The Future of US Health Care Policy

Bauchner, Howard; Fontanarosa, Phil B.

doi:10.1001/jama.2016.2447

Cited by 9 publications

(12 citation statements)

References 12 publications

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“…This rate is 3-to 5-fold higher than the current Medicare rates for office payment or even 2-fold higher than the ASC payment. Key words: Medicare, physician payment schedules, HOPD and ASC payment schedule, site-of-service differentials, soft tissue injections, intraarticular injections actment of efforts designed to bend the cost curve downward, the Centers for Medicare & Medicaid Services (CMS) projected that the 2016 total health care spending reached nearly 3.3 trillion dollars, up 4.3% from 2015 with per capita spending increasing to $10,348 in 2016 (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). The agency attributed the increase, in large part, to the aging population and rising prices for health care services in the United States (1).…”

Section: Cost Calculation Methodology Exacerbatesmentioning

confidence: 99%

“…With numerous alternate models of payments, and the escalating issues of opioid use, abuse, and deaths (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(21)(22)(23)(24)(25), President Trump has declared the opioid issue as a national health care crisis (26), and is promoting non-opioid interventions. Thus, understanding payment methodology and site of service differentials is critical for interventional pain specialists who are at the forefront of this battle.…”

Section: Cost Calculation Methodology Exacerbatesmentioning

confidence: 99%

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Cost Calculation Methodology Exacerbates Site-of-Service Differentials by 10- to 18-Fold for Soft Tissue and Joint Injections in Hospital Outpatient Departments

Manchikanti

2017

PMCR

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In recent years, physicians and facilities have faced a multitude of reforms, regulations, and payment models to reduce health care costs, and to improve access and quality. Despite these measures, total health care cost increased to $3.3 trillion in 2016, up 4.3% from 2015. An aging population and an increase in cost are two of the factors that account for most of the increase in costs. Price intensity from physicians and facilities are influenced by Medicare rate-setting methodology with site-of-service differentials. Site-of-service differentials for payments are increasingly being recognized as a topic that requires discussion. Intraarticular and soft tissue injections are performed in physician offices (90%), ambulatory surgery centers (ASCs) (1%), and hospital outpatient departments (HOPDs) (9%), however, the payment rates differ 10- to 18-fold among these settings with 63% of total payments to HOPDs, 2% to ASCs, and 37% to offices. In this manuscript, we describe significant payment differentials, based on cost calculation methodology that indicate a potential substantial savings of more than $125 million per year if HOPDs are reimbursed at the same rate as ASCS, utilizing any of the formulas, even if the current ASC rate is doubled. This effort would also save significantly when it comes to copayments, which are 27% by patients, instead of the 20% in offices and ASCs. The addition of Medicare Advantage recipients, which constitutes approximately 30% of the overall Medicare population will increase these estimations by 30%. In conclusion, utilizing accurate payment rate calculations for intraarticular and soft tissue injections will result in substantial changes in the payment rates. In fact, just the differences in the copay itself would make the copay $66.06 (which is 27% of $244.68). This rate is 3- to 5-fold higher than the current Medicare rates for office payment or even 2-fold higher than the ASC payment. Key words: Medicare, physician payment schedules, HOPD and ASC payment schedule, site-of-service differentials, soft tissue injections, intraarticular injections

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Section: Cost Calculation Methodology Exacerbatesmentioning

confidence: 99%

Section: Cost Calculation Methodology Exacerbatesmentioning

confidence: 99%

Cost Calculation Methodology Exacerbates Site-of-Service Differentials by 10- to 18-Fold for Soft Tissue and Joint Injections in Hospital Outpatient Departments

Manchikanti

2017

PMCR

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“…More than 70,000 pages of regulations have been written (43)(44)(45)(46)(47). Implementation of the ACA has resulted in the creation of dozens of new agencies, boards, commissions, and other government entities (2)(3)(4)(42)(43)(44)(45)(46)(47)(48). Several parts of the law have been changed or postponed, often by executive order and the courts (5).…”

Section: Affordable Care Actmentioning

confidence: 99%

“…Health care coverage for the elderly and indigent with the passage of Medicare and Medicaid in T he enactment in 2010 of the Affordable Care Act (ACA), also known as Obamacare, was the most monumental change in US health care policy since the passage of Medicaid and Medicare in 1965 (1)(2)(3)(4). The ACA, despite its complexity, was enacted with 3 primary goals: increasing the number of insured, improving the quality of care, and controlling health care costs (2)(3)(4)(5)(6)(7)(8)(9)(10). The legislation, which was passed on partisan grounds, has had strong support from its proponents, while attracting ongoing criticism from its opponents.…”

Section: Impetus For Reformmentioning

confidence: 99%

A Critical Analysis of Obamacare: Affordable Care or Insurance for Many and Coverage for Few?

Manchikanti¹,

Helm²,

Benyamin³

et al. 2017

Pain Phys

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The Affordable Care Act (ACA), of 2010, or Obamacare, was the most monumental change in US health care policy since the passage of Medicaid and Medicare in 1965. Since its enactment, numerous claims have been made on both sides of the aisle regarding the ACA’s success or failure; these views often colored by political persuasion. The ACA had 3 primary goals: increasing the number of the insured, improving the quality of care, and reducing the costs of health care. One point often lost in the discussion is the distinction between affordability and access. Health insurance is a financial mechanism for paying for health care, while access refers to the process of actually obtaining that health care. The ACA has widened the gap between providing patients the mechanism of paying for healthcare and actually receiving it. The ACA is applauded for increasing the number of insured, quite appropriately as that has occurred for over 20 million people. Less frequently mentioned are the 6 million who have lost their insurance. Further, in terms of how health insurance is been provided, the majority the expansion was based on Medicaid expansion, with an increase of 13 million. Consequently, the ACA hasn’t worked well for the working and middle class who receive much less support, particularly those who earn more than 400% of the federal poverty level, who constitute 40% of the population and don’t receive any help. As a result, exchange enrollment has been a disappointment and the percentage of workers obtaining their health benefits from their employer has decreased steadily. Access to health care has been uneven, with those on Medicaid hampered by narrow networks, while those on the exchanges or getting employer benefits have faced high out-of-pocket costs. The second category relates to cost containment. President Obama claimed that the ACA provided significant cost containment, in that costs would have been even much higher if the ACA was not enacted. Further, he attributed cost reductions generally to the ACA, not taking into account factors such as the recession, increased out-of-pocket costs, increasing drug prices, and reduced coverage by insurers. The final goal was improvement in quality. The effort to improve quality has led to the creation of dozens of new agencies, boards, commissions, and other government entities. In turn, practice management and regulatory compliance costs have increased. Structurally, solo and independent practices, which lack the capability to manage these new regulatory demands, have declined. Hospital employment, with its associated increased costs, has been soaring. Despite a focus on preventive services in the management of chronic disease, only 3% of health care expenditures have been spent on preventive services while the costs of managing chronic disease continue to escalate. The ACA is the most consequential and comprehensive health care reform enacted since Medicare. The ACA has gained a net increase in the number of individuals with insurance, primarily through Medicaid expansion. The reduction in costs is an arguable achievement, while quality of care has seemingly not improved. Finally, access seems to have diminished.This review attempts to bring clarity to the discussion by reviewing the ACA’s impact on affordability, cost containment and quality of care. We will discuss these aspects of the ACA from the perspective of proponents, opponents, and a pragmatic point of view. Key words: Affordable Care Act (ACA), Obamacare, Medicare, Medicaid, Medicare Modernization Act (MMA), cost of health care, quality of health care, Merit-Based Incentive Payments System (MIPS)

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“…reform health care in the United States have sought to modify the delivery of care in the U.S. (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). Among the many modalities utilized in managing chronic low back pain, interventional techniques and complex surgical interventions take center stage, seemingly despite the utilization of multiple other modalities, most notably extensive use of opioids (1,2,(20)(21)(22)(23)(24)(25)(26)(27)(28)(29).…”

mentioning

confidence: 99%

Usage Patterns of Sacroiliac Joint Injections - A Comparative Evaluation of Pre and Post Affordable Care Act in Medicare Population

Manchikanti¹

2018

PMCR

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Background: The sacroiliac joints (SIJ) have been implicated as highly prevalent, pervasive, expensive, causes of chronic low back pain. The utilization of SIJ injections is escalating. A recent analysis demonstrated a reversal of growth of utilization patterns of interventional techniques post passage of the Affordable Care Act (ACA). Bearing that in mind, SIJ injections along with facet joint interventions seem to have increased modestly in that same period. Study Design: Analysis of growth patterns of SIJ injections from 2000 to 2016 with comparative analysis of pre- and post- ACA. Objectives: To assess utilization patterns of SIJ injections from 2000 to 2016. Methods: The Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) Master dataset was utilized in this analysis. Results: The results of the evaluation from 2000 to 2016 showed, 11.7% increase from 2009 to 2016, with an annual increase of 1.6% per 100,000 Medicare population compared to an increase of 299.8% from 2000 to 2009 with annual increase of 16.6%. Limitations: The limitations of this study included a lack of inclusion of Medicare Advantage patients and the possibility that state claims data may include claims from other states. As with all claims based data analyses, this study is retrospective and thus potentially limited by bias. Finally, patients who are self or commercially insured are not part of the dataset. Conclusions: Study shows dampened increase in utilization patterns of SIJ injections from 2009 to 2016 as compared with a like time period prior. Key words: Chronic spinal pain, low back pain, sacroiliac joint arthritis, interventional techniques, interventional pain management, sacroiliac joint injections

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The Future of US Health Care Policy

Cited by 9 publications

References 12 publications

Cost Calculation Methodology Exacerbates Site-of-Service Differentials by 10- to 18-Fold for Soft Tissue and Joint Injections in Hospital Outpatient Departments

Cost Calculation Methodology Exacerbates Site-of-Service Differentials by 10- to 18-Fold for Soft Tissue and Joint Injections in Hospital Outpatient Departments

A Critical Analysis of Obamacare: Affordable Care or Insurance for Many and Coverage for Few?

Usage Patterns of Sacroiliac Joint Injections - A Comparative Evaluation of Pre and Post Affordable Care Act in Medicare Population

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