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Treatment of periprosthetic joint infections (PJIs) typically requires more resource utilization than primary total joint arthroplasty. This study quantifies the amount of time spent in the electronic medical record (EMR) for patients who have PJI requiring surgical intervention. A retrospective analysis of EMR activity for 165 hip and knee PJIs was performed to capture work during the preoperative and postoperative time periods. Independent sample t tests were conducted to compare total time based on procedure, age, insurance, health literacy, sex, race, and ethnicity. The EMR work performed by the orthopaedic team was 338.4 minutes (min) (SD 130.3), with 119.4 minutes (SD 62.8) occurring preoperatively and 219.0 minutes (SD 112.9) postoperatively. Preoperatively, the surgeon's work accounted for 35.7 minutes (SD 25.4), mid-level providers 21.3 minutes (SD 15.9), nurses 38.6 minutes (SD 36.8), and office staff 32.7 minutes (SD 29.9). Infectious disease colleagues independently performed 158.9 minutes (SD 108.5) of postoperative work. Overall, PJI of the knees required more postoperative work. Secondary analysis revealed that patients who have hip PJI and a body mass index <30 and patients <65 years of age required more work when compared to the PJI of heavier and older individuals. There was no difference in total work based on insurance, health literacy, race, or ethnicity. Over 8 hours of administrative work is required for surgical management of PJI. Surgeons alone performed 451% more work for PJI during the preoperative period (7.9 versus 35.7 min) compared to primary total joint arthroplasty. In efforts to provide best care for our sickest patients, much work is required perioperatively. This work is necessary to consider when assigning value and physician reimbursement. [ABSTRACT FROM AUTHOR]

Value-based healthcare payment models are an alternative insurance payment system that compensates healthcare providers based on their patients' outcomes rather than the individual services healthcare workers provide. This shift from the current fee-for-service model that predominates our medical system has received renewed popularity and attention within organized medicine such as the American Medical Association. Advocates believe that this new payment model will address many of the unsolved issues in healthcare such as medical waste and unsustainable healthcare costs. In practice, however, this model is plagued with a myriad of unresolved issues of its own. In this commentary, we outline these issues and suggest that the intentions of those advocating for value-based payment models are either misguided or disingenuous. We then offer solutions that preserve our current fee-for-service model while making necessary changes that will benefit both physicians and patients nationwide. [ABSTRACT FROM AUTHOR]

Previously documented trends of major joint arthroplasty demonstrate increasing volume and decreasing reimbursement for primary total knee and total hip arthroplasty procedures. As such, the purpose of this study was to evaluate trends in revision knee and hip arthroplasty volume and true Medicare reimbursements to physicians. The publicly accessible Centers for Medicare and Medicaid files were evaluated. Data were retrieved from the Part B National Summary Data File and queried for revision knee and hip arthroplasty billed to Medicare from 2000 to 2021. The total charge submitted to Medicare, Medicare reimbursement, number of revision arthroplasty surgeries performed, and average reimbursement per surgery were collected for each year. All monetary data were adjusted for inflation to 2021 dollars. There were 492,360 revision total knee arthroplasty surgeries and 424,163 revision hip arthroplasty procedures billed to Medicare from 2000 to 2021. Medicare was billed a total of $919,603,674.86 for revision knee and $862,979,761.57 for revision hip arthroplasty during that time. Medicare reimbursed physicians an average of $1,499.89 per knee revision and $1,603.32 per hip revision surgery. The total volume of revision knee arthroplasty increased by 9,380 (62%) and revision hip decreased by 1,743 (9%) from the year 2000 to 2021. However, there was a decrease of average reimbursement per procedure of more than 37% ($1,987.14 to 1,254) and 39% ($2,149.87 to 1,311.17), respectively. Despite a notable increase in the volume of revision total knee and stagnant revision hip arthroplasty, total billings to and reimbursements from Medicare for these procedures have not changed markedly per year. Importantly, this means that physicians are conducting more of these high-impact procedures yearly, while being reimbursed per procedure at a declining rate. This may indicate a need to re-assess billing and reimbursement rates for revision arthroplasty, in the context of the ever-increasing inflation rate. [ABSTRACT FROM AUTHOR]

Abstract Objectives Given the scarcity of data exploring reimbursement trends in the field of hematology/oncology, we sought to characterize these trends for common procedures in this field from 2012 to 2023. Methods Using the Centers for Medicare and Medicaid Services' Physician Fee Schedule Look‐Up Tool we collected reimbursement data for 40 hematology/oncology procedure codes from 2012 to 2023. Data was adjusted to 2023 United States (US) dollars using the Consumer Price Index (CPI). Results From 2012 to 2023 gross reimbursement for the facility price decreased 4.4% and increased 9.2% for the non‐facility price. When adjusted for inflation, compensation decreased 96.1% and 96.6%, respectively. None of the 40 examined Current Procedural Terminology (CPT) codes increased in net reimbursement over the study period. Conclusions Medicare reimbursement for common hematology/oncology procedures decreased from 2012 to 2023. Further research is necessary to explore the implications of these trends on the delivery of patient care.

Objectives: Given the scarcity of data exploring reimbursement trends in the field of hematology/oncology, we sought to characterize these trends for common procedures in this field from 2012 to 2023. Methods: Using the Centers for Medicare and Medicaid Services' Physician Fee Schedule Look‐Up Tool we collected reimbursement data for 40 hematology/oncology procedure codes from 2012 to 2023. Data was adjusted to 2023 United States (US) dollars using the Consumer Price Index (CPI). Results: From 2012 to 2023 gross reimbursement for the facility price decreased 4.4% and increased 9.2% for the non‐facility price. When adjusted for inflation, compensation decreased 96.1% and 96.6%, respectively. None of the 40 examined Current Procedural Terminology (CPT) codes increased in net reimbursement over the study period. Conclusions: Medicare reimbursement for common hematology/oncology procedures decreased from 2012 to 2023. Further research is necessary to explore the implications of these trends on the delivery of patient care. [ABSTRACT FROM AUTHOR]

This paper studies the effect of large changes in Medicaid reimbursement rates on the quantity of care supplied to Medicare beneficiaries. In 2015, the payment parity provision of the Affordable Care Act ended, causing widespread decreases in reimbursements to primary care providers for Medicaid services. Difference‐in‐differences and triple‐differences model estimates show that decreasing physician payments for Medicaid caused a small increase in the number of services provided to Medicare beneficiaries. I explore the mechanisms driving this result, giving context and insight into some current puzzles regarding the effects of the ACA's Medicaid expansion. [ABSTRACT FROM AUTHOR]

BackgroundUpcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incorporate capitated payments for chronic disease management. Prior research on the effect of capitated payments on chronic disease management has shown mixed results. We assessed the patient, physician, and practice characteristics of practices with capitation as the majority of revenue, and evaluated the association of capitated reimbursement with quality of chronic disease care.MethodsWe performed a cross-sectional analysis of visits in the United States' National Ambulatory Medical Care Survey (NAMCS) for patients with hypertension, diabetes, or chronic kidney disease (CKD). Our predictor was practice reimbursement type, classified as 1) majority capitation, 2) majority FFS, or 3) other reimbursement mix. Outcomes were quality indicators of hypertension control, diabetes control, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use, and statin use.ResultsAbout 9% of visits were to practices with majority capitation revenue. Capitated practices, compared with FFS and other practices, had lower visit frequency (3.7 vs. 5.2 vs. 5.2, p = 0.006), were more likely to be located in the West Census Region (55% vs. 18% vs. 17%, p

Background: Low-value healthcare is costly and inefficient and may adversely affect patient outcomes. Despite increases in low-value service use, little is known about how the receipt of low-value care differs across payers. Objective: To evaluate differences in the use of low-value care between patients with commercial versus Medicaid coverage. Design: Retrospective observational analysis of the 2017 Rhode Island All-payer Claims Database, estimating the probability of receiving each of 14 low-value services between commercial and Medicaid enrollees, adjusting for patient sociodemographic and clinical characteristics. Ensemble machine learning minimized the possibility of model misspecification. Participants: Medicaid and commercial enrollees aged 18–64 with continuous coverage and an encounter at which they were at risk of receiving a low-value service. Intervention: Enrollment in Medicaid or Commercial insurance. Main Measures: Use of one of 14 validated measures of low-value care. Key Results: Among 110,609 patients, Medicaid enrollees were younger, had more comorbidities, and were more likely to be female than commercial enrollees. Medicaid enrollees had higher rates of use for 7 low-value care measures, and those with commercial coverage had higher rates for 5 measures. Across all measures of low-value care, commercial enrollees received more (risk difference [RD] 6.8 percentage points; CI: 6.6 to 7.0) low-value services than their counterparts with Medicaid. Commercial enrollees were also more likely to receive low-value services typically performed in the emergency room (RD 11.4 percentage points; CI: 10.7 to 12.2) and services that were less expensive (RD 15.3 percentage points; CI 14.6 to 16.0). Conclusion: Differences in the provision of low-value care varied across measures, though average use was slightly higher among commercial than Medicaid enrollees. This difference was more pronounced for less expensive services indicating that financial incentives may not be the sole driver of low-value care. [ABSTRACT FROM AUTHOR]

Background: Medicare reimbursement is rapidly declining in many specialties. An in-depth analysis of Medicare reimbursement for routinely performed diagnostic imaging procedures in the United States is warranted. Purpose/Hypothesis: The purpose of this study was to evaluate Medicare reimbursement trends for the 20 most common lower extremity imaging procedures performed between 2005 and 2020, including radiographs, computed tomography (CT), and magnetic resonance imaging (MRI). We hypothesized that Medicare reimbursement for imaging procedures would decline substantially over the studied period. Study Design: Cohort study. Methods: The Physician Fee Schedule Look-up Tool from the Centers for Medicare and Medicaid Services was analyzed for reimbursement rates and relative value units associated with the top 20 most utilized Current Procedural Terminology (CPT) codes in lower extremity imaging from 2005 to 2020. Reimbursement rates were adjusted for inflation and listed in 2020 US dollars using the US Consumer Price Index. To compare year-to-year changes, the percentage change per year and compound annual growth rate were calculated. A 2-tailed t test was used to compare the unadjusted and adjusted percentage change over the 15-year period. Results: After adjusting for inflation, mean reimbursement for all procedures decreased by 32.41% (P =.013). The mean adjusted percentage change per year was –2.82%, and the mean compound annual growth rate was –1.03%. Compensation for the professional and technical components for all CPT codes decreased by 33.02% and 85.78%, respectively. Mean compensation for the professional component decreased by 36.46% for radiography, 37.02% for CT, and 24.73% for MRI. Mean compensation for the technical component decreased by 7.76% for radiography, 127.66% for CT, and 207.88% for MRI. Mean total relative value units decreased by 38.7%. The commonly billed imaging procedure CPT 73720 (MRI lower extremity, other than joint, with and without contrast) had the greatest adjusted decrease of 69.89%. Conclusion: Medicare reimbursement for the most billed lower extremity imaging studies decreased by 32.41% between 2005 and 2020. The greatest decreases were noted in the technical component. Of the modalities, MRI had the largest decrease, followed by CT and then radiography. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Retention in HIV care remains a national challenge. Addressing structural barriers to care may improve retention. We examined the association between physician reimbursement and retention in HIV care, including racial differences. Methods: We integrated person-level administrative claims (Medicaid Analytic eXtract, 2008–2012), state Medicaid-to-Medicare physician fee ratios (Urban Institute, 2008, 2012), and county characteristics for 15 Southern states plus District of Columbia. The fee ratio is a standardized measure of physician reimbursement capturing Medicaid relative to Medicare physician reimbursement across states. Generalized estimating equations assessed the association between the fee ratio and retention (≥2 care markers ≥90 days apart in a calendar year). Stratified analyses assessed racial differences. We varied definitions of retention, subsamples, and definitions of the fee ratio, including the fee ratio at parity. Results: The sample included 55,237 adult Medicaid enrollees with HIV (179,002 enrollee years). Enrollees were retained in HIV care for 76.6% of their enrollment years, with retention lower among non-Hispanic Black (76.1%) versus non-Hispanic White enrollees (81.3%, P < 0.001). A 10-percentage point increase in physician reimbursement was associated with 4% increased odds of retention (adjusted odds ratio 1.04, 95% confidence interval: 1.01 to 1.07). In stratified analyses, the positive, significant association occurred among non-Hispanic Black (1.08, 1.05–1.12) but not non-Hispanic White enrollees (0.87, 0.74–1.02). Findings were robust across sensitivity analyses. When the fee ratio reached parity, predicted retention increased significantly overall and for non-Hispanic Black enrollees. Conclusion: Higher physician reimbursement may improve retention in HIV care, particularly among non-Hispanic Black individuals, and could be a mechanism to promote health equity. [ABSTRACT FROM AUTHOR]

Abstract Background Upcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incorporate capitated payments for chronic disease management. Prior research on the effect of capitated payments on chronic disease management has shown mixed results. We assessed the patient, physician, and practice characteristics of practices with capitation as the majority of revenue, and evaluated the association of capitated reimbursement with quality of chronic disease care. Methods We performed a cross-sectional analysis of visits in the United States’ National Ambulatory Medical Care Survey (NAMCS) for patients with hypertension, diabetes, or chronic kidney disease (CKD). Our predictor was practice reimbursement type, classified as 1) majority capitation, 2) majority FFS, or 3) other reimbursement mix. Outcomes were quality indicators of hypertension control, diabetes control, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use, and statin use. Results About 9% of visits were to practices with majority capitation revenue. Capitated practices, compared with FFS and other practices, had lower visit frequency (3.7 vs. 5.2 vs. 5.2, p = 0.006), were more likely to be located in the West Census Region (55% vs. 18% vs. 17%, p

• What is currently known about this topic? • Currently, physician compensation and productivity-based incentives are work relative value units (wRVU)-based. • What new information is contained in this article? • When designing compensation plans, is important to align the physician goals with those of the department and institution and monitor the outcomes. Several behavioral economic strategies can be used to incentivize. In recent history, healthcare payment reform and legislative initiatives have drastically altered the practice environment for many physicians. Individual providers have migrated from self-managed smaller practices toward employed positions with larger entities, in which provider productivity is tracked. In academic institutions, surgical departments are tasked with meeting clinical productivity metrics while maintaining research and education missions. The objective was to review the current literature regarding the status of physician compensation. A narrative review of the literature with a defined search strategy using Pubmed and MEDLINE was performed. Using keywords of physician reimbursement, physician compensation, performance-based incentives, relative value unit, RVU, searches were completed and subsequently reviewed by the authors for inclusion. Subsequently, all review articles had their included studies hand searched by the research team and any relevant articles were included in our review. In total, fifteen papers were deemed to meet inclusion criteria. Articles were then divided into 7 domains (Origins of the Work Relative Value Unit, Adjusting for Clinical Complexity, Alternative Compensation Strategies, Aligning Compensation with Department Goals, Individual versus Group Incentives, Minimizing Complexity, Maximize Efficiency, Minimize Loss). As external powers continue to apply pressure to surgeon compensation, leaders have had to increasingly focus on clinical productivity, while the missions of research and education become more neglected. One solution could be the development of metrics to best align incentives for clinical, research, and education activities with institutional goals. [ABSTRACT FROM AUTHOR]

The Hawai'i Medical Service Association's (HMSA) Population-based Payments for Primary Care (3PC) system has been in effect since 2016. There is limited literature regarding physician opinions on this payment transformation policy change. The objective of this study was to evaluate physician responses to a survey regarding the 3PC payment transformation system and identify methods to support physicians in Hawai'i. An online survey was sent to 2478 Hawai'i physicians and yielded 250 responses. A total of 77% respondents reported being unhappy with payment transformation, while 12.9% and 10.1% reported being indifferent and happy, respectively. Of responding physicians, 60.6% reported a decrease in overall income, whereas 24.9% and 14.5% reported no change or an overall increase, respectively. Open-ended responses were categorized into theme clusters: negative impact on primary care, increased administrative burdens, decreased quality of patient care, decreased physician reimbursement, preference to treat healthier patients, harm to private practice, harm to newer practices, ignored physician sentiments, and worsened physician shortage in Hawai'i. Respondents, especially those working in primary care, are dissatisfied with payment transformation. Future research is needed to compare the thematic clusters identified in the current study with relevant literature. [ABSTRACT FROM AUTHOR]

Relative value units (RVUs) are integral to the U.S. physician compensation system used by the Centers for Medicare & Medicaid Services. The use of 'work RVUs' (herein, wRVUs) is intended to reimburse physicians according to the amount of expertise and effort needed to safely and effectively perform a procedure. Our purpose was to determine: 1) the number of wRVUs/hour generated by common sports medicine surgical procedures; and 2) how patient characteristics, surgical approach, and practice setting are associated with the number of wRVUs/hour. This analysis was performed to infer whether wRVUs are assigned appropriately according to the factors on which they are purported to be based. We queried the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database for common sports medicine surgical procedures performed in 2018. Data from 19,877 patients (8,258 women) with a mean age of 48 years (range, 18–90) who underwent a surgical sports medicine procedure were analyzed. Work RVUs and operative time were used to calculate work RVUs/hour for each surgical procedure. Univariate and multivariate analyses were used to assess correlations between patient characteristics and wRVUs/hour. Knee chondroplasty generated the most mean (± standard deviation) wRVUs/hour at 22 ± 0.5, whereas 'open tenodesis of biceps tendon, long head' generated the least at 9.6 ± 0.25 wRVUs/hour. Factors associated with a greater mean number of wRVUs/hour were younger patient age, female sex, arthroscopic approach, and outpatient setting. Arthroscopic procedures also generated more wRVUs/hour than the same procedures performed through an open approach. wRVUs were not correlated with case complexity or surgical time. wRVUs/hour in surgical sports medicine procedures vary widely depending on the procedure type, patient characteristics, surgical approach, and practice setting. [ABSTRACT FROM AUTHOR]

The objective of this investigation was to evaluate patient characteristics associated with medical disposition in treatment of ankle fractures. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was interrogated with data extracted related to the 6 current procedural terminology (CPT) codes available pertaining to ankle fractures: 27766, 27769, 27792, 27814, 27822, and 27823. The primary outcome analysis involved a comparison of patient characteristics and short-term adverse outcomes between those fractures repaired on an inpatient basis versus outpatient basis. A secondary analysis was then performed on patient characteristics and adverse short-term outcomes between those fractures treated on an inpatient basis who were discharged home versus elsewhere. Age (p <.001), race (p <.001), ethnicity (p <.001), body mass index (BMI) (p <.001), estimated probability of mortality (p <.001), estimated probability of morbidity (p <.001), CPT code of fracture designation (p <.001), functional status (p <.001), elective surgery designation (p <.001), American Society of Anesthesiologists class (p <.001), diabetes (p <.001), smoking status (p <.001), dyspnea (p <.001), COPD (p <.001), congestive heart failure (p <.001), hypertension (p <.001), dialysis (p <.001), cancer (p <.001), steroid use (p <.001), blood transfusion history (p <.001), and sepsis/systemic inflammatory response syndrome history (p <.001) were all independently associated with the ankle fracture repair being performed on an inpatient basis on regression analysis. Age (p <.001), race (p =.025), ethnicity (p <.001), BMI (p =.001), CPT code of fracture designation (p <.001), preoperative functional status (p <.001), and American Society of Anesthesiologists class (p <.001) were all independently associated with inpatient ankle fracture repairs being discharged to home following the procedure on regression analysis. The results of this investigation demonstrate that differences in patient demographic characteristics might contribute to medical decision-making as it relates to patient management and discharge disposition in the treatment of ankle fractures. [ABSTRACT FROM AUTHOR]

Abstract Background Physicians’ financial interests might conflict with the best service to patients. It is essential to gain a thorough understanding of the effect of remuneration systems on physician behaviour. Methods We conducted a controlled laboratory experiment using a within-subject design to investigate physician behaviour underpayment heterogeneity. Each physician provided medical care to patients whose treatments were paid for under fee-for-service (FFS) or capitation (CAP). Results We observed that physicians customized their care in response to the payment system. FFS patients received considerably more medical care than did CAP patients with the same illness and treatment preference. Physicians over-served FFS patients and under-served CAP patients. After a CAP payment reduction, we observed neither a quantity reduction under CAP nor a spillover in FFS patients’ treatment. Conclusions The results suggest that, in our experimental model, fee regulation can be used to some extent to control physician spending since we did not identify a behavioural response to the CAP payment cut. Physicians did not recoup lost income by altering treatment behaviour toward CAP and/or FFS patients. Experimental economics is an excellent tool for ensuring the welfare of all those involved in the health system. Further research should investigate payment incentives as a means of developing health care teams that are more efficient.

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

Work relative value units (wRVUs) have been assigned to current procedural terminology codes in an effort to help establish physician compensation. However, the ability of these to accurately and efficiently capture the time, technical, and perioperative managerial aspects required of various procedures has recently been called into question for several surgical subspecialties. Therefore, the objective of this investigation was to evaluate various measures of medical complexity against wRVUs for foot and ankle surgical procedures. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify and extract data related to the perioperative medical complexity of 16 foot and ankle surgical current procedural terminology codes. We observed a "weak" positive relationship between wRVUs and operation time as defined by a correlation coefficient of 0.234 (p <.001). Other variables associated with medical complexity in the perioperative period were found to significantly vary between wRVUs categories, but these differences were neither consistently nor directly associated with assigned relative values. We conclude that wRVUs might not always represent an efficient means for determining compensation for foot and ankle surgical procedures. [ABSTRACT FROM AUTHOR]

Performance on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey can affect up to 33% of a physician's reimbursement from the Centers for Medicare & Medicaid Services. At this pseudo-private orthopedic practice, the authors characterized how physicians often achieve drastically different scores between HCAHPS and an Internal Patient Satisfaction Questionnaire (IPSQ). Eighteen physicians were ranked separately according to percentage of top-box scores on HCAHPS and IPSQ. There was an inverse relationship between physician rank for the 2 surveys according to Spearman correlation coefficient (ρ = -0.36, P = .15). Qualitative subanalysis indicated that although "physician interaction" was the most common reason for negative comments on HCAHPS, "ancillary staff" and "workflow" concerns were common on IPSQ. The outpatient setting remains a critical component in achieving high-quality orthopedic care. Consequently, HCAHPS alone may not be a sufficient indicator of patient satisfaction for orthopedic and other subspecialty practices. [ABSTRACT FROM AUTHOR]

Objective We aimed to evaluate trends in government monetary reimbursement (Medicare) for 10 of the most commonly performed pediatric orthopedic procedures from 2000 to 2020. Methods Utilizing the Centers for Medicare and Medicaid Services website, we collected data for 10 of the most commonly performed pediatric orthopedic surgical procedures and their variations. The reimbursement data for each procedure was taken from the Current Procedural Terminology (CPT) code, which was collected from the Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services (Baltimore County, MD). The reimbursement values were adjusted for inflation to the 2022 US dollar (USD) using the changes to the Consumer Price Index. The compound annual growth rates (CAGRs) and total percentage changes in reimbursement were calculated for all the procedures and put into relative value units. Results Reimbursement for 20 of the 22 total procedures decreased by 32.65% from 2000 to 2022 after adjusting for inflation. Achilles tenotomy with local anesthesia saw the greatest decrease (-54.38%), whereas the procedure revision of spinal fusion saw the highest increase (26.00%) in mean adjusted reimbursement during this study period. Adjusted reimbursement decreased by an average of 2.08% on a yearly basis. Conclusion This study is the first to take an in-depth view and evaluate trends in procedural Medicare reimbursement for pediatric orthopedic surgery. When adjusted for inflation, Medicare reimbursement for 20 of 22 included procedures has steadily decreased from 2000 to 2022. There needs to be an increased awareness and consideration of these trends as they will be important for policymakers, hospitals, and surgeons to ensure continued access to meaningful surgical pediatric orthopedic care in the United States., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Faust et al.)

Background: Physicians' financial interests might conflict with the best service to patients. It is essential to gain a thorough understanding of the effect of remuneration systems on physician behaviour. Methods: We conducted a controlled laboratory experiment using a within-subject design to investigate physician behaviour underpayment heterogeneity. Each physician provided medical care to patients whose treatments were paid for under fee-for-service (FFS) or capitation (CAP). Results: We observed that physicians customized their care in response to the payment system. FFS patients received considerably more medical care than did CAP patients with the same illness and treatment preference. Physicians over-served FFS patients and under-served CAP patients. After a CAP payment reduction, we observed neither a quantity reduction under CAP nor a spillover in FFS patients' treatment. Conclusions: The results suggest that, in our experimental model, fee regulation can be used to some extent to control physician spending since we did not identify a behavioural response to the CAP payment cut. Physicians did not recoup lost income by altering treatment behaviour toward CAP and/or FFS patients. Experimental economics is an excellent tool for ensuring the welfare of all those involved in the health system. Further research should investigate payment incentives as a means of developing health care teams that are more efficient. [ABSTRACT FROM AUTHOR]

Purpose: To assess radiologists' performance in the Merit-Based Incentive Payment System (MIPS), with attention to the impact of the novel MIPS-Alternative Payment Models (APMs) participation option created under the Medicare Access and CHIP Reauthorization Act.Methods: Data regarding radiologists' 2017 MIPS performance was extracted from the Physician Compare 2017 Individual EC Public Reporting-overall MIPS Performance data set, and additional physician characteristics were extracted from multiple CMS data sets.Results: Among 20,956 MIPS-participating radiologists, 16.6% participated using individual reporting, 68.9% group reporting, and 13.4% APM reporting. Average Quality scores were 59.7 84.0, and 92.5, respectively. The fractions of radiologists scored in Advancing Care Information were 4.1%, 27.0%, and 100.0%. When scored, average scores in this category were 61.9, 94.6, and 80.9. A total of 27.7% and 42.7% of interventional radiologists were scored in this category using individual and group reporting, respectively. However, general radiologists and subspecialists other than interventional radiologists were rarely (<5%) scored. Average scores in Improvement Activities were 37.5, 92.5, and 100.0 for individual reporting, group reporting, and APM reporting, respectively. Average Final Scores were 56.5, 85.6, and 90.6. The better performance of APM versus group reporting was most apparent for smaller practices (ie, for practice sizes ≤15, average Final Score of 84.1 for APM versus 75.0 for group reporting).Conclusion: Although radiologists perform much better in MIPS using group versus individual reporting, performance improves even further through APM reporting, particularly for smaller practices. Radiologists seeking better performance under MIPS should carefully explore APM opportunities. [ABSTRACT FROM AUTHOR]

The 6-min walk test (6MWT) is a commonly used test for the objective assessment of functional exercise capacity for the management of patients with moderate-to-severe pulmonary disease. Unlike pulmonary function testing, the 6MWT captures the often coexisting extrapulmonary manifestations of chronic respiratory disease, including cardiovascular disease, frailty, sarcopenia, and cancer. In contrast with cardiopulmonary exercise stress testing, this test does not require complex equipment or technical expertise. In this low complexity, safe test, the patient is asked to walk as far as possible along a 30-m minimally trafficked corridor for a period of 6 min with the primary outcome measure being the 6-min walk distance (6MWD) measured in meters. There has been interest in other derived indexes, such as distance-desaturation product (the product of nadir oxygen saturation and walk distance), which in small studies has been predictive of morbidity and mortality in certain chronic respiratory conditions. Special attention to methodology is required to produce reliable and reproducible results. Factors that can affect walk distance include track layout (continuous vs straight), track length, oxygen amount and portability, learning effect, and verbal encouragement. The absolute 6MWD and change in 6MWD are predictive of morbidity and mortality in patients with COPD, pulmonary arterial hypertension, and idiopathic pulmonary fibrosis and patients awaiting lung transplant, highlighting its use in management decisions and clinical trials. As of January 2018, Current Procedural Terminology code 94620 (simple pulmonary stress test) has been deleted and replaced by two new codes, 94617 and 94618. Code 94617 includes exercise test for bronchospasm including pre- and postspirometry, ECG recordings, and pulse oximetry. Code 94618, pulmonary stress testing (eg, 6MWT), includes the measurement of heart rate, oximetry, and oxygen titration when performed. If 94620 is billed after January 2018 it will not be reimbursed. [ABSTRACT FROM AUTHOR]

Ever since Medicare began covering nearly every patient with end-stage renal disease in the United States, reimbursement for dialysis services has deviated from traditional fee-for-service. The method of reimbursing physicians for outpatient dialysis care has undergone a series of reforms in an effort to improve the overall quality of dialysis care and to control healthcare costs-changes that we are still seeing today. In 2004, the Centers for Medicare and Medicaid Services (CMS) changed the Monthly Capitation Payment (MCP) for physician reimbursement to the tiered fee-for-service system that is used today. This most recent reform encouraged more frequent face-to-face visits to patients receiving dialysis. While the quantity of visits increased in response to the change in reimbursement, the quality of care did not meaningfully improve, the policy may have had unintended negative health consequences and may have led to increases in wasteful physician and advanced practitioner effort. There are several promising opportunities to reform economic incentives around physician dialysis care that could improve the quality and value of care. These include new pay-for-performance initiatives, implementing incentives for high-quality care within fully capitated payment models, and reforming the MCP itself to link payment to high-value dialysis services. [ABSTRACT FROM AUTHOR]

There has been tremendous evolution in the care of cardiac surgical patients in 2018. In this article, 4 topics of considerable impact on cardiac surgical care in the current landscape are reviewed based on recent publications. The first topic reviews the recent paradigm shift to value-based payments and the potential role of bundled payments on health care and physician reimbursement. The second topic highlights the impact of the opioid crisis on cardiac surgery. The third topic demonstrates the increasing utilization and expanding role of novel percutaneous suction thrombectomy technique in the extraction of caval and right-sided intracardiac thrombi and vegetations with veno-venous bypass. The final topic reviews the current trend of minimally invasive left ventricular assist device placement. Each of these topics addresses the contemporary issues in cardiac surgery with the reasoning for evolution in our current practices in 2018. [ABSTRACT FROM AUTHOR]

This paper investigates how office-based physicians respond to Medicare reimbursement changes. Using variation from an Affordable Care Act policy that increased reimbursements for office-based care in four states, we use a triple difference analysis, comparing physicians with higher and lower reimbursement changes in treated states to similar physicians in untreated states. We find two mechanisms through which physicians respond. First, the reimbursement change affected integration—physicians with larger increases in office-based reimbursement were less likely to vertically integrate with hospitals and more likely to continue providing office-based care than physicians with smaller reimbursement increases. Second, we find some evidence that physicians who continued practicing in an office setting increased the volume of services provided. [ABSTRACT FROM AUTHOR]

Purpose: To quantify the Medicare reimbursement disparity between female and male vitreoretinal surgeons. Methods: Reimbursement reports were obtained from the US Center for Medicare and Medicaid Services from 2013 through 2020, which detail all Medicare Part B services. A vitreoretinal surgeon was defined as any provider with at least 10 charges of a Healthcare Common Procedure Coding System code related to vitrectomy or retinal detachment repair. Providers were grouped by sex, and the average total reimbursement rate and additional secondary statistics to quantify the reimbursement disparity were identified. Results: On average, female vitreoretinal surgeons were reimbursed 65% that of their male counterparts in 2020, $1.66 million to $2.56 million. The percentage of the average male vitreoretinal specialist's total reimbursement that the average female vitreoretinal specialist received decreased 8.8% from 2013 to 2020, from 73.8% to 65.0%. Conclusions: The reimbursement that the average female vitreoretinal surgeon receives from Medicare is only two thirds that of the average male vitreoretinal surgeon. In addition, there was no identifiable improvement in this disparity over the study period. Further efforts must be taken to establish concerted efforts to improve the reimbursement disparity and to identify the systematic inequities that led to its presence in the first place., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Study Design: Retrospective cohort study.Objective: To identify trends in spinal procedure reimbursement in our practice since 2010.Summary Of Background Data: In an uncertain healthcare climate with continuous reform, trends in physician reimbursement are unclear. Market forces of supply and demand, legislation imposing penalties for quality measures, local competition, and geographic location have the potential to affect reimbursement. An emphasis on quality-of-care and cost reduction is placed on providers and insurers. In a high-cost area such as spine surgery, it is unknown what the reimbursement trends have been over the last 7 years of major healthcare reforms.Methods: We collected payments received data for the 20 most commonly billed Current Procedural Terminology (CPT) codes for spinal surgery from January 2010 to December 2016. Payments were adjusted for inflation using the Consumer Price Index for Medical Care in the Northeastern United States. Insurers were separated into four groups: Medicare, Medicaid, Private Insurance, and Workers Compensation and No Fault (WC/NF). Using a weighted average to adjust for variation in procedures performed, average payments were trended over time. Average payments were trended by insurance group averaged by CPT code.Results: After adjusting for inflation, average overall payments for spinal claims from 2010 to 2016 increased 13.6%. Average reimbursement declined 1.9% from 2010 to 2013 and rose 16.8% from 2014 to 2016. Average Medicaid payments increased 150.1% since 2010 whereas average Medicare payments rose 4.9%. Average reimbursement from private insurers and WC/NF claims decreased 16.2% and 8.5%, respectively, from 2010 to 2013; increasing 14.2% and 12.5%, respectively, from 2014 to 2016. From 2010 to 2016, reimbursement for private insurance decreased 9.3% and increased 8.2% for WC/NF claims.Conclusion: Since 2010, inflation-adjusted reimbursement for spinal procedures increased in our practice. There was a decline from 2010 to 2013. Increases occurred from 2014 to 2016 across all insurers. Medicaid payments more than doubled since 2010.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Decreasing health care expenditures has been one of the main objectives of the Affordable Care Act. To achieve this goal, the Centers for Medicare and Medicaid Services (CMS) has been tasked with experimenting with provider reimbursement methods in an attempt to increase quality, while decreasing costs. The purpose of this research was to study the effects of the Affordable Care Act on physician reimbursement rates from CMS to determine the most cost-effective method of delivering health care services. The CMS has experimented with payment methods in an attempt to increase cost-effectiveness. Medicare has offered shared cost-savings incentives to reward quality care to both primary care providers and preventative services. The CMS has determined fee-for-service payments obsolete, opting instead for a value-based purchasing method of payment. Although a universal payment method has yet to be adopted, it has been evident that a value-based purchasing model and preventative care can be used to decrease health care expenditure. [ABSTRACT FROM AUTHOR]

Objective: To calculate the associations between Medicare payment and service volume for complex and noncomplex cataract surgeries.Data Sources: The 2005-2009 CMS Part B National Summary Data Files, CMS Part B Carrier Summary Data Files, and the Medicare Physician Fee Schedule.Study Design: Conducting a retrospective, longitudinal analysis using a fixed-effects model of Medicare Part B carriers representing all 50 states and the District of Columbia from 2005 to 2009, we calculated the Medicare payment-service volume elasticities for noncomplex (CPT 66984) and complex (CPT 66982) cataract surgeries.Data Extraction: Service volume data were extracted from the CMS Part B National Summary and Carrier Summary Data Files. Payment data were extracted from the Medicare Physician Fee Schedule.Principal Findings: From 2005 to 2009, the proportion of total cataract services billed as complex increased from 3.2 to 6.7 percent. Every 1 percent decrease in Medicare payment was associated with a nonsignificant change in noncomplex cataract service volume (elasticity = 0.15, 95 percent CI [-0.09, 0.38]) but a statistically significant increase in complex cataract service volume (elasticity = -1.12, 95 percent CI [-1.60, -0.63]).Conclusions: Reduced Medicare payment was associated with a significant increase in complex cataract service volume but not in noncomplex cataract service volume, resulting in a shift toward performing a greater proportion of complex cataract surgeries from 2005 to 2009. [ABSTRACT FROM AUTHOR]

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

Study Design: Structured key informant interviews with follow-up.Objective: The aim of the study was to describe innovative reimbursement models in spine care and gather perspectives on the future of spine care reimbursement.Summary Of Background Data: The United States spends $90 billion annually on medical expenses for low back pain. One approach to promoting high-quality, cost-effective care is through bundled payments and other reimbursement models wherein physicians are held accountable for costs and utilization. Little data exist on innovative payment models in spine care.Methods: Through literature review and discussions with leaders in the field, we identified organizations that were engaged in bundled payment initiatives for spine care and surgery. These included healthcare systems, physician groups, organizations helping to set up bundles, and a large employer. We conducted interviews to understand the background and specific features of each initiative, generalizable success factors and challenges, and perspectives on the future of spine reimbursement.Results: We interviewed 24 stakeholders across 18 organizations that collectively perform approximately 12,000 inpatient spine surgeries annually. Fee-for-service reimbursement accounts for a majority of revenue, but several organizations expect 30% to 45% of their spine volume to be covered under bundled payments within 3 years and cite new patient volume, increased surgical yield, and financial benefits from efficiency improvements as reasons for adopting bundled payments. Current initiatives are heterogeneous, but share similar success factors and challenges. Institutions are more hesitant to adopt risk-based payment models for chronic back care, citing difficulty modeling risk, patient heterogeneity, and difficulty aligning incentives.Conclusion: Payment models outside of the traditional fee-for-service paradigm are emerging in spine care. Providers that preemptively adopt bundled payments can increase patient volumes from payers seeking cost-effective care. Going forward, organizations should begin considering reimbursement models that focus on noninterventional spine care. Finally, developments in spine reimbursement may apply to other procedure-based specialties, including orthopedics and cardiology.Level Of Evidence: 5. [ABSTRACT FROM AUTHOR]