The link between varicoceles and male infertility has been a matter of debate for more than half a century. Varicocele is considered the most common correctable cause of male infertility, but some men with varicoceles are able to father children, even without intervention. In addition, improvements in semen quality after varicocelectomy do not always result in spontaneous pregnancy. Studies regarding possible pathophysiological mechanisms behind varicocele-induced infertility have tried to address these controversies. Oxidative stress seems to be a central mechanism; however, no single theory is able to explain the differential effect of varicoceles on infertility. As a consequence, careful patient selection for treatment based on couple fertility status, varicocele grade, and semen quality is critical for achieving a chance of a subsequent pregnancy. A substantial amount of data on the effects of varicocelectomy has been gathered, but inadequate study design and considerable heterogeneity of available studies mean that these data are rarely conclusive. Current evidence suggests a beneficial effect of varicocelectomy on semen quality and pregnancy outcomes in couples with documented infertility only if the male partner has a clinically palpable varicocele and affected semen parameters.
The Affordable Care Act supports the growth of accountable care organizations (ACOs) as a potentially powerful model for health care delivery and payment. The model focuses on primary care. However, surgeons and other specialists have a large role to play in caring for ACOs' patients. No studies have yet investigated the role of surgical care in the ACO model. Using case studies and a survey, we examined the early experience of fifty-nine Medicare-approved ACOs in providing surgical care. We found that ACOs have so far devoted little attention to surgical care. Instead, they have emphasized coordinating care for patients with chronic conditions and reducing unnecessary hospital readmissions and ED visits. In the years to come, ACOs will likely focus more on surgical care. Some ACOs have the ability to affect surgical practice patterns through referral pressures, but local market conditions may limit ACOs' abilities to alter surgeons' behavior. Policy makers, ACO administrators, and surgeons need to be aware of these trends because they have the potential to affect the surgical care provided to ACO patients as well as the success of ACOs themselves.A ccountable care organizations (ACOs) are a new and potentially powerful payment model authorized by the Affordable Care Act. In ACOs approved by the Centers for Medicare and Medicaid Services (CMS), groups of physicians, together with other possible partners such as hospitals, take responsibility for the cost and quality of care for a set of Medicare patients and share in the savings if total costs are reduced below the benchmarked, expected costs. ACOs are designed to provide incentives for cost savings without limiting patient choice or compromising the quality of care.CMS approved the first fifty-nine Medicare ACOs in 2012. The agency is overseeing two different ACO models under its Medicare Shared Savings Program and the Pioneer ACO program. The programs differ primarily in terms of how much risk the ACOs in them assume.1 An Advance Payment Model that is part of the Shared Savings Program offers capital assistance to ACOs without inpatient facilities and with annual revenues of less than $50 million and to rural ACOs with critical-access hospitals, low-volume hospitals, or both and with annual revenues of less than $80 million.2 Many ACO-like arrangements have appeared in the private sector as well.Patients are attributed to an ACO if they obtain a plurality of their care from a primary care physician in the ACO. Medicare tracks the performance of individual ACOs against cost and quality benchmarks for the beneficiaries attributed to them.
Discussion | In this study, postoperative opioid prescribing was not correlated with HCAHPS pain measures. The study examined a subset of patients used to generate HCAHPS scores and was limited to a single payer in Michigan. Nonetheless, surgical patients are a key contributor to HCAHPS scores, and opioids account for almost 40% of surgical prescriptions. 4 Given the growing evidence demonstrating postoperative opioid prescriptions exceed patient requirements, 6 these findings suggest reducing opioid prescriptions may not worsen HCAHPS scores and hospital reimbursement in Michigan. Moreover, these results may also inform policy makers in the current decision to remove pain management from determination of hospital payments.
The primary challenge to identifying and addressing barriers in access to care for male factor infertility is accurate measurement of the prevalence of male infertility. Current estimates are based on couples pursuing assisted reproduction, and likely underestimate the problem. These estimates also fail to account for the number of patients facing infertility due to cancer or cancer treatment. Lack of health insurance coverage for the diagnosis and treatment of infertility presents a major barrier for couples struggling with infertility. However, it is not the only barrier. Education level, household income, cultural norms, religious beliefs, geographic location, and the availability of specialty-trained reproductive urologists are all important factors in determining the ease with which patients access and obtain infertility care. Addressing each of these obstacles directly is imperative to improving reproductive care and outcomes for infertile couples in the United States.
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