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Background and objectives In Belgium, monitoring antibiotic consumption relies on reimbursement data, which is obtained with a time delay and does not account for over-the-counter or nonreimbursed products. This study aims to bridge this gap by comparing reimbursement and retail data for primary care to understand variations and assess the accuracy of current surveillance methods. Method Reimbursement data were obtained from the National Institute for Health and Disability Insurance, and retail data were obtained from IQVIA for the period 2013–22. The community consumption of systemic antibiotics was expressed in defined daily doses (DDD—WHO ATC/DDD Index 2023) per inhabitants per day (DID). Relative differences in DID (RDs) based on the two data sets were computed and validated through Bland–Altman plots and correlation analysis. Results The sales of antibiotics declined from 22.89 DID (2013) to 20.50 (2022), with a steep drop during the COVID-19 pandemic—from 21.31 DID in 2019 to 16.55 DID in 2020—and a subsequent rebound. Reimbursement data slightly underestimated consumption compared to retail data, with RDs ranging from 2% (2013) to 9% (2022) when including quinolones and from 2% to 4% when excluding them. Bland–Altman plots showed high agreement between reimbursement and retail estimates, identifying quinolones as outliers. Conclusion Our findings suggest that reimbursement data are generally reliable for monitoring antibiotic consumption, but incorporating retail data is crucial for accurate assessments. The use of retail data can facilitate timely interventions and inform public health strategies to effectively address antimicrobial resistance. [ABSTRACT FROM AUTHOR]

The value-based payment (VBP) system aims to improve the quality of healthcare while enhancing cost-efficiency, delivering better patient outcomes without increasing overall healthcare costs. It has been proposed as an alternative payment system to help sustain national insurance systems in response to the social and economic challenges posed by rising healthcare expenditures. Radiology plays a crucial role in disease prevention, diagnosis, and treatment; however, it is often undervalued. This review explores how radiology can be fully recognized for its inherent value in the VBP system and continue to enhance patient outcomes and societal value.

Personalized medicine, aiming to tailor treatments based on individual patient characteristics, holds immense potential in oncology. However, its widespread adoption in Europe faces numerous challenges, as illustrated by the case study of the Oncotype DX Breast Recurrence Score® assay, a genomic test for breast cancer. This manuscript delineates the multifaceted obstacles encountered during the introduction of the Oncotype DX®test (Oncotype DX Breast Recurrence Score test) in Europe from 2004 to 2018. In June 2018, the TAILORx results were published in the New England Journal of Medicine Sparano JA, Gray RJ, Makower DF, Pritchard KI, Albain KS, Hayes DF, et al. Adjuvant chemotherapy guided by a 21-gene expression assay in breast cancer. N Engl J Med 2018;379:111–21, Sparano JA, Gray RJ, Ravdin PM, Makower DF, Pritchard KI, Albain KS, et al. Clinical and genomic risk to guide the use of adjuvant therapy for breast cancer. N Engl J Med 2019;380:2395–405, and reported that among 6,711 women with hormone-receptor–positive, HER2-negative, node–negative breast cancer and a midrange recurrence score of 11–25 on the Oncotype DX assay, endocrine therapy was not inferior to chemoendocrine therapy, which provides evidence that adjuvant chemotherapy was not beneficial in these patients. Through a comprehensive analysis of clinical evidence, commercial presence, reimbursement mechanisms, guideline recommendations, regulatory pathways, and local experiences, this study sheds light on the intricate dynamics influencing the adoption of personalized medicine technologies. This article examines the various obstacles encountered during the introduction of the Oncotype DX Breast Cancer Assay in Europe from 2004 to 2018. By analyzing clinical evidence, commercial presence, reimbursement mechanisms, guideline recommendations, regulatory pathways, and local experiences, this study reveals the complex factors that influence the adoption of personalized medicine technologies. By highlighting these challenges, this article offers valuable insights into strategies to facilitate the integration of innovative diagnostic tools into clinical practice across Europe, ultimately leading to improved treatment decision-making for cancer patients. [ABSTRACT FROM AUTHOR]

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]

Aim: In April 2020, the Japanese government introduced a Specific Medical Fee for managing secondary dysmenorrhea (SD). This initiative provided financial incentives to medical facilities that provide appropriate management of SD with hormonal therapies. We aimed to assess how this policy affects the management processes and outcomes of patients with SD. Methods: Using a large Japanese administrative claims database, we identified outpatient visits of patients diagnosed with SD from April 2018 to March 2022. We used an interrupted time‐series analysis and defined before April 2020 as the pre‐introduction period and after April 2020 as the post‐introduction period. Outcomes were the monthly proportions of outpatient visits due to SD and hormonal therapy among women in the database and the proportions of outpatient visits for hormonal therapy and continuous outpatient visits among patients with SD. Results: We identified 815 477 outpatient visits of patients diagnosed with SD during the pre‐introduction period and 920 183 outpatient visits during the post‐introduction period. There were significant upward slope changes after the introduction of financial incentives in the outpatient visits due to SD (+0.29% yearly; 95% confidence interval, +0.20% to +0.38%) and hormonal therapies (+0.038% yearly; 95% confidence interval, +0.030% to +0.045%) among the women in the database. Similarly, a significant level change was observed after the introduction of continuous outpatient visits among patients with SD (+2.68% monthly; 95% confidence interval, +0.87% to +4.49%). Conclusions: Government‐issued financial incentives were associated with an increase in the number of patients diagnosed with SD, hormonal therapies, and continuous outpatient visits. [ABSTRACT FROM AUTHOR]

According to a national claims database, remote retinal imaging utilization in the U.S. increased rapidly from 2011 to 2020, but insurance coverage declined, with disproportionate impact on vulnerable populations including older, Black, and lower-income patients.

Abstract Background Nearly 30 years post legalisation and introduction, midwifery is still not optimally integrated within the health system of Canada’s largest province, Ontario. Funding models have been identified as one of the main barriers. Methods Using a constructivist perspective, we conducted a qualitative descriptive study to examine how antepartum, intrapartum, and postpartum funding arrangements in Ontario impact midwifery integration. We conceptualized optimal ‘integration’ as circumstances in which midwives’ knowledge, skills, and model of care are broadly respected and fully utilized, interprofessional collaboration and referral support the best possible care for patients, and midwives feel a sense of belonging within hospitals and the greater health system. We collected data through semi-structured telephone interviews with midwives, obstetricians, family physicians, and nurses. The data was examined using thematic analysis. Results We interviewed 20 participants, including 5 obstetricians, 5 family physicians, 5 midwives, 4 nurses, and 1 policy expert. We found that while course-of-care-based midwifery funding is perceived to support high levels of midwifery client satisfaction and excellent clinical outcomes, it lacks flexibility. This limits opportunities for interprofessional collaboration and for midwives to use their knowledge and skills to respond to health system gaps. The physician fee-for-service funding model creates competition for births, has unintended consequences that limit midwives’ scope and access to hospital privileges, and fails to appropriately compensate physician consultants, particularly as midwifery volumes grow. Siloing of midwifery funding from hospital funding further restricts innovative contributions from midwives to respond to community healthcare needs. Conclusions Significant policy changes, such as adequate remuneration for consultants, possibly including salary-based physician funding; flexibility to compensate midwives for care beyond the existing course of care model; and a clearly articulated health human resource plan for sexual and reproductive care are needed to improve midwifery integration.

Introduction Research on psychiatric deinstitutionalization has neglected that reforms in this field are nested in a health system that has undergone financial reforms. This subordination could introduce incentives that are misaligned with new mental health policies. According to Chile’s National Mental Health Plan, this would be the case in the Community Mental Health Centers (CMHC). The goal is to understand how the CMHCpayment mechanism is a potential incentive for community mental health. Methods A mixed quantitative-qualitative convergent study using grounded theory. We collected administrative production data between 2010 and 2020. Following the payment mechanism theory, we interviewed 25 payers, providers, and user experts. We integrated the results through selective coding. This article presents the relevant results of mixed selective integration. Results Seven payment mechanisms implemented heterogeneously in the country’s CMHC are recognized. They respond to three schemes subject to rate limits and prospective public budget. They differ in the payment unit. They are associated with implementing the community mental health model negatively affecting users, the services provided, the human resources available, and the governance adopted. Governance, management, and payment unit conditions favoring the community mental health model are identified. Conclusions A disjointed set of heterogeneously implemented payment schemes negatively affects the community mental health model. Formulating an explicit financing policy for mental health that is complementary to existing policies is necessary and possible.

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

Abstract Background Long waiting times for health care services are a prominent health policy issue. Waiting time guarantees may limit time to assessment and treatment. Methods This study aims to investigate the information and support given to patients when the waiting time guarantee cannot be fulfilled from a care provider and administrative management perspective. Semi-structured interviews (N = 28) were conducted with administrative management and care providers (clinic staff and clinic line managers) in specialized clinics in the Stockholm Region, Sweden. Clinics were purposefully sampled for maximum variation in ownership (private, public), complexity of care, geographical location, volume of production, and waiting times. Thematic analysis was applied. Results Care providers reported that patients received inconsistent information and support with regard to the waiting time guarantee and that information was not adapted to health literacy or individual patient needs. Contrary to local law, they made some patients responsible for finding a new care provider or arranging a new referral. Furthermore, financial interests affected whether patients were referred to other providers. Administrative management steered care providers’ informing practices at specific time points (upon establishment of a new unit and after six months of operation). A specific regional support function, Region Stockholm’s Care Guarantee Office, helped patients change care providers when long waiting times occurred. However, administrative management perceived that there was no established routine to assist care providers in informing patients. Conclusions Care providers did not consider patients’ health literacy when informing them about the waiting time guarantee. Administrative management’s attempts to provide information and support to care providers are not producing the results they expect. Soft-law regulations and care contracts seem insufficient, and economic mechanisms undermine care providers’ willingness to inform patients. The described actions are unable to mitigate the inequality in health care that arises from differences in care-seeking behavior.

Introduction More than 600 thousand people in Chile live with morbid obesity. Effective, safe, cost-effective therapeutic interventions are critical for healthcare systems and insurance schemes. In 2022, two bundled payment codes for bariatric surgery (gastric bypass and gastric sleeve) were incorporated into the National Health Fund's free-choice modality fee scheme. The objective was to characterize the execution of this payment mechanism program associated with bariatric surgery diagnosis in its first year of implementation.More than six hundred thousand people in Chile are estimated to live with morbid obesity. Effective, safe, cost-effective therapeutic interventions are critical for health systems and insurance schemes. In 2022, FONASA incorporated two Bariatric Surgery codes into the Free Choice Modality: Gastric Bypass and Sleeve Gastrectomy. Our objective was to characterize the execution of the Bariatric Surgery Bundled Payment Program in its first year of implementation. Methods Descriptive and observational study of the pragmatic approach of the national execution of the payment associated with diagnosis in bariatric surgery. We examined sociodemographic variables (sex, age brackets, and National Health Fund tranches) and characterization of surgeries by code broken down by public or private provider, period of issue, unit cost, co-payment, and medical loans between March and December 2022. Results We recorded n = 13 118 surgeries (45.81% bypass versus 54.19% sleeve), of which n = 2424 (18.48%) used medical loans. A total of 85.01% (p = 0.01) of the procedures were in women, in people between 35 and 39 years of age (20.15%), and 45.12% in beneficiaries of tranche B. Private providers performed a total of 99.21% of the surgeries. Ten accounted for 50% of the activity (range n = 1200 to 426 surgeries per year; n = 4.8 to 1.7 surgeries per working day). Total program expenditure was $71 626 948 350 CLP, accounting for 5.04% of the total activity of the national Diagnosis Associated Payment Program. Conclusions The implementation of this bariatric surgery voucher benefited more than 13 thousand people living with obesity, mostly women of productive ages and with purchasing capacity. As an equity strategy, regardless of the access route through the voucher, it will be important to safeguard the activity in the public network.

Background: Nearly 30 years post legalisation and introduction, midwifery is still not optimally integrated within the health system of Canada's largest province, Ontario. Funding models have been identified as one of the main barriers. Methods: Using a constructivist perspective, we conducted a qualitative descriptive study to examine how antepartum, intrapartum, and postpartum funding arrangements in Ontario impact midwifery integration. We conceptualized optimal 'integration' as circumstances in which midwives' knowledge, skills, and model of care are broadly respected and fully utilized, interprofessional collaboration and referral support the best possible care for patients, and midwives feel a sense of belonging within hospitals and the greater health system. We collected data through semi-structured telephone interviews with midwives, obstetricians, family physicians, and nurses. The data was examined using thematic analysis. Results: We interviewed 20 participants, including 5 obstetricians, 5 family physicians, 5 midwives, 4 nurses, and 1 policy expert. We found that while course-of-care-based midwifery funding is perceived to support high levels of midwifery client satisfaction and excellent clinical outcomes, it lacks flexibility. This limits opportunities for interprofessional collaboration and for midwives to use their knowledge and skills to respond to health system gaps. The physician fee-for-service funding model creates competition for births, has unintended consequences that limit midwives' scope and access to hospital privileges, and fails to appropriately compensate physician consultants, particularly as midwifery volumes grow. Siloing of midwifery funding from hospital funding further restricts innovative contributions from midwives to respond to community healthcare needs. Conclusions: Significant policy changes, such as adequate remuneration for consultants, possibly including salary-based physician funding; flexibility to compensate midwives for care beyond the existing course of care model; and a clearly articulated health human resource plan for sexual and reproductive care are needed to improve midwifery integration. [ABSTRACT FROM AUTHOR]

Access to comprehensive dementia care is limited. Recent changes in billing for professional services, including new physician fee schedule codes, encourage clinicians to provide new services; however, current reimbursement does not cover costs for all needed elements of dementia care. The Payment Model for Comprehensive Dementia Care Conference convened more than 50 national experts from diverse perspectives to review promising strategies for payment reform including ways to accelerate their adoption. Recommendations for reform included payments for services to family caregivers; new research to determine success metrics; education for consumers, providers, and policymakers; and advancing a population health model approach to tier coverage based on risk and need within a health system.

Access to comprehensive dementia care is limited. Recent changes in billing for professional services, including new physician fee schedule codes, encourage clinicians to provide new services; however, current reimbursement does not cover costs for all needed elements of dementia care. The Payment Model for Comprehensive Dementia Care Conference convened more than 50 national experts from diverse perspectives to review promising strategies for payment reform including ways to accelerate their adoption. Recommendations for reform included payments for services to family caregivers; new research to determine success metrics; education for consumers, providers, and policymakers; and advancing a population health model approach to tier coverage based on risk and need within a health system.

ObjectiveThe Inter Organizational Practice Committee convened a workgroup to provide rapid guidance about teleneuropsychology (TeleNP) in response to the COVID-19 pandemic.MethodA collaborative panel of experts from major professional organizations developed provisional guidance for neuropsychological practice during the pandemic. The stakeholders included the American Academy of Clinical Neuropsychology/American Board of Clinical Neuropsychology, the National Academy of Neuropsychology, Division 40 of the American Psychological Association, the American Board of Professional Neuropsychology, and the American Psychological Association Services, Inc. The group reviewed literature; collated federal, regional, and state regulations and information from insurers; and surveyed practitioners to identify best practices.ResultsLiterature indicates that TeleNP may offer reliable and valid assessments, but clinicians need to consider limitations, develop new informed consent procedures, report modifications of standard procedures, and state limitations to diagnostic conclusions and recommendations. Specific limitations affect TeleNP assessments of older adults, younger children, individuals with limited access to technology, and individuals with other individual, cultural, and/or linguistic differences. TeleNP may be contraindicated or infeasible given specific patient characteristics, circumstances, and referral questions. Considerations for billing TeleNP services are offered with reservations that clinicians must verify procedures independently. Guidance about technical issues and "tips" for TeleNP procedures are provided.ConclusionThis document provides provisional guidance with links to resources and established guidelines for telepsychology. Specific recommendations extend these practices to TeleNP. These recommendations may be revised as circumstances evolve, with updates posted continuously at IOPC.online.

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

The article describes the contribution of pharmacists integrated into primary care offices within a community practice health system to two Merit-based Incentive Payment System (MIPS) care improvement activities and to medication adherence gains, which improved the health system's overall Medicare Part C and Part D star rating. It discusses the roles of the pharmacists integrated within the primary care locations of St. Joseph's/Chandler Health System. It explains the quality metrics evaluated.

Background: Long waiting times for health care services are a prominent health policy issue. Waiting time guarantees may limit time to assessment and treatment. Methods: This study aims to investigate the information and support given to patients when the waiting time guarantee cannot be fulfilled from a care provider and administrative management perspective. Semi-structured interviews (N = 28) were conducted with administrative management and care providers (clinic staff and clinic line managers) in specialized clinics in the Stockholm Region, Sweden. Clinics were purposefully sampled for maximum variation in ownership (private, public), complexity of care, geographical location, volume of production, and waiting times. Thematic analysis was applied. Results: Care providers reported that patients received inconsistent information and support with regard to the waiting time guarantee and that information was not adapted to health literacy or individual patient needs. Contrary to local law, they made some patients responsible for finding a new care provider or arranging a new referral. Furthermore, financial interests affected whether patients were referred to other providers. Administrative management steered care providers' informing practices at specific time points (upon establishment of a new unit and after six months of operation). A specific regional support function, Region Stockholm's Care Guarantee Office, helped patients change care providers when long waiting times occurred. However, administrative management perceived that there was no established routine to assist care providers in informing patients. Conclusions: Care providers did not consider patients' health literacy when informing them about the waiting time guarantee. Administrative management's attempts to provide information and support to care providers are not producing the results they expect. Soft-law regulations and care contracts seem insufficient, and economic mechanisms undermine care providers' willingness to inform patients. The described actions are unable to mitigate the inequality in health care that arises from differences in care-seeking behavior. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although medically necessary in some cases, there is growing concern that compounded medications are being overprescribed, leading to questions about safety and necessity for high use and cost. Safety concerns regarding compounded medications were highlighted by the 2013 contamination of steroid injections by the New England Compounding Center, which caused serious infections and other injuries to at least 751 patients and resulted in at least 64 patient deaths. A study contributed to our understanding of compounded medication use and cost, finding in a sample of commercially insured population that the average ingredient cost for compounded medication prescriptions was $710.36, which is 130% higher than for noncompounded medication prescriptions. The literature on use and cost of compounded medications in noncommercially insured populations and related regulations, however, is sparse. The California Workers Compensation System (CAWCS)-the largest U.S. workers compensation system and a public health system experiencing high compounded medication costs-provided an opportunity for additional analysis of these issues. Furthermore, CAWCS data on compounded medication use and cost allow for the exploration of alternative pricing mechanisms that may control costs. OBJECTIVES: To (a) examine use, cost, and billing and reimbursement practices for compounded medications in a public health system-CAWCS- and (b) evaluate regulations and recommend an alternative pricing mechanism that could control costs in California. METHODS: Descriptive statistics for use, cost, and reimbursement patterns of all compounded medication prescriptions included in CAWCSs Workers Compensation Information System claims datasets from 2011 to 2013 were determined. This study coded a unique dataset that (a) identified compounded medications at the ingredient level; (b) grouped compounded medications from ingredient level to compounded medications as a whole; and (c) categorized compounded medications into applicable Colorado pricing categories. T-tests assessed if regulation AB 378, which targets compounded medications, was associated with a difference in mean cost. The Colorado pricing scheme was applied to estimate cost and provide recommendations. RESULTS: Despite the AB 378 requirement for compounded medications to be billed at the ingredient level for reimbursement, 15% of pharmacy-dispensed and 6% of physician-dispensed medications were not billed at the ingredient level. For pharmacy-dispensed compounded medications billed at the ingredient level, mean amount paid (SD) per ingredient was $45.40 (195.97), and for those medications billed at the single compounded medication level, mean amount paid (SD) per medication was $95.20 (326.33) over all years. For physician-dispensed medications billed at the ingredient level, mean amount paid (SD) per ingredient was $75.47 (205.51), and when billed at the single medication level was $204.83 (221.01). T-tests showed a mean increase in compounded medication mean amount paid between pre- and post-AB 378 groups of $12.27 (P < 0.001) for pharmacy-dispensed medications and $11.34 (P < 0.001) for physician-dispensed medications, suggesting that AB 378 did not curb compounded medication mean amount paid. CONCLUSIONS: The average cost of CAWCS pharmacy- and physician-dispensed compounded medications consistently increased. Various factors may have influenced this increase, but AB 378 did not achieve its full regulatory intent to standardize billing and reimbursement and control cost. Grouping of ingredients into compounded medications allowed for application of the Colorado pricing scheme to CAWCS claims data. Adoption of Colorado pricing would save 46% of current compounded medication cost for less complicated medications, while increasing cost for more complicated medications. The analyses recommended a revised Colorado pricing scheme, which would provide improved incentives for accurate billing and lead to savings for CAWCS. DISCLOSURES: Funding for this study was provided by the California Workers Compensation System. The authors had final control regarding study design, study conduct, and writing of the manuscript. The authors report no conflicts of interest.

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.

OBJECTIVE:Examine 30-day readmission rates for indicator conditions before and after adoption of the Hospital Readmissions Reduction Program (HRRP). DATA:California hospital discharge data, 2005 to 2014. STUDY DESIGN:Estimated difference between pre-HRRP trends and post-HRRP rates of hospital readmissions after hospitalization for indicator conditions targeted by the HRRP (heart attack, heart failure, and pneumonia) by payer among insured adults. PRINCIPAL FINDINGS:Post-HRRP, reductions occurred for the three conditions among Fee-for-Service (FFS) Medicare. Readmissions decreased for heart attack and heart failure in Medicare Managed Care (MC). No reductions were observed in the younger commercially insured. CONCLUSIONS:Post-HRRP, greater than expected reductions occurred in rehospitalizations for patients with Medicare FFS and Medicare MC. HRRP incentives may be influencing system-wide changes influencing care outside of traditional Medicare.

This paper examines how health care providers respond to a reference pricing insurance program that increases consumer cost sharing when consumers choose high-priced surgical providers. We use geographic variation in the population covered by the program to estimate supply-side responses. We find limited evidence of market segmentation and price reductions for providers with baseline prices above the reference price. Finally, approximately 75% of the reduction in provider prices is in the form of a positive externality that benefits a population not subject to the program.

Objectives: The objective of this research was to evaluate managed access policy in England, drawing upon the expertise of a range of stakeholders involved in its implementation. Methods: Seven focus groups were conducted with payer and health technology assessment representatives, clinicians, and representatives from industry and patient/carer organizations within England. Transcripts were analyzed using framework analysis to identify stakeholders’ views on the successes and challenges of managed access policy. Results: Stakeholders discussed the many aims of managed access within the National Health Service in England, and how competing aims had affected decision making. While stakeholders highlighted a number of priorities within eligibility criteria for managed access agreements (MAAs), stakeholders agreed that strict eligibility criteria would be challenging to implement due to the highly variable nature of innovative technologies and their indications. Participants highlighted challenges faced with implementing MAAs, including evidence generation, supporting patients during and after the end of MAAs, and agreeing and reinforcing contractual agreements with industry. Conclusions: Managed access is one strategy that can be used by payers to resolve uncertainty for innovative technologies that present challenges for reimbursement and can also deliver earlier access to promising technologies for patients. However, participants cautioned that managed access is not a “silver bullet,” and there is a need for greater clarity about the aims of managed access and how these should be prioritized in decision making. Discussions between key stakeholders involved in managed access identified challenges with implementing MAAs and these experiences should be used to inform future managed access policy. [ABSTRACT FROM AUTHOR]

Objectives: Value-based agreements (VBAs) link access, reimbursement, or price to the realworld usage and impact of a medicine, thereby enabling patient access while reducing clinical or financial uncertainty for the payer. VBAs have the potential to support improved patient outcomes, given the value-oriented approach to care, and lead to overall savings, while enabling payers to share risk and reduce uncertainty. Methods: This commentary outlines the key challenges, enablers, and a framework for successful implementation by comparing the experience of two VBAs for AstraZeneca medicines, aiming to increase confidence in their future use. Results: Engagement by payers, manufacturers, physicians, and provider institutions, and robust data collection systems that are accessible, simple to use, and add little burden to physicians were key to successfully negotiating a VBA that worked for all stakeholders. In both country systems, a legal/policy framework enabled innovative contracting. Conclusions: These examples demonstrate proof of concept for VBA implementation in different settings, and may inform future VBAs. [ABSTRACT FROM AUTHOR]

Health care provider payment schemes consist of a complex set of arrangements used to influence provider behavior towards specific health policy objectives. The study aimed at: 1) providing a structured, comparative overview of current payment schemes within the public health system in selected Central and Eastern European (CEE) countries for different health care providers; 2) identifying and comparing major changes in payment schemes since 2010. Methods included: 1) data collection form development; 2) desk research; 3) national experts' consultations; 4) comparative analysis. The results indicate that the nine CEE countries (Bulgaria, Croatia, Czechia, Estonia, Latvia, Lithuania, Hungary, Poland, and Romania) show numerous similarities in provider payment method mix and in the general direction of the recent changes conducted in this field. Output-based payment methods prevail across all countries and types of providers. Primary health care (PHC) providers are characterized by the most diverse payment method mix. PHC and hospital inpatient care have experienced the most frequent changes in their payment schemes within the last 13 years. These focused mostly on modifying existing payment methods (e.g. detailing payment categories), and applying additional methods to pay for specific services or performance (e.g. fee-for-service, bonus payments). The objectives of conducted change were often similar, thus, there is high potential for a shared, cross-country learning., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2025. Published by Elsevier B.V.)

Objectives: To assess the impact of a parallel regulatory and reimbursement process on (1) direction of funding decisions, (2) time lag until funding recommendation, and (3) type of evidence submitted, for cancer medicines., Methods: Public regulatory and reimbursement decision documents were reviewed for cancer medicines considered by the Pharmaceutical Benefits Advisory Committee since the introduction of parallel processing. Medicine-indication pairs were identified from these documents and data extracted on the type and quality of evidence submitted, funding decisions, and timelines, by type of review process. Associations were explored using univariate and multivariable logistic regression analysis., Results: A total of 182 cases were selected from the 1590 screened. Compared with sequential evaluation, a higher proportion of parallel review submissions presented a cost-effectiveness/cost-utility analysis (67.0% vs 79.7% P < .01) and used the same pivotal evidence as used for market authorization (77.5% vs 90.0%, P = .08). There was no difference in the quality of supporting evidence and other decision-relevant predictors used for either process. Submissions undergoing parallel review were not more likely to receive a negative public funding decision (adjusted odds ratio 0.46; 95% CI 0.14-1.39; P = .17). Under parallel processing, the lag between drug registration and Pharmaceutical Benefits Advisory Committee funding recommendation was drastically reduced (67 weeks) when compared with the sequential process., Conclusions: The type of evidence supplied to regulators and health technology assessment bodies and the funding decisions that ensue have not been affected by the introduction of parallel processing in Australia. The parallel process has, however, drastically reduced the time taken to the initial funding decision., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2025. Published by Elsevier Inc.)

Objective: To analyze and quantify the change in United States of America Medicare reimbursement rates for the 30 most commonly performed spinal imaging procedures., Materials and Methods: The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was utilized to find and extract the 28 most billed spinal imaging procedures. All data was adjusted for inflation and listed in 2020 US dollars. Percent change in reimbursement and Relative Value Units between 2005 and 2020, both unadjusted and adjusted, were calculated and compared. Additionally, percent change per year and compound annual growth rate were calculated and compared., Results: After adjusting for inflation, the average reimbursement for all analyzed spinal imaging procedures between the years 2005 and 2020 decreased by 45.9%. The adjusted reimbursement rate for all procedures decreased at an average 4.3% per year and experienced an average compound annual growth rate (CAGR) of - 4.4%. Magnetic resonance imaging (MRI) had the most substantial adjusted decline of all imaging modalities at - 72.6%, whereas x-ray imaging had the smallest decline at - 27.33%. The average total RVUs per procedure decreased by 50.1%, from 7.96 to 3.97., Conclusion: From the years 2005 to 2020, Medicare reimbursement significantly decreased for all advanced imaging modalities involving the most common spinal imaging procedures. Among all practices, imaging procedures may be experiencing some of the largest decreases from Medicare reimbursement cutbacks., Competing Interests: Declarations. Conflict of interest: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

We study a policy introducing diagnosis related payment for inpatient mental health care in Germany with rates decreasing over length of stay. Using data on all hospital cases, we first examine which hospitals voluntarily opt into the new scheme. We show that specialized hospitals that treat more complicated cases and are reimbursed more highly under the new scheme select into it. Second, we study the effect of diagnosis related payment on length of stay. We find that diagnosis related payment is associated with large reductions in length of stay but has no effect on mortality, post-acute care, or the ambulatory sector. We argue that the reductions in length of stay are driven by the fact that diagnoses related reimbursement is higher for more complex cases and by payment decreasing over length of stay. This novel evidence contributes to a scarce literature on the role of payment systems for inpatient mental health care and provides important insights for policymakers., (© 2024 John Wiley & Sons Ltd.)

Background: The cost of a medical service and its mode of payment are known to play a role in patient decision-making, as demonstrated by the pioneering RAND Corporation Health Insurance Experiment (HIE). This study explores second medical opinion (SO) utilization by payment tracks- "financial reimbursement track" and "network track" by holders of an optional supplementary health insurance. It estimates SO utilization patterns before and after a "Reimbursement-to-Networks Arrangement" regulatory reform initiated on 2015 that eliminated the reimbursement option for SO consultations specifically involving surgeons, and identifies demographic and clinical predictors associated with each payment track before the reform., Methods: Retrospective analysis of medical records data, including secondary care visits data from Clalit Health Services, Israel's largest healthcare provider, and claims data from Clalit's supplementary insurance. An algorithm based on data from Clalit's electronic medical records was used to identify SO instances by payment method. Multivariate logistic regression was used to identify characteristics of SO seekers by their payment method., Results: There was an increase of 28% in patient demand for SO consultations via the supplementary insurance's co-payment track from 2015 to 2017 due to the regulatory reform initiated in 2015. Before this reform, patients from the Arab sector, low socio-economic groups, immigrants, and residents of central geographical areas tended to seek SO via the "network track". Whereas patients from peripheral areas and Jewish Orthodox tended to seek SOs via the financial reimbursement track., Conclusions: In line with the RAND Corporation HIE, we show that incentive structures, such as provider payment methods, can explain some of the variability seen in seeking specialists across health plans or payment tracks. Considerations other than cost, such as geographic distance from the service provider, play a role in deciding on the mode-of-payment for a SO. Analyzing utilization patterns can improve the tracking of regulations' consequences on expenditure, policy, clinical outcomes, and patient satisfaction., Competing Interests: Declarations. Ethics approval and consent to participate: The study was approved by “MEIR” Medical Center’s ethics committee for non-clinical (approval #: K2010/137). Informed consent was waived by the committee due to the retrospective nature of the data. MEIR Medical Center is affiliated with Clalit Health Services, Israel's largest healthcare organization. It's important to clarify that while Bar-Ilan University is not directly affiliated with MEIR Medical Center, the study's data originated from Clalit Health Services, whose ethical review board is housed within MEIR Medical Center. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Objective: National Reimbursement Drug Price Negotiation (NRDPN) refers to a government-led process of negotiating with pharmaceutical companies to reach reasonable prices for exclusive drugs covered by national reimbursement. Since 2016, the Chinese government has regularly implemented eight rounds of NRDPN. This systematic review aimed to determine the effects of NRDPN on drug price, availability, affordability, utilization, cost, and health outcomes in China in the years 2016-2023., Methods: We searched the electronic databases PubMed (which includes MEDLINE), Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang, and VIP for all associated studies published in English or Chinese between January 2016 and December 2023. One of the following outcomes had to be reported: drug price, availability, affordability, utilization, cost, or health outcomes. The study design had to be a randomized or non-randomized trial, an interrupted time series (ITS) analysis, a repeated measures study, or a controlled before-after (CBA) study. Two reviewers independently extracted data and assessed the studies according to Cochrane Effective Practice, Organization of Care (EPOC) guidelines., Results: From a total of 2628 studies, we identified 20 studies that met the inclusion criteria (16 interrupted time-series studies and 4 controlled before-after studies). Most of the studies (66%, n = 12) have some limitations (unclear risk of bias). The published studies indicated the implementation of the NRDPN policy decreased drug prices, ranging from 24 to 72%, which increased the affordability of success-negotiated drugs (refer to those medications that have undergone a successful price negotiation process between pharmaceutical companies and healthcare authorities) and decreased out-of-pocket expenditures. The availability rate increased form 27% to 47%. It has been suggested that the NRDPN was conducive to narrowing disparities in availability and affordability across regions, hospital levels, and types of health insurance. In addition, it was associated with the increased drug expenditure by 61% due to the increased use of successful-negotiated drugs. However, there is insufficient evidence to explore the health outcome changes after the NRDPN policy., Conclusion: Evidence to date generally suggests the NRDPN policy is an effective way to decrease drug prices, improve access to innovative medicines, and improve fairness. It provides useful experience and lessons in improving access to innovative medicines for other low-and middle-income countries., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Importance: The impact of Medicaid telehealth reimbursement policies on staffing and patient-centered care in the safety net are largely unknown but critical to successful and equitable access to telehealth., Objective: To identify and characterize federally qualified health center (FQHC) staff and leadership's perceptions of the benefits and drawbacks of Medicaid telehealth reimbursement policies., Design, Setting, and Participants: This qualitative study used semistructured interviews conducted from April 2022 to January 2024 with snowballed sampled participants consisting of FQHC leadership, clinicians, and administrative staff in 6 FQHCs representing the 5 boroughs in New York, New York., Main Outcomes and Measures: Participants described telehealth experiences, including factors impending or contributing to staff turnover, patient satisfaction, and financial sustainability within FQHCs. Thematic analysis was used to analyze the data., Results: Of 56 interviews, 26 participants (46.4%) were part of the leadership team, 18 (32.1%) were clinical staff, 8 (14.3%) were program support staff, 7 (12.5%) were enabling services staff, 3 (5.4%) were site directors, and 3 (5.4%) were another staff category. Three overarching themes characterized staff and leadership understanding of the impact of Medicaid telehealth reimbursement policies on FQHCs: (1) Medicaid telehealth policy design was perceived to exacerbate a workforce shortage, particularly among mental health care practitioners; (2) patients ranged in preferences and ability to access telehealth while FQHCs struggled to attain resources for telehealth; and (3) FQHC leadership envisioned a productive hybrid model where telehealth complements on-site care. FQHC staff and leadership reported opportunities to improve compliance, no-shows, and workflows through telehealth, but improvements in funding policy, such as payment parity and more grants that can be used to address telehealth infrastructure (eg, Internet access, equipment, and literacy), are urgently needed., Conclusions and Relevance: In this qualitative study, staff at FQHCs perceived the current telehealth Medicaid reimbursement policies in New York State as a factor that exacerbated inequities to accessing care, particularly for mental health needs. These findings indicate that although telehealth brings new opportunities to advance patient-centered care, there are serious challenges on the path toward equitable care because telehealth is not yet integrated into payment in a sustainable way.

Office-based gynecologic procedures (OBGPs) are reimbursed at lower rates than similar office urology and dermatology procedures. But there is a broader "hidden curriculum" in health professions training that perpetuates clinicians' and organizations' acceptance of these patterns of poor reimbursement, disincentivizes research on improving OBGP pain management, and exacerbates tolerance of poor control of patients' OBGP pain. This article suggests strategies for equitable reimbursement that would also likely motivate better, more equitable OBGP pain control., (Copyright 2025 American Medical Association. All Rights Reserved.)

Objective: This study aimed to investigate the critical factors for reimbursement decisions of innovative medicines in Scotland and to explore the feasibility of machine learning models for predicting decisions., Method: All appraisals for innovative medicines issued by the Scottish Medicines Consortium (SMC) from 2016 to 2020 were screened to extract decision outcomes and 24 explanatory factors. SelectKBest with chi-square test was used for factor selection. The factors with P-value <0.05 were considered to have statistically significant associations with decision outcomes and were selected. Six machine learning models including decision tree, random forest, support-vector machine, Xgboost and K-nearest neighbours and logistic regression were used to build models with selected factors. Indicators comprising accuracy, precision, recall, F1-score were used to evaluate the performance of models., Result: A total of 111 appraisals were identified, among which, 47 medicines were recommended, 48 recommended with restricted use and 16 not recommended. Seven were identified to be significant and selected for the prediction models. The factors of request for restriction on indication by manufacture, uncertainty of economic evidence, validation of primary outcomes and acceptance of comparator were identified as the most important predictors for SMC decisions. Four models had good prediction performance with both accuracy and F1-score over 0.9 in the internal validation, and random forest had the best prediction performance., Conclusion: Low uncertainty of economic evidence, validated primary outcomes and accepted comparators were significantly associated with positive SMC decisions. Machine learning models may be feasible for predicting reimbursement decisions in the future., Competing Interests: Conflict of interest All authors have no conflicts of interest to report in this work. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2024 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Relative value units (RVUs) were first introduced by the Omnibus Budget Reconciliation Act of 1989 to standardize physician compensation based on the effort, skill, and resources required for medical services. This methodology replaced the "usual, customary, and reasonable" standard, which reduced variability in payments across providers. RVUs are comprised of physician work, practice expenses, and malpractice costs. In arthroplasty, declining inflation-adjusted reimbursements for total hip and knee replacements are primarily due to a lack of inflation adjustments, rather than nominal decreases values of RVUs values or the Medicare Conversion Factor. While value-based care models like the Comprehensive Care for Joint Replacement initiative and the Merit-Based Incentive Payment System aim to link RVU-based payments with quality and cost metrics, compensation remains largely tied to fee-for-service models. Major challenges include inadequate compensation for revision arthroplasty and the administrative burden of RVU management. Despite its limitations, the RVU system has enhanced transparency in physician reimbursement, though improvements are needed to better align financial incentives with value-based care principles in orthopaedics., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: In 2013, South Korea introduced risk-sharing agreements (RSAs) as a new reimbursement mechanism to enhance access to new medicines and to manage pharmaceutical expenditures. This study evaluates RSAs in South Korea from the viewpoints of key stakeholders., Methods: In 2022, a survey and semi-structured interviews were conducted. Study participants were recruited from academia ( n  = 3), domestic ( n  = 4) and foreign ( n  = 6) manufacturers, and government agencies ( n  = 6) using a purposive sampling method., Results: Key stakeholders perceived the objective of RSAs to be 'access to medicines' and understood RSAs to manage uncertainty about 'expenditures.' They responded that financial- and performance-based RSAs address uncertainty about 'expenditures' and 'clinical effectiveness,' respectively. All stakeholders agreed that RSAs have increased the likelihood that new medicines will be listed and have reduced out-of-pocket expenditures for patients. However, foreign manufacturers insisted that the benefits of RSAs are marginal, while the administrative burden on manufacturers is high., Conclusion: The gaps in perception between stakeholders could be narrowed by conducting a comprehensive evaluation. Financial- and performance-based RSAs need to be clearly distinguished and aligned to address the uncertainties of a new medicine in health systems.

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 increasing reliance on digital tools for standard healthcare practices in uninsured populations is poorly understood. This study aims to assess the impacts of a newly implemented digital reimbursement system at a student-run primary care clinic associated with an academic medical institution serving uninsured New York City residents. Pharmacy records of 94 unique patients receiving a total of 2770 reimbursements between October 17th, 2016, and May 18th, 2023, were analyzed. Patients were divided into two groups (in-person vs. digital) based on their reimbursement preferences type. Demographic analyses were performed in addition to assessing reimbursement volumes, number of refunds, and duration until receipt of payment for each group. The clinic's total monthly reimbursement volume, number of prescriptions, and number of patients for the period before introduction of digital refunds was compared to the period after. The mean age (in-person = 52.7 ± 14.7 years, digital = 54.9 ± 12.9 years) was not statistically different between the groups. Patients in the digital group requested on average more refunds (digital = 47 refunds, in-person = 14 refunds), received higher total reimbursement amount (digital = $1131.24, in-person = $289.36), and they were reimbursed faster (digital = 56 days, in-person = 62 days). Since the introduction of the digital reimbursement option, our three-month reimbursement volume more than doubled from $481 to $1298. The average number of monthly reimbursements increased from 27 to 45 refunds, and the number of monthly patients increased from 6 to 9 patients. In summary, digital reimbursement options can facilitate medication reimbursement among uninsured patients. These results suggest that digital reimbursement systems result in higher utilization, faster refunds, and larger total reimbursements amount for uninsured and underserved patients., Competing Interests: Declarations. IRB compliance statement and ethical adherence: This study was written in compliance with our institutional ethical review board. IRB exception was obtained with the following protocol code: 24-01026970-01. Competing interest: The authors have no personal or institutional interest with regard to the authorship and/or publication of this manuscript., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: To analyze the time from drug registration to reimbursement recommendations, we examined medicinal products, including new clinical indications, registered by the EMA between 2014 and 2019 across various therapeutic areas., Materials and Methods: The Polish Agency for Health Technology Assessment and Tariffication (AOTMiT) was compared with 11 agencies in England, Wales, Ireland, Scotland, the Netherlands, Norway, France, Germany, New Zealand, Canada, Australia. A total of 1,942 recommendations published by 12 HTA agencies were analyzed., Results: The time from registration to recommendation in Poland was statistically significantly longer than for the other countries. The analysis revealed noticeable differences in the time it takes from drug registration to recommendation across the countries included in this analysis. Analyzing trends from 2014 to 2019 across individual countries, there appears to be a slight tendency toward a decrease in the median time from registration to recommendation in many agencies., Conclusions: This may suggest improvements in the processes of the recommending authorities and the companies responsible for providing data for assessment. Despite Poland having one of the longest times from registration to recommendation among the countries analyzed, there has been a clear year-over-year decrease in the time to publication of reimbursement recommendations.

Background: With the implementation of the hierarchical medical system (HMS) in China, Zhejiang Province introduced an innovative payment scheme called "payment method by disease types with point counting". This scheme was initially adopted in Jinhua in July 2017, and was later integrated with the "same disease, same price" policy in Hangzhou in January 2020. This study aimed to investigate the impact of these reforms on the distribution of health service volume., Methods: Data were obtained from 104 hospitals, including 12 tertiary and 14 secondary hospitals from each of four regions: Jinhua (intervention) vs. Taizhou (control), and Hangzhou (intervention) vs. Ningbo (control). A total of 3848 observation points were examined using two sets of controlled interrupted time series analyses to assess the effects of this new case-based payment, without and with "same disease, same price", on the proportion of discharges, total medical revenue and hospitalization revenue. The Herfindahl-Hirschman Index (HHI) were analyzed to evaluate changes in market competition., Results: Following the introduction of the new case-based payment without "same disease, same price", secondary hospitals in Jinhua experienced a significant decline in the proportion of discharges (β 6  = -0.1074, p = 0.047), total medical revenue (β 6  = -0.0729, p = 0.026), and hospitalization revenue (β 6  = -0.1062, p = 0.037) compared to those in Taizhou, while tertiary hospitals showed a non-significant increase. After incorporating "same disease, same price", the proportion of discharges (β 6  = 0.2015, p = 0.031), total medical revenue (β 6  = 0.1101, p = 0.041) and hospitalization revenue (β 6  = 0.1248, p = 0.032) in Hangzhou's secondary hospitals increased compared with Ningbo's, yet the differences in both the level and trend changes between tertiary hospitals in the two cities were not statistically significant. The HHI in Jinhua (β 7  = 0.0011, p = 0.043) presented an upward trend during the pilot period of the case-based payment, while the HHI in Hangzhou (β 6  = -0.0234, p = 0.021) decreased immediately after the introduction of "same disease, same price"., Conclusion: This new case-based payment scheme may worsen the disproportionate distribution of service volume across hospitals of different levels. While "same disease, same price" shows potential benefits, further evidence is needed to assess its effectiveness in promoting HMS. Policymakers should consider hospital interests in payment design and address unintended strategic behaviors., Competing Interests: Declarations. Ethics approval and consent to participate: Ethical approval was received from the Ethics Committee of Hangzhou Normal University (2023–1042). The study was performed in accordance with the Declaration of Helsinki. Consent to participate was not required, as this study does not involve data related to any animal or human. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: The sustainability of community pharmacies in the United States depends, in large part, on policies enacted by the Centers for Medicare and Medicaid Services (CMS). In 2003, CMS policy allowed retrospective direct and indirect remuneration (DIR) fees to manage costs. From 2024, only prospective DIR fees are permitted. The current study explores how existing payment models have impacted practice and how the policy change might impact future practice., Methods and Materials: Semi-structured qualitative interviews were conducted with community pharmacists knowledgeable about third-party payment and reimbursement practices in the state of Missouri. Interviews were recorded, transcribed, and reflectively analysed to identify broad themes. Final codes were applied to direct quotes. Participants checked transcripts and drafts of the manuscript for accuracy and completeness., Results: Twelve pharmacists (11 males) with self-expressed knowledge of fees impacting their practice(s) participated. The pharmacists owned or worked for community pharmacies. The median percentage of patients served on Medicare Part D was 35% (range 24% to 60%). Four main themes and one overarching theme were identified. Theme 1 describes a sense of being punished for the basic component of pharmacy practice, i.e. safely dispensing prescription medications. Theme 2 describes a diversification of the business model to subsidise losses on the basic component. Theme 3 describes anticipated challenges given the policy change. Theme 4 describes what may be needed to achieve payment reform. The overarching theme describes the purpose of community pharmacy, including who community pharmacists are and who they serve, i.e. their community., Conclusion: Community pharmacies require a financially viable and sustainable business model to deliver the legally required basic component of practice: safely dispensing prescription medications. Legislative action could help to ensure community pharmacies are appropriately compensated for work at the federal and state levels. Where services beyond the basics cost-effectively benefit public health, payment models could support them., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2025 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

This summary of the proceedings of the 2023 ACR Intersociety Meeting discusses the seven most important challenges facing radiology today: declining reimbursement, corporatization and consolidation, inadequate labor force, imaging appropriateness, burnout, turf wars with nonphysicians, and workflow efficiency. Participants in the Intersociety Summer Conference-2023 focused their effort on identifying potential solutions given how critical these topics are to the sustainability of the profession., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Medicare Advantage (MA) plans report diagnoses more completely than they are reported in traditional Medicare. As a result, payment to MA plans is greater than it would be if coding patterns were identical in the two sectors. The Medicare Payment Advisory Commission estimates that the overpayment to MA attributable to differential coding was $50 billion in 2024. We analyzed potential changes aimed at reducing MA plan overpayments that occur as a result of differential diagnostic coding between MA and traditional Medicare-specifically, changes that would reduce payments to MA contracts that code most intensely. The contract-level equity and efficiency problems created by differential MA coding could be solved almost completely if the Centers for Medicare and Medicaid Services excluded ten diagnosis groups from the payment model. With these groups excluded, the average MA risk score would be similar to that of traditional Medicare, and there would be very little relationship between contract-level coding intensity and risk scores. However, this change would increase incentives for risk selection and reduce incentives to provide high-quality care to beneficiaries with diagnoses in the excluded groups. Policy makers will need to balance the ability to improve equity and efficiency in the MA payment system against concerns about increasing incentives for risk selection.

Objectives: This study quantified the public value (PV) of the criteria and sub-criteria in the current drug reimbursement systems in South Korea and examined sociodemographic factors that associated with PV., Methods: The Analytic Hierarchy Process (AHP) was used to quantify the PVs of criteria and sub-criteria. We developed a questionnaire to generate pairwise comparison matrices among criteria and sub-criteria. From 27 March to 1 April 2023, we recruited 1,000 study participants using a quota sampling method stratified by age, sex, and region based on Korean census data., Results: The PVs for the criteria were highest for clinical usefulness (28.5%), followed by cost-effectiveness (27.1%), budget impact (24.3%), and reimbursement in other countries (20.1%). The sociodemographic characteristics of the participants had a significant impact on the PVs of the criteria. Willingness to pay additional premiums for national health insurance was negatively associated with PV for clinical usefulness and cost-effectiveness and positively associated with PV for reimbursement in other countries., Conclusions: The public prioritized clinical usefulness and cost-effectiveness as the main criteria. However, the PVs of the criteria were divergent and associated with sociodemographic factors. Divergent public interests require an evidence-informed deliberative process for reimbursement decisions.

In this update, we discuss a position statement from the National Institute of Health and Care Excellence (NICE) on the use of artificial intelligence for evidence generation and publications reviewing the use of real-world data as external control arms. Finally, we discuss a number of recent studies investigating the real-world effectiveness of glucagon-like peptide-1 receptor agonists and whether these studies are informative for reimbursement decision making.

In France, the short-stay activities of public and private sector healthcare facilities have been financed since 2004 by activity-based pricing (T2A). The principle is to allow for payment determined primarily by the nature and volume of activities. T2A has enabled a major transformation compared to the old financing system, chiefly for public sector facilities that used to operate under a general allocation, and convergence between payment methods in the public and private sectors. However, official reports and public pronouncements by many hospital healthcare stakeholders have also highlighted the limits of this method of financing, leading to several reform projects. With that in mind, round table 3 of the Giens Workshops, including experts from academia and/or hospitals, institutions, and industry, questioned the impact of the new T2A reforms on access to innovative health care products in hospitals. After scoping out the issue and drawing up observations, the round table proposed six general recommendations that would be avenues for improving access to innovative health care products for hospital service users., (Copyright © 2024 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

Introduction: Recent federal regulatory changes governing the delivery of methadone treatment for opioid use disorder at Opioid Treatment Programs (OTPs) support continued practice changes towards greater and flexible methadone take-home medication. Existing payment models for OTPs were closely tied with onsite medication administration and thus misaligned with the need to conduct more and flexible take-homes. This study aims to understand OTP organizations' experience with the newly created OTP bundled payment model in New York State as an alternative to the pre-existing per-service payment model during 2020-2023 to inform financing strategies to support and sustain practice changes., Methods: The study conducted semi-structured interviews with financial leaders and staff from OTP organizations in New York State. Purposeful sampling of OTP organizations based on their billing practices was supplemented by snowball sampling. Qualitative data from 12 interviews (with 11 OTP organizations and 1 trade organization) were analyzed with an integrated (inductive and deductive) approach to derive themes., Results: Study informants recognized that the bundled payment model served to protect revenue in a time when OTPs had to pivot quickly to increase take-home medication to patients. Informants described a wide spectrum of practices to operationalize billing in the alternative payment systems, revealing confusion with the billing rules and significant logistical and technical challenges. Informants expressed concerns regarding the substantial difference between the full bundled rate, paid in weeks with one or more qualifying services, and the medication-only rate, reporting that extended (2 weeks or more) take-homes might not be sustainable under the two-tiered model with the low medication-only rate and advocating for a single bundled rate. Informants believed that increased take-home medication and federal regulatory changes had profound implications for the delivery of counseling services, the counselor workforce, and financial viability for OTPs., Conclusions: Our study of OTP organization experience in New York State provided data on OTP organization perspectives regarding the potential revenue-protecting effects of bundled payments and generated insights to inform future research and policy experimentation to support flexible take-home medication. Future implementation studies are needed to better understand the roles of financing strategies at large in supporting clinical practice changes in substance use disorder treatment., Competing Interests: Declaration of competing interest Authors report no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

In 2018, Medicare introduced new codes to the Endoscopic Sinus Surgery (FESS) and balloon sinus dilation (BSD) families of Current Procedural Terminology (CPT) codes. Using the Medicare Part B National Summary Data File from 2010 to 2022, an interrupted time-series analysis examined trends in volume and reimbursements before and after 2018. Prior to 2018, volume and reimbursements for FESS grew at a mean rate of 2.5% ± 2.2% per year and 6.9% ± 6.6% per year, respectively, before reimbursements decreased significantly in 2018 by -13.9% (P = .014), leading to a stabilization of volume (growth of 0.72%, P = .602). Volume and reimbursements for BSD saw rapid growth from 2011 to 2015 which plateaued prior to the introduction of bundled codes and did not appear to change significantly in 2018 (-0.6%, P = .306 and 11.9%, P = .392, respectively). In addition to concurrent devaluation of FESS and BSD codes, bundling appears to have further contributed to falling reimbursements in rhinology., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Introduction: Indirect treatment comparisons (ITCs) evaluate novel treatments compared to appropriate comparators when direct evidence is unavailable or infeasible. The objective of this study was to highlight the prevalence of different ITC methods in oncology drug submissions and to provide insights into how ITCs have been used in recent regulatory approval, reimbursement recommendations, or pricing decisions across various regions and diverse assessment frameworks., Methods: A targeted literature review was conducted to identify assessment documents for oncology drug submissions that included ITCs. This included hand searches of the websites of four regulatory bodies and four health technology assessment (HTA) agencies with varying assessment frameworks across North America, Europe, and Asia-Pacific., Results: A total of 185 documents were included for synthesis. Documents were retrieved from all four HTA agencies and the European Medicines Agency (EMA), the only regulatory body with eligible records. Within these, 188 unique submissions included a total of 306 supporting ITCs of various methods. Authorities more frequently favored anchored or population-adjusted ITC techniques for their effectiveness in data adjustment and bias mitigation. Furthermore, ITCs in orphan drug submissions more frequently led to positive decisions compared to non-orphan submissions., Conclusions: This review highlights the crucial role and widespread use of ITCs in global healthcare decision-making, particularly when direct evidence is lacking, and in the discernment of market-specific clinical benefits. This work contributes to bolstering the credibility and recognition of ITCs across regulatory and HTA agencies of diverse regions and assessment frameworks., Competing Interests: Declarations. Conflict of Interest: Ataru Igarashi received consulting fees from PhRMA Japan, JPMA, EFPIA Japan, Janssen, Eli Lilly Japan K.K., Shionogi & Co. Ltd., Takeda Pharmaceuticals, Novo Nordisk Japan, Eisai Japan, Medtronic Japan, Chugai Pharmaceuticals, Edwards LifeScience, GSK Japan. Ataru Igarashi received collaborative research funds from Moderna Japan Inc, Taiho Yakuhin, Otsuka Pharmaceuticals, Intuitive Surgical Inc. Shiro Tanaka has received lecture fee from MSD K.K. and Datack. He has received consultation fee and outsourcing fee from Daiichi Sankyo Company, Limited, Janssen Pharmaceutical K.K., and Public Health Research Foundation. He has received a research grant from Novo Nordisk. De Moor Raf, Li Nan, and Hirozane Mariko are employees of Janssen Pharmaceutical K.K. Wu David Bin-Chia, Hong Li Wen, and Yu Dae Young are employees of Janssen Pharmaceutical Companies of Johnson and Johnson Asia Pacific Regional Office Singapore. Mahmoud Hashim is an employee of Janssen Vaccines & Prevention B.V. in the Netherlands. De Moor Raf, Li Nan, and Hirozane Mariko have stock or stock options of Johnson & Johnson. Brian Hutton has previously received honoraria from EVERSANA™ and Evidinno Outcomes Inc. for the provision of methodologic advice related to systematic reviews, meta-analyses, and indirect comparisons. Krista Tantakoun, Christopher Olsen, Fatemeh Mirzayeh Fashami, Imtiaz Samjoo, and Chris Cameron are employees of EVERSANA™, which was a paid consultant to Janssen Pharmaceutical K.K. in connection with the development of this manuscript; Chris Cameron is also a shareholder of EVERSANA™. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Ethical Approval: This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors., (© 2024. The Author(s).)

Objective: To construct a framework and calculation tool to compare the consequences of implementing different payment models for high-cost, one-off potentially curative therapies and enable decision making to ultimately enhance timely patient access to innovative health interventions., Methods: A framework outlining steps to determine potentially suitable payment models was developed. Based on the framework, a supporting calculation tool operationalised as an Excel-based model was constructed to quantify the associated costs for an average patient during the timeframe of the intended payment agreement, the total budget impact and associated benefits expressed in quality-adjusted life-years for the total expected lifetime of the patient population. To demonstrate the potential of the framework, three case studies were used: onasemnogene abeparvovec (Zolgensma ® ), brexucabtagene autoleucel (Tecartus ® ) and etranacogene dezaparvovec (Hemgenix ® ). A hypothetical case study was used to illustrate the output of the calculation tool., Results: Part 1 of the framework presents steps for matching a suitable reimbursement and payment model with the disease and treatment characteristics. The reimbursement and payment models are further specified in Part 2. Part 3 guides end users through the setup of a calculation tool with which the financial impact can be calculated of two payment models: a price discount model and an outcome-based spread payment model with a discount. Part 4 concerns the output of the calculation tool, showing how different payment models lead to different financial consequences under three assumptions of longer term effectiveness., Conclusions: The presented framework provides decision makers with insight into the financial consequences of their chosen payment model under different assumptions. This can aid reimbursement negotiations by clarifying the optimal choice given a therapy's characteristics., Competing Interests: Declarations. Funding: This project was funded by the Dutch National Health Care Institute (Zorginstituut Nederland) as part of the Research Network for Health Technology Assessment. Conflicts of Interest/Competing Interests: Rick A. Vreman reports that at the time the study was conducted, he was working in accordance with the above-mentioned affiliations. He is now employed by Roche. He reports no other conflicts of interest that are directly relevant to this study. Marcelien H.E. Callenbach, Christine Leopold, Aukje K. Mantel-Teeuwisse and Wim G. Goettsch declare that the research was conducted in the absence of any commercial interests that could be construed as a potential conflict of interest. Ethics Approval: This study did not require ethics approval because no patient data were used. Consent to Participate: Not applicable. Consent for Publication: Not applicable. Availability of Data and Material: The datasets generated and/or analysed during the current study are available from the corresponding author upon reasonable request. Code Availability: Not applicable Authors’ Contributions: Concept and design: MHEC, CL, RAV, AKM-T, WGG. Analysis and interpretation of data: MHEC, RAV, AKM-T, WGG. Drafting of the manuscript: MHEC. Critical revision of the paper for important intellectual content: Leopold, RAV, AKM-T, WGG., (© 2024. The Author(s).)

Background Total shoulder arthroplasty (TSA) has been demonstrated to be an effective treatment for multiple shoulder pathologies. The purpose of our study was to compare the relative value units (RVUs) per minute of surgical time for primary and revision TSA. Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients that underwent primary TSA, one-component revision TSA, and two-component revision TSA between January 1, 2015 and December 31, 2017 using current procedure terminology codes. RVUs were divided by mean operative time for each procedure to determine the amount of revenue generated per minute. Rates were compared between the groups using a one-way analysis of variance with post-hoc Tukey test. Statistical significance was set at p