Search

Background: Iran's healthcare system has a significant discrepancy between the national tariff and the cost of global surgical procedures (GSPs). This study aimed to compare the actual costs of GSPs with national tariffs in Iran's public hospitals. Methods: This retrospective cross-sectional study was conducted in 2017. Using the census method, 6126 GSPs performed in three public hospitals were investigated in this study. Additionally, national tariffs from the Supreme Council of Health Insurance were obtained. The tariff-cost gap was the discrepancy between a GSP's actual costs and tariff. Multiple linear regression analysis determined factors affecting the tariff-cost gap. Results: The average actual cost of GSPs was 637 USD, while the average tariff was 495 USD. The reimbursement covered only 78% of the costs. The gap was higher in older (B = 1.05, 95% CI: 0.76-1.35, P < 0.001), females (B = 26.7, 95% CI: 15.5-37.9, P < 0.001), patients with a longer stay (B = 81.2, 95% CI: 77.5-84.8, P < 0.001), and procedures performed by full-time surgeons (B = 67.3, 95% CI: 56.9-77.5, P < 0.001). Furthermore, neurosurgery had the highest effect on forecasting the gap between actual costs and tariffs among surgical specialties (B = 346.9, 95% CI: 214.3-479.5, P < 0.001). Conclusion: Public hospitals suffer from large financial losses due to the national tariff for many GSPs not covering their actual costs. It is suggested that tariffs be increased for certain customer segments that can bear higher costs and global tariffs be adjusted to match actual service delivery costs. [ABSTRACT FROM AUTHOR]

Abstract Upcoding in Medicare has been a topic of interest to economists and policy makers for nearly 40 years. While upcoding is generally understood as “billing for services at higher level of complexity than the service actually pro- vided or documented,” it has a wide range of definitions within the literature. This is largely because the financial incentives across programs and aspects under the coding control of billing specialists and providers are different, and have evolved substantially over time, as has the published literature. Arguably, the primary importance of analyzing upcoding in different parts of Medicare is to inform policy makers on the magnitude of the process and to suggest approaches to mitigate the level of upcoding. Financial estimates for upcoding in traditional Medicare (Medicare Parts A and B), are highly variable, in part reflecting differences in methodology for each of the services covered. To resolve this variability, we used summaries of audit data from the Comprehensive Error Rate Testing program for the period 2010–2019. This program uses the same methodology across all forms of service in Medicare Parts A and B, allowing direct comparisons of upcoding magnitude. On average, upcoding for hospitalization under Part A represents $656 million annually (or 0.53% of total Part A annual expenditures) during our sample period, while up- coding for physician services under Part B is $2.38 billion annually (or 2.43% of Part B annual expenditures). These numbers compare to the recent consistent estimates from multiple different entities putting upcoding in Medicare Part C at $10–15 billion annually (or approximately 2.8–4.2% of Part C annual expenditures). Upcoding for hospitalization under Medicare Part A is small, relative to overall upcoding expenditures.

Upcoding in Medicare has been a topic of interest to economists and policy makers for nearly 40 years. While upcoding is generally understood as "billing for services at higher level of complexity than the service actually pro- vided or documented," it has a wide range of definitions within the literature. This is largely because the financial incentives across programs and aspects under the coding control of billing specialists and providers are different, and have evolved substantially over time, as has the published literature. Arguably, the primary importance of analyzing upcoding in different parts of Medicare is to inform policy makers on the magnitude of the process and to suggest approaches to mitigate the level of upcoding. Financial estimates for upcoding in traditional Medicare (Medicare Parts A and B), are highly variable, in part reflecting differences in methodology for each of the services covered. To resolve this variability, we used summaries of audit data from the Comprehensive Error Rate Testing program for the period 2010–2019. This program uses the same methodology across all forms of service in Medicare Parts A and B, allowing direct comparisons of upcoding magnitude. On average, upcoding for hospitalization under Part A represents $656 million annually (or 0.53% of total Part A annual expenditures) during our sample period, while up- coding for physician services under Part B is $2.38 billion annually (or 2.43% of Part B annual expenditures). These numbers compare to the recent consistent estimates from multiple different entities putting upcoding in Medicare Part C at $10–15 billion annually (or approximately 2.8–4.2% of Part C annual expenditures). Upcoding for hospitalization under Medicare Part A is small, relative to overall upcoding expenditures. [ABSTRACT FROM AUTHOR]

Antimicrobial resistance is a major global health threat, which is increased by the irrational use of antibiotics, for example, in the treatment of respiratory tract infections in community care. By using rapid point-of-care diagnostics, overuse can be avoided. However, the diagnostic tests are rarely used in most European countries. We mapped potential barriers and facilitators in health technology assessment (HTA), pricing, and funding policies related to the use of rapid diagnostics in patients with community-acquired acute respiratory tract infections. Expert interviews were conducted with representatives of public authorities from five European case study countries: Austria, Estonia, France, Poland, and Sweden. Barriers to the HTA process include the lack of evidence and limited transferability of methods established for medicines to diagnostics. There was no price regulation for the studied diagnostics in the case study countries, but prices were usually indirectly determined via procurement. The lack of price regulation and weak purchasing power due to regional procurement processes were mentioned as pricing-related barriers. Regarding funding, coverage (reimbursement) of the diagnostic tests and the optimized remuneration of physicians in their use were mentioned as facilitators. There is potential to strengthen peri-launch policies, as optimized policies may promote the uptake of POCT. [ABSTRACT FROM AUTHOR]

The Home Health Value-based Purchasing (HHVBP) demonstration, incorporating a payment formula designed to incentivize both high-quality care and quality improvement, is expected to become a national program after 2022, when the demonstration ends. This study investigated the relationship between costs and several quality dimensions, to inform HHVBP policy. Using Medicare cost reports, OASIS and Home Health Compare data for 7,673 home health agencies nationally, we estimated cost functions with instrumental variables for quality. The estimated net marginal costs varied by composite quality measure, baseline quality, and agency size. For four of the five composite quality measures, the net marginal cost was negative for low-quality agencies, suggesting that quality improvement was cost saving for this agency type. As the magnitude of the net marginal cost is commensurate with the payment incentive planned for HHVBP, it should be considered when designing the incentives for HHVBP, to maximize their effectiveness.

ABSTRACT Purpose: In Brazil, healthcare services traditionally follow a fee-for-service (FFS) payment system, in which each medical procedure incurs a separate charge. An alternative reimbursement with the aim of reducing costs is diagnosis related group (DRG) remuneration, in which all patient care is covered by a fixed amount. This work aimed to perform a systematic review followed by meta-analysis to assess the effectiveness of the Budled Payment for Care Improvement (BPCI) versus FFS. Methods: Our work was performed following the items of the PRISMA report. We included only observational trials, and the primary outcome assessed was the effectiveness of FFS and DRG in appendectomy considering complications. We also assessed the costs and length of hospital stay. Meta-analysis was performed with Rev Man version 5.4. Results: Out of 735 initially identified articles, six met the eligibility criteria. We demonstrated a shorter hospital stay associated with the DRG model (mean difference = 0.39; 95% confidence interval – 95%CI – 0.38–0.40; p < 0.00001; I2 = 0%), however the hospital readmission rate was higher in this model (odds ratio = 1.57; 95%CI 1.02–2.44, p = 0.04; I2 = 90%). Conclusions: This study reveals a potential decrease in the length of stay for appendectomy patients using the DRG approach. However, no significant differences were observed in other outcomes analysis between the two approaches.

Background Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge. Methods and Results Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95-1.00). Lower odds of IRF versus home discharge were observed in people aged

Background The hospice movement has provided an excellent model of specialist palliative care for those with advanced illness approaching the end of life. However, there are marked inequities in provision of this care, and major geographical variations in the resourcing of palliative care, often resulting in a poor match between the needs of a patient/family and resources provided to meet those needs. Objective To develop/test a casemix classification to accurately capture the complex needs of patients with advanced disease, better quantify those needs and more fairly allocate resources to meet them. A ‘casemix classification’ groups patients into classes according to differing care needs to help inform the resources needed to meet those care needs. Design Workstream 1 comprised the validating and refining of patient-centred measures of health status and well-being. In workstream 2, stakeholder interviews with patients, families, policy-makers, service providers and commissioners were carried out to understand complexity/casemix and models of specialist palliative care. In workstream 2 the casemix classification was developed through a multicentre cohort study. Workstream 4 comprised a longitudinal mixed-methods study to test the casemix classification, with a nested qualitative study to explore experiences of transitions between care settings. Setting Voluntary sector and NHS specialist palliative care services across England. Participants Patients ≥ 18 years receiving specialist palliative care, their families and the professionals delivering this care. Results For the Integrated Palliative care Outcome Scale validation: data from 376 patient participants and 161 clinicians showed this measure has a strong ability to distinguish between clinically relevant groups, good internal consistency (α = 0.77), and acceptable-to-good test–retest reliability (60% of items kw > 0.60). The Phase of Illness measure showed function and symptoms/concerns varied significantly by Phase of Illness, but Phase of Illness reflected additional construct(s) and so is important for casemix (workstream 1 conducted 2013–15). To gain stakeholder perspectives, 65 participants were interviewed. Based on emergent themes, we developed a theoretical framework to conceptualise complexity in specialist palliative care. This framework emphasises that considering physical, psychological and social needs is not enough to characterise complexity. Number, severity and range of needs all need to be considered in the development of a meaningful casemix classification. To understand models of care, semistructured interviews were conducted with 14 participants, 54 further participants took part in a two-round Delphi survey and interviews were conducted with 21 service leads. Twenty criteria were adopted to define/distinguish models of specialist palliative care (workstream 2 conducted 2014–16). For the development of the casemix classification, a total of 2469 patients were recruited, providing data on 2968 episodes of specialist palliative care. The mean age was 71.6 years, 51% of patients were male, 74% were white and 25% were non-cancer patients. Episodes of care lasted a median of 8 days (range 1–402 days) in hospital advisory care, 12 days (range 1–140 days) in inpatient units, 30 days (range 1–313 days) in the community. The median costs per day (lower–upper quartiles) were: £56 (£31–£100) in hospital advisory, £365 (£176–£698) for inpatient, and £21 (£6–£49) in community care. Seven hospital advisory, six inpatient and six community casemix classes for specialist palliative care were developed, based on levels of pain, other physical symptoms, psychological symptoms, functional status, palliative Phase of Illness, living alone and family distress (workstream 3 conducted 2016–18). For the testing of the casemix classification, a total of 309 patients (mean age 66.9 years, 55% female, 85% white) provided data on 751 episodes of specialist palliative care. The casemix classification was able to accurately predict the actual cost-per-day of care, especially for hospital advisory and community care. The actual costs of inpatient hospice care were consistently higher than predicted class costs, although cost weights remained consistent. Interviews to understand transitions between care settings were conducted with 26 participants (mean age 68 years, range 36–91 years). Four themes emerged: uncertainty about the new care setting, biographical disruption, the importance of continuity of care and the need for emotional/practical support during transition (workstream 4 conducted 2018–19). Limitations Recruitment was challenging but adding new sites helped to overcome this. Models of palliative care proved more diverse and harder to categorise than expected. This casemix classification needs broader testing among those with non-cancer conditions, especially those with multiple conditions. Conclusions The Integrated Palliative care Outcome Scale is a valid, reliable outcome measure for use in advanced illness. We have developed (1) an evidence-based framework to conceptualise complexity of palliative care needs, (2) defined criteria to characterise/differentiate models of specialist palliative care and (3) a casemix classification for specialist palliative care. Each person needing specialist palliative care is different, with varying degrees of complex needs. We now have the casemix classification to understand and capture this, systematically and at scale, for practice, policy and research. This has the potential to help address inequities and provide more equitable specialist palliative care to all who need it. Future research is needed, including further validation of measures, more detailed research into models of care, and further testing of the casemix classification. Study registration This trial is registered as ISRCTN90752212. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and is published in full in Programme Grants for Applied Research; Vol. 11, No. 7. See the NIHR Funding and Awards website for further award information. It was also supported by the NIHR Applied Research Collaboration South London (NIHR ARC South London, previously Collaboration for Leadership in Applied Health Research and Care) at King’s College Hospital NHS Foundation Trust. Plain language summary Hospices have provided an excellent model of palliative care for those with advanced illness in the last months of life. However, some people do not get the care they need and provision varies considerably between different regions of England. We therefore aimed to develop a classification system to accurately reflect the care needs of those with advanced illness, so that resources can be better matched to needs. We interviewed different patients, families, service providers and funders to understand the complex care needs that people have and how a system could be developed. Then we undertook a large study with those with advanced illness to develop a system. Finally, we tested the system with a new group of people experiencing advanced illness. Sixty-five participants were interviewed. Based on these interviews, we developed a way to better understand complex needs, with the individual person at the heart of this understanding. A total of 2469 people contributed to our large study. We established the resources used to provide palliative care: on average, the cost per patient was an additional £56 per day for those receiving specialist palliative care in hospital, £365 per day for those receiving inpatient hospice care and £21 per day for those receiving specialist palliative care at home. We developed a system based on factors such as pain and other symptoms, level of family distress, and whether or not the patient was living alone. These factors indicate what palliative care is needed and how much it might cost. We tested this system with 309 further people with advanced illness, and it was able to predict costs well. Scientific summary Background The hospice movement has provided an excellent model of specialist palliative care for those with advanced disease in the last year of life. However, little is known about costs of care and there are marked inequities in provision across England. Older patients or those with non-cancer conditions access specialist palliative care less often and receive proportionately fewer resources when they do. There are also major geographical variations in resourcing palliative and end-of-life care, often resulting in a poor match between the needs of a patient/family, the resources provided to meet those needs and the improvement in well-being achieved. Aims The aims of this programme were to develop and test a person-centred, nationally applicable casemix classification for adult specialist palliative care provision in England, to accurately capture the complex needs of patients with advanced disease in last year of life, to better quantify those needs and to support more equitable allocation of resources to meet them. Objectives The C-CHANGE programme had five objectives: to validate or refine new and existing person-centred outcome measures designed to assess the main health status and symptoms/concerns of patients receiving specialist palliative care to utilise the perspectives of key stakeholders on the complexity in palliative care to inform subsequent casemix development to understand the criteria which distinguish different models of palliative care to help inform how a casemix classification can be utilised across different models of specialist palliative care to develop a person-centred palliative care casemix classification, based on individual patient needs and costs of care, for adults with both cancer and non-cancer conditions in the last year of life to test this person-centred palliative care casemix classification in terms of ability to predict resource use in the last year of life and to better understand transitions between services in order to improve care. Methods Workstream 1: measures In Workstream 1, several studies were undertaken from 2013 to 2015 to improve our knowledge of the psychometrics, relationships and clinical utility of the measures proposed for workstreams 3 and 4: A cognitive interview study to refine the prototype Integrated Palliative care Outcome Scale (IPOS), a brief measure of symptoms/concerns in advanced illness. Purposively sampled patients were recruited from four inpatient and community settings. Interviews were analysed using thematic analysis, and the prototype measure refined accordingly. A validation study for the IPOS to validate both the patient self-report and staff proxy-report versions. In a longitudinal cohort study, we tested construct validity (factor analysis, known-group comparisons and correlational analysis), reliability (internal consistency, agreement and test–retest reliability), and responsiveness. A secondary analysis of routinely collected clinical data to describe palliative Phase of Illness, and determine associations between Phase of Illness and the other measures proposed for this programme. A survey to examine patients’ Views on Care (VoC), a brief measure of patient perspectives on the quality of their care. Adults receiving specialist palliative care in eight hospital, hospice inpatient and community settings across England were recruited. We reported associations between VoC and changes in health status. Secondary analysis of pre-existing qualitative interviews to understand patient experiences of uncertainty and how these influence understanding of care. Interviews were sampled using maximum variation sampling and analysed using a thematic approach. Workstream 2: stakeholder perspectives To explore the perspectives of key stakeholders on complexity in palliative care, we undertook a qualitative study using semistructured interviews with key stakeholders in specialist palliative care between 2014 and 2015. Participants were professionals from participating sites or were policy/national leads. Data were analysed using framework analysis. To understand the criteria which characterise/distinguish different models of palliative care, we undertook a mixed-methods study during 2015–16, which comprised the following: Semistructured interviews about preliminary criteria with clinical leads from 14 participating sites. Findings were used to expand/refine these criteria. A two-round Delphi survey [conducted following CREDES (Conducting and REporting DElphi Studies in palliative care) guidance], which identified additional criteria, sought consensus on criteria definitions and ranked criteria by importance. Structured interviews with service providers to assess the acceptability and feasibility of the final criteria, with participants recruited from participating sites from workstreams 3 and 4. Workstream 3: development of the casemix classification To determine the costs of specialist palliative care and develop a casemix classification for UK specialist palliative care, we undertook a multicentre prospective cohort study between 2017 and 2018, collecting potential casemix variables and actual costs over episodes of specialist palliative care. Guidance for Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) was followed. Patients were recruited from four hospital advisory, five inpatient hospice and seven community-based services. Consecutive adult patients (aged ≥ 18 years) were included. Casemix variables included were age, sex, ethnicity, living circumstances, need for interpreter, primary diagnosis, palliative Phase of Illness, functional status, dependency and symptoms/problem severity. Our primary outcome was the cost of specialist palliative care per day. The sample size estimation was 2674 episodes of care. For the analyses we examined the distribution of costs by setting and developed a cost-predictive model using classification and regression tree analysis. Workstream 4: testing of the casemix classification To test the palliative care casemix classification developed in workstream 3, we undertook a multicentre prospective cohort study between 2018 and 2019, following patients during episodes of specialist palliative care, with a qualitative nested component (i.e. interviews with a subsample of participants to better understand the experience of transitions between care settings). Patients were recruited from: three hospital advisory, eight inpatient hospice and five community-based services. Inclusion criteria were adult patients (≥ 18 years) able to consent. Exclusion criteria were < 18 years, unable to consent. Collected data included demographic and clinical variables, episode start and end dates, casemix variables and costs of providing care. The casemix classes developed in workstream 3 were applied to predict costs for episodes of care and this was compared/contrasted with the actual costs captured for each episode. A subsample of participants experiencing at least two transitions between care settings were interviewed, using purposive sampling criteria of age, sex, diagnosis and types of transitions. We undertook thematic analysis, with attention to patient/family perspectives on the experience of transitions between care settings and how these were supported/resourced. Results Workstream 1: measures Twenty-five cognitive interviews were conducted. Overall, comprehension and acceptability of the prototype IPOS was good. Identified difficulties were comprehension problems with some specific terms and judgement difficulties. Based on these findings, the prototype IPOS was refined. In the IPOS validation study, we recruited 376 patients and 161 clinicians. We confirmed a three-factor structure (physical symptoms, emotional symptoms and communication/practical issues). The measure showed strong ability to distinguish between clinically relevant groups; total IPOS scores and IPOS subscale scores were higher – reflecting more problems – in those with ‘unstable’ or ‘deteriorating’ versus ‘stable’ Phase of Illness (F = 15.1; p < 0.001). The IPOS showed good internal consistency (α = 0.77) and acceptable-to-good test–retest reliability (60% of items kw > 0.60). In the study of Phase of Illness, function and symptoms/other concerns varied significantly by Phase of Illness. Mean function (scored using the Australia-modified Karnofsky Performance Status from 0–100, where 100 is best function) was highest in the stable phase [65.9, 95% confidence interval (CI) 63.4 to 68.3] and lowest in dying phase (16.6, 95% CI 15.3 to 17.8). Mean pain (scored 0–4 where 4 is worst pain) was highest in the unstable phase (1.43, 95% CI 1.36 to 1.51). Palliative Phase of Illness reflects additional construct beyond function and symptoms. In the survey to examine VoC, 212 participants were recruited, with a mean age of 65.84 years [standard deviation (SD) 13.5 years]. Most indicated that palliative care was giving positive benefit. Participants reporting that ‘things had got better’ were more likely to have improved overall health status (χ2 = 6.057; p = 0.48). There was significant positive association between those reporting that ‘things had got better’ and improved physical symptoms (χ2 = 11.254; p = 0.004). In the secondary analysis of pre-existing qualitative interviews to understand patient experiences of uncertainty, 30 transcripts were analysed. Participants had a median age of 75 years (range 43–95 years). A typology of patient responses to uncertainty was developed, depending on the level of engagement of each individual patient with their illness and treatment, their preferences for information and their temporal focus. Workstream 2: stakeholder perspectives In study of stakeholder perspectives on complexity, 65 participants (comprising patients, family, health-care professionals and policy makers) were recruited. Based on the emergent themes, we developed a theoretical framework – adapted from Bronfenbrenner’s Ecological Systems Theory – to conceptualise complexity in specialist palliative care. This framework emphasises that considering physical, psychological, social and spiritual domains is not enough to characterise complexity. The number, severity and range of needs – as well as ‘hidden’ or overlooked aspects of complexity – all need to be considered in the development of a meaningful casemix classification for specialist palliative care. Semistructured interviews were conducted with 14 service leads discussing 12 settings of care (five hospice inpatient units, two hospital advisory teams and five community teams). Of the 28 initial criteria to describe models of care, 11 were removed, 17 were refined and a further 17 were created. Thirty-four criteria were taken into the Delphi survey. Fifty-four participants took part in the Delphi survey. In round 1, six criteria did not reach the pre-defined consensus standard and four new criteria were created; this resulted in a refined list of criteria. In round 2, the revised criteria were ranked and rated, and 16 criteria reached the pre-defined consensus standard. In the third component of this study, interviews were then conducted with 21 service leads from 19 different services (six hospice inpatients, four hospital advisory and nine community settings). Criteria were acceptable and feasible, but four contextual criteria were added, resulting in 20 final criteria to define a model of specialist palliative care. Workstream 3: development of the casemix classification In the multicentre prospective cohort study to develop the casemix classification, 2469 patients were recruited, providing data on 2968 complete episodes of specialist palliative care. Patients had a mean age 71.6 years (SD 13.9 years) and were 51% male, 74% white and 25% non-cancer patients. Episodes of care lasted a median of 8 days (range 1–402 days) in hospital advisory care, 12 days (range 1–140 days) in inpatient units and 30 days (range 1–313 days) in community-based care. The median costs per day (lower-upper quartiles) were £56 (£31–100) in hospital advisory care, £365 (£176–698) for inpatient care and £21 (£6–49) in community care. Seven hospital advisory, six inpatient, and six community casemix classes for specialist palliative care were developed, based on seven casemix variables (pain, other physical symptoms, psychological symptoms, functional status, palliative Phase of Illness, living alone and family distress). These casemix criteria, measured at the start of the episode of care, provided the optimal classes to predict costs per day for the episode of care. The per cent variance explained (and root-mean-squared error) were 20% (0.30), 51% (0.51) and 27% (0.36) for hospital advisory, inpatient hospice and community episodes, respectively. Workstream 4: testing of the casemix classification In the multicentre prospective cohort study to test the casemix classification, 309 patients (mean age 66.9 years, SD 13.1 years; 55% female, 85% white) were recruited, providing data on 751 episodes of specialist palliative care. As expected, the median duration of an episode of care was shortest for hospital advisory episodes (10 days) and longest for community episodes (26 days). The casemix classification was able to accurately predict the actual cost per day of care, especially for hospital advisory and community care. The actual costs of inpatient hospice care were consistently higher than the predicted class costs, although the cost weights remained consistent. For the qualitative nested interviews, to understand transitions between care settings, 20 interviews with 26 participants were conducted (mean age 68 years, range 36–91 years). Fourteen interviews were individual and six were joint interviews. Four themes emerged: uncertainty about the new care setting – a lack of information about the new setting of care added to feelings of uncertainty and stress biographical disruption – a loss of independence and difficulty maintaining a sense of normality challenged participants’ self-identity as they moved place of care importance of continuity of care – continuity of care had an impact on feelings of safety in the new care setting and also influenced decisions about the transition need for emotional/practical support – most participants expressed a greater need for emotional and practical support when transitioning to a new care setting. Conclusions The Integrated Palliative care Outcome Scale is a valid and reliable outcome measure, both in its patient self-report and staff proxy-report versions. It can assess/monitor symptoms and concerns in advanced illness, reflect the impact of healthcare interventions and demonstrate quality of care. This represents a major step forward internationally for palliative care outcome measurement. Palliative Phase of Illness has value as a clinical measure of overall palliative need, capturing additional information beyond function and symptoms. In addition, VoC (reflecting patient perspectives on quality of care) is brief and easy to use with patients receiving palliative care across different settings. To the best of our knowledge, it is unique in its brevity and ease of use for ill patients receiving palliative care, which allows the measure to provide patient-level feedback in real time. To the best of our knowledge, workstream 2 provided for the first time in palliative care an evidence-based framework to conceptualise the complexity of palliative care needs of those with advanced illness. Overall, participants reported that they thought it acceptable to measure complexity at the individual patient level using the proposed criteria. To our knowledge, until now there has not been a clear set of criteria to define models of UK specialist palliative care, making it challenging to compare different models of care provided by services. This component of the programme identified the criteria needed to characterise and differentiate models of specialist palliative care, a major paradigm shift to enable accurate reporting and comparison in practice and research. Our detailed evidence on specialist palliative care costs and the casemix classification for specialist palliative care deliver a major advance for the sector. Each person needing specialist palliative care is different, with varying degrees of complex needs. We now have the means to understand this, systematically and at scale, for practice, policy (including resourcing of palliative care) and research. The casemix classes show cost weight variations up to 4.5-fold in inpatient hospices and almost 3-fold in community care. The needs of each person are varied – not fixed – and require different resources to deliver care effectively. Understanding this has the potential to help address inequities and provide more equitable specialist palliative care to all who need it. The casemix classification will inform NHS England currency development. Study registration This trial is registered as ISRCTN90752212. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and is published in full in Programme Grants for Applied Research; Vol. 11, No. 7. See the NIHR Funding and Awards website for further award information. It was also supported by the NIHR Applied Research Collaboration South London (NIHR ARC South London, previously Collaboration for Leadership in Applied Health Research and Care) at King’s College Hospital NHS Foundation Trust.

Background Diagnosis-related group (DRG)-based hospital payment can potentially be inadequately low (or high) for highly variable, highly specialized, and/or low volume care. DRG-based payment can be combined with other payment mechanisms to avoid unintended consequences of inadequate payment. The aim of this study was to analyze these other payment mechanisms for acute inpatient care across six countries (Germany, Denmark, England, Estonia, France, the United States [Medicare]).Methods Information was collected about elements excluded from DRG-based payment, the rationale for exclusions, and payment mechanisms complementing DRG-based payment. A conceptual framework was developed to systematically describe, visualise and compare payment mechanisms across countries.Results Results show that the complexity of exclusion mechanisms and associated additional payment components differ across countries. England and Germany use many different additional mechanisms, while there are only few exceptions from DRG-based payment in the Medicare program in the United States. Certain areas of care are almost always excluded (eg, certain areas of cancer care or specialized pediatrics). Denmark and England use exclusion mechanisms to steer service provision for highly complex patients to specialized providers.Conclusion Implications for researchers and policy-makers include: (1) certain areas of care might be better excluded from DRG-based payment; (2) exclusions may be used to incentivize the concentration of highly specialized care at specialized institutions (as in Denmark or England); (3) researchers may apply our analytical framework to better understand the specific design features of DRG-based payment systems.

To evaluate differences regarding the number of treatment sessions, costs, and outcomes (including relapses) between a regular payment-per-session system and the recently introduced product payment system in The Netherlands. Prospective cohort study. Dutch physical therapy practices in primary care over a 2-year period. 16,103 patients with low back pain (LBP). The new product payment system is compared with the regular payment-per-session system. Pain, disability, recovery, number of physical therapy sessions, therapy duration, costs (per episode), and LBP relapse. At baseline, we found greater pain and disability scores associated with an increased risk profile in both payment systems. With regard to the payment systems, we found greater costs (€283.8 vs €210.8) and a greater percentage of relapse (4.5% vs 2.8%) for the product payment system compared with the payment-per-session system. Comparing the 2 payment systems within each risk strata, we found no significant differences, except for a decrease in pain in the medium-risk stratum. Concerning the therapy characteristics, we found that in the payment-per-session group, the therapy took 6 days longer for low-risk patients (median 27 vs 21 days) and 7 days shorter for high-risk patients (median 42 vs 49 days) compared with the product payment group. Moreover, the mean number of sessions in the payment-per-session group was greater for low-risk patients (5.4 vs 4.8 sessions) and lower for high-risk patients (7.7 vs 8.1 sessions) compared with the payment-per-session group. Finally, the costs were significantly greater in all strata of the product payment group compared with the payment-per-session group. The 2 payment systems are largely comparable regarding patient outcomes, therapy duration, and treatment sessions. Both the average cost per patient per LBP episode and the number of relapses in the product payment system are statistically significantly greater than in the payment-per-session system. [ABSTRACT FROM AUTHOR]

Background: In Iran, a combination of three methods of budget payment, fee for service and case-based payment (known as the global payment system) is used to reimburse the cost of hospital services. The aim of this study was to investigate the costs of 90 services of the Global Hospital Reimbursement System at Tehran University of Medical Sciences. Methods: This descriptive cross-sectional applied study was performed from March 2017 to March 2019 in the hospitals of Tehran University of Medical Sciences. The billing and record data of all patients whose services were reimbursed on a global payment system basis were extracted from hospital information systems. Data were analyzed using descriptive statistics (frequency mean. std deviation, maximum & minimum) in SPSS 21 and Excel 2016. Results: During two years in TUMS, the costs of services provided to 143,866 patients have been reimbursed based on the global payment system., which had a cost of 2300 billion rials. 80% of the total services and costs were related to 10 services. 78.46% of the cases were related to two specialized groups of ophthalmology and obstetrics and gynecology. 83.17% of the total costs of services reimbursed globally at the TUMS were related to these two specialized groups. The average cost per service was about 16 million Rials, but varied greatly for different services, ranging from about 1.8 million Rials to 67 million Rials. On average, for a global service, the share of each of the cost subgroups of diagnostic services, hoteling and nursing services, medicine and consumables, operating room and surgery, physician's visit and consultation, respectively 3.1%, 11.6%, 21.4%, 49.9% and 13.9%. Conclusion: Managers need to focus on high-frequency and high-cost services to reduce the cost and financial losses for services that are under the global payment system. Depending on the specific cost pattern of each service, the strategies adopted to control the costs of that service should also be different.

Background and Aim: Implementing the diagnostic‐related groups (DRGs) promotes the efficiency of healthcare. Therefore, the present study aimed to identify the challenges facing implementing the DRGs in Iran. Methods: The present study is a strategic applied research conducted in two phases. In the first phase, the challenges facing DRGs were extracted through a literature review. Then the collected data is entered into a checklist consisting of five sections including technological, cultural, organizational, strategic, and natural challenges. In the second phase, data were collected by purposive sampling and semistructured interviews with 10 managers of the Medical Services Organization of Tehran, Iran. Data analysis was performed by conventional content analysis using MAXQDA software and descriptive using SPSS software version 19. Results: The challenges facing the implementing DGRs from the experts' perspective included technological, organizational, nature, strategic, and cultural in order of priority. The three main fundamental challenges were reported; lack of integrating the DGRs with health information system (70%), frequent changes of management (70%), reducing the quality of care following early patient discharge (60%). Conclusion: The results of the present study showed that the DRG system faced with challenges and healthcare officials should apply policies and guidelines to reform the system before changing the reimbursement system in Iran. By considering the leading countries experiences in the nationalizing the DRG system field, the problems and solutions of the system can be identified and aid in the more successful implementation of these systems. [ABSTRACT FROM AUTHOR]

Background: Diagnosis-related group (DRG)-based hospital payment can potentially be inadequately low (or high) for highly variable, highly specialized, and/or low volume care. DRG-based payment can be combined with other payment mechanisms to avoid unintended consequences of inadequate payment. The aim of this study was to analyze these other payment mechanisms for acute inpatient care across six countries (Germany, Denmark, England, Estonia, France, the United States [Medicare]). Methods: Information was collected about elements excluded from DRG-based payment, the rationale for exclusions, and payment mechanisms complementing DRG-based payment. A conceptual framework was developed to systematically describe, visualise and compare payment mechanisms across countries. Results: Results show that the complexity of exclusion mechanisms and associated additional payment components differ across countries. England and Germany use many different additional mechanisms, while there are only few exceptions from DRG-based payment in the Medicare program in the United States. Certain areas of care are almost always excluded (eg, certain areas of cancer care or specialized pediatrics). Denmark and England use exclusion mechanisms to steer service provision for highly complex patients to specialized providers. Conclusion: Implications for researchers and policy-makers include: (1) certain areas of care might be better excluded from DRG-based payment; (2) exclusions may be used to incentivize the concentration of highly specialized care at specialized institutions (as in Denmark or England); (3) researchers may apply our analytical framework to better understand the specific design features of DRG-based payment systems. [ABSTRACT FROM AUTHOR]

Abstract Background Case-mix based prospective payment of homecare is being implemented in several countries to work towards more efficient and client-centred homecare. However, existing models can only explain a limited part of variance in homecare use, due to their reliance on health- and function-related client data. It is unclear which predictors could improve predictive power of existing case-mix models. The aim of this study was therefore to identify relevant predictors of homecare use by utilizing the expertise of district nurses and health insurers. Methods We conducted a two-round Delphi-study according to the RAND/UCLA Appropriateness Method. In the first round, participants assessed the relevance of eleven client characteristics that are commonly included in existing case-mix models for predicting homecare use, using a 9-Point Likert scale. Furthermore, participants were also allowed to suggest missing characteristics that they considered relevant. These items were grouped and a selection of the most relevant items was made. In the second round, after an expert panel meeting, participants re-assessed relevance of pre-existing characteristics that were assessed uncertain and of eleven suggested client characteristics. In both rounds, median and inter-quartile ranges were calculated to determine relevance. Results Twenty-two participants (16 district nurses and 6 insurers) suggested 53 unique client characteristics (grouped from 142 characteristics initially). In the second round, relevance of the client characteristics was assessed by 12 nurses and 5 health insurers. Of a total of 22 characteristics, 10 client characteristics were assessed as being relevant and 12 as uncertain. None was found irrelevant for predicting homecare use. Most of the client characteristics from the category ‘Daily functioning’ were assessed as uncertain. Client characteristics in other categories – i.e. ‘Physical health status’, ‘Mental health status and behaviour’, ‘Health literacy’, ‘Social environment and network’, and ‘Other’ – were more frequently considered relevant. Conclusion According to district nurses and health insurers, homecare use could be predicted better by including other more holistic predictors in case-mix classification, such as on mental functioning and social network. The challenge remains, however, to operationalize the new characteristics and keep stakeholders on board when developing and implementing case-mix classification for homecare prospective payment.

Objectives This study analyzed the effects of computerization of medical information systems and a hospital payment scheme on medical care outcomes. Specifically, we examined the effects of Electronic Medical Records (EMRs) and a diagnosis procedure combination/per-diem payment scheme (DPC/PDPS) on the average length of hospital stay (ALOS). Methods Post-intervention changes in the monthly ALOS were measured using an interrupted time-series analysis. Results The level changes observed in the monthly ALOS immediately post-DPC/PDPS were −1.942 (95% confidence interval [CI], −2.856 to −1.028), −1.885 (95% CI, −3.176 to −0.593), −1.581 (95% CI, −3.081 to −0.082) and −2.461 (95% CI, −3.817 to 1.105) days in all ages,

Abstract Background and Aim Implementing the diagnostic‐related groups (DRGs) promotes the efficiency of healthcare. Therefore, the present study aimed to identify the challenges facing implementing the DRGs in Iran. Methods The present study is a strategic applied research conducted in two phases. In the first phase, the challenges facing DRGs were extracted through a literature review. Then the collected data is entered into a checklist consisting of five sections including technological, cultural, organizational, strategic, and natural challenges. In the second phase, data were collected by purposive sampling and semistructured interviews with 10 managers of the Medical Services Organization of Tehran, Iran. Data analysis was performed by conventional content analysis using MAXQDA software and descriptive using SPSS software version 19. Results The challenges facing the implementing DGRs from the experts' perspective included technological, organizational, nature, strategic, and cultural in order of priority. The three main fundamental challenges were reported; lack of integrating the DGRs with health information system (70%), frequent changes of management (70%), reducing the quality of care following early patient discharge (60%). Conclusion The results of the present study showed that the DRG system faced with challenges and healthcare officials should apply policies and guidelines to reform the system before changing the reimbursement system in Iran. By considering the leading countries experiences in the nationalizing the DRG system field, the problems and solutions of the system can be identified and aid in the more successful implementation of these systems.

Importance: Medicare transitional pass-through payments (TPTPs) provide supplemental reimbursement that is intended to facilitate adoption of new devices in the outpatient setting. The US Centers for Medicare & Medicaid Services (CMS) have historically evaluated manufacturer applications for TPTPs based on newness, cost, and evidence of substantial clinical improvement, ie, the traditional pathway. In 2020, CMS introduced an alternative pathway to allow US Food and Drug Administration (FDA)-designated breakthrough devices to qualify for supplemental reimbursement without demonstrating substantial clinical improvement., Objective: To characterize CMS TPTP approval rates and the premarket evidence used by FDA to support authorization of new outpatient medical devices considered for CMS TPTP., Design and Setting: This was a cross-sectional study of TPTP applications for new outpatient medical devices from 2017 to 2023. Using the Federal Register, CMS Outpatient Prospective Payment System final rules for fiscal years 2017 through 2023 were obtained, from which all manufacturer applications for TPTPs were identified. For each application, the CMS TPTP review pathway (traditional/alternative), CMS final decision (award/deny), and FDA authorization pathway were assessed., Main Outcomes and Measures: Characteristics of devices considered for CMS TPTPs and design, effectiveness end points, and patient demographic characteristics of premarket clinical studies used to support FDA authorization., Results: CMS approved 17 of 43 (40%) applications for TPTPs, including all 8 (100%) alternative pathway applications for breakthrough devices and 9 of 35 applications (26%) using the traditional pathway. Devices approved for TPTPs were more likely to have been assessed in premarket clinical studies than devices denied TPTPs (12/17 [71%] vs 2/26 [8%]). Among the 14 premarket studies of TPTP-approved devices, 8 (57%) used surrogate markers as primary effectiveness end points and 5 (42%) did not meet all primary end points. The median (IQR) percentage of female, Black, and Hispanic patients among the trials that reported demographic data was 26% (17%-36%), 6% (2%-17%), and 4% (3%-5%), respectively., Conclusions and Relevance: The findings of this cross-sectional analysis indicated that CMS more commonly awarded supplemental outpatient payment through TPTPs for devices assessed in premarket clinical studies to support FDA authorization. However, these studies often lacked generalizability to Medicare beneficiaries, used surrogate markers of effectiveness, or did not meet all primary end points. As more breakthrough devices receive FDA authorization and effectively qualify for automatic supplemental payments, strengthening premarket clinical evidence requirements for CMS TPTP approvals would provide better information to guide clinical decision-making and ensure that supplemental reimbursement enhances care for Medicare beneficiaries.

Background: Rising health care costs and consequent increases in Medicare reimbursements have led to many payment reforms over the years. Implementation of the prospective payment system (PPS) for hospitals in 1983 incentivized hospitals to either purchase skilled nursing facilities (SNFs) or utilize their excess capacity to establish one within the hospital. With PPS reimbursement being applied to SNFs in 1998, prior monetary incentives for hospitals to own an SNF disappeared. However, despite the reduction in numbers, many hospitals continued to operate their hospital-based skilled nursing facilities (HBSNFs)., Purpose: This study examines the organizational and market-level factors associated with the survival of HBSNFs using the population ecology of organizations framework., Methodology: Using American Hospital Association survey data, event histories of all U.S. acute care hospitals with an open HBSNF in 1998 were plotted to examine if a hospital closed its HBSNF during a 22-year period (1998-2020). The primary independent variables included hospital size, ownership, total margin, market competition, and Medicare Advantage penetration. The independent and control variables were lagged by 1 year. Cox regressions were conducted to estimate the hazard ratios capturing the risk of HBSNF closure., Results: The results showed that HBSNFs located in large, not-for-profit hospitals and those operating in less competitive markets had greater odds of surviving., Practice Implications: The HBSNF administrators of small, for-profit hospitals and those operating in highly competitive markets could utilize the findings of this study to judiciously allocate slack resources to their HBSNFs to keep those open given the current emphasis on continuity of care by regulatory bodies., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Aim of the Study: Short stay processes are incentives to unburden chronically stressed healthcare systems. The aim of this study is to analyze financial implications of day admission (DAS) and outpatient strategies for colon resections in a prospective payment system (PPS) using Diagnosis Related Group (DRG) coding., Methods: Consecutive patients undergoing left and right colonic resections between January 1, 2019 and December 31, 2020 were included. Medico-economic evaluations of the virtual outpatient and day admission surgery groups based on predefined criteria were compared to the identical group of patients who underwent surgery in the actual traditional inpatient setting. In a second step, postoperative complications of the virtual outpatient group were assessed. Cost-revenue analysis was performed using a micro-costing approach including direct medical costs., Results: Overall (N = 257), 97 (37.7%) colectomies would have been potentially eligible for an outpatient strategy. The global costs of the actual inpatient strategy totaled USD 3 634 392 with a global revenue of USD 3 571 069, corresponding to a cost coverage rate of 98%. The result of the virtual DAS strategy would have been a net loss of USD 15 800 (coverage rate of 99%) due to 4 low length of stay outliers triggering a reimbursement reduction and preventing a positive net result of USD 16 208. The pilot reference outpatient case's revenue and cost amounted to respectively USD 7479 and USD 6911 (cost coverage of 108%)., Conclusion: From both any given hospital and healthcare system point of view, elective outpatient colectomy for selected patients is the most cost-saving option. However, in a prospective payment system implemented to avoid bad incentives, the latter can unintentionally disadvantage best performing hospitals and impede widespread adoption of high-value strategies., 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) 2024.)

This paper addresses the increasing challenges faced by hospital clinicians in coordinating and recommending postacute care for patients, focusing on issues related to access to the most common postacute services: skilled nursing facilities (SNFs) and home health agencies (HHAs). In coordinating discharges, hospital clinicians have minimal information on care delivery in these settings. This knowledge gap is exacerbated by the disrupted continuum of patient care between acute care hospitals, SNFs, and HHAs. To address these challenges, hospital clinicians must understand how recent federal policies have impacted SNF and HHA care provision. The paper provides an overview of recent Centers for Medicare and Medicaid Services (CMS) policies and programs affecting SNFs and HHAs, including: (1) fee-for-service reimbursement reform (ie, Patient Driven Payment Model [PDPM] and the Patient Driven Groupings Model [PDGM]); (2) bundled payment programs; (3) accountable care organizations; (4) Medicare Advantage plans. Overall, this paper aims to help hospital clinicians stay informed about the evolving landscape of postacute care delivery by providing relevant information on how recent policy changes have impacted patient care., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The transformation from the retrospective to the prospective payment system is significant to improve the quality of public healthcare (QPH). This article used the quasinatural experiment of the global budget payment reform of government (GBPRG) in Chengdu, adopted the difference in difference (DID) method to estimate the effect of the GBPRG on the QPH, and concluded that GBPRG has a significant positive impact on the healthcare outcome and has a significant effect on improving the QPH. Policy implications drawn from the results show that the government should continue to explore compound healthcare insurance payment method (HIPM), improve the governance capabilities of the government, reduce transaction costs, improve healthcare insurance reimbursement policies, adjust the proportion of healthcare insurance reimbursements, continuously optimize the allocation of healthcare resources, establish an incentive mechanism to improve the QPH, and realize the pareto optimal choice of healthcare resource allocation. [ABSTRACT FROM AUTHOR]

Background: In Iran, a combination of three methods of budget payment, fee for service and case-based payment (known as the global payment system) is used to reimburse the cost of hospital services. The aim of this study was to investigate the costs of 90 services of the Global Hospital Reimbursement System at Tehran University of Medical Sciences. Methods: This descriptive cross-sectional applied study was performed from March 2017 to March 2019 in the hospitals of Tehran University of Medical Sciences. The billing and record data of all patients whose services were reimbursed on a global payment system basis were extracted from hospital information systems. Data were analyzed using descriptive statistics (frequency mean. std deviation, maximum & minimum) in SPSS 21 and Excel 2016. Results: During two years in TUMS, the costs of services provided to 143,866 patients have been reimbursed based on the global payment system., which had a cost of 2300 billion rials. 80% of the total services and costs were related to 10 services. 78.46% of the cases were related to two specialized groups of ophthalmology and obstetrics and gynecology. 83.17% of the total costs of services reimbursed globally at the TUMS were related to these two specialized groups. The average cost per service was about 16 million Rials, but varied greatly for different services, ranging from about 1.8 million Rials to 67 million Rials. On average, for a global service, the share of each of the cost subgroups of diagnostic services, hoteling and nursing services, medicine and consumables, operating room and surgery, physician's visit and consultation, respectively 3.1%, 11.6%, 21.4%, 49.9% and 13.9%. Conclusion: Managers need to focus on high-frequency and high-cost services to reduce the cost and financial losses for services that are under the global payment system. Depending on the specific cost pattern of each service, the strategies adopted to control the costs of that service should also be different. [ABSTRACT FROM AUTHOR]

Prospective payment systems reimburse hospitals based on diagnosis‐specific flat fees, which are generally based on average costs. While this encourages cost‐consciousness on the part of hospitals, it introduces undesirable incentives for patient transfers. Hospitals might feel encouraged to transfer patients if the expected treatment costs exceed the diagnosis‐related flat fee. A transfer fee would discourage such behavior and, therefore, could be welfare enhancing. In 2003, New Zealand introduced a fee to cover situations of patient transfers between hospitals. We investigate the effects of this fee by analyzing 4,020,796 healthcare events from 2000 to 2007 and find a significant reduction in overall transfers after the policy change. Looking at transfer types, we observe a relative reduction in transfers to non‐specialist hospitals but a relative increase in transfers to specialist facilities. It suggests that the policy change created a focusing effect that encourages public health care providers to transfer patients only when necessary to specialized providers and retain those patients they can treat. We also find no evidence that the transfer fee harmed the quality of care, measured by mortality, readmission and length of stay. The broader policy recommendation of this research is the introduction or reassessment of transfer payments to improve funding efficiency. [ABSTRACT FROM AUTHOR]

Abstract Background To evaluate the performance of the patient clinical complexity level (PCCL) mechanism, which is the patient-level complexity adjustment factor within the Korean Diagnosis-Related Groups (KDRG) patient classification system, in explaining the variation in resource consumption within age adjacent diagnosis-related groups (AADRGs). Methods We used the inpatient claims data from a public hospital in Korea from 1 January 2017 to 30 June 2019, with 18 846 claims and 138 AADRGs. The differences in the total average payment between the four PCCL levels for each AADRG was tested using ANOVA and Duncan’s post hoc test. The three patterns of differences with R-squared were as follows: the PCCL reflected the complexity well (valid); the average payment for PCCL 2, 3, and 4 was greater than PCCL 0 (partially valid); the PCCL did not reflect the complexity (not valid). Results There were 9 (6.52%), 26 (18.84%), and 103 (74.64%) ADRGs included in the valid, partially valid, and not valid categories, respectively. The average R-squared values were 32.18, 40.81, and 35.41%, respectively, with an average R-squared for all patterns of 36.21%. Conclusions Adjustment using the PCCL in the KDRG classification system exhibited low performance in explaining the variation in resource consumption within AADRGs. As the KDRG classification system is used for reimbursement under the new DRG-based prospective payment system (PPS) pilot project, with plans for expansion, there should be an overall review of the validity of the complexity and rationality of using the KDRG classification system.

To describe differences in characteristics and outcomes of patients with traumatic brain injury by inpatient rehabilitation facility (IRF) profit status. Retrospective database review using the Uniform Data System for Medical Rehabilitation. IRFs. Individual discharges (N=53,630) from 877 distinct rehabilitation facilities for calendar years 2016 through 2018. Not applicable. Patient demographic data (age, race, primary payer source), admission and discharge FIM, FIM gain, length of stay efficiency, acute hospital readmission from for-profit and not-for-profit IRFs within 30 days, and community discharges by facility profit status. Patients at for-profit facilities were significantly older (69.69 vs 64.12 years), with lower admission FIM scores (52 vs 57), shorter lengths of stay (13 vs 15 days), and higher discharge FIM scores (88 vs 86); for-profit facilities had higher rates of community discharges (76.8% vs 74.6%) but also had higher rates of readmission (10.3% vs 9.9%). The finding that for-profit facilities admit older patients who are reportedly less functional on admission and more functional on discharge, with higher rates of community discharge but higher readmission rates than not-for-profit facilities is an unexpected and potentially anomalous finding. In general, older, less functional patients who stay for shorter periods of time would not necessarily be expected to make greater functional gains. These differences should be further studied to determine if differences in patient selection, coding and/or billing, or other unreported factors underlie these differences. [ABSTRACT FROM AUTHOR]

Background: Case-mix based prospective payment of homecare is being implemented in several countries to work towards more efficient and client-centred homecare. However, existing models can only explain a limited part of variance in homecare use, due to their reliance on health- and function-related client data. It is unclear which predictors could improve predictive power of existing case-mix models. The aim of this study was therefore to identify relevant predictors of homecare use by utilizing the expertise of district nurses and health insurers.Methods: We conducted a two-round Delphi-study according to the RAND/UCLA Appropriateness Method. In the first round, participants assessed the relevance of eleven client characteristics that are commonly included in existing case-mix models for predicting homecare use, using a 9-Point Likert scale. Furthermore, participants were also allowed to suggest missing characteristics that they considered relevant. These items were grouped and a selection of the most relevant items was made. In the second round, after an expert panel meeting, participants re-assessed relevance of pre-existing characteristics that were assessed uncertain and of eleven suggested client characteristics. In both rounds, median and inter-quartile ranges were calculated to determine relevance.Results: Twenty-two participants (16 district nurses and 6 insurers) suggested 53 unique client characteristics (grouped from 142 characteristics initially). In the second round, relevance of the client characteristics was assessed by 12 nurses and 5 health insurers. Of a total of 22 characteristics, 10 client characteristics were assessed as being relevant and 12 as uncertain. None was found irrelevant for predicting homecare use. Most of the client characteristics from the category 'Daily functioning' were assessed as uncertain. Client characteristics in other categories - i.e. 'Physical health status', 'Mental health status and behaviour', 'Health literacy', 'Social environment and network', and 'Other' - were more frequently considered relevant.Conclusion: According to district nurses and health insurers, homecare use could be predicted better by including other more holistic predictors in case-mix classification, such as on mental functioning and social network. The challenge remains, however, to operationalize the new characteristics and keep stakeholders on board when developing and implementing case-mix classification for homecare prospective payment. [ABSTRACT FROM AUTHOR]

Copyright of JBES: Brazilian Journal of Health Economics / Jornal Brasileiro de Economia da Saúde is the property of JBES: Brazilian Journal of Health Economics and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract Background A series of policy changes in 2011 altered reimbursement arrangements and guidance on use of erythropoiesis-stimulating agents for end-stage renal disease (ESRD) patients with anaemia in the US. While the policy changes were principally directed at care delivered in an outpatient setting, these had the potential to affect inpatient care also. This study used HCUP-NIS data (2008–2016) to examine trends in recorded anaemia among ESRD hospitalizations and analyse disparities in inpatient outcomes among ethnic groups following policy changes. Methods The International Classification of Diseases codes were used to identify ESRD admissions, recorded anaemia due to chronic kidney disease (CKD), and to generate an age-adjusted Deyo-Charlson comorbidity index. Linear splines with a knot placed at the time point of policy changes and multivariable logistic regression were used to examine the likelihood of recorded anaemia, adjusted for a range of socio-demographic and clinical covariates. Difference-in-difference analyses investigated the impact of policies on recorded anaemia. Other outcomes included hospital cost, mortality and place of discharge. Results The percentage of inpatient episodes with recorded anaemia arising from CKD increased from 26.2% in 2008 to 50.0% in 2016. Anaemia was more likely to be recorded as a complication of ESRD among minority ethnic groups and Native American admissions, in particular, (OR 1.20, 95%CI 1.15–1.25) relative to White American admissions; and these disparities widened following changes to reimbursement. Minorities were less likely to die in hospital and to be discharged to another healthcare facility, and (with the exception of Black American admissions) they were more expensive to treat. Conclusions Our findings provide evidence of an increase in recorded anaemia consistent with a shift of patients from outpatient to inpatient settings in the wake of changes to reimbursement enacted in 2011. In addition, the study highlights the existence of ethnic disparities that widened after the policy initiated reimbursement changes.

This systematic review and meta-analysis aimed to evaluate the impact of prospective payment systems (PPSs) on cholecystectomy. A comprehensive literature review was conducted, examining studies published until December 2023. The review process focused on identifying research across major databases that reported critical outcomes such as length of stay (LOS), mortality, complications, admissions, readmissions, and costs following PPS for cholecystectomy. The studies were specifically selected for their relevance to the impact of PPS or the transition from fee-for-service (FFS) to PPS. The study analyzed six papers, with three eligible for meta-analysis, to assess the impact of the shift from FFS to PPS in laparoscopic and open cholecystectomy procedures. Our findings indicated no significant changes in LOS and mortality rates following the transition from FFS to PPS. Complication rates varied and were influenced by the diagnosis-related group categorization and surgeon cost profiles under episode-based payment. There was a slight increase in admissions and readmissions, and mixed effects on hospital costs and financial margins, suggesting varied responses to PPS for cholecystectomy procedures. The impact of PPS on cholecystectomy is nuanced and varies across different aspects of healthcare delivery. Our findings indicate a need for adaptable, patient-centered PPS models that balance economic efficiency with high-quality patient care. The study emphasizes the importance of considering specific surgical procedures and patient demographics in healthcare payment reforms.

Background: Quality rating systems exist to grade the value of care provided by hospitals, but the extent to which these rating systems correlate with patient outcomes is unclear. The association of quality rating systems and hospital characteristics with excess readmission penalties for total hip arthroplasty (THA) and total knee arthroplasty (TKA) was studied., Methods: The fiscal year 2022 Inpatient Prospective Payment System final rule was used to identify 2,286 hospitals subject to the Hospital Readmissions Reduction Program. Overall, 6 hospital quality rating systems and 5 hospital characteristics were obtained. These factors were analyzed to determine the effect on hospital penalties for THA and TKA excess readmissions., Results: Hospitals that achieved a higher Medicare Overall Hospital Quality Star Rating demonstrated a significantly lower likelihood of receiving THA and TKA readmission penalties (Cramer's V = 0.236 and R p  = -0.233; P < .001 for both). Hospitals ranked among the US News & World Report's top 50 best hospitals for orthopaedics were significantly less likely to be penalized (V = 0.042; P = .043). The remaining 4 quality rating systems were not associated with readmission penalties. Penalization was more likely for hospitals with fewer THA and TKA discharges (R p  = -0.142; P < .001), medium-sized institutions (100 to 499 beds; V = 0.075; P = .002), teaching hospitals (V = 0.049; P = .019), and safety net hospitals (V = 0.043; P = .039). Penalization was less likely for West and Midwest hospitals (V = 0.112; P < .001)., Conclusions: A higher Overall Hospital Quality Star Rating and recognition among the US News & World Report's top 50 orthopaedic hospitals were associated with a reduced likelihood of THA and TKA readmission penalties. The other 4 widely accepted quality rating systems did not correlate with readmission penalties. Teaching and safety net hospitals may be biased toward higher readmission rates., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: To evaluate the performance of the patient clinical complexity level (PCCL) mechanism, which is the patient-level complexity adjustment factor within the Korean Diagnosis-Related Groups (KDRG) patient classification system, in explaining the variation in resource consumption within age adjacent diagnosis-related groups (AADRGs).Methods: We used the inpatient claims data from a public hospital in Korea from 1 January 2017 to 30 June 2019, with 18 846 claims and 138 AADRGs. The differences in the total average payment between the four PCCL levels for each AADRG was tested using ANOVA and Duncan's post hoc test. The three patterns of differences with R-squared were as follows: the PCCL reflected the complexity well (valid); the average payment for PCCL 2, 3, and 4 was greater than PCCL 0 (partially valid); the PCCL did not reflect the complexity (not valid).Results: There were 9 (6.52%), 26 (18.84%), and 103 (74.64%) ADRGs included in the valid, partially valid, and not valid categories, respectively. The average R-squared values were 32.18, 40.81, and 35.41%, respectively, with an average R-squared for all patterns of 36.21%.Conclusions: Adjustment using the PCCL in the KDRG classification system exhibited low performance in explaining the variation in resource consumption within AADRGs. As the KDRG classification system is used for reimbursement under the new DRG-based prospective payment system (PPS) pilot project, with plans for expansion, there should be an overall review of the validity of the complexity and rationality of using the KDRG classification system. [ABSTRACT FROM AUTHOR]

Medicare continues to implement payment reforms that shift reimbursement from fee-for-service toward episode-based payment, affecting average and marginal payment. We contrast the effects of two reforms for home health agencies. The home health interim payment system in 1997 lowered both types of payment; our conceptual model predicts a decline in the likelihood of use and costs, both of which we find. The home health prospective payment system in 2000 raised average but lowered marginal payment with theoretically ambiguous effects; we find a modest increase in use and costs. We find little substantive effect of either policy on readmissions or mortality.

To examine the cost structure of home health agencies by estimating an empirical cost function for those that are Medicare-certified, ten years following the implementation of prospective payment. 2010 national Medicare cost report data for certified home health agencies were merged with case-mix information from the Outcome and Assessment Information Set (OASIS). We estimated a fully interacted (by tax status) hybrid cost function for 7,064 agencies and calculated marginal costs as percent of total costs for all variables. The home health industry is dominated by for-profit agencies, which tend to be newer than the non-profit agencies and to have higher average costs per patient but lower costs per visit. For-profit agencies tend to have smaller scale operations and different cost structures, and are less likely to be affiliated with chains. Our estimates suggest diseconomies of scale, zero marginal cost for contracting with therapy workers, and a positive marginal cost for contracting with nurses, when controlling for quality. Our findings suggest that efficiencies may be achieved by promoting non-profit, smaller agencies, with fewer contract nursing staff. This conclusion should be tested further in future studies that address some of the limitations of our study.

One of the most significant events in the development of the modern Russian economy is the creation of a Perspective Payment System (PPS). The scope of the payments and settlements made now is striking in its scale, and the expected results from its use determine the genuine interest from both the direct participants of the payment turnover and the scientific researchers. The purpose of this article is to offer the author's periodization of the development of faculty, which will make a contribution to the study of the processes of forming a full-fledged, competitive national payment system. To achieve this goal, the features and factors that determine the development vector for each stage of its development were identified and analyzed, and the main directions for further qualitative growth were determined. Despite the relevance inherent to the topic, the area of questions considered in the article is not distinguished by a high degree of knowledge, which in turn increases the significance of the study. In the process of research, methods of comparative and factor analysis, detailing and generalization, systematization, tabular method of statistical analysis were used. The materials of the article may be useful to researchers of the problems of development of payment systems in the further development of this topic.

This paper examines the behaviour of mental health care providers in response to marginal payment incentives induced by a discontinuous per diem reimbursement schedule with varying tariff rates over the length of stay. The analyses use administrative data on 12,627 cases treated in 82 psychiatric hospitals and wards in Germany. We investigate whether substantial reductions in marginal reimbursement per inpatient day led to strategic discharge behaviour once a certain length of stay threshold is exceeded. The data do not show gaps and bunches at the duration of treatment when marginal reimbursement decreases. Using logistic regression models, we find that providers did not react to discontinuities in marginal reimbursement by significantly reducing inpatient length of stay around the threshold. These findings are robust in terms of different model specifications and subsamples. The results indicate that if regulators aim to set incentives to decrease LOS, this might not be achieved by cuts in reimbursement over LOS. [ABSTRACT FROM AUTHOR]

Context: Across the member countries of the Organisation for Economic Co-Operation and Development, policy makers are searching for new ways to pay hospitals for inpatient care to move from volume to value. This paper offers an overview of the latest reforms and their evidence to date., Methods: We reviewed reforms to DRG payment systems in 10 high-income countries: Australia, Austria, Canada (Ontario), Denmark, France, Germany, Norway, Poland, the United Kingdom (England), and the United States., Findings: We identified four reform trends among the observed countries, them being (1) reductions in the overall share of inpatient payments based on DRGs, (2) add-on payments for rural hospitals or their exclusion from the DRG system, (3) episode-based payments, which use one joint price to pay providers for all services delivered along a patient pathway, and (4) financial incentives to shift the delivery of care to less costly settings. Some countries have combined some or all of these measures with financial adjustments for quality of care. These reforms demonstrate a shift away from activity and efficiency towards a diversified set of targets, and mirror efforts to slow the rise in health expenditures while improving quality of care. Where evaluations are available, the evidence indicates mixed success in improving quality of care and reducing costs and expenditures., Competing Interests: Declaration of competing interest The authors declare no competing interest. The opinions expressed and arguments employed herein are those of the author and do not necessarily reflect the official views of the OECD or of its member countries., (Copyright © 2023. Published by Elsevier B.V.)

A final rule has been issued that increases Medicare fee-for-service payment rates for individuals experiencing homelessness. This rule provides new, incentivized opportunities to better screen for and document homelessness among patients in acute inpatient settings. With greater identification of homeless patients, there may be increased needs to develop comprehensive discharge plans that involve coordination with housing providers and social service agencies to prevent the high repeated use of acute care found among many homeless patients.

Purpose: Non-operating revenue (NOR), derived from investments, contributions, government appropriations, and medical space rentals, can contribute to financial stability of hospitals by offsetting operating losses and improving profitability. NOR might benefit rural hospitals that often face intense financial pressures. However, little is known about how much rural hospitals rely on NOR and if certain organizational characteristics are associated with differences in NOR., Methods: Healthcare Cost Report Information System data from 2011 to 2019 were used to analyze sources of revenue among Critical Access Hospitals (CAHs) and Rural Prospective Payment System (R-PPS) hospitals through descriptive statistics and regression models. Reliance on NOR was measured by the percentage of total revenue from non-operating sources., Findings: Results indicate that both CAHs and R-PPS hospitals rely on NOR; however, CAHs have a higher percentage of total revenue derived from non-operating sources (3.2%) as compared to R-PPS hospitals (1.9%) (p < 0.001). Government-owned hospitals have significantly higher reliance on NOR than other ownership types. System affiliation also influences reliance on NOR. Lastly, results suggest that NOR may play a role in improving overall profit margins., Conclusions: As rural hospitals disproportionately face challenges related to declining profitability and the risk for closure, they may rely on NOR to continue to strengthen financial performance and provide health care to their communities. However, NOR is not guaranteed, and reliance on NOR further reiterates the value of stable, adequate reimbursement to guard against fluctuations in NOR., (© 2023 National Rural Health Association.)

Background: The Korean Diagnosis-Related Groups (KDRG) was revised in 2003, modifying the complexity adjustment mechanism of the Australian Refined Diagnosis-Related Groups (AR-DRGs). In 2014, the Complication and Comorbidity Level (CCL) of the existing AR-DRG system was found to have very little correlation with cost. Objective: Based on the Australian experience, the CCL for KDRG version 3.4 was reviewed. Method: Inpatient claim data for 2011 were used in this study. About 5,731,551 episodes, which had one or no complication and comorbidity (CC) and met the inclusion criteria, were selected. The differences of average hospital charges by the CCL were analysed in each Adjacent Diagnosis-Related Group (ADRG) using analysis of variance followed by Duncan's test. The patterns of differences were presented with R 2 in three patterns: The CCL reflected the complexity well (VALID); the average charge of CCL 2, 3, 4 was greater than CCL 0 (PARTIALLY VALID); the CCL did not reflect the complexity (NOT VALID). Results: A total of 114 (19.03%), 190 (31.72%) and 295 (49.25%) ADRGs were included in VALID, PARTIALLY VALID and NOT VALID, respectively. The average R 2 for hospital charge of CCL was 4.94%. The average R 2 in VALID, PARTIALLY VALID and NOT VALID was 4.54%, 5.21%, and 4.93%, respectively. Conclusion: The CCL, the first step of complexity adjustment using secondary diagnoses, exhibited low performance. If highly accurate coding data and cost data become available, the performance of secondary diagnosis as a variable to reflect the case complexity should be re-evaluated. Implications: Lack of reviewing the complexity adjustment mechanism of the KDRG since 2003 has resulted in outdated CC lists and levels that no longer reflect the current Korean healthcare system. Reliable cost data (vs. charge) and accurate coding are essential for accuracy of reimbursement. [ABSTRACT FROM AUTHOR]

The End Stage Renal Disease (ESRD) Prospective Payment System (PPS), implemented by the Centers for Medicare and Medicaid Services in January 2011, encouraged use of peritoneal dialysis (PD) through various financial incentives. Our goal was to determine whether PPS effectively increased PD use in incident dialysis patients. Methods: Our study used the United States Renal Data System (USRDS) to identify 430,927 adult patients who initiated dialysis between 2009 and 2012. The interrupted time series method was used to evaluate the association Centers for Medicare and Medicaid Services of PPS with PD use at dialysis initiation. We further stratified by patient demographics, predialysis care, and facility chain and profit status. Results: Interrupted time series analysis indicated PPS was associated with increased PD use in the 2-year period after PPS (change in slope = 0.04, P < 0.0001), although there was no immediate change in the level of PD use at the beginning of PPS (P = 0.512). Stratified analyses indicated PPS led to increased PD use across all age, race, and sex groups (P < 0.05) although marginally among females (P = 0.09). Notably, small dialysis organizations and nonprofit organizations appeared to increase use of PD faster compared to large dialysis organizations and for-profit units, respectively. Discussion: Implementation of the Centers for Medicare and Medicaid Services ESRD payment reform was associated with an increased use of PD in the 2 years after PPS. Our findings highlight the role of financial incentives in changing practice patterns to increase use of a dialysis modality considered to be both more cost-effective and empowering to ESRD patients. However, even after PPS, rates of PD use remain low among the dialysis population in the USA.