Retrospective Analysis and Forecasted Economic Impact of a Virtual Cardiac Rehabilitation Program in a Third-Party Payer Environment

Background: Participation in cardiac rehabilitation (CR) is recommended for all patients with coronary artery disease (CAD) following hospitalization for acute coronary syndrome or stenting. Yet, few patients participate due to the inconvenience and high cost of attending a facility-based program, factors which have been magnified during the ongoing COVID pandemic. Based on a retrospective analysis of CR utilization and cost in a third-party payer environment, we forecasted the potential clinical and economic benefits of delivering a home-based, virtual CR program, with the goal of guiding future implementation efforts to expand CR access.Methods: We performed a retrospective cohort study using insurance claims data from a large, third-party payer in the state of Pennsylvania. Primary diagnostic and procedural codes were used to identify patients admitted for CAD between October 1, 2016, and September 30, 2018. Rates of enrollment in facility-based CR, as well as all-cause and cardiovascular hospital readmission and associated costs, were calculated during the 12-months following discharge.Results: Only 37% of the 7,264 identified eligible insured patients enrolled in a facility-based CR program within 12 months, incurring a mean delivery cost of $2,922 per participating patient. The 12-month all-cause readmission rate among these patients was 24%, compared to 31% among patients who did not participate in CR. Furthermore, among those readmitted, CR patients were readmitted less frequently than non-CR patients within this time period. The average per-patient cost from hospital readmissions was $30,814 per annum. Based on these trends, we forecasted that adoption of virtual CR among patients who previously declined CR would result in an annual cost savings between $1 and $9 million in the third-party healthcare system from a combination of increased overall CR enrollment and fewer hospital readmissions among new HBCR participants.Conclusions: Among insured patients eligible for CR in a third-party payer environment, implementation of a home-based virtual CR program is forecasted to yield significant cost savings through a combination of increased CR participation and a consequent reduction in downstream healthcare utilization.

U.S. budget impact (BI) model for selinexor, bortezomib, and dexamethasone (XVd) for the treatment of patients with previously treated multiple myeloma (MM).

e18839 Background: Despite advances in the treatment of MM, prognosis remains poor for most patients due to its refractory nature. In a phase 3 study, a once-per-week regimen of XVd showed a novel, effective, and convenient option for patients with previously treated MM. This study was conducted to estimate the projected budget impact (BI) of XVd in patients with previously treated MM from the perspective of a third-party payer and Medicare in the US. Methods: The introduction of XVd as a treatment option for patients with previously treated MM compared to the status quo (i.e. without the introduction of XVd) was considered from a private third-party US payer and a Medicare perspective in one-year increments for the first 3 years. The model assumed market uptake of 5.9%, 7.2%, and 7.7% at years 1, 2 and 3, respectively. Total annual treatment costs (2020 US dollars [USD]) were calculated as the sum of drug costs, the costs of treating serious treatment emergent adverse events (grade ≥3), ongoing best supportive care costs, and mortality costs. Results: In the base-case analysis for a private third-party payer plan (1,000,000 members), 3 to 4 patients were projected to receive XVd out of 47 to 49 eligible patients each year. The absolute BI (Millions, USD) of including XVd from a private third-party payer plan perspective was $0.06, $0.07, $0.08 and $0.22 for years 1, 2, 3, and overall, respectively. The relative BI of including XVd was 0.33%, 0.40%, 0.43%, and 0.38% for years 1, 2, 3, and overall, respectively. This translated to a per member per month (PMPM) budget impact of $0.005, $0.006, $0.007, and $0.006 (USD), for years 1, 2, 3, and overall, respectively. In the base-case analysis from the Medicare perspective (59,499,015 members), 1,361 to 1,808 patients were projected to receive XVd out of 22,892 to 23,425 eligible patients each year. From a Medicare perspective, the absolute BI (Millions, USD) of including XVd was $29.68, $36.62, $39.42 and $105.72 for years 1, 2, 3, and overall, respectively. The relative BI of including XVd was 0.33%, 0.40%, 0.43%, and 0.38% percent for years 1, 2, 3, and overall, respectively. This translated to a PMPM budget impact of $0.041, $0.051, $0.054, and $0.049 (USD), for years 1, 2, 3, and overall, respectively. One-way sensitivity analyses showed general consistency with the base-case findings. Conclusions: Understanding the potential BI of new therapies in MM is vital for decision makers to manage spending and assess the value of treatments. The introduction of XVd presents a small and manageable BI for a third-party US payer and Medicare.

AB0810 COST-EFFECTIVENESS ANALYSIS OF THE CLINICAL APPROACH FOR RA PATIENTS IN THE EARLY PHASE VERSUS THOSE IN THE ESTABLISHED PHASE FROM A FOURTH-LEVEL HEALTH SERVICE PROVIDER INSTITUTION IN COLOMBIA

Background:Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease that without treatment causes disability, pain, quality of life impairment, and premature mortality. It causes significant economic repercussions on patients, their families, and the health system. The costs of RA for Sanitary Systems are described in terms of medications and hospitalization. Also, the cost of treatment for patients whose disease was not adequately controlled from an early stage may involve joint replacement surgery and prolonged hospitalizations.Objectives:To determine and analyze the cost-effectiveness of the clinical approach to rheumatoid arthritis in a cohort of patients in the early phase versus a cohort of patients in the established phase from a fourth-level Health Service Provider Institution in Colombia, from the perspective of the third-party payer with a time horizon of six-months.Methods:An economic evaluation of the cost-effectiveness of the clinical approach was carried out in the early phase versus the established phase in a cohort of patients from May 2013 until December 2018, with rheumatoid arthritis from a fourth-level Health Service Provider Institution in Colombia, from the perspective of the third-party payer with a time horizon of six-months. The costs and effectiveness of each of the phases were estimated. A decision tree model was created, and the incremental cost-effectiveness ratio was calculated. The deterministic and probabilistic sensitivity analysis was performed.Results:The early phase clinical approach for patients with rheumatoid arthritis represents savings of approximately 600 USD per patient in remission or low disease activity level in the first 6 months of follow-up from the perspective of the third-party payer.Conclusion:The clinical approach to rheumatoid arthritis in the early phase is a less costly and more effective alternative versus established phase and generates savings for the third-party payer with a time horizon of six-months.Figure 1.Acceptability curveDisclosure of Interests:None declared

Third-party Reimbursement of Pharmacist-Led Cardiovascular and Diabetes Preventive Health Services for Workplace Health Initiatives: A Narrative Systematic Review

Objective: To summarize available literature describing third-party payer reimbursement models for pharmacist-led preventive health services as part of workplace health initiatives. Methods: A combination of search terms related to pharmacists, preventive health, and third-party reimbursement were searched in MEDLINE, EMBASE, and PubMed. Included studies described community pharmacist-led cardiovascular and diabetes preventive health service to employees older than 18 years of age as part of a workplace health program with corresponding third-party reimbursement models. Programs that were reimbursed by government resources or studies lacking reimbursement model details were excluded. One reviewer performed level 1 screening and three reviewers analyzed included studies. Results: The search criteria yielded 863 results. Sixteen articles were reviewed after level 1 screening and 13 were ineligible and excluded. Three studies with varying quality of reporting were included. Reimbursement models varied from $40 USD for a 20-minute visit to $391 to $552 USD total per patient with an average of 6 visits per patient. Conclusion: There is a lack of quality literature describing third-party reimbursement models for pharmacist-led preventive health services, which hinders the ability to implement a standardized model. High quality studies evaluating the cost of reimbursing pharmacist-led cardiovascular preventive health services compared to the savings to the third-party payer should be performed to inform the standardization of payment models.

‘If he dies with the papers of his brother, his brother will be considered dead’. Moral understandings of health professionals about the use of deception to overcome restrictions in access to healthcare

Although scholars in bioethics usually consider the exclusion of migrants from basic healthcare as unjust, it remains unclear how health professionals should ethically deal with policies restricting access to healthcare for undocumented migrants. Debates on offering less than the most beneficial healthcare have been limited to contributions on ethical bedside rationing. This article draws on semi-structured in-depth interviews that explore health professional’s acceptance, as well as their willingness to resort to the use of deception to secure third-party payer approval for undocumented migrants. The results show that health professionals (1) are sceptical about both the possibility and desirability of verifying whether a patient’s declarations are deceitful in the setting of a consultation, but (2) are reluctant to use deception themselves to circumvent government policies restricting access to healthcare for undocumented migrants. We discuss how this approach of ‘relative impartiality’ threatens professional autonomy and conclude that professional associations should play a much more important role in supporting health professionals in relation to healthcare institutions and governments when their members are confronted with specific rationing practices forcing them to provide suboptimal healthcare.

A Guide to Coding and Billing for the Audiological Management of Patients Receiving Ototoxic Medical Treatments

Purpose Improved medical care leading to increased survivorship among patients with cancer and infectious diseases has created a need for ototoxicity monitoring programs nationwide. The goal of this report is to promote effective and standardized coding and 3rd-party payer billing practices for the audiological management of symptomatic ototoxicity. Method The approach was to compile the relevant International Classification of Diseases, 10th Revision (ICD-10-CM) codes and Current Procedural Terminology (CPT; American Medical Association) codes and explain their use for obtaining reimbursement from Medicare, Medicaid, and private insurance. Results Each claim submitted to a payer for reimbursement of ototoxicity monitoring must include both ICD-10-CM codes to report the patient's diagnosis and CPT codes to report the services provided by the audiologist. Results address the general 3rd-party payer guidelines for ototoxicity monitoring and ICD-10-CM and CPT coding principles and provide illustrative examples. There is no “stand-alone” CPT code for high-frequency audiometry, an important test for ototoxicity monitoring. The current method of adding a –22 modifier to a standard audiometry code and then submitting a letter rationalizing why the test was done has inconsistent outcomes and is time intensive for the clinician. Similarly, some clinicians report difficulty getting reimbursed for detailed otoacoustic emissions testing in the context of ototoxicity monitoring. Conclusions Ethical practice, not reimbursement, must guide clinical practice. However, appropriate billing and coding resulting in 3rd-party reimbursement for audiology services rendered is critical for maintaining an effective ototoxicity monitoring program. Many 3rd-party payers reimburse for these services. For any CPT code, payment patterns vary widely within and across 3rd-party payers. Standardizing coding and billing practices as well as advocacy including letters from audiology national organizations may be necessary to help resolve these issues of coding and coverage in order to support best practice recommendations for ototoxicity monitoring.