Hannah Alphs Jackson

A surgeon's guide to bundled payment models for episodes of care

The Patient Protection and Affordable Care Act (Public Law 111-148) has created several provisions and programs that link payments to quality outcomes, including establishment of the Center for Medicare and Medicaid Innovation (CMMI), to support the development of innovative models that achieve the “triple aim” (better care for patients, better health for our communities, and lowering the per capita costs of health care).1 Both the executive and legislative branches of the US government have restated their commitment to expansion of value-based delivery (VBD), shifting from volumebased fee-for-service (FFS) to fee-for-value (FFV) models. In January 2015, the Department of Health and Human Services made a commitment to have 50% of all Medicare payments tied to quality or value through alternative payment models by 2018 and 90% of all remaining Medicare FFS payments tied to value or quality.2 In March 2015, the House passed, with bipartisan support, the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015, which included a long-awaited fix to replace the sustainable growth rate formula. The Centers for Medicare and Medicaid Services Office of the Actuary notes that there are such favorable incentives for adoption of VBD models embedded in this legislation that by 2019, payments to physicians participating in alternative payment models would constitute 60% of Medicare physician spending with continued increases thereafter.3 As continued evidence of the federal commitment to VBD, in July 2015, the Centers for Medicare and Medicaid Services announced the launch of the Comprehensive Care for Joint Replacement, a mandatory orthopedic bundled payment program proposed for 75 geographic areas defined by metropolitan statistical areas.4 The commitment to VBD models is not limited to Medicare. Both state Medicaid programs and the commercial payer industry, including self-insured employers, have also engaged in payment reform strategies that include a variety of value-based constructs.

Data Mining Derived Treatment Algorithms From the Electronic Medical Record Improve Theoretical Empirical Therapy for Outpatient Urinary Tract Infections

PURPOSE We determined whether data mining derived algorithms from electronic databases can improve empirical antimicrobial therapy in outpatients with a urinary tract infection. MATERIALS AND METHODS The electronic medical records from 3,308 visits associated with a positive urine culture at Northwesterns outpatient Urology and Internal Medicine clinics and Emergency Department from 2005 to 2009 were interrogated. Bacterial species and susceptibility rates for trimethoprim-sulfamethoxazole, ciprofloxacin and nitrofurantoin were compared. Using data mining techniques we created algorithms for empirical therapy of urinary tract infections and compared the theoretical outcomes from data mining derived therapy to those from conventional therapy. RESULTS Patients were significantly older in the Department of Urology vs Internal Medicine vs Emergency Department, and more patients in the Department of Urology were male. During the 5-year period the susceptibility rates for ciprofloxacin in the Department of Urology and trimethoprim-sulfamethoxazole in Internal Medicine decreased significantly. In the Department of Urology the susceptibility rate for nitrofurantoin was greater than for ciprofloxacin, which was greater than for trimethoprim-sulfamethoxazole. In all departments, bacteria were more resistant to trimethoprim-sulfamethoxazole than to ciprofloxacin or nitrofurantoin. All drugs were more effective in the Emergency Department and Internal Medicine than the Department of Urology. Prior resistance patterns were the strongest predictor of current susceptibility profiles. In the Department of Urology the algorithms for patients with or without prior cultures theoretically outperformed conventional therapy in men (13.2%) and women (10.1%). CONCLUSIONS Antimicrobial resistance patterns in outpatient urinary tract infections are time dependent, and drug and site specific. Data mining directed therapy significantly improved theoretical outcomes compared to conventional therapy for Department of Urology outpatients and for female patients in the Emergency Department.

Intricacies of Transplant Physician/Surgeon Coding, Billing, and Reimbursement

While the principles of coding, billing, and reimbursement for transplant physicians and surgeons bear significant overlap with those of all other surgical disciplines, there are sufficient differences to warrant additional comment. More specifically, congressionally mandated regulatory oversight requirements based on the National Transplant Organ Act (NOTA, 1984) that governs transplant practice in the United States have inherently resulted in unique reimbursement methodologies for transplant hospitals that have in turn created a number of mechanisms by which physicians and surgeons can bill and be reimbursed that fall outside standard E&M and CPT coding, billing, and reimbursement constructs. These relate primarily to Medicare patients, but commercial payers, for over two decades, have also instituted different care delivery and reimbursement models consisting of bundled services and payments for transplantation that differ significantly from standard models used in other healthcare disciplines.