Impact of Remote and Virtual Care Models on the Sustainability of Small Health Care Businesses: Perceptual Analysis of Small Clinics, Physician Offices, and Pharmacies in Colorado.

BACKGROUND: Lockdowns and shelter-in-place orders during COVID-19 have accelerated the adoption of remote and virtual care (RVC) models, potentially including telehealth, telemedicine, and internet-based electronic physician visits (e-visits) for remote consultation, diagnosis, and care, deterring small health care businesses including clinics, physician offices, and pharmacies from aligning resources and operations to new RVC realities. Current perceptions of small health care businesses toward remote care, particularly perceptions of whether RVC adoption will synergistically improve business sustainability, would highlight the pros and cons of rapidly adopting RVC technology among policy makers. OBJECTIVE: This study aimed to assess the perceptions of small health care businesses regarding the impact of RVC on their business sustainability during COVID-19, gauge their perceptions of their current levels of adoption of and satisfaction with RVC models and analyze how well that aligns with their perceptions of the current business scenario (SCBS), and determine whether these perceptions influence their view of their midterm sustainability (SUST). METHODS: We randomly sampled small clinics, physician offices, and pharmacies across Colorado and sought assistance from a consulting firm to collect survey data in July 2020. Focal estimated study effects were compared across the three groups of small businesses to draw several insights. RESULTS: In total, 270 respondents, including 82 clinics, 99 small physician offices, and 89 pharmacies, across Colorado were included. SRVC and SCBS had direct, significant, and positive effects on SUST. However, we investigated the effect of the interaction between SRVC and SCBS to determine whether RVC adoption aligns with their perceptions of the current business scenario and whether this interaction impacts their perception of business sustainability. Effects differed among the three groups. The interaction term SRVC×SCBS was significant and positive for clinics (P=.02), significant and negative for physician offices (P=.05), and not significant for pharmacies (P=.76). These variations indicate that while clinics positively perceived RVC alignment with the current business scenario, the opposite held true for small physician offices. CONCLUSIONS: As COVID-19 continues to spread worldwide and RVC adoption progresses rapidly, it is critical to understand the impact of RVC on small health care businesses and their perceptions of long-term survival. Small physician practices cannot harness RVC developments and, in contrast with clinics, consider it incompatible with business survival during and after COVID-19. If small health care firms cannot compete with RVC (or synergistically integrate RVC platforms into their current business practices) and eventually become nonoperational, the resulting damage to traditional health care services may be severe, particularly for critical care delivery and other important services that RVC cannot effectively replace. Our results have implications for public policy decisions such as incentive-aligned models, policy-initiated incentives, and payer-based strategies for improved alignment between RVC and existing models.

Healthcare costs for abortions performed in ambulatory surgery centers vs office-based settings.

BACKGROUND: Several states require that abortions be provided in ambulatory surgery centers. Supporters of such laws argue that they make abortions safer, yet previous studies have found no differences in abortion-related morbidities or adverse events for abortions performed in ambulatory surgery centers versus office-based settings. However, little is known about how costs of abortions provided in ambulatory surgery centers differ from those provided in office-based settings. OBJECTIVE: To compare healthcare expenditures for abortions performed in ambulatory surgery centers versus office-based settings using a large national private insurance claims database. MATERIALS AND METHODS: A retrospective cohort study compared expenditures for abortions performed in ambulatory surgery centers versus office-based settings. Data on women who had abortions in an ambulatory surgery center or office-based setting between January 1, 2011, and December 31, 2014 were obtained from the MarketScan Commercial Claims and Encounters database. The sample was limited to women who were continuously enrolled in their insurance plans for at least 1 year before and at least 6 weeks after the abortion. Healthcare expenditures were assessed separately for the index abortion and the 6-week period after the abortion. Costs were measured from the perspective of the healthcare system and included all payments to the provider, including insurance company payments and any patient out-of-pocket payments. RESULTS: Overall, 49,287 beneficiaries who had 50,311 abortions met inclusion criteria. Of the included abortions, 47% were first-trimester aspiration, 27% first-trimester medication, and 26% second-trimester or later abortions. Most abortions (89%) were provided in office-based settings, with 11% provided in ambulatory surgery centers. Unadjusted mean index abortion costs were higher in ambulatory surgery centers than in office-based settings ($1704 versus $810; P < .001). After adjusting for patient clinical and demographic characteristics, costs of index abortions were $772 higher (95% confidence interval, $746-$797), total follow-up costs for abortions that had any follow-up care were $1099 higher (95% confidence interval, $1004-$1,195), and total follow-up costs for abortions that had an abortion-related morbidity or adverse event were not significantly different in ambulatory surgery centers compared to office-based settings. There were also no significant differences in the likelihood of having any follow-up care or abortion-related event follow-up care. CONCLUSION: Abortions performed at ambulatory surgery centers are significantly more costly than those performed in office-based settings, with no difference in the likelihood of receiving follow-up care. Laws requiring that abortions be provided in ambulatory surgery centers may only result in increased costs for abortions, with no effect on abortion safety.

Same-Day vs Different-Day Elective Upper and Lower Endoscopic Procedures by Setting.

Importance: Performing elective upper and lower endoscopic procedures on the same day is a patient-centered and less costly approach than a 2-stage approach performed on different days, when clinically appropriate. Whether this practice pattern varies based on practice setting has not been studied. Objectives: To estimate the rate of different-day upper and lower endoscopic procedures in 3 types of outpatient settings and investigate the factors associated with the performance of these procedures on different days. Design, Setting, and Participants: A retrospective analysis was conducted of Medicare claims between January 1, 2011, and June 30, 2018, for Medicare beneficiaries who underwent a pair of upper and lower endoscopic procedures performed within 90 days of each other at hospital outpatient departments (HOPDs), freestanding ambulatory surgery centers (ASCs), and physician offices. Main Outcomes and Measures: Undergoing an upper and a lower endoscopic procedure on different days, adjusted for patient characteristics (age, sex, race/ethnicity, residence location and region, comorbidity, and procedure indication) and physician characteristics (sex, years in practice, procedure volume, and primary specialty). Adjusted odds ratios (aORs) and 95% CIs were calculated. Results: A total of 4 028 587 procedure pairs were identified, of which 52.5% were performed in HOPDs, 43.3% in ASCs, and 4.2% in physician offices. The rate of different-day procedures was 13.6% in HOPDs, 22.2% in ASCs, and 47.7% in physician offices. For the 7564 physicians who practiced at both HOPDs and ASCs, their different-day procedure rate changed from 14.1% at HOPDs to 19.4% at ASCs. For the 993 physicians who practiced at both HOPDs and physician offices, their different-day procedure rate changed from 15.8% at HOPDs to 37.4% at physician offices. Patients were more likely to undergo different-day procedures at physician offices and ASCs compared with HOPDs, even after adjusting for patient and physician characteristics (physician office vs HOPD: aOR, 2.02; 95% CI, 1.85-2.20; ASC vs HOPD: aOR, 1.27; 95% CI, 1.23-1.32). Older age (85-94 years vs 65-74 years: aOR, 1.10; 95% CI, 1.08-1.11; 95 years or older vs 65-74 years: aOR, 1.14; 95% CI, 1.03-1.26), black and Hispanic race/ethnicity (black: aOR, 1.15; 95% CI, 1.12-1.17; Hispanic: aOR, 1.12; 95% CI, 1.10-1.14), and residing in the Northeast region (adjusted OR, 1.32; 95% CI, 1.28-1.36) were risk factors for undergoing different-day procedures. Micropolitan location (aOR, 0.94; 95% CI, 0.92-0.96) and rural location (aOR, 0.91; 95% CI, 0.89-0.93), more comorbidities (≥5: aOR, 0.75; 95% CI, 0.74-0.76), physician's fewer years in practice (aOR, 0.84; 95% CI, 0.81-0.87), physician's higher procedure volume (aOR, 0.65; 95% CI, 0.62-0.68), and physician's specialty of general surgery (aOR, 0.86; 95% CI, 0.80-0.91) were protective factors. Conclusions and Relevance: Physician offices and ASCs had much higher different-day procedure rates compared with HOPDs. This disparity may represent an opportunity for quality improvement and financial savings for common endoscopic procedures.

Differences in spending on provider-administered chemotherapy by site of care in Medicare.

OBJECTIVES: To compare Medicare spending on provider-administered chemotherapy in hospital outpatient departments (HOPDs) and physician offices after controlling for cancer type. STUDY DESIGN: Secondary data analysis. METHODS: We used 2010-2013 claims data for a random sample of Medicare fee-for-service beneficiaries who had cancer and received chemotherapy services either in physician offices or in HOPDs. We constructed 2 spending measures: (1) spending on chemotherapy drugs and (2) spending on chemotherapy administration. Each spending measure was the allowed payment, which includes both Medicare reimbursement and patient out-of-pocket spending. We compared the spending measures in the 2 care settings using regression analysis to control for certain patient risk factors, including cancer type. We also compared the number of chemotherapy and administration claims per beneficiary and spending per claim by cancer type to understand differences in utilization patterns in the 2 care settings. RESULTS: Risk-adjusted chemotherapy drug spending per beneficiary was $2451 lower in HOPDs compared with physician offices. Risk-adjusted chemotherapy administration spending was $322 higher in HOPDs than in physician offices. Patients in physician offices received chemotherapy drugs more frequently than those in HOPDs. However, the chemotherapy spending per claim line was higher in HOPDs than physician offices. CONCLUSIONS: Chemotherapy drug spending per Medicare beneficiary was lower in HOPDs than in physician offices, driven by less frequent use of chemotherapy in HOPDs. As the site of provider-administered chemotherapy shifts from physician offices to HOPDs, continuing assessment of cancer care spending by site of care is necessary.

In-office vs. operating room procedures for recurrent respiratory papillomatosis.

We conducted a study to analyze hospital and patient costs, outcomes, and patient satisfaction among adults undergoing in-office and operating room procedures for the treatment of recurrent respiratory papillomatosis. Our final study population was made up of 17 patients-1 man and 16 women, aged 30 to 86 years (mean: 62). The mean number of in-office laser procedures per patient was 4.2, and the mean interval between procedures was 5.4 months (although 10 patients underwent only 1 office procedure); the mean number of operating room procedures was 13.5, and the mean interval between procedures was 14.3 months. An equal number of patients reported complications or adverse events with the two types of procedures-5 each. The difference in cost between the office procedure (mean: $3,413.00) and the operating room procedure (mean: $12,382.59) was almost $9,000, but these savings were offset by the fact that the office procedures needed to be performed three times as often. Patients reported slightly more anxiety and discomfort during the office procedures and, overall, they appeared to prefer the operating room procedure. We conclude that office procedures are significantly more cost-effective than operating room procedures, but their use may be limited by patient tolerance and the increased frequency of the procedure.

Community pharmacist-delivered Medicare Annual Wellness Visits within a family medicine practice.

OBJECTIVE: To identify the steps to implement a community pharmacist into a family medicine practice to deliver Medicare Annual Wellness Visits (AWVs). SETTING: Medicine Mart Pharmacy is a locally owned and operated pharmacy that has served the West Columbia, SC, area for over 30 years. The services offered by the pharmacy have expanded over the past 3 years through the addition of a community pharmacy resident. PRACTICE INNOVATION: A stepwise approach was developed for a community pharmacist to identify, market, and establish an AWV service through a collaborative practice agreement with a local family medicine practice. EVALUATION: The pharmacy team contacted each office and obtained information about the physician practices and their willingness to participate in the program. Two financial models were created and evaluated to determine budget implications. RESULTS: Many patients were seen at the physician offices; they were eligible for AWV, but had not received them. Meetings were scheduled with 3 of the 6 offices; however, none of the offices moved forward with the proposed program. CONCLUSION: Integrating a pharmacist into the AWV role may be profitable to both the pharmacy and the medical office with persistence and time to have a successful collaboration.

Differences in Health Care Use and Costs Among Patients With Cancer Receiving Intravenous Chemotherapy in Physician Offices Versus in Hospital Outpatient Settings.

PURPOSE: The current shift in site of care from community oncology practices to the hospital outpatient department to deliver oncology services may have significant implications for the economic and clinical outcomes of cancer care. Therefore, this study compares health care use and costs among patients with cancer receiving intravenous (IV) chemotherapy in physician offices (PO) versus in hospital outpatient settings (HOP). METHODS: This retrospective study, which was based on medical and pharmacy claims data, included patients (age, 18 to 64 years) initiating IV chemotherapy/biologic treatment between January 1, 2006, and August 31, 2012, who were diagnosed with early or metastatic breast cancer, metastatic lung cancer, metastatic colorectal cancer, or non-Hodgkin lymphoma or chronic lymphocytic leukemia. Patients were assigned to PO or HOP groups on the basis of where they received > 95% of their IV cancer therapy. RESULTS: The study sample included 18,740 patients (12,899 PO; 5,841 HOP) who had a mean age of 51.6 years and a Deyo-Charlson Comorbidity Index score of 5.37. Overall office visits (21.8 ± 13.8 PO v 21.2 ± 12.9, P < .005) and outpatient services (50.8 ± 35.5 PO v 48.5 ± 33.6, P < .001) were higher in the PO group than in the HOP group. Cancer-related inpatient hospitalizations (0.6 ± 1.2 PO v 0.7 ± 1.4 HOP, P = .002) were lower in the PO group than in the HOP group. Although quality-of-care metrics were similar between the HOP and PO groups, follow-up all-cause costs ($82,773 PO v $122,473 HOP) and cancer-related health care costs ($69,037 PO v $108,177 HOP) were higher in the HOP group than in the PO group. CONCLUSION: Despite similar resource use, all-cause and cancer-related health care costs in HOP were significantly higher compared with those in PO settings.

Avoidable Technical and Clinical Denial Write-Off Management in Hospitals, Physician Offices, and Clinics.

PURPOSE/OBJECTIVES: This article reviews the various types of technical and clinical denials that are usually "written off" and proposes strategies to prevent this loss. For purposes of this writing, avoidable technical and clinical denial write-offs are defined as revenue lost from "first-pass" denials rejections. For example, a procedure that requires an authorization is performed without having had an authorization obtained. After appeals and attempts to recoup the revenue, often unsuccessful, the organization ultimately "writes off" the revenue as not collectable. The question to ask is: Are these claims really not collectable or can actionable steps be taken to conserve these dollars and improve the bottom line? PRIMARY PRACTICE SETTING: Acute care hospitals, physician offices, and clinics. FINDINGS AND CONCLUSIONS: In today's environment, the need to manage costs is ubiquitous. Cost management is on the priority list of all savvy health care executives, even if margins are healthy, revenue is under pressure, and the magnitude of cost reduction needed is greater than what past efforts have achieved. As hospitals and physician clinics prioritize areas for improvement, reduction in lost revenue-especially avoidable lost revenue-should be at the top of the list. Attentively managing claim denial write-offs will significantly reduce lost revenue. IMPLICATIONS FOR CASE MANAGEMENT: There is significant interface between case management and the revenue cycle. Developing core competencies for reducing clinical and technical denials should be a critical imperative in overall cost management strategy. Case managers are well placed to prevent these unnecessary losses through accurate status determination and clinical documentation review. These clinical professionals can also provide insight into work flow and other processes inherent in the preauthorization process.

Nasolacrimal duct office probing in children under the age of 12 months: Cure rate and cost evaluation.

INTRODUCTION: Controversy exists regarding the treatment of infants with symptomatic nasolacrimal duct obstruction. One philosophy advocates "early" nasolacrimal duct probing, generally in the office - a relatively common approach in France, while others prefer to wait until the age of 12 months to offer a procedure under general anesthesia. The goal of this study is to report results of immediate office probing for congenital nasolacrimal duct obstruction (CNLDO) under age 1 year in terms of efficacy and cost. METHODS: A retrospective study was performed on 329 patients (443 eyes) treated by probing for CNLDO under the age of 12 months age. A single probing was performed at the first visit in the office under topical anesthesia without sedation. In order to determine the factors associated with failure of probing, univariate analysis was performed using the Student t-test, Pearson's, homogeneity Chi(2) or Fisher's exact tests. For cost evaluation, hypothetical estimates of spontaneous resolution month by month were used according to data in the literature, along with health insurance reimbursement data. RESULTS: The ages of the patients ranged from 2 to 11 months (mean 7.0 ± SD 2.3). The overall success rate for cure by immediate office probing was 76.7%. Unilateral CNLDO had an 80.4% success rate whereas bilateral CNLDO had a 73.2% success rate for each eye (P=0.09). Discharge during probing was associated with failed probing (P=0.02). The cost for the spontaneous resolution strategy was 1.56 times higher than for the immediate probing strategy. A strategy which would apply the spontaneous resolution strategy for children ≤ 5 months and the probing strategy to children>5 months would be the most cost-effective. CONCLUSIONS: Immediate office probing between the ages of 5 to 12 months is a safe, effective method to relieve CNLDO and is the most cost-effective.

[Factors associated with investment in an office medicine project by general practice residents]. / Déterminants du projet d'installation en ambulatoire des internes de médecine générale.

OBJECTIVE: To identify thefactors associated with investment in an office medicine project by French general practice (GP) residents. METHODS: We conducted a national survey using a web-based self-administered questionnaire and analyzed the data collected by multiple logistic regressions. The dependent variable was "an office medicine project" The explanatory variables were both individual (socio-demographic and linked to training trajectories) and contextual (related to the available training programmes and the regional medical demography). RESULTS: The response rate was 48.5%. Out of the 1,695 residents of the study sample, 315 (18.6%) already had a project to setup an office practice during their third cycle ofmedical studies. The main factors associated with this project were (p < 0.05): to receive strong academic support, to live in a rural or semi-rural area, to work as a GP locum, to perform residency training in the same city as the medical training and to perform residency training in a region with a high percentage of GPs 55years and older. CONCLUSIONS: This study showed that a project to setup an office practice was influenced by both individual and contextualfactors. Special attention should be paid to the means and content of training to ensure better supportfor residents, which could make office general practice more attractive.

Economic Impact of Orthopedic Adult Reconstruction Office Practice: The Implications of Hospital Employment Models on Local Economies.

The purpose of this study was to evaluate the economic attributes of private practice adult reconstruction (AR) offices. 458 AAHKS surgeons responded; 65% were in private practice (fee-for-service, non-salaried, non-employed AR surgeons). 54% had considered hospital employment in the past two years. The average group employs 13.4 orthopedic surgeons (3.4 AR), and 105 other employees. The average total budget is $12.5 million per year with $4 million in salaries, and $238,000 in tax revenue generated. Co-management joint ventures are a better model than hospital employment for aligning AR surgeons and hospitals and realizing the cost effectiveness and quality improvement goals of PPACA and AARA while preserving the economic impact of AR private practice.

Intravitreal injections: what do patients prefer? Analysis of patient's satisfaction and preferences about where to perform intravitreal injections.

OBJECTIVE: To analyse satisfaction and patient preferences on the location where they receive an intravitreal injection. METHOD: A survey was conducted with the intention of analysing these patients who attended the macula clinic and have been intervened using an intravitreal injection at least once in the day hospital or in the theatre setting, comparing both locations. RESULTS: The majority of the interviewed patients preferred the day hospital (50.0 versus 37.5%), mostly because of the comfort and the quick service. In patients with severe age-related macular degeneration (AMD) the option is reversed. The overall satisfaction level was positive in both cases (with 87.5% of patients satisfied or very satisfied in the day hospital and 91.1% in the theatre setting). Through the analysis of different aspects of clinical care the assessment was the same or superior for 75.0% of these patients, except in the waiting time. There were no cases of endophthalmitis. CONCLUSION: In general, patients prefer the clinical intervention in the consulting room than in the theatre setting because of the quicker service. There are several characteristics that can influence this choice and should be taken into account.

Costs of adult vaccination in medical settings and pharmacies: an observational study.

BACKGROUND: Community pharmacies are a convenient setting for vaccinating adults against infectious diseases in the United States. Whether the costs paid for vaccination in pharmacies differ from those in medical settings is unclear. OBJECTIVE: To examine whether the direct medical costs paid for adult vaccination differ by vaccination setting. METHODS: This was an observational retrospective study using 2010 MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases. Adults receiving herpes zoster or shingles vaccine, pneumococcal vaccine 23-valent, or influenza vaccines were identified using Current Procedural Terminology codes and National Drug Code numbers from medical and pharmacy claims files, respectively, between January 1 and December 31, 2010, in 1 of the following 3 settings: physician offices; other medical settings (e.g., inpatient/outpatient hospitals, emergency rooms); and pharmacies. Patients were adults aged ≥60 years on the date of zoster vaccination and aged ≥19 years on the date of pneumococcal or influenza vaccinations. The final study samples meeting inclusion/exclusion criteria were 54,042 for zoster vaccine, 154,994 for pneumococcal vaccine, and 1,657,264 for influenza vaccine. The vaccination costs included the health plan and enrollee paid amounts for the product; vaccine administration; dispensing fee; and, where applicable, the visit. The mean (SD) vaccination costs paid per vaccine administration were estimated by vaccine and type of setting, overall, and by geographic region and type of health plan. The costs paid for the same vaccine across vaccination settings were compared using analysis of variance with post hoc tests (Tukey). RESULTS: Of those receiving zoster, pneumococcal, and influenza vaccines, 25%, 1%, and 7%, respectively, received the vaccines at a pharmacy. Compared with other U.S. regions, pharmacy-based vaccination for these 3 vaccines was generally more frequent in the West and the South. Overall, the mean (SD) costs paid per enrollee per vaccine administration at physician offices, other medical settings, and pharmacies were as follows: for zoster vaccine, $208.72 (42.10), $209.51 (50.83), and $168.50 (15.66), respectively (P <0.05); for pneumococcal vaccine, $65.69 (27.54), $72.11 (49.95), and $54.98 (9.72), respectively (P <0.05); and for influenza vaccine, $29.29 (15.29), $24.20 (13.12), and $21.57 (6.63), respectively (P <0.05). The mean amounts paid also differed by geographic region and type of health plan, with costs usually lower for the vaccinations given at pharmacies. CONCLUSIONS: The average direct costs paid per adult vaccination were lower in pharmacies compared with physician offices and other medical settings by 16%-26% and 11%-20%, respectively. These results were mostly consistent across geographic regions and types of health plans. These data may help payers and policymakers understand the economic value of adult vaccination in different settings, especially in pharmacies.

Financial implications of pharmacist-led Medicare annual wellness visits.

OBJECTIVE: To determine if pharmacist-led Medicare Annual Wellness Visits (AWVs) are a feasible mechanism to financially support a pharmacist position in physicians' offices. SETTING: Large, teaching, ambulatory clinic in North Carolina. PRACTICE DESCRIPTION: The Mountain Area Health Education Family Health Center is a family medicine practice that houses a large medical residency program. The Department of Pharmacotherapy comprises five pharmacists and two pharmacy residents providing direct patient care. PRACTICE INNOVATION: In April 2012, pharmacists began conducting Medicare AWVs for patients referred by their primary care physicians within the practice. MAIN OUTCOME MEASURES: Visit reimbursement, annual revenue, number of patients who must be seen to cover the cost of a pharmacist's salary. RESULTS: A small practice requires all eligible Medicare patients to complete an AWV to generate enough revenue to support a new pharmacist position. A medium-sized practice requires a 54% utilization rate, and a large practice requires an 18% utilization rate. Two additional AWVs per half-day of clinic are needed to support an existing pharmacotherapy clinic. A total of 1,070 AWVs per year are required to support a pharmacist's salary, regardless of practice size. CONCLUSIONS: AWV reimbursement may significantly contribute to supporting the cost of a pharmacist, particularly in medium- to large-sized practices. In larger practices, enough revenue can be generated to support the cost of multiple pharmacists.

Diagnostic needle arthroscopy and the economics of improved diagnostic accuracy: a cost analysis.

BACKGROUND: Hundreds of thousands of surgical arthroscopy procedures are performed annually in the United States (US) based on MRI findings. There are situations where these MRI findings are equivocal or indeterminate and because of this clinicians commonly perform the arthroscopy in order not to miss pathology. Recently, a less invasive needle arthroscopy system has been introduced that is commonly performed in the physician office setting and that may help improve the accuracy of diagnostic findings. This in turn may prevent unnecessary follow-on arthroscopy procedures from being performed. OBJECTIVE: The purpose of this analysis is to determine whether the in-office diagnostic needle arthroscopy system can provide cost savings by reducing unnecessary follow on arthroscopy procedures. METHODS: Data obtained from a recent trial and from a systematic review were used in comparing the accuracy of MRI and VisionScope needle arthroscopy (VSI) with standard arthroscopy (gold standard). The resultant false positive and false negative findings were then used to evaluate the costs of follow-on procedures. These differences were then modeled for the US patient population diagnosed and treated for meniscal knee pathology (most common disorder) to determine if a technology such as VSI could save the US healthcare system money. Data on surgical arthroscopy procedures in the US for meniscal knee pathology were used (calendar year [CY] 2010). The costs of performing diagnostic and surgical arthroscopy procedures (using CY 2013 Medicare reimbursement amounts), costs associated with false negative findings, and the costs for treating associated complications arising from diagnostic and therapeutic arthroscopy procedures were assessed. RESULTS: In patients presenting with medial meniscal pathology (International Classification of Diseases, 9th edition, Clinical Modification [ICD9CM] diagnosis 836.0), VSI in place of MRI (standard of care) resulted in a net cost savings to the US system of US$115-US$177 million (CY 2013) (use of systematic review and study data, respectively). In patients presenting with lateral meniscus pathology (ICD9CM 836.1), VSI in place of MRI cost the healthcare system an additional US$14-US$97 million (CY 2013). Overall aggregate savings for meniscal (lateral plus medial) pathology were identified in representative care models along with more appropriate care as fewer patients were exposed to higher risk surgical procedures. CONCLUSIONS: Since in-office arthroscopy is significantly more accurate, patients can be treated more appropriately and the US healthcare system can save money, most especially in medial meniscal pathology.

Economic impact of converting an interventional pain medicine physician office-based practice into a provider-based ambulatory pain practice.

BACKGROUND: One consequence of the shifting economic health care landscape is the growing trend of physician employment and practice acquisition by hospitals. These acquired practices are often converted into hospital- or provider-based clinics. This designation brings the increased services of the hospital, the accreditation of the hospital, and a new billing structure verses the private clinic (the combination of the facility and professional fee billing). One potential concern with moving to a provider-based designation is that this new structure might make the practice less competitive in a marketplace that may still be dominated by private physician office-based practices. The aim of the current study was to evaluate the impact of the provider-based/hospital fee structure on clinical volume. OBJECTIVE: Determine the effect of transition to a hospital- or provider-based practice setting (with concomitant cost implications) on patient volume in the current practice milieu. SETTING:   Community hospital-based academic interventional pain medicine practice. STUDY DESIGN: Economic analysis of effect of change in price structure on clinical volumes. METHODS: The current study evaluates the effect of a change in designation with price implications on the demand for clinical services that accompany the transition to a hospital-based practice setting from a physician office setting in an academic community hospital. RESULTS: Clinical volumes of both procedures and clinic volumes increased in a mature practice setting following transition to a provider-based designation and the accompanying facility and professional fee structure. Following transition to a provider-based designation clinic visits were increased 24% while procedural volume demand did not change. LIMITATIONS: Single practice entity and single geographic location in southeastern United States. CONCLUSIONS: The conversion to a hospital- or provider-based setting does not negatively impact clinical volume and referrals to community-based pain medicine practice. These results imply that factors other than price are a driver of patient choice.