Payment Systems for Telemedicine: Comparative Study (Preprint)

BACKGROUND Many researchers have addressed the lack of reimbursement for telemedicine as one of the most important barriers to telemedicine adoption. However, little is known on how telemedicine should be implemented in reimbursement policy, how it must be financed, and what the right incentives are for an effective and efficient telemedicine use. OBJECTIVE To help future researchers to provide reimbursement policy recommendations, and to facilitate reimbursement decision-making, this paper analyzed and compared the telemedicine payment models of ten countries. METHODS A convenience sample was created of Western countries inside and outside Europe that already reimburse to some extent telemedicine. Ten countries met this criterion: Australia, Belgium, Denmark, France, Germany, Luxembourg, the Netherlands, Canada (Ontario province), Switzerland, and the United Kingdom. The study was based on the countries’ official physician fee schedules, listing all reimbursed medical services performed by physicians, including telemedicine. Based on the fee schedules, a comparative analysis of the payment models of telemedicine was conducted. RESULTS Televisits are reimbursed in all countries, which is not the case for telemonitoring and tele-expertise services. Telemonitoring is often restricted for patients with implanted cardiac devices. Telemedicine services are mainly paid fee-for-service, except for the telemonitoring of patients with implanted cardiac devices, which is paid through an episodic payment system in Australia. Payment parity exists across televisits and visits in person in France, Luxembourg, the Netherlands, and Switzerland, meaning that an equal fee is given for both services. CONCLUSIONS Our findings show that fees for telemedicine are lacking, especially for telemonitoring and tele-expertise. As telemedicine might enlarge disparities in healthcare access, policymakers should consider payment parity across televisits and face-to-face visits, and across telephone and video visits. Furthermore, an episodic physician payment system complemented with bonuses for quality outcomes, should be considered by policymakers for telemonitoring as it might capture the specificities of telemonitoring better than a fee-for-service system. Future research is needed on payment models, including research linking cost-effectiveness analyses with analyses on payment models, to allow profound reimbursement recommendations and a faster decision-making process for the reimbursement of telemedicine.

Clinical Ambiguity and Conflicts of Interest in Interventional Cardiology Decision Making

Problem definition: Among the most vexing issues in the U.S. healthcare ecosystem is inappropriate use of percutaneous coronary intervention (PCI) procedures, also known as overstenting. A key driver of overstenting is physician subjectivity in eyeballing a coronary angiogram. Advanced tests such as fractional flow reserve (FFR) provide more precise and objective measures of PCI appropriateness, yet the decision to perform these tests is endogenous and not immune to clinical ambiguity associated with eyeballing. Additionally, conflicts of interest, arising from revenue-generating incentives, play a role in overstenting. Academic/practical relevance: Conventional wisdom suggests more precise diagnostic testing will help reduce overtreatment. However, the literature rarely recognizes that the testing decision is itself endogenous. Our research highlights the role of endogeneity surrounding interventional cardiology decision making. Methodology: This study uses stochastic modeling and simulation. Results: Under a low conflict-of-interest level, the physician performs the advanced test for intermediate lesions. Under a high conflict-of-interest level, however, the physician would perform the advanced test only for high-grade lesions, because of a financial disincentive: Performing the advanced test may lower PCI revenue if the test results argue against the procedure. Surprisingly, despite this disincentive, a more revenue-driven physician can be more inclined to perform the advanced test. Managerial implications: Our model leads to implications for various efforts aimed at tackling overstenting: (1) Attention should be paid not only to the sheer quantity of FFR procedures but to which patients receive FFR procedures; (2) reducing the risk of the advanced test has a behavior-inducing effect, yet a modest risk reduction may lower patient welfare; and (3) offering a bonus to the physician for performing FFR procedures equal to a third of its reimbursement rate will cause only a 5% increase in average physician payment while inducing a 26% decline in overstenting. In addition, we show implementing a bundled payment scheme may discourage the use of FFR procedures and lead to more salient overstenting.

Adoption of a laboratory EMR system and inappropriate laboratory testing in Ontario: a cross-sectional observational study

Background Electronic medical record (EMR) systems have the potential to facilitate appropriate laboratory testing. We examined three common medical tests in primary care—hemoglobin A1c (HbA1c), lipid, and thyroid stimulating hormone (TSH)— to assess whether adoption of a laboratory EMR system in Ontario had an impact on the rate of inappropriate testing among primary care physicians. Methods We used FY2016–17 population-level laboratory data to estimate the association between adoption of a laboratory EMR system and the rate of inappropriate testing. Inappropriate testing was assessed based on recommendations for screening, monitoring, and follow-up that take into account risk factors related to patient age and certain clinical conditions. To overcome the problem of potential endogeneity of physician choice to use the EMR, the EMR penetration rate in the physician’s geographical area of practice was used as an instrumental variable in an ordinary least squares (OLS) regression. We then simulated the change in the rate of inappropriate testing, by physician payment model, as the EMR penetration rate increased from the baseline percentage. Results The simulation models showed that an increase in the rate of EMR penetration from a baseline average was associated with a statistically significant decrease in inappropriate hbA1c and lipid testing, but a statistically insignificant increase in inappropriate TSH testing. The impact of EMR penetration also varied by payment model. Conclusions This study demonstrated a positive association between availability of an EMR system and appropriate service utilization. Varying impacts of the EMR system availability by primary care payment model may be reflective of different incentives or attributes inherent in payment models. Policies to encourage physicians to increase their use of laboratory EMR systems could improve the quality and continuity of patient care.

Industry Payments to Plastic Surgeons: What Has Changed Over the Last Six-Years Following Implementation of the Physician Payment Sunshine Act?

Background The Open Payments Program, as designated by the Physician Payments Sunshine Act is the single largest repository of industry payments made to licensed physicians within the United States. Though sizeable in its dataset, the database and user interface are limited in their ability to permit expansive data interpretation and summarization. Objectives We sought to comprehensively compare industry payments made to plastic surgeons with payments made to all surgeons and all physicians to elucidate industry relationships since implementation. Methods The Open Payments Database was queried between 2014 and 2019, and inclusion criteria were applied. These data were evaluated in aggregate and for yearly totals, payment type, and geographic distribution. Results 61,000,728 unique payments totaling $11,815,248,549 were identified over the six-year study period. 9,089 plastic surgeons, 121,151 surgeons, and 796,260 total physicians received these payments. Plastic surgeons annually received significantly less payment than all surgeons (p=0.0005). However, plastic surgeons did not receive significantly more payment than all physicians (p = 0.0840). Cash and cash equivalents proved to be the most common form of payment; Stock and stock options were least commonly transferred. Plastic surgeons in Tennessee received the most in payments between 2014-2019 (mean $ 76,420.75). California had the greatest number of plastic surgeons to receive payments (1,452 surgeons). Conclusions Plastic surgeons received more in industry payments than the average of all physicians but received less than all surgeons. The most common payment was cash transactions. Over the past six years, geographic trends in industry payments have remained stable.