Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items; Update to the Master List of Items Frequently Subject to Unnecessary Utilization. Master list deletions.

This document announces the deletion of four Healthcare Common Procedure Coding System (HCPCS) codes from the Master List of Items Frequently Subject to Unnecessary Utilization that could be potentially subject to Prior Authorization as a condition of payment.

Caesarean section rate and cost control effectiveness of case payment reform in the new cooperative medical scheme for delivery: evidence from Xi County, China.

BACKGROUND: In China, increases in both the caesarean section (CS) rates and delivery costs have raised questions regarding the reform of the medical insurance payment system. Case payment is useful for regulating the behaviour of health providers and for controlling the CS rates and excessive increases in medical expenses. New Cooperative Medical Scheme (NCMS) agencies in Xi County in Henan Province piloted a case payment reform (CPR) in delivery for inpatients. We aimed to observe the changes in the CS rates, compare the changes in delivery-related variables, and identify variables related to delivery costs before and after the CPR in Xi County. METHODS: Overall, 28,314 cases were selected from the Xi County NCMS agency from 2009 to 2010 and from 2014 to 2015. One-way ANOVA and chi-square tests were used to compare the distributions of CS and vaginal delivery (VD) before and after the CPR under different indicators. We applied multivariate linear regressions for the total medical cost of the VD and CS groups and total samples to identify the relationships between medical expenses and variables. RESULTS: The CS rates in Xi County increased from 26.1% to 32.5% after the CPR. The length of stay (LOS), total medical cost, and proportion of county hospitals increased in the CS and VD groups after the CPR, which had significant differences. The total medical cost in the CS and VD groups as well as the total samples was significantly influenced by inpatient age, LOS, and hospital type, and had a significant correlation with the CPR in the VD group and the total samples. CONCLUSION: The CPR might fail to control the growth of unreasonable medical expenses and regulate the behaviour of providers, which possibly resulted from the unreasonable compensation standard of case payments, prolonged LOS, and the increasing proportion of county hospitals. The NCMS should modify the case payment standard of delivery to inhibit providers' motivation to render CS services. The LOS should be controlled by implementing clinical guidelines, and a reference system should be established to guide patients in choosing reasonable hospitals.

[Prescribed drugs - a new crime field?]. / Drogenersatzmittel - Ein Neues Kriminalitatsfeld?

The first chapter of the following article discusses measures in terms of substitution treatment of a program of the Austrian Minister of the Interior. The relevance of psychosocial measures and aims of substitution treatment for opioid-dependent patients is illuminated. The abstinence as the only goal definition is modified and by the results of the study PREMOS a target differentiation at addiction work is illustrated. The second chapter addresses the misuse of prescribed drugs. Thereby police report data will be analyzed and the market situation of opioids will be outlined.

Ten common questions (and their answers) on medical futility.

The term medical futility is frequently used when discussing complex clinical scenarios and throughout the medical, legal, and ethics literature. However, we propose that health care professionals and others often use this term inaccurately and imprecisely, without fully appreciating the powerful, often visceral, response that the term can evoke. This article introduces and answers 10 common questions regarding medical futility in an effort to define, clarify, and explore the implications of the term. We discuss multiple domains related to futility, including the biological, ethical, legal, societal, and financial considerations that have a bearing on definitions and actions. Finally, we encourage empathetic communication among clinicians, patients, and families and emphasize how dialogue that seeks an understanding of multiple points of view is critically important in preventing or attenuating conflict among the involved parties.

[Rationalization and rationing at the bedside. A normative and empirical status quo analysis]. / Rationalisierung und Rationierung am Krankenbett. Normativ-empirische Analyse zum Status quo.

BACKGROUND: The topic of bedside rationing is increasingly discussed in Germany. Further need for clarification exists for the question how bedside rationing (e.g., in the area of overcare) can be justified despite coexistent inefficiencies. DISCUSSION: This paper outlines and analyses the relationship of waste avoidance and rationing from an ethical perspective. Empirical findings regarding the status quo of bedside rationing and rationalization are presented. These normative and empirical explorations will then be further specified regarding opportunities for future physician-driven activities to tackle overuse. CONCLUSION: The self-government partners in Germany should communicate more explicitly within their communities and to the public how and with which benchmarks they aim to reduce inefficient health care (overuse) in an appropriate manner. Physician-driven activities such as the "Choosing Wisely®" initiative in the USA could provide a first step to raise the awareness for overuse among physicians as well as in the public.

La gestión de la responsabilidad profesional médica desde el colectivo de la profesión médica y enfocada a la seguridad clínica / The management of medical professional liability from the medical profession and focused on clinical safety

El sistema de aseguramiento de responsabilidad profesional médica debe cubrir óptima y eficazmente posibles defectos de praxis, promover mejoras en seguridad clínica y contribuir a la prevención de la «malpractice crisis» descrita en otros países. Este artículo revisa el escenario del aseguramiento de la responsabilidad profesional médica y propone una gestión directa acorde a los principios y valores del colectivo médico. Esta gestión permite adoptar medidas beneficiosas como el análisis de datos, identificando áreas de riesgo y guiando actuaciones en seguridad clínica (guías de práctica clínica, programas de calidad…). Frente a modelos tradicionales, el modelo implementado en Cataluña, aplicable en otros entornos, logra mejoras innegables mediante una gestión enfocada a la buena praxis médica, siendo este el principal objetivo de los colegios oficiales de médicos. Garantiza una respuesta responsable a la sociedad ante los posibles defectos de praxis, desde la experiencia, excelencia y profesionalidad en la tramitación y defensa, el trato atento al facultativo, cubriendo de manera integral la asistencia y aprendiendo de los errores (AU)

The medical professional liability insurance system must cover optimally and effectively potential defects of medical praxis, promote improvements in clinical safety and help preventing the situation of «malpractice crisis» reported in abroad.We review the medical professional liability system and propose a direct management model, according to the principles and values of the medical community. It has advantages such as data analysis to identify risk areas and guide clinical safety actions (clinical-practice-guidelines, quality-programs…).Faced with traditional models, the model implemented in Catalonia, applicable in other settings, brings undeniable improvements achieved by focusing on good medical practice, which is the main objective of physicians colleges. This ensures an appropriate response to society in case of errors, based on experience, excellence and professionalism in handling and defense, caring for the involved physician, comprehensively covering assistance and learning from errors (AU)

[Quality of genetic services--analysis of medical genetic expert opinions solicited by private health insurance companies]. / Versorgungsqualität bei genetisch bedingten Erkrankungen - Sekundäranalyse humangenetischer Gutachten.

Service quality for patients with genetic conditions can be assessed through the analysis of clinical genetic data sets, as was the case in this study. It represents a secondary analysis of a compilation of a single genetic expert's medical opinions covering the years 2000 to 2009, solicited by private health insurance companies with the intention of probing into medical necessity and adequacy of genetic testing ordered by physicians. Genetic testing has become an increasingly important part of clinical diagnostic services. Controlling these services does not only reduce costs but also saves patients from unwarranted over-utilisation. Therefore, the reasons given by doctors when ordering genetic tests are part of the quality of service delivery. The study revealed that more than 30% of the molecular genetic tests ordered lack sound medical reasoning and 30% of the cases studied show violation or neglect of guidelines and recommendations for diagnostic procedures with respect to genetic testing. In essence, the findings indicate a need for human genetic information among physicians. Their professional organisations are called upon to design and offer CME/CPD programmes in medical genetics to maintain and continually improve the quality of medical genetic care for patients with genetic conditions.