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Results for “reimbursement policy”

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At least 19 recordsLinked to original sources
PubMedDate not supplied

Medicare-Medicaid reimbursement policies: report of a study conducted by the Institute of Medicine.

On contract with the Social Security Administration, a special steering committee of the institute of Medicine was appointed to (1) study and report on equitable methods of reimbursement for physician's services under Titles 18 and 19 in teaching hospitals; (2) determine to what extent funds from the act are supporting training in specialties in excess supply; (3) determine how funds could be expended to support a more rational distribution of physician manpower both geographically and by specialty; (4) determine the extent these federal funds are being used to encourage teaching programs attracting disproportionate numbers of foreign medical graduates; and (5) determine the extent to which these funds are expended to meet the salaries of interns and residents. Ninety-six hospitals were field studied and 1,400 hospitals studied by questionnaire. These studies have now been completed and reports forwarded to Congress, the Health, Education and Welfare Department (HEW), and the Social Security Administration.

Fees, Medical↗
PubMed2024

Cost-effectiveness of population-wide genomic screening for Lynch Syndrome and polygenic risk scores to inform colorectal cancer screening.

PURPOSE: Genomic screening to identify individuals with Lynch Syndrome (LS) and those with a high polygenic risk score (PRS) promises to personalize colorectal cancer (CRC) screening. Understanding its clinical and economic impact is needed to inform screening guidelines and reimbursement policies. METHODS: We developed a Markov model to simulate individuals over a lifetime. We compared LS+PRS genomic screening with standard of care (SOC) for a cohort of US adults at age 30. The Markov model included health states of no CRC, CRC stages (A-D), and death. We estimated incidence, mortality, and discounted economic outcomes of the population under different interventions. RESULTS: Screening 1000 individuals for LS+PRS resulted in 1.36 fewer CRC cases and 0.65 fewer deaths compared with SOC. The incremental cost-effectiveness ratio was $124,415 per quality-adjusted life year; screening had a 69% probability of being cost-effective using a willingness-to-pay threshold of $150,000/quality-adjusted life year . Setting the PRS threshold at the 90th percentile of the LS+PRS screening program to define individuals at high risk was most likely to be cost-effective compared with 95th, 85th, and 80th percentiles. CONCLUSION: Population-level LS+PRS screening is marginally cost-effective, and a threshold of 90th percentile is more likely to be cost-effective than other thresholds.

Humans↗
PubMed2026

Costs of surgeries in low- and middle-income countries: a systematic literature review.

BACKGROUND: Surgical care is essential for achieving global health equity, yet low- and middle-income countries (LMICs) face major gaps in access and planning, partly due to limited evidence on the costs and resource requirements of surgical interventions. Understanding these costs is vital for designing efficient and equitable health systems. METHODS: We conducted a systematic literature review (covering MEDLINE, EMBASE, Global Health, EconLit and grey literature) to identify studies reporting the costs of surgeries in LMICs from January 2000 to June 2023. Minor and major surgical procedures were considered, focusing on therapeutic procedures (excluding diagnostic interventions). Studies that clearly identified, quantified and costed hospital resources and services deployed in the provision of surgical care, and included at least two of the surgical production factors (ie, consumables, diagnostics, personnel, infrastructure and overhead) in the costing were included. Costs were standardised to 2023 International dollars (I$) for comparability. RESULTS: A total of 74 studies from 29 countries met the inclusion criteria, with 210 cost estimates across 65 procedure groups. Costs varied widely: from I$1.54 for a caesarean section in Tanzania to I$618 098 for paediatric cataract surgery in Zambia. Full costing studies reported higher estimates than partial costing studies. Most studies (60%) originated from upper-middle-income countries, with limited data (10%) from low-income settings. CONCLUSION: This review provides a reference list of surgical procedure costs across LMICs, highlighting considerable cost variation by procedure, specialty and country. The findings underscore the need for better-quality, standardised cost data-especially from low-income countries-to inform national surgical plans, universal health coverage benefit packages and reimbursement policies.

Developing Countries↗
PubMed1978

How will dental education adapt to the third-party payment system?

An increasing number of dental patients will contract for and pay a third party to assume the fiscal responsibility for their dental care. Dental schools, through faculty and students, regularly provide the most carefully monitored, high quality dental services. Dental schools must continue to provide these services in the most "deinstitutionalized" and personalized manner possible. Third parties, whether commercial or governmental, must assure their clients (dental patients) of comprehensive dental coverage and reimbursement policies that are realistic, equitable, and based only upon receiving quality coverage. The quality of the dental educational system is essential to the success of any dental health care program.

Dental Care↗
PubMed2026

Availability and public reimbursement of early breast cancer care across European expert centres: a PORTRAIT from an EUSOMA initiative.

BACKGROUND: Cross-country disparities in access to guideline-recommended early breast cancer care persist across Europe. PORTRAIT is a clinician-reported, cross-sectional access study mapping availability and state reimbursement of key services across the early breast cancer pathway. METHODS: A 49-item survey covering diagnostics, pathology and genomics, systemic therapy, surgery, radiotherapy, and supportive care was emailed from June to September 2024 to multidisciplinary teams at one expert breast centre in 42 European countries. Respondents provided a consensus perspective on service availability and reimbursement. Descriptive proportions with full, partial, or no access were calculated. RESULTS: Thirty-nine countries responded (93%). Core diagnostics were widely available, but gaps persisted: MRI-guided biopsy was absent in 29% of countries and vacuum-assisted biopsy was fully reimbursed in 66%. Genomic assays were unavailable in 14% and not fully reimbursed in 35%. Public funding gaps were reported for PARP inhibitors (33%) and CDK4/6 inhibitors (26%). Immediate implant-based reconstruction and biological meshes lacked reimbursement in 21% and 33%, respectively. Despite broad availability of hypofractionated radiotherapy, 38% of countries still used per-fraction reimbursement. Psycho-oncology was limited in 35%, fertility preservation in 46%, and patient-reported outcome measures absent in 43%. CONCLUSION: Basic services are nearly universal, but gaps persist in advanced imaging, molecular testing, targeted therapies, radiotherapy reimbursement, reconstructive/oncoplastic surgery, and survivorship care. PORTRAIT identifies practical targets for policy audit, reimbursement alignment, and resource stewardship. Findings reflect clinician perspectives from expert centres, potentially representing best specialist care rather than average national care, and are not population-representative estimates or direct measures of patient outcomes.

Humans↗
PubMed2026

Financing and health system capacity for precision medicine in Asia: a six country landscape analysis.

BACKGROUND: Precision medicine (PM) adoption is accelerating across Asia, but implementation remains uneven due to differences in financing, infrastructure, governance, and health-system readiness. OBJECTIVES: To examine how six Asian countries (Singapore, South Korea, China, Malaysia, Thailand, and Indonesia) adopt, finance, and integrate PM technologies, and identify common implementation patterns and challenges. METHODS: A landscape review of peer-reviewed literature, government publications, and HTA reports (2010-2026) was conducted, supplemented by stakeholder consultations. PM applications were grouped into public health screening (hereditary breast and ovarian cancer [HBOC] and familial hypercholesterolemia [FH] cascade testing), next-generation sequencing (NGS) applications (rare diseases, oncology, pharmacogenomics), and AI-enabled PM. Evidence was synthesized across access, awareness, reimbursement, and implementation. RESULTS: Public health genomic screening demonstrated the highest implementation readiness, followed by precision oncology, while rare disease diagnostics remained infrastructure-dependent and pharmacogenomics and AI-enabled PM platforms were at earlier stages. Four readiness profiles emerged: highly aligned systems; reimbursement-constrained systems with strong governance and infrastructure; systems strengthening governance, public financing and infrastructure; and strategy-led systems expanding implementation through pilot programs and referral centers. CONCLUSIONS: PM implementation across Asia remains heterogeneous. The identified readiness profiles highlight governance, financing, and infrastructure priorities for sustainable and equitable PM diffusion.

Asia↗
PubMed2026

Pricing Combination Therapies: A Systematic Review of Value Attribution, Cost-Sharing Mechanisms and Policy Frameworks.

BACKGROUND: Combination therapies are increasingly central to modern pharmacotherapy, particularly in oncology and other high-burden diseases. However, pharmaceutical pricing and reimbursement systems remain largely designed for single-product-single-indication interventions. When multiple patented medicines are used together, especially when owned by different manufacturers, conventional pricing frameworks may struggle to align prices with the value of the combination while preserving incentives for innovation and timely patient access. OBJECTIVE: To identify, describe, and critically assess the methods, models, and policy frameworks proposed in the literature to establish prices for combination therapies, with particular attention to value attribution mechanisms, cost-sharing arrangements between manufacturers, and budget impact considerations. METHODS: A systematic literature review was conducted in accordance with PRISMA guidelines and a pre-registered Open Science Framework protocol. Searches were performed in MEDLINE, Scopus, Web of Science, EconLit, CRD databases, and grey literature sources for publications up to July 2025. Eligible studies analysed pricing approaches, economic models, reimbursement mechanisms, or policy frameworks relevant to combination therapies, including more recent multi-indication pricing literature. Given the heterogeneity of the literature, findings were synthesized using a structured narrative and thematic approach. RESULTS: Sixty-nine studies met the inclusion criteria. The literature was dominated by conceptual and policy analyses, with relatively few empirical or implementation-oriented studies. Value attribution emerged as the central methodological challenge in pricing combination therapies. Several complementary approaches were proposed to operationalise value attribution, including adaptations of indication- or pathway-based pricing, manufacturer cost-sharing arrangements, managed entry agreements, and outcome-based reimbursement mechanisms. Empirical evidence suggests that health systems continue to rely primarily on pragmatic and often partial solutions rather than fully specified pricing frameworks. A complementary review of the multi-indication pricing literature indicates that, although the two fields address different pricing problems, they share important methodological and institutional lessons that can inform the development of pricing frameworks for combination therapies. CONCLUSIONS: The literature provides a growing repertoire of conceptual approaches for pricing combination therapies but limited empirical evidence on implementation. Pricing frameworks should place value attribution at their core while combining complementary policy mechanisms adapted to national pricing and reimbursement systems. Lessons from multi-indication pricing provide a valuable foundation but require additional governance mechanisms to address value attribution, multi-manufacturer negotiation, and implementation challenges specific to combination therapies.

Journal Article↗
PubMed1978

Physician participation in state Medicaid programs.

Medicaid requires that physicians who accept Medicaid reimbursement for treating a patient agree to accept its payment as payment in full. Policy instruments under Medicaid's control are both levels of reimbursement and various administrative burdens imposed on physicians by the program. A model depicting the physician's participation decision is developed, and predictions from the comparative statics analysis are discussed. Data came from a 1975--76 survey of fee-for-service physicians. The results indicate that high fee schedules and low administrative burdens are ways to stimulate physician involvement with Medicaid patients. Results on the Medicaid policy instruments and other explanatory variables on the whole lend support to the model of physician behavior proposed earlier in the paper.

Economics, Medical↗
PubMed2025

Comparing the performance of exome and genome sequencing for rare disease diagnostics: A randomized implementation effectiveness trial.

PURPOSE: Exome sequencing (ES) and genome sequencing (GS) can improve rare disease diagnosis but are not routinely available in many jurisdictions. To inform implementation, we report on a randomized implementation effectiveness trial comparing ES and GS. METHODS: Eligible trios were randomized to receive ES or GS in the same clinically accredited laboratory. Patient-level data on diagnostic utility and turnaround times were collected. Outcomes were compared statistically between clinically important subgroups. RESULTS: Of 1048 patients, 68.5% had syndromic intellectual disability/developmental delay (ID/DD) and 20.5% had multisystem disorders without ID/DD. Most had prior genetic test(s) that were nondiagnostic (95.5%), and of these, 91.6% included chromosome microarray. Diagnostic yields were 33.8% and 33.6%, for ES (n = 526) and GS (n = 522), respectively. Within sequencing groups, diagnostic results were more frequent among those with ID/DD than those without (P < .005). For routine (ie, nonexpedited) patients (n = 1020), 87.0% were reported in <12 weeks, and the mean turnaround time was 55.5 days (SD: 24.0). Turnaround time for ES and GS did not differ; however, result type (P < .001) and age of onset (P < .005) significantly affected turnaround time. CONCLUSION: Findings provide robust evidence of diagnostic utility and timeliness of ES and GS and will inform policy related to the organization, delivery, and reimbursement of clinical-grade genome diagnostics for rare diseases.

Adolescent↗
PubMed1979

Substitution of outpatient care for inpatient care:problems and experience.

This paper provides a logical framework for considering possible alternatives to inpatient care. First it presents the concept of a substitute-complement relationship among factors of production (or goods and services in consumption) and examines several problems often encountered when applying this concept. Second, it presents four general sources of substitution: (1) technological innovation; (2) changes in organization; (3) capital accumulation; and (4) the dissemination of knowledge. Third, it examines nine activities which are frequently mentioned as providing alternatives to inpatient care. Fourth, it examines some problems and consequences of governmental efforts to plan substitution. The general thrust of the paper is that the substitution process is complex and often depends upon amorphous variables whose influences are subtle, generally nonquantifiable, and often of overriding importance. These variables introduce a downward bias in estimates of program costs and an upward bias in the estimates of program accomplishments. The result is that government attempts to plan substitution are not well conceived and will generally fall short of announced goals and/or cost significantly more than original estimates.

Ambulatory Care↗
PubMed1979

Cost of elective surgery and utilization of ancillary services in teaching hospitals.

Measures of surgical utilization studied are the number of elective tests performed preoperatively and the total cost per case. The unit of analysis is a matched pair of patients who underwent the same elective procedure, one a Veterans Administration patient, and the other a municipal or voluntary hospital patient. Federal ownership of the hospital ahd the strongest impact on tests and cost per case. On average, costs for the VA patients were 52 percent more per case. The foreign medical graduate variable had a large positive (inflationary) effect on the number of tests, but a slight downward influence in the cost regressions. The fraction of surgeons with faculty appointments had a strong negative (curtailing) impact on elective testing, but an upward influence on cost per case. Additional variables such as age, average laboratory turnaround time, and fraction of the medical school's students doing their surgical clerkship at the hospital ahd a slight upward influence on utilization. The three policy issues raised in the study involve changing the hospital reimbursement incentives, targeting continuing education programs to categories of staff that need it most, and redistributing faculty and students.

Cholecystectomy↗
PubMed1979

Bureau of Program Policy.

Explore the source record for details and available documents.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2026

Ten years on, still out of reach: barriers to PrEP access and retention in France according to frontline actors (QualiPrEP Study).

Pre-exposure prophylaxis (PrEP) for HIV has been available in France since 2014, and reimbursed since 2016, with general practitioners allowed to prescribe it since 2021. Despite these policy advances, uptake remains low among some of the most affected populations. This community-based qualitative study explored barriers to PrEP access and retention ten years into its implementation.Interviews were conducted with 28 PrEP frontline actors (healthcare professionals and community-based workers involved in promoting, prescribing, or supporting PrEP). The sample included one group discussion (n = 5), two triads (n = 6), two dyads (n = 4), and nine individual interviews (n = 13). Thematic analysis was inductive, with barriers classified across four main domains.Participants were mostly cisgender men, median age 48, born in France and abroad, and employed by NGOs in Paris. Thirteen barriers and four major themes emerged: (1) Internal psychosocial barriers: lack of knowledge, negative health-related reactions; HIV stigma; STI risk perception, taboos; (2) Internal pragmatic barriers: perceived limits of protection, usage and follow-up constraints; (3) External psychosocial barriers: limited physician knowledge and reluctance; (4) External pragmatic barriers: communication failures; structural constraints, lack of human and financial resources.Findings call for more targeted messaging, simplified care models and provider training. They highlight the need to address social and symbolic dimensions of PrEP, with insights from those supporting users to ensure more equitable implementation.

Humans↗
PubMed1979

Paying for physician services under Medicare and Medicaid.

Public systems for physician reimbursement aim to reconcile two disparate objectives: ensuring availability of services to the poor and aged; and keeping rates of cost increase within acceptable limits. Several interesting--and unorthodox--policy simulations of physician pricing behavior are investigated through econometric estimation. Current arrangement for paying physicians are fraught with difficulties. The objectives of Medicare and Medicaid are not well served.

Aged↗