vs 22.2%, p<0.0001) and 12-lead electrocardiograms (98.7% vs 54.4%, p<0.0001). There was a higher rate of ischaemic evaluations in the group evaluated by a cardiologist, but those differences did not achieve statistical significance. Testing led to longer length of stay (4.35 vs 3.46 days, p=0.0032) in the cohort evaluated by a cardiologist driven primarily by delay to procedure of 0.76 days (3.14 vs 2.38 days, p=0.001). Estimated costs resulting from the longer length of stay and increased testing was $10 624 per patient. There were zero major adverse cardiac events in either group., Conclusion: Preoperative consultation to a cardiologist before a low-risk procedure is associated with more preoperative testing. This preoperative testing increases length of stay and cost without affecting outcomes., Competing Interests: Competing interests: None declared.

Background: The success of initiatives intended to increase the value of health care depends, in part, on the degree to which cost-conscious care is endorsed by current and future physicians. This study aimed to first analyze attitudes of U.S. physicians by age and then compare the attitudes of physicians and medical students., Methods: A paper survey was mailed in mid-2012 to 3897 practicing physicians randomly selected from the American Medical Association Masterfile. An electronic survey was sent in early 2015 to all 5,992 students at 10 U.S. medical schools. Survey items measured attitudes toward cost-conscious care and perceived responsibility for reducing healthcare costs. Physician responses were first compared across age groups (30-40 years, 41-50 years, 51-60 years, and > 60 years) and then compared to student responses using Chi square tests and logistic regression analyses (controlling for sex)., Results: A total of 2,556 physicians (65%) and 3395 students (57%) responded. Physician attitudes generally did not differ by age, but differed significantly from those of students. Specifically, students were more likely than physicians to agree that cost to society should be important in treatment decisions (p < 0.001) and that physicians should sometimes deny beneficial but costly services (p < 0.001). Students were less likely to agree that it is unfair to ask physicians to be cost-conscious while prioritizing patient welfare (p < 0.001). Compared to physicians, students assigned more responsibility for reducing healthcare costs to hospitals and health systems (p < 0.001) and less responsibility to lawyers (p < 0.001) and patients (p < 0.001). Nearly all significant differences persisted after controlling for sex and when only the youngest physicians were compared to students., Conclusions: Physician attitudes toward cost-conscious care are similar across age groups. However, physician attitudes differ significantly from medical students, even among the youngest physicians most proximate to students in age. Medical student responses suggest they are more accepting of cost-conscious care than physicians and attribute more responsibility for reducing costs to organizations and systems rather than individuals. This may be due to the combined effects of generational differences, new medical school curricula, students' relative inexperience providing cost-conscious care within complex healthcare systems, and the rapidly evolving U.S. healthcare system.

Background: The financial impact regarding choice of physician within the workers' compensation domain has not been well studied., Objective: The aim of this study was to assess the difference in claim cost between employee- and employer-directed choice of treating physician after injury., Methods: Thirty-five thousand six hundred forty indemnity lost time claims from a 13-year period at a nationwide company were analyzed with multivariate logistic regression to determine the association of medical direction with risk of high-cost claims., Results: States that have employer-directed physician choice were associated with a lower risk of having high-cost claims (≥$50,000) but higher attorney involvement than employee direction. The net effect of this enhanced presence of attorneys offsets the benefits of employer choice of treating physician., Conclusion: States that permit employer selection of treating physician have slightly higher cost due to the higher prevalence of attorney involvement in the claims process.

Objective: To examine the impact of provider competition under global budgeting on the use of cesarean delivery in Taiwan., Data Sources/study Setting: (1) Quarterly inpatient claims data of all clinics and hospitals with birth-related expenses from 2000 to 2008; (2) file of health facilities' basic characteristics; and (3) regional quarterly point values (price conversion index) for clinics and hospitals, respectively, from the fourth quarter in 1999 to the third quarter in 2008, from the Statistics of the National Health Insurance Administration., Study Design: Panel data of quarterly facility-level cesarean delivery rates with provider characteristics, birth volumes, and regional point values are analyzed with the fractional response model to examine the effect of external price changes on provider behavior in birth delivery services., Principal Findings: The decline in de facto prices of health services as a result of noncooperative competition under global budgeting is associated with an increase in cesarean delivery rates, with a high degree of response heterogeneity across different types of provider facilities., Conclusions: While global budgeting is an effective cost containment tool, intensified financial pressures may lead to unintended consequences of compromised quality due to a shift in provider practice in pursuit of financial rewards., (© Health Research and Educational Trust.)

Predictive analytics can support a better integrated health system providing continuous, coordinated, and comprehensive person-centred care to those who could benefit most. In addition to dollars saved, using a predictive model in healthcare can generate opportunities for meaningful improvements in efficiency, productivity, costs, and better population health with targeted interventions toward patients at risk.

Background: Physician assistants (PAs) are commonly employed in plastic surgery. However, limited data exist on their impact, which may guide decisions regarding how best to integrate them into practice., Methods: A review of the practices of 2 breast reconstructive surgeons was performed. A comparison was made between a 1-year period before to a 1-year period after the addition of a PA into practice. The practice model was a one-to-one pairing of a plastic surgeon and a PA., Results: A total of 4141 clinic encounters and 1356 surgical cases were reviewed. After the addition of PAs, there was a significant increase in relative value units (1057 vs 1323 per month per surgeon, P < 0.001). Operative times were similar with and without PAs (P = 0.45). However, clinic encounter times for surgeons were shorter for all visit types when patients were first seen by a PA before the surgeon: global follow-up (P = 0.03), other follow-up (P = 0.002), consultation (P = 0.76), and preoperative (P = 0.02), translating to 9 additional patients seen per day. Charges (P = 0.001) and payments (P = 0.007) also increased, which offset the cost of using a PA. However, the financial contribution from PA involvement as first assistant in surgery was limited (5.2%). The peak effect of PAs was observed between the third and fourth quarters., Conclusions: In breast reconstruction, PAs primarily enhance the efficiency of plastic surgeons, particularly in the clinic, with downstream clinical and financial gains of an indirect nature for surgeons.

Background: Increasing health costs in developed countries are a major concern for decision makers. A variety of cost containment tools are used to control this trend, including maximum price regulation and reimbursement methods for health technologies. Information regarding expenditure-related outcomes of these tools is not available., Objective: To evaluate the association between different cost-regulating mechanisms and national health expenditures in selected countries., Methods: Price-regulating and reimbursement mechanisms for prescription drugs among OECD countries were reviewed. National health expenditure indices for 2008-2012 were extracted from OECD statistical sources. Possible associations between characteristics of different systems for regulation of drug prices and reimbursement and health expenditures were examined., Results: In most countries, reimbursement mechanisms are part of publicly financed plans. Maximum price regulation is composed of reference-pricing, either of the same drug in other countries, or of therapeutic alternatives within the country, as well as value-based pricing (VBP). No association was found between price regulation or reimbursement mechanisms and healthcare costs. However, VBP may present a more effective mechanism, leading to reduced costs in the long term., Conclusions: Maximum price and reimbursement mechanism regulations were not found to be associated with cost containment of national health expenditures. VBP may have the potential to do so over the long term.

This brief reviews the evidence on how key ACA provisions have affected the growth of health care costs. Coverage expansions produced a predictable jump in health care spending, amidst a slowdown that began a decade ago. Although we have not returned to the double-digit increases of the past, the authors find little evidence that ACA cost containment provisions produced changes necessary to "bend the cost curve." Cost control will likely play a prominent role in the next round of health reform and will be critical to sustaining coverage gains in the long term.

Objectives: Over the past few years, the United States has seen the rapid growth of dedicated musculoskeletal urgent care centers owned and operated by individual orthopaedic practices. In June of 2014, our practice opened the first dedicated orthopaedic urgent care in the region staffed by physician assistants and supervised by orthopaedic surgeons. Our hypothesis is that such centers can safely improve orthopaedic care for ambulatory orthopaedic injuries, decrease volume for overburdened emergency departments (EDs), reduce wait times and significantly decrease the cost of care while improving access to orthopaedic specialists., Design: Retrospective review., Setting: Level 2 trauma center and physician-owned orthopaedic urgent care., Patients: Consecutive series of patients seen in the hospital ED (n = 87,629) and orthopaedic urgent care (n = 12,722)., Intervention: None., Outcomes: ED wait time, total visit time, time until being seen by provider, time until consultation with orthopaedic surgeon, total visit charges, and effect on orthopaedic practice revenue., Results: During the 12 months of study, 12,722 patients were treated in our urgent care. The average urgent care wait time until being seen by a provider was 17 minutes compared with 45 minutes in hospital ED. Total visit time was 43 minutes in the urgent care and 156 minutes in the hospital ED. Time to being seen by an orthopaedic specialist was 1.2 days for urgent care patients compared with 3.4 days for ED patients. The average charge for an urgent care visit was $461 compared with $8150 in hospital ED. During the course of study, urgent care treatment reduced charges to health care system by $97,819,458. Hospital ED orthopaedic volume did decrease as expected but total ED patient volume remained the same. There was no measureable effect on hospital ED wait times. Hospital surgical case volume did not change over the period of study and the orthopaedic census remained stable. Urgent care construction, marketing, administration, imaging, and labor costs totaled $1,664,445. Urgent care revenue from evaluation and management, imaging, durable medical equipment, and casting totaled $2,577,707. Practice revenue from follow-up care of patients who entered practice through the urgent care totaled $7,657,998., Conclusion: Dedicated musculoskeletal urgent care clinics operated by orthopaedic surgery practices can be extremely beneficial to patients, physicians, and the health care system. They clearly improve access to care, whereas significantly decreasing overall health care costs for patients with ambulatory orthopaedic conditions and injuries. In addition, they can be financially beneficial to both patients and orthopaedic surgeons alike without cannibalizing local hospital surgical volumes., Level of Evidence: Therapeutic Level III.

Implant costs comprise the largest proportion of operating room supply costs for orthopedic trauma care. Over the years, hospitals have devised several methods of controlling these costs with the help of physicians. With increasing economic pressure, these negotiations have a tremendous ability to decrease the cost of trauma care. In the past, physicians have taken no responsibility for implant pricing which has made cost control difficult. The reasons have been multifactorial. However, industry surgeon consulting fees, research support, and surgeon comfort with certain implant systems have played a large role in slowing adoption of cost-control measures. With the advent of physician gainsharing and comanagement agreements, physicians now have impetus to change. At our facility, we have used 3 methods for cost containment since 2009: dual vendor, matrix pricing, and sole-source contracting. Each has been increasingly successful, resulting in massive savings for the institution. This article describes the process and benefits of each model.

The Price-Volume Agreement Program (PVAP) was promulgated in 2007 in South Korea as the first attempt to adjust drug pricing according to total consumption in order to contain drug expenditure. This study was designed to assess the impact of the PVAP on diabetes drug expenditure for a period of a 10-year period (2003-2012) using claims data from the National Health Insurance Service. We estimated a multilevel mixed-effects linear regression model by comparing the level of total monthly diabetes drug expenditure for drugs subject to PVAP and existing drugs after adjusting the average differences in drug expenditure before and after the PVAP. The monthly total expenditure for drugs that were newly listed through the PVAP (negotiation drugs) was 7.03% higher on average compared to that for existing drugs, controlling for the baseline differences in expenditure before and after the PVAP. This increase was observed in all four subgroups of diabetes drugs, including sitagliptin, vildagliptin, exenatide, and others. The growth rate of total diabetes drug expenditure was reduced after the PVAP despite the sustained escalation of expenditure levels, which may imply that the PVAP has the potential to be an effective tool for drug expenditure control in the long term., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

This study analyzed factors contributing to increases in the actual sales volumes relative to forecasted volumes of drugs under price-volume agreement (PVA) policy in South Korea. Sales volumes of newly listed drugs on the national formulary are monitored under PVA policy. When actual sales volume exceeds the pre-agreed forecasted volume by 30% or more, the drug is subject to price-reduction. Logistic regression assessed the factors related to whether drugs were the PVA price-reduction drugs. A generalized linear model with gamma distribution and log-link assessed the factors influencing the increase in actual volumes compared to forecasted volume in the PVA price-reduction drugs. Of 186 PVA monitored drugs, 34.9% were price-reduction drugs. Drugs marketed by pharmaceutical companies with previous-occupation in the therapeutic markets were more likely to be PVA price-reduction drugs than drugs marketed by firms with no previous-occupation. Drugs of multinational pharmaceutical companies were more likely to be PVA price-reduction drugs than those of domestic companies. Having more alternative existing drugs was significantly associated with higher odds of being PVA price-reduction drugs. Among the PVA price-reduction drugs, the increasing rate of actual volume compared to forecasted volume was significantly higher in drugs with clinical usefulness. By focusing the negotiation efforts on those target drugs, PVA policy can be administered more efficiently with the improved predictability of the drug sales volumes., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: The present study was designed to obtain insights into guideline adherence regarding the use of expensive drugs in The Netherlands in daily practice and into the patients' perspective on the decision-making process., Material and Methods: A retrospective review of medical charts regarding the use of trastuzumab in early and metastatic breast cancer (EBC/MBC) and bortezomib in multiple myeloma (MM) was conducted. Prescription according to clinical practice guidelines was assessed. The review was supplemented with patient interviews., Results: Of 702 adjuvant-treated EBC patients, 97% had a documented human epidermal growth factor receptor 2 (HER2) testing (23% HER2 positive). 92% (147/160) of the HER2-positive EBC patients were treated with trastuzumab. Of 594 MBC patients, 81% had a documented HER2 testing (19% HER2 positive). 82% (75/91) of the HER2-positive MBC patients were treated with trastuzumab. Of 68 MM patients, 50% were treated with bortezomib. Reasons not to treat were consistent with the guidelines. Patients were generally satisfied with the decision-making process; improvements in patient education were suggested (e.g., repeating the information given, adding information on side effects)., Conclusions: Guidelines were generally well followed with respect to trastuzumab and bortezomib, indicating that funding did not influence the treatment decisions of physicians. In view of the growing numbers of both cancer patients and expensive new anticancer drugs, and increasing budget constraints, it is unclear whether the present-day policies will guarantee a similar level of guideline adherence. Patient involvement in decision-making could be increased by improving the patient education on treatment., (© 2016 S. Karger GmbH, Freiburg.)

Objective: To estimate the proportion of patients with ischemic stroke who fall within and above the total outpatient rehabilitation caps before and after the Balanced Budget Act of 1997 took effect; and to estimate the cost of poststroke outpatient rehabilitation cost and resource utilization in these patients before and after the implementation of the caps., Design: Retrospective cohort study., Setting: Medicare reimbursement system., Participants: Medicare beneficiaries from the state of South Carolina: the 1997 stroke cohort sample (N=2667) and the 2004 stroke cohort sample (N=2679)., Interventions: Not applicable., Main Outcome Measures: Proportion of beneficiaries with bills within and above the cap before and after the cap was enacted, and total estimated 1-year rehabilitation Medicare payments before and after the cap., Results: The proportion of patients with stroke exceeding the cap in 2004 after the Balanced Budget Act of 1997 was enacted was significantly lower (5.8%) than those in 1997 (9.5%) had there been a cap at that time (P=.004). However, when the proportion of individuals exceeding the cap among both the outpatient provider and facility files was examined, there was a greater proportion of patients with stroke in 2004 (64.6%) than in 1997 (31.9%) who exceeded the cap (P<.0001). The estimated average 1-year Medicare payments for rehabilitation services, when examining only the Part B outpatient provider bills, did not differ between the cohorts (P=.12), and in fact, decreased slightly from $1052 in 1997 to $833 in 2004. However, when examining rehabilitation costs using all available outpatient Medicare bills, the average estimated payments greatly increased (P<.0001) from $5691 in 1997 to $9606 in 2004., Conclusions: These findings suggest that billing practices may have changed after outpatient rehabilitation services caps were enacted by the Balanced Budget Act of 1997. Rehabilitation services billing may have shifted from Part B provider bills to being more frequently included in facility charges., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

In 2009 China announced plans to reform provider payment methods at public hospitals by moving from fee-for-service (FFS) to prospective and aggregated payment methods that included the use of diagnosis-related groups (DRGs) to control health expenditures. In October 2011 health policy makers selected six Beijing hospitals to pioneer the first DRG payment system in China. We used hospital discharge data from the six pilot hospitals and eight other hospitals, which continued to use FFS and served as controls, from the period 2010-12 to evaluate the pilot's impact on cost containment through a difference-in-differences methods design. Our study found that DRG payment led to reductions of 6.2 percent and 10.5 percent, respectively, in health expenditures and out-of-pocket payments by patients per hospital admission. We did not find evidence of any increase in hospital readmission rates or cost shifting from cases eligible for DRG payment to ineligible cases. However, hospitals continued to use FFS payments for patients who were older and had more complications than other patients, which reduced the effectiveness of payment reform. Continuous evidence-based monitoring and evaluation linked with adequate management systems are necessary to enable China and other low- and middle-income countries to broadly implement DRGs and refine payment systems., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: Faced with economic pressure and with the insufficient funding of investments many hospitals are in deficit. However, there is little evidence whether these circumstances translate into rationing of services and which factors might be relevant in this context. Concerning the development of the number of patients it is also unclear, whether economic incentives lead to an overprovision of medical services., Method: Based on earlier studies and semi-structured interviews with hospital executives professional group specific questionnaires were developed and sent to almost 5.000 chief physicians, hospital managers and directors of nursing. The response rate was 43 %., Results: All respondents perceived considerable economic restrictions. In consequence, 46 % of chief physicians have rationed useful services or replaced them by cheaper less effective alternatives. Although rationing is a concern in all medical disciplines the intensity is modest. Moreover, the chief physicians perceived a tendency to overprovision - especially in orthopedy and cardiology., Conclusion: Due to financial restrictions of health funds and federal states the economic pressure will stay high. This implies political actions to prevent negative consequences for patient care., (© Georg Thieme Verlag KG Stuttgart · New York.)

The objective of this research is to evaluate empirically the effectiveness of eHealth in Nishi-aizu Town, Fukushima Prefecture, based on a mail survey to the residents and their receipt data of National Health Insurance from November 2006 to February 2007. The residents were divided into two groups, users and non-users, and sent questionnaires to ask their characteristics or usage of the system. Their medical expenditures paid by National Health Insurance for five years from 2002 to 2006 are examined. The effects were analyzed by comparison of medical expenditures between users and non-users. The interests are focused on four chronic diseases namely heart diseases, high blood pressure, diabetes, and strokes. A regression analysis is employed to estimate the effect of eHealth to users who have these diseases and then calculate the monetary effect of eHealth on reduction of medical expenditures. The results are expected to be valid for establishment of evidence-based policy such as reimbursement from medical insurance to eHealth.

Background: Cost-containment strategies are required to deal with rising drug expenditure, also in oncology. Drug wastage related to the preparation of chemotherapy drugs for patients is costly, but solutions exist for optimizing the use of unconsumed anticancer drugs., Objective: Our pharmacy department makes use of a computerized drug storage bank, which records stability data and the amounts of unconsumed drugs available, and is connected to prescription software via an interface. We aimed to evaluate the real cost savings generated by this system., Method: We assessed the cost savings achieved with this system, for 37 different anticancer drugs, over a 1-year period. French drug pricing and the amounts of drugs from the storage bank potentially re-used were assessed., Results: The re-use of unconsumed anticancer drugs generated substantial cost savings, for nine drugs in particular: azacitidine, bevacizumab, bortezomib, cetuximab, docetaxel, liposomal doxorubicin, rituximab, topotecan and trastuzumab. Overall cost savings accounted for about 5 % of total anticancer drug expenditure at our hospital (8.5 M)., Conclusion: In medical hematology-oncology, drug wastage reduction and a computerized physician order entry system could be applied in routine practice at centralized drug-processing units, with significant financial benefits.

The health care industry is grappling with the challenges of working with and analyzing large, complex, diverse data sets. Blue Cross and Blue Shield of North Carolina provides several promising examples of how big data can be used to reduce the cost of care, to predict and manage health risks, and to improve clinical outcomes.

Objectives: In emergency departments (EDs), overcrowding, workload complexity, and cost containment represent current operational problems. In this retrospective observational study, we analyzed the effects of a professional quality management (QM) system on patient flow, diagnostic validity, and hospital costs., Materials and Methods: In 2005/2006, the main ED at the University Medical Center Goettingen was reorganized. A professional QM system according to DIN EN ISO 9001:2008 was introduced in 2008. In a retrospective observational study, we compared the number of cases, the spectrum of clinical diagnoses, the validity of diagnoses, and hospital costs in the ED before (2005) and 2 years after the introduction of the QM system (2010)., Results: In the ED at the University Medical Center Goettingen, the number of cases increased by 22.7% between 2005 and 2010. After the introduction of the QM system, a significant reduction in patients' length of stay within the ED was achieved (P<0.001). Furthermore, the rate of diagnostic errors for patients assigned for admission within the ED could be reduced significantly (P=0.002). A reduction of patient-related hospital costs of 8.9% was achieved by restriction of diagnostic tests according to standard operating procedures for each emergency diagnosis., Conclusion: The introduction of a professional QM system in EDs improves patient flow as well as quality of medical care and results in a significant reduction in hospital costs. Further analyses should evaluate the effects of QM on quality indicators in a prospective multicenter study. Validation of results has to be performed in a dynamic model for process simulation.

The average length of stay (LOS) is considered one of the most significant indicators of hospital management. The steep decline in the average LOS among Japanese hospitals since the 1980s is considered to be due to cost-containment policies directed at reducing LOS. Japan's hospital sector is characterised by a diversity of ownership types. We took advantage of this context to examine different hospital behaviours associated with ownership types. Analysing government data published from 1971 to 2008 for the effect of a series of cost-containment policies aimed at reducing LOS revealed distinctly different paths behind the declines in LOS between privately owned and publicly owned hospitals. In the earlier years, private hospitals focused on providing long-term care to the elderly, while in the later years, they made a choice between providing long-term care and providing acute care with reduced LOS and bonus payments. By contrast, the majority of public hospitals opted to provide acute care with reduced LOS in line with public targets., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Under the Affordable Care Act, up to thirteen million adults have the opportunity to obtain health insurance through an expansion of the Medicaid program. A great deal of effort is currently being devoted to eligibility verification, outreach, and enrollment. We look beyond these important first-phase challenges to consider what people who are transitioning back to the community after incarceration need to receive effective care. It will be possible to deliver cost-effective, high-quality care to this population only if assistance is coordinated between the correctional facility and the community, and across diverse treatment and support organizations in the community. This article discusses several examples of successful coordination of care for formerly incarcerated people, such as Project Bridge and the Community Partnerships and Supportive Services for HIV-Infected People Leaving Jail (COMPASS) program in Rhode Island and the Transitions Clinic program that operates in ten US cities. To promote broader adoption of successful models, we offer four policy recommendations for overcoming barriers to integrating individuals into sustained, community-based care following their release from incarceration.

Introduction: In our previous studies investigating the drug therapy in patients suffering from inflammatory bowel disease (IBD) in the Rhein-Main region, Germany, we detected serious discrepancies between treatment reality and treatment guidelines. Consecutively, patient outcome in this cohort was compromised. Following this pilot project a network between primary deliverers of care for IBD patients and one large health-care insurance company [BKK Taunus (Gesundheit), the second largest insurance company in Hessen, Germany] was established., Patients and Methods: An analysis of treatment and socioeconomic data from 220 IBD patients (Crohn's disease - CD = 96, ulcerative colitis - UC = 124) entering the integrative health-care programme between 1.1.-30.9.2009 was performed., Results: Remission rates for CD and UC in the integrated health-care programme could be improved from 60 - 73 % (CD) and from 61 - 79 % (UC). Guideline-conform treatment was observed in 81 % of patients with CD and 85 % with UC, respectively. Although medication costs increased, total costs could be cut by 162 304.- €, as secondary costs for hospitalisation and days off work could be reduced., Conclusion: The study shows that networking of deliverers of care for IBD patients with health insurances provides an excellent possibility to optimise medical treatment and can cut down costs significantly., (© Georg Thieme Verlag KG Stuttgart · New York.)

With Medicare spending projected to increase to 24 percent of all federal spending and to equal 6 percent of the gross domestic product by 2037, policy makers are again considering ways to curb the program's spending growth. We used a microsimulation approach to estimate three scenarios: imposing a means-tested premium for Part A hospital insurance, introducing a premium support credit to purchase health insurance, and increasing the eligibility age to sixty-seven. We found that the scenarios would lead to reductions in cumulative Medicare spending in 2012-36 of 2.4-24.0 percent. However, the scenarios also would increase out-of-pocket spending for enrollees and, in some cases, cause millions of seniors not to enroll in the program and to be left without coverage. To achieve substantial cost savings without causing substantial lack of coverage among seniors, policy makers should consider benefit changes in combination with other options, such as some of those now being contemplated by the Obama administration and Congress.

Many policy makers believe that when Medicare constrains its payment rates for hospital inpatient care, private insurers end up paying higher rates as a result. I tested this "cost-shifting" theory using a unique new data set that combines MarketScan private claims data with Medicare hospital cost reports. Contrary to the theory, I found that hospital markets with relatively slow growth in Medicare inpatient hospital payment rates also had relatively slow growth in private hospital payment rates during 1995-2009. Using regression analyses, I found that a 10 percent reduction in Medicare payment rates led to an estimated reduction in private payment rates of 3 percent or 8 percent, depending on the statistical model used. These payment rate spillovers may reflect an effort by hospitals to rein in their operating costs in the face of lower Medicare payment rates. Alternatively, hospitals facing cuts in Medicare payment rates may also cut the payment rates they seek from private payers to attract more privately insured patients. My findings indicate that repealing cuts in Medicare payment rates would not slow the growth in spending on hospital care by private insurers and would in fact be likely to accelerate the growth in private insurers' costs and premiums.

In Europe drug reimbursement decisions often weigh how new drugs perform relative to those already on the market and how cost-effective they are relative to certain metrics. In the United States such comparative-effectiveness and cost-effectiveness evidence is rarely considered. Which approach allows patients greater access to drugs? In 2000-11 forty-one oncology drugs were approved for use in the United States and thirty-one were approved in Europe. We compared patients' access to the twenty-nine cancer drugs introduced into the health care systems of the United States and four European countries. Relative to the approach used in the US Medicare program in particular, the European evidence-based approach appears to have led to reduced prices for those drugs deemed worthy of approval and reimbursement. The result is improved affordability for payers and increased access for patients to those drugs that were available. The United States lacks a systematic approach to assessing such evidence in the coverage decision-making process, which may prove inadequate for controlling costs, improving outcomes, and reducing inequities in access to care.

Objective: This article examines the relationship between drug price and drug quality and how it varies across two of the most common regulatory regimes in the pharmaceutical market: minimum efficacy standards (MES) and a mix of MES and price control mechanisms (MES + PC)., Data Sources: Our primary data source is the Tufts-New England Medical Center-Cost Effectiveness Analysis Registry which have been merged with price data taken from MEPS (for the United States) and AIFA (for Italy)., Study Design: Through a simple model of adverse selection we model the interaction between firms, heterogeneous buyers, and the regulator., Principal Findings: The theoretical analysis provides two results. First, an MES regime provides greater incentives to produce high-quality drugs. Second, an MES + PC mix reduces the difference in price between the highest and lowest quality drugs on the market., Conclusion: The empirical analysis based on United States and Italian data corroborates these results., (© Health Research and Educational Trust.)

Meeting the medical and social needs of elderly people is likely to be costly, disruptive, and at odds with personal preferences if efforts to do so are not well coordinated. We compared two different models of primary care in four different continuing care retirement communities. In the first model, used in one community, the physicians and two part-time nurse practitioners delivered clinical care only at that site, covered all settings within it, and provided all after-hours coverage. In the second model, used in three communities, on-site primary care physician hours were limited; the same physicians also had independent practices outside the retirement community; and after-hours calls were covered by all members of the practices, including physicians who did not practice on site. We found that residents in the first model had two to three times fewer hospitalizations and emergency department visits. Only 5 percent of those who died did so in a hospital, compared to 15 percent at the other sites and 27 percent nationally. These findings provide insight into what is possible when medical care is highly integrated into a residential retirement setting.

Hospital readmission after discharge is often a costly failing of the U.S. health care system to adequately manage patients who are ill. Increasing the numbers of family physicians (FPs) is associated with significant reductions in hospital readmissions and substantial cost savings.

Background: Unit costs of health services are substantially higher in the United States than in any other developed country in the world, without a correspondingly healthier population. An alternative payment structure, especially for high volume, high cost episodes of care (eg, total knee replacement), is needed to reward high quality care and reduce costs., Methods: The National Inpatient Sample of administrative claims data was used to measure risk-adjusted mortality, postoperative length-of-stay, costs of routine care, adverse outcome rates, and excess costs of adverse outcomes for total knee replacements performed between 2002 and 2005. Empirically identified inefficient and ineffective hospitals were then removed to create a reference group of high-performance hospitals. Predictive models for outcomes and costs were recalibrated to the reference hospitals and used to compute risk-adjusted outcomes and costs for all hospitals. Per case predicted costs were computed and compared with observed costs., Results: Of the 688 hospitals with acceptable data, 62 failed to meet effectiveness criteria and 210 were identified as inefficient. The remaining 416 high-performance hospitals had 13.4% fewer risk-adjusted adverse outcomes (4.56%-3.95%; P < 0.001; χ) and 9.9% lower risk-adjusted total costs ($12,773-$11,512; P < 0.001; t test) than all study hospitals. Inefficiency accounted for 96% of excess costs., Conclusions: A payment system based on the demonstrated performance of effective, efficient hospitals can produce sizable cost savings without jeopardizing quality. In this study, 96% of total excess hospital costs resulted from higher routine costs at inefficient hospitals, whereas only 4% was associated with ineffective care.

Objectives: In a region of Schleswig-Holstein, a regional budget was used to investigate which structural changes would be brought about by a financial plan which enables (clinical) treatment that defies rigid financial limits and makes flexible treatment in various settings possible., Results: In 5 years, the number of inpatient treatment places in the care region was reduced considerably. The length of stay per patient and year decreased by 25 %. Day care and outpatient treatment offers were expanded substantially and new treatment concepts were established. The quality of treatment remained safeguarded., Conclusions: A regional budget is suitable for bringing about fundamental changes in terms of content and structure in psychiatric care. The result is clearly improved flexibility as compared to previous care structures; incentives for disorders are reduced. The principle "outpatient before inpatient" is strengthened. The financial plan can be transposed onto other regions, whereby modifications according to the structure of the care region seem necessary., (© Georg Thieme Verlag KG Stuttgart · New York.)

Health services demonstrate key features of complex adaptive systems (CAS), they are dynamic and unfold in unpredictable ways, and unfolding events are often unique. To better understand the complex adaptive nature of health systems around a core attractor we propose the metaphor of the health care vortex. We also suggest that in an ideal health care system the core attractor would be personal health attainment. Health care reforms around the world offer an opportunity to analyse health system change from a complex adaptive perspective. At large health care reforms have been pursued disregarding the complex adaptive nature of the health system. The paper details some recent reforms and outlines how to understand their strategies and outcomes, and what could be learnt for future efforts, utilising CAS principles. Current health systems show the inherent properties of a CAS driven by a core attractor of disease and cost containment. We content that more meaningful health systems reform requires the delicate task of shifting the core attractor from disease and cost containment towards health attainment.

Purpose: A program in which health-system pharmacists and pharmacy technicians provide medication therapy management (MTM), wellness, and condition care (disease management) services under contract with local businesses is described., Summary: The health-system pharmacy department's Center for Medication Management contracts directly with company benefits departments for defined services to participating employees. The services include an initial wellness and MTM session and, for certain patients identified during the initial session, ongoing condition care. The initial appointment includes a medication history, point-of-care testing for serum lipids and glucose, body composition analysis, and completion of a health risk assessment. The pharmacist conducts a structured MTM session, reviews the patient's test results and risk factors, provides health education, discusses opportunities for cost savings, and documents all activities on the patient's medication action plan. Eligibility for the condition care program is based on a diagnosis of diabetes, hypertension, asthma, heart failure, or hyperlipidemia or elevation of lipid or glucose levels. Findings are summarized for employers after the initial wellness screening and at six-month intervals. Patients receiving condition care sign a customized contract, establish goals, attend up to four MTM sessions per year, and track their information on a website; employers may offer incentives for participation. When pharmacists recommend adjustments to therapy or cost-saving changes, it is up to patients to discuss these with their physician. A survey completed by each patient after the initial wellness session has indicated high satisfaction. Direct cost savings related to medication changes have averaged $253 per patient per year. Total cost savings to companies in the first year of the program averaged $1011 per patient. For the health system, the program has been financially sustainable. Key laboratory values indicate positive clinical outcomes., Conclusion: A business model in which health-system pharmacists provide MTM and condition care services for company employees has demonstrated successful outcomes in terms of patient satisfaction, cost savings, and clinical benefits.

Background: Cancer is in the focus of public and scientific interest as one of the leading causes of death, with an increasing case load due to demographic changes and rising treatment costs. Comparatively, little is known about health care utilization of cancer patients., Methods: This article first gives an overview of health services research and claims data of German statutory health insurance funds. Second, claims data of the Gmünder ErsatzKasse (GEK) for a period of 3 months (10-12/2008) are used to analyze patterns of drug prescriptions by oncologists., Results: A total of 1.98 million prescriptions were included. Based on all prescriptions, the proportion of compounded prescriptions is about 17 times higher for oncologists compared to other physicians (34.4% vs. 2.0%). Fur- thermore, the costs of these solutions prescribed by oncologists are higher (median: 397.68 Euros vs. 15.45 Euros)., Conclusion: Health services research in oncology is urgently needed. Claims data of German health insurance funds offer a broad range of opportunities, especially when linked with other data. However, in the case of individually prepared solutions, claims data provide no further information on the drug.

This paper aims to examine reduction of medical expenditures by utilizing the system of Nishi-aizu Town, Fukushima Prefecture. The town office has been implementing it since 1994 and keeps receipts on medical expenditures of its approximately 4,000 residents paid by National Health Insurance for 5 years from 2002 to 2006. We select (1) users; and (2) non-users of the e-health system, and by comparing their medical expenditures, we examine: (i) difference in medical expenditures between two groups; and (ii) negative correlation between medical expenditures and the length of usage of the e-health system. We find that total medical expenditures of users are larger than those of non-users, whereas by restricting to lifestyle-related illnesses such as high blood pressure, cerebral infarction, strokes, and diabetes, medical expenditures of users are found to be smaller than those of non-users. The results we obtained here provide the rigorous economic foundation of the e-health system.

Purpose: The Deficit Reduction Act of 2005 (DRA) sharply reduced technical component payments for private office magnetic resonance imaging (MRI) and computed tomographic (CT) imaging. Although radiologists have no control over referrals, nonradiologist physicians (NRPs) can potentially make up for revenue shortfalls by self-referring more examinations. The purpose of this study was therefore to compare the effects of the DRA on the in-office MRI and CT practices of radiologists and NRPs., Materials and Methods: The nationwide Medicare Part B databases for 2002 to 2007 were studied. All MRI and CT codes were selected. Using Medicare physician specialty and place-of-service codes, examinations performed in private offices by radiologists were identified and compared with those performed by NRPs. Trends in procedure volume and payments were studied. The pre-DRA compound annual growth rates for 2002 to 2006 and the post-DRA one-year rates for 2007 are reported., Results: For MRI, radiologists' private office volume increased by 8.4% yearly from 2002 to 2006 but then dropped by 2.0% in 2007. Nonradiologist physicians' office volume increased by 24.8% yearly, then increased by another 7.6% in 2007. Office MRI payments to radiologists increased by 11.2% yearly from 2002 to 2006 but then dropped by 30.1% in 2007. Nonradiologist physicians' office MRI payments increased by 25.7% yearly, then dropped by 23.5% in 2007. For CT imaging, radiologists' private office volume increased by 11.2% yearly from 2002 to 2006 but then increased by only 2.9% in 2007. Nonradiologist physicians' office volume increased by 31.8% yearly, then increased by another 18.1% in 2007. Office CT payments to radiologists increased by 13.4% yearly from 2002 to 2006 but then dropped by 5.2% in 2007. Nonradiologist physicians' office CT payments increased by 34.9% yearly, then increased by another 8.3% in 2007., Conclusion: After the DRA took effect, office MRI volume dropped among radiologists but increased among NRPs. Payments for MRI to both dropped, but the percentage decrease to radiologists was greater. Office CT volume increased slightly among radiologists but increased much more among NRPs on a percentage basis. Payments for CT imaging to radiologists dropped, but they increased to NRPs. These results suggest that NRPs may be able to ameliorate the effects of the DRA by increasing self-referral. These trends are of concern and should be scrutinized in future years.

Background: In response to limited resources, health care systems have adopted diverse cost-containment strategies and give priority to differing types of interventions. The perception of physicians, who witness the effects of these strategies, may provide useful insights regarding the impact of system-wide priority setting on access to care., Methods: We conducted a cross-sectional survey to ascertain generalist physicians' perspectives on resources allocation and its consequences in Norway, Switzerland, Italy and the UK., Results: Survey respondents (N = 656, response rate 43%) ranged in age from 28-82, and averaged 25 years in practice. Most respondents (87.7%) perceived some resources as scarce, with the most restrictive being: access to nursing home, mental health services, referral to a specialist, and rehabilitation for stroke. Respondents attributed adverse outcomes to scarcity, and some respondents had encountered severe adverse events such as death or permanent disability. Despite universal coverage, 45.6% of respondents reported instances of underinsurance. Most respondents (78.7%) also reported some patient groups as more likely than others to be denied beneficial care on the basis of cost. Almost all respondents (97.3%) found at least one cost-containment policy acceptable. The types of policies preferred suggest that respondents are willing to participate in cost-containment, and do not want to be guided by administrative rules (11.2%) or restrictions on hospital beds (10.7%)., Conclusion: Physician reports can provide an indication of how organizational factors may affect availability and equity of health care services. Physicians are willing to participate in cost-containment decisions, rather than be guided by administrative rules. Tools should be developed to enable physicians, who are in a unique position to observe unequal access or discrimination in their health care environment, to address these issues in a more targeted way.

Objectives: The purpose of this intervention was to evaluate the efficacy of low-literacy asthma education and the provision of free asthma controller medications to persons living in the urban inner-city., Methods: The intervention was conducted as a series of three studies. A health educator from the Johnson Health Center (JHC) performed chart reviews in the first two studies to identify urban asthma patients with frequent emergency department (ED) visits. The third study evaluated participants from the community-at-large who came to the ED for episodic asthma care. Free controller medications and education were provided to participants in all three studies., Results: Emergency department utilization, inpatient admissions, and consumer medical costs were greatly reduced in all three studies during the 5-year intervention period. Lung function improved, and participants reported an improved quality of life., Conclusion: The provision of free asthma controller medications resulted in greatly improved asthma management and reduced costs. There was no evidence that an asthma education component per se produced any of the changes.

Purpose: To highlight the impact of the laparoscopic experience of the surgical team on achievement of satisfactory results with cost containment in performing laparoscopic radical nephrectomy (LRN)., Patients and Methods: We compared the cost components of 15 consecutive uncomplicated LRNs performed in 2001 (LRN01) with 15 consecutive uncomplicated laparoscopic radical nephrectomies performed in 2003 (LRN03) and with 15 consecutive uncomplicated procedures performed at our institution by the same surgical team in the year 1999 matched for patient age, tumor size, and disease stage. The groups were comparable in demographics., Results: The operative times were 250, 225, and 195 minutes in the LRN01, LRN03, and open-surgery groups, respectively, while the lengths of postoperative stay were 3.8, 3.1, and 6.5 days. Operating room costs, excluding the disposable instruments, were 11.00 /min for the open surgery and 10.00 /min for laparoscopic nephrectomy, and the cost of the postoperative stay was 300 to 310 per day. The cost of disposable instruments was 952.18 for LRN01 and 146.37 for LRN03. The overall costs were 4155.00 for the open-surgery group, 4672.00 for LRN01, and 3336.37 for LRN03., Conclusions: Cost containment in laparoscopic nephrectomy is possible. A proper team learning curve and the employment of reliable reusable instruments is the key to reducing costs, making this procedure as economically advantageous as the equivalent open procedure.

An analysis of the possible influences on primary health care utilization is made. The theoretical framework is the health behavioural model of R. M. Andersen, dividing the influencing variables into the components predisposing characteristics, enabling resources, and need factors. The study was based on data from the German National Health Examination and Interview Survey of the adult population in 1998. The data were linked to regional structural data and aggregated account data. The total number of contacts, the number of contacts with general practitioners and internists, and the number of different specialists contacted in the last 12 months, as calculated from interview data, were used to indicate primary health care utilization. In addition to the expected strong influence of need factors such as morbidity and health-related quality of life, the predisposing characteristics such as region, urban/rural, age, and gender have a significant influence on the primary care utilization. With regard to the enabling factors, persons with a family doctor had more contacts overall, which contrasts with the family doctor's assumed gate-keeper function. From the results of the study, recommendations on possible regulatory measures are given, but also some restrictions for influencing the number of contacts are pointed out.