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Meshkin RS, Blumenthal J, Hoyek S, Strand E, Manz S, Akrobetu D, Feng Y, Miller JB, Patel NA. Academic versus Community Retinal Surgery for Primary Retinal Detachment: Characteristics, Duration, and Value Analysis of Teaching Modifier. Ophthalmol Retina 2024:S2468-6530(24)00223-9. [PMID: 38697515 DOI: 10.1016/j.oret.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/22/2024] [Accepted: 04/26/2024] [Indexed: 05/05/2024]
Abstract
PURPOSE To compare operative time and case characteristics of primary rhegmatogenous retinal detachment (RRD) repairs between academic and community vitreoretinal surgeons. DESIGN A retrospective, observational clinical study. SUBJECTS Patients who underwent primary RRD repair surgeries at Massachusetts Eye and Ear between 2019 and 2021. METHODS A random sample of 20 vitreoretinal surgeons distributed evenly among the academic or community setting was selected. Fifteen consecutive cases of primary RRD repair surgeries were included from each surgeon. A cost analysis was performed for the teaching modifier for the physician fee and for hospital costs. MAIN OUTCOME MEASURES Length of surgery. RESULTS Of 300 primary RRD repairs, fellows were present in 75%, which comprised all academic surgeon cases and 50% of community surgeon cases, P < 0.001. Mean operation length was shorter for community surgeon cases without fellows (55.0 ± 24.1) than either academic (73.0 ± 30.8) or community surgeon cases with fellows (75.7 ± 32.5) (P < 0.001). There was a higher percentage of macula-off RRDs in academic versus community surgeon cases (52.7% vs. 38.0%, P = 0.002) and higher rates of combined scleral buckle (SB)/pars plana vitrectomy (PPV) repairs (14% vs. 3%, P < 0.001). When excluding combined SB/PPV cases, there was no difference in operative time between academic and community surgeon cases. Among RRDs repaired by PPV only, there was a 31.4% (16.6 minutes) greater procedure duration in cases with fellows compared with cases without fellows (P < 0.001). Covariates associated with greater surgery time: addition of an SB (β = 32.6), membrane peel (β = 18.5), presence of a fellow (β = 14.5), proliferative vitreoretinopathy (β = 12.8), and greater number of retinal breaks (β = 2.4). The teaching modifier adds 16% extra reimbursement ($184.16) to the physician fee, which is 50.9% of what is necessary to cover the percentage increase in surgeon time (31.4%). Using a time-driven activity-based costing for hospital costs, the extra 16.6 minutes leads to an additional $1038.00, which is 5.6 times more than the reimbursement for the modifier. CONCLUSIONS Retinal detachment repair cases performed by academic surgeons are more likely to be macula-off and include the addition of an SB, which drive longer operative times. Medicare's reimbursement of the assistant modifier in a teaching facility significantly undercompensates the time-driven activity-based costing of trainee participation. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Ryan S Meshkin
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Jonah Blumenthal
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Sandra Hoyek
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Eric Strand
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Sarah Manz
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Dennis Akrobetu
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Yilin Feng
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - John B Miller
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Nimesh A Patel
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts.
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Iachecen F, Dallagassa MR, Portela Santos EA, Carvalho DR, Ioshii SO. Is it possible to automate the discovery of process maps for the time-driven activity-based costing method? A systematic review. BMC Health Serv Res 2023; 23:1408. [PMID: 38093275 PMCID: PMC10720189 DOI: 10.1186/s12913-023-10411-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 11/30/2023] [Indexed: 12/17/2023] Open
Abstract
OBJECTIVES The main objective of this manuscript was to identify the methods used to create process maps for care pathways that utilized the time-driven activity-based costing method. METHODS This is a systematic mapping review. Searches were performed in the Embase, PubMed, CINAHL, Scopus, and Web of Science electronic literature databases from 2004 to September 25, 2022. The included studies reported practical cases from healthcare institutions in all medical fields as long as the time-driven activity-based costing method was employed. We used the time-driven activity-based costing method and analyzed the created process maps and a qualitative approach to identify the main fields. RESULTS A total of 412 studies were retrieved, and 70 articles were included. Most of the articles are related to the fields of orthopedics and childbirth-related to hospital surgical procedures. We also identified various studies in the field of oncology and telemedicine services. The main methods for creating the process maps were direct observational practices, complemented by the involvement of multidisciplinary teams through surveys and interviews. Only 33% of the studies used hospital documents or healthcare data records to integrate with the process maps, and in 67% of the studies, the created maps were not validated by specialists. CONCLUSIONS The application of process mining techniques effectively automates models generated through clinical pathways. They are applied to the time-driven activity-based costing method, making the process more agile and contributing to the visualization of high degrees of variations encountered in processes, thereby making it possible to enhance and achieve continual improvements in processes.
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Affiliation(s)
- Franciele Iachecen
- Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná., 1155, Imaculada Conceição st., Curitiba, Paraná, 80215-90, Brazil.
| | - Marcelo Rosano Dallagassa
- Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná., 1155, Imaculada Conceição st., Curitiba, Paraná, 80215-90, Brazil
| | | | - Deborah Ribeiro Carvalho
- Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná., 1155, Imaculada Conceição st., Curitiba, Paraná, 80215-90, Brazil
| | - Sérgio Ossamu Ioshii
- Graduate Program in Health Technology, Pontifícia Universidade Católica do Paraná., 1155, Imaculada Conceição st., Curitiba, Paraná, 80215-90, Brazil
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Micevych PS, Taha AM, Poddar A, Stewart JM. Individual and Systems-Based Risk Factors for Diabetic Vitrectomy in an Urban Safety-Net Hospital. Ophthalmol Retina 2023; 7:1027-1034. [PMID: 37236319 DOI: 10.1016/j.oret.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/14/2023] [Accepted: 05/18/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To identify individual and systems-focused risk factors for pars plana vitrectomy among patients with proliferative diabetic retinopathy (PDR) in a diverse, urban, safety-net hospital setting. DESIGN Single-center, retrospective, observational, case-control study at Zuckerberg San Francisco General Hospital and Trauma Center between 2017 and 2022. SUBJECTS Two hundred twenty-two patients with PDR over a 5-year span (2017-2022), consisting of 111 cases who underwent vitrectomy for vision-threatening complications (tractional retinal detachment, nonclearing vitreous hemorrhage, and neovascular glaucoma) and 111 controls with PDR with no history of vitrectomy or vision-threatening complications. Controls were matched 1:1 through incidence density sampling. METHODS Medical records were reviewed from time of entry into hospital system to vitrectomy date (or date-matched clinic visit for controls). Individual-focused exposures included age, gender, ethnicity, language, homelessness, incarceration, smoking status, area deprivation index, insurance status, baseline retinopathy stage, baseline visual acuity, baseline hemoglobin A1c, panretinal photocoagulation status, and cumulative anti-VEGF treatments. System-focused exposures included external department involvement, referral route, time within hospital and ophthalmology systems, interval between screening and ophthalmology appointment, interval between conversion to proliferative disease and panretinal photocoagulation or first treatment, and loss-to-follow-up in intervals of active proliferative disease. MAIN OUTCOME MEASURES Odds ratios (ORs) for each exposure on vision-threatening diabetic complications requiring vitrectomy. RESULTS The absence of panretinal photocoagulation was the primary significant individual-focused risk factor for vitrectomy in the multivariable analysis (OR, 4.78; P = 0.011). Systems-focused risk factors included longer interval between PDR diagnosis and initial treatment (weeks; OR, 1.06; P = 0.024) and greater cumulative duration of loss-to-follow-up during intervals of active PDR (months; OR, 1.10; P = 0.002). Greater duration in the ophthalmology system was the primary systems-focused protective factor against vitrectomy (years; OR, 0.75; P = 0.035). CONCLUSIONS Largely modifiable variables modulate risk of complications requiring diabetic vitrectomy. Each additional month of loss-to-follow-up for patients with active proliferative disease increased odds of vitrectomy by 10%. Optimizing modifiable factors to promote earlier treatment and maintain critical follow-up in proliferative disease may reduce vision-threatening complications requiring vitrectomy in a safety-net hospital setting. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Paul S Micevych
- Department of Ophthalmology, University of California San Francisco, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Abu M Taha
- Department of Ophthalmology, University of California San Francisco, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Aunoy Poddar
- Department of Ophthalmology, University of California San Francisco, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| | - Jay M Stewart
- Department of Ophthalmology, University of California San Francisco, San Francisco, California; Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.
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Pan WW, Portney DS, Mian SI, Rao RC. The Cost of Standard and Complex Pars Plana Vitrectomy for Retinal Detachment Repair Exceeds Its Reimbursement. Ophthalmol Retina 2023; 7:948-953. [PMID: 37399975 DOI: 10.1016/j.oret.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To measure the total costs and reimbursements associated with standard and complex pars plana vitrectomy using time-driven activity-based costing (TDABC). DESIGN Economic analysis at a single academic institution. SUBJECTS Patients who underwent standard or complex pars plana vitrectomy (PPV; Current Procedural Terminology codes 67108 and 67113) at the University of Michigan in the calendar year 2021. METHODS Process flow mapping for standard and complex PPVs was used to determine the operative components. The internal anesthesia record system was used to calculate time estimates, and financial calculations were constructed from published literature and internal sources. A TDABC analysis was used to determine the costs of standard and complex PPVs. Average reimbursement was based on Medicare rates. MAIN OUTCOME MEASURES The primary outcomes were the total costs for standard and complex PPVs and the resulting net margin at current Medicare reimbursement levels. The secondary outcomes were the differential in surgical times, costs, and margin for standard and complex PPV. RESULTS Over the 2021 calendar year, a total of 270 standard and 142 complex PPVs were included in the analysis. Complex PPVs were associated with significantly increased anesthesia time (52.28 minutes; P < 0.001), operating room time (51.28 minutes; P < 0.0001), surgery time (43.64 minutes; P < 0.0001), and postoperative time (25.95 minutes; P < 0.0001). The total day-of-surgery costs were $5154.59 and $7852.38 for standard and complex PPVs, respectively. Postoperative visits incurred an additional cost of $327.84 and $353.86 for standard and complex PPV, respectively. The institution-specific facility payments were $4505.50 and $4935.14 for standard and complex PPV, respectively. Standard PPV yielded a net negative margin of -$976.93, whereas complex PPV yielded a net negative margin of -$3271.10. CONCLUSIONS This analysis demonstrated that Medicare reimbursement is inadequate in covering the costs of PPV for retinal detachment, with a particularly large negative margin for more complex cases. These findings demonstrate that additional steps may be necessary to mitigate adverse economic incentives so that patients continue to have timely access to care to achieve optimal visual outcomes after retinal detachment. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Warren W Pan
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan
| | - David S Portney
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan
| | - Shahzad I Mian
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan
| | - Rajesh C Rao
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan; Department of Pathology, University of Michigan, Ann Arbor, Michigan; Department of Human Genetics, University of Michigan, Ann Arbor, Michigan; Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan; Center of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan; Center for RNA Biomedicine, University of Michigan, Ann Arbor, Michigan; A. Alfred Taubman Medical Research Institute, University of Michigan, Ann Arbor, Michigan; Section of Ophthalmology, Surgery Service, Veterans Administration Ann Arbor Healthcare System, Ann Arbor, Michigan.
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Shah PN, Mishra DK, Shanmugam MP, Agarwal M, Susvar P, Sen AC, Ramanjulu R, Dave V, Saravanan V, Kannan N, Sinha T, Sindal MD, Singh SR, Rajanna MK, Ayachit AG, Maitray A, Yadav NK, Balakrishnan D, Nigam E, Narula R, Khadar SMA, Atri N, Mittal S, Murthy H, Mahalingam PS, Pillai GS, Nagpal M, Walinjkar J, Gupta V, Kothari A. Incidence of post vitrectomy endophthalmitis in India - A multicentric study by VRSI study Group. Eye (Lond) 2023; 37:2915-2920. [PMID: 36754984 PMCID: PMC10516918 DOI: 10.1038/s41433-023-02430-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/22/2022] [Accepted: 01/27/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION The incidence of post vitrectomy endophthalmitis (PVE) is reported to be between 0.02 and 0.84%. Resterilization of single use instruments is a common practice amidst developing countries to make it more affordable to the patients by reducing the cost of the surgery and also reduce the environmental hazard. The aim of our study is to evaluate the incidence of PVE amidst existing sterilization practices of reused instruments in multiple vitreoretinal centres in India. METHODOLOGY Centres with an endophthalmitis tracking system were invited to participate in a survey. Twenty-five centres were sent a questionnaire via email. The questionnaire included details about the institution, number of vitrectomies performed in a year, sterilization practices followed pre-operatively, intraoperatively and postoperatively, incidence of endophthalmitis and instrument reuse policies. RESULTS A total of 29 cases of endophthalmitis were reported out of the 47,612 vitrectomies performed across various centres. The mean incidence of endophthalmitis was 0.06%. There was no difference in the rates of endophthalmitis based on various pre-operative, intraoperative or postoperative prophylactic measures. Nearly 80% of the centres change most of the instruments after every case, while the rest reused. The mean number of times a cutter was being reused until discarded was 4.7. Nearly 76% followed a performance-based protocol, and the remaining 24% had a fixed protocol for the number of times an instrument can be reused before discarding it. CONCLUSION PVE rates are not significantly different in India despite the multiuse of single use instruments. The purpose of this paper is not to suggest an alternate protocol but to creating one in the future with these results in mind, to rationalise the use of single use instruments, make VR surgery more affordable and also have a positive impact on the carbon footprint of consumables in surgery.
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Affiliation(s)
| | | | | | | | | | - Alok C Sen
- Sadguru Netra Chikitsalaya, Chitrakoot, Madhya Pradesh, India
| | | | - Vivek Dave
- L V Prasad Eye Institute, Hyderabad, Telangana, India
| | | | | | | | - Manavi D Sindal
- Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Pondicherry, India
| | - Simar Rajan Singh
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | | | | | | | - Eesh Nigam
- Aditya Birla Sankara Nethralaya, Kolkata, West Bengal, India
| | | | | | | | | | - Hemanth Murthy
- Retina Institute Of Karnataka, Bengaluru, Karnataka, India
| | | | - Gopal S Pillai
- Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | | | - Jaydeep Walinjkar
- Aditya Jyot Eye Hospital (P) Limited (A Unit Of Dr Agarwals Eye Hospital), Mumbai, Maharashtra, India
| | - Vishali Gupta
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Bommakanti N, Young BK, Wubben TJ, Zacks DN, Johnson MW. Increase in Retinal Detachment Repair Over a Ten-Year Period at an Academic Center Compared to National Trends. Ophthalmic Surg Lasers Imaging Retina 2023; 54:505-511. [PMID: 37708225 DOI: 10.3928/23258160-20230809-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND AND OBJECTIVE This study aimed to determine whether cases of surgical retinal detachment (RD) repair at a tertiary care center from January 1, 2011 to December 31, 2020 increased proportionately to macular surgery cases as a control and to national trends. PATIENTS AND METHODS Current Procedural Terminology codes were used to identify cases of primary RD repair (67107, 67108), complex RD repair (67113), pneumatic retinopexy (67110), and vitrectomy with membrane peeling (67041, 67042) at an academic center and in the Part B National Summary Data Files. Numbers of cases and mean case times at the academic center were determined. RESULTS We identified 5,183 and 948,831 operative cases locally and nationally, respectively. Between 2011 and 2019, the total volume of RD repair at the academic center increased by 118.7%, compared to 23.3% for cases of membrane peeling. In contrast, surgical RD repairs and membrane peelings increased by 26.0% and 6.8% cases nationally. The ratio of RD repairs to membrane peelings from 2011 to 2019 increased from 1.5 to 2.6 locally compared to 0.6 to 0.7 nationally. Complex RD repairs increased more than primary RD repairs locally (129.3% vs 110.9% cases) and less than primary RD repairs nationally (20.6% versus 30.2% cases). CONCLUSION Cases of surgical RD repair increased disproportionately compared to macular surgery at our institution and compared to RD repairs nationwide. [Ophthalmic Surg Lasers Imaging Retina 2023;54:505-511.].
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Leung EH, Patel S, Reddy R, Boucher N, Sharma C, Blim J, Ferrone PJ, Hahn P. Opportunity Cost of Vitreoretinal Surgeries. JOURNAL OF VITREORETINAL DISEASES 2023; 7:275-280. [PMID: 37927325 PMCID: PMC10621695 DOI: 10.1177/24741264231178590] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Purpose: To compare physician reimbursements for vitreoretinal surgeries with office-based patient care. Methods: A theoretical model was performed comparing physician work reimbursements for the 10 most common vitreoretinal surgeries with office-based work relative value units (wRVUs) that could have been generated during the same global time period. The reference physician was modeled at 40 patients per 8-hour workday. A lower volume physician and higher volume physician were modeled at 30 patients/day and 50 patients/day, respectively. The reimbursement rates and allocated times for surgery were based on the 2021 values set by Medicare, and the average wRVU per office visit was based on 2021 real-world data from the Vestrum Retinal Healthcare Database. Results: In the reference case, performing any of the 10 most common vitreoretinal surgeries was associated with an opportunity cost with a weighted mean of 49% (range, 40%-68%) relative to lost office productivity. The Centers for Medicare & Medicaid Services (CMS) allocated a weighted mean intraservice time of 73 minutes; however, the reference physician would have to complete the surgery with a weighted average of 5 minutes (range, -31-12 minutes) for surgical wRVUs to equal office-based reimbursements. Performing these 10 surgeries was associated with a 25% opportunity cost even for the lower volume physician and 61% for the higher volume physician. Probability sensitivity analysis with a range of conditions identified opportunity costs from surgery in over 99% of simulated scenarios. Conclusions: Medicare reimbursements for the physician work component of vitreoretinal surgeries represented a significant opportunity cost for the physician relative to office-based patient care of equivalent time, especially for busier physicians. The model did not explore practice overhead and professional liability insurance, which are factored separately by CMS and may influence the opportunity cost depending on utilization. The average threshold surgery times for surgical reimbursements to equal office-based reimbursements may be difficult to achieve.
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Affiliation(s)
| | - Shriji Patel
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rahul Reddy
- Department of Ophthalmology, University of Arizona, Phoenix, AZ, USA
| | | | | | - Jill Blim
- American Society of Retina Specialists, Chicago, IL, USA
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Portney DS, Berkowitz ST, Garner DC, Qalieh A, Tiwari V, Friedman S, Patel S, Parikh R, Mian SI. Comparison of Incremental Costs and Medicare Reimbursement for Simple vs Complex Cataract Surgery Using Time-Driven Activity-Based Costing. JAMA Ophthalmol 2023; 141:358-364. [PMID: 36892825 PMCID: PMC9999278 DOI: 10.1001/jamaophthalmol.2023.0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/08/2023] [Indexed: 03/10/2023]
Abstract
Importance Cataract surgery is one of the most commonly performed surgeries across medicine and an integral part of ophthalmologic care. Complex cataract surgery requires more time and resources than simple cataract surgery, yet it remains unclear whether the incremental reimbursement for complex cataract surgery, compared with simple cataract surgery, offsets the increased costs. Objective To measure the difference in day-of-surgery costs and net earnings between simple and complex cataract surgery. Design, Setting, and Participants This study is an economic analysis at a single academic institution using time-driven activity-based costing methodology to determine the operative-day costs of simple and complex cataract surgery. Process flow mapping was used to define the operative episode limited to the day of surgery. Simple and complex cataract surgery cases (Current Procedural Terminology codes 66984 and 66982, respectively) at the University of Michigan Kellogg Eye Center from 2017 to 2021 were included in the analysis. Time estimates were obtained using an internal anesthesia record system. Financial estimates were obtained using a mix of internal sources and prior literature. Supply costs were obtained from the electronic health record. Main Outcomes and Measures Difference in day-of-surgery costs and net earnings. Results A total of 16 092 cataract surgeries were included, 13 904 simple and 2188 complex. Time-based day-of-surgery costs for simple and complex cataract surgery were $1486.24 and $2205.83, respectively, with a mean difference of $719.59 (95% CI, $684.09-$755.09; P < .001). Complex cataract surgery required $158.26 more for costs of supplies and materials (95% CI, $117.00-$199.60; P < .001). The total difference in day-of-surgery costs between complex and simple cataract surgery was $877.85. Incremental reimbursement for complex cataract surgery was $231.01; therefore, complex cataract surgery had a negative earnings difference of $646.84 compared with simple cataract surgery. Conclusions and Relevance This economic analysis suggests that the incremental reimbursement for complex cataract surgery undervalues the resource costs required for the procedure, failing to cover increased costs and accounting for less than 2 minutes of increased operating time. These findings may affect ophthalmologist practice patterns and access to care for certain patients, which may ultimately justify increasing cataract surgery reimbursement.
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Affiliation(s)
- David S. Portney
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
| | - Sean T. Berkowitz
- Vanderbilt Eye Institute, Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Desmond C. Garner
- Vanderbilt Eye Institute, Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adel Qalieh
- Department of Ophthalmology, Henry Ford Health System, Detroit, Michigan
| | - Vikram Tiwari
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Shriji Patel
- Vanderbilt Eye Institute, Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
- Genentech, South San Francisco, California
| | - Ravi Parikh
- Manhattan Retina and Eye Consultants, New York, New York
- Department of Ophthalmology, New York University Grossman School of Medicine, New York
| | - Shahzad I. Mian
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor
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Che-Ngoc H, Do-Thi N, Nguyen-Trang T. Profitability of Ichimoku-Based Trading Rule in Vietnam Stock Market in the Context of the COVID-19 Outbreak. COMPUTATIONAL ECONOMICS 2022; 62:1-19. [PMID: 36254141 PMCID: PMC9558011 DOI: 10.1007/s10614-022-10319-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/30/2022] [Indexed: 06/16/2023]
Abstract
Ichimoku Kinkohyo or Ichimoku Cloud Chart is one of the most popular technical indicators used by traders all over the world. However, its profitability is heavily influenced by the market environment, to which it is applied. Furthermore, the COVID-19 outbreak may have an impact on the market environment as well as the performance of all technical indicators. This study is the first to look into the profitability of Ichimoku-based trading rules in the Vietnamese stock market in the context of the COVID-19 outbreak. More particularly, the COVID-19 outbreak has a positive influence on the performance of this strategy when considering the entire market as well as a variety of industries including real estate industry, food and beverage industry, resource industry, and automotive and electronic components industry. Compared to the pre-pandemic period, the return on investment obtained per each transaction using the Ichimoku-based strategy increased by roughly 8 - 9 % in the pandemic period. Compared to the Buy-and-hold method, the Ichimoku-based strategy could slightly increase Accumulated return while posing a lower risk. The findings indicate that the Ichimoku-based strategy is applicable to the Vietnam stock market, regardless of the adverse effects of the pandemic on the industries.
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Affiliation(s)
- Ha Che-Ngoc
- Faculty of Mathematics and Statistics, Ton Duc Thang University, Ho Chi Minh City, Vietnam
| | - Nga Do-Thi
- School of Management, College of Business, University of Economics Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Thao Nguyen-Trang
- Laboratory for Applied and Industrial Mathematics, Institute for Computational Science and Artificial Intelligence, Van Lang University, Ho Chi Minh City, Vietnam
- Faculty of Basic Sciences, Van Lang University, Ho Chi Minh City, Vietnam
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Patel S, Garner DC, Berkowitz ST, Sternberg P. Implications of the presence of private equity in ophthalmology: an academic perspective. Curr Opin Ophthalmol 2022; 33:377-380. [PMID: 35819904 DOI: 10.1097/icu.0000000000000856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Private equity acquisitions of ophthalmology private practices have been steadily increasing over the past decade with far-reaching implications. Ophthalmology departments at academic medical centers are not insulated from the impact of this trend. RECENT FINDINGS The limited data on this subject in the ophthalmology literature identify the growing number of practice acquisitions. However, the lack of transparency obfuscates a clear understanding of the effect on patients and practice patterns. SUMMARY Leaders at academic medical centers need to be aware of surrounding practice consolidation because of private equity as this could affect revenue streams and patient referral patterns, accelerating expansion. Trainees are entering an uncertain job marketplace that may create a compelling argument to practice in an academic medical center ophthalmology department.
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Affiliation(s)
- Shriji Patel
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Young BK, Hwang M, Johnson MW, Besirli CG, Wubben TJ. A Caveat about Financial Incentives for Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Retinopathy. Am J Ophthalmol 2022; 243:77-82. [PMID: 35901996 DOI: 10.1016/j.ajo.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 05/19/2022] [Accepted: 07/15/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE To highlight the financial incentive to the physician of choosing an intravitreal anti-VEGF based strategy for treatment of non-proliferative and proliferative diabetic retinopathy and its possible risks to the patient and costs to the healthcare system. DESIGN Perspective, with retrospective cost and profit analysis METHODS: Review and synthesis of selected literature on the treatment of diabetic retinopathy, with interpretation of activity- and time-based costing of an intravitreal aflibercept strategy for diabetic retinopathy. Data from the DRCR Retina Network Protocols W and AB and from the PANORAMA trial are used to illustrate the potential financial incentive underlying such a treatment strategy. RESULTS Physician treatment algorithms for diabetic vitreous hemorrhage and non-proliferative diabetic retinopathy may be influenced by the substantial financial incentives intravitreal aflibercept strategies present despite functional equivalence with alternative, less profitable, strategies. For example, pursuing an intravitreal aflibercept based strategy for diabetic vitreous hemorrhage presents a 76% increased profit over pars plana vitrectomy with laser, with equivalent functional outcomes. For non-proliferative diabetic retinopathy, preventative aflibercept injections represent a potential 414% increase in profit over observation and an increased cost of $12164 to $17542 over two years per patient, with no improvement in visual function. These findings demonstrate that there may be misaligned financial incentives in the management of diabetic retinopathy. CONCLUSIONS While anti-VEGF therapy is a useful tool in the management of proliferative diabetic retinopathy and diabetic macular edema, we believe physicians should avoid overreliance on anti-VEGF injections in the treatment of diabetic retinopathy. Retina specialists should be cognizant of the limitations, costs and risks of anti-VEGF monotherapy and prophylactic therapy, and of the imperative to avoid bias towards financially remunerative practice patterns when equally effective alternatives exist.
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Affiliation(s)
- Benjamin K Young
- Department of Ophthalmology and Visual Sciences, University of Michigan, Kellogg Eye Center, Ann Arbor, Michigan, USA
| | - Min Hwang
- Department of Ophthalmology and Visual Sciences, University of Michigan, Kellogg Eye Center, Ann Arbor, Michigan, USA
| | - Mark W Johnson
- Department of Ophthalmology and Visual Sciences, University of Michigan, Kellogg Eye Center, Ann Arbor, Michigan, USA.
| | - Cagri G Besirli
- Department of Ophthalmology and Visual Sciences, University of Michigan, Kellogg Eye Center, Ann Arbor, Michigan, USA
| | - Thomas J Wubben
- Department of Ophthalmology and Visual Sciences, University of Michigan, Kellogg Eye Center, Ann Arbor, Michigan, USA.
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12
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Leung EH, Leder HA, Patel S, Reddy R, Boucher N, Sharma C, Blim J, Awh C, Hahn P. Opportunity Cost of Retinal Detachment Surgery vs Office-Based Patient Care. JOURNAL OF VITREORETINAL DISEASES 2022; 6:278-283. [PMID: 37007922 PMCID: PMC9976036 DOI: 10.1177/24741264221098669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: This work compares physician reimbursements for retinal detachment (RD) surgery with office-based patient care. Methods: A theoretical model was constructed from the physician’s perspective for performing a 90-minute uncomplicated RD surgery with its associated perioperative work in the global period (Current Procedural Terminology code 67108) compared with managing 40 patients per 8-hour clinic day in the equivalent time period. The reimbursement rates were based on the 2019 values set by the US Centers for Medicare and Medicaid Services (CMS). Sensitivity analyses were performed varying the perioperative times, clinical productivity, and postoperative visits. Results: The CMS physician reimbursement rate for 67108 surgery was 17.13 work relative value units (wRVUs); meanwhile, the physician in the reference case could have generated 40.89 wRVUs in the office. CMS reimbursement therefore represented a 58% opportunity cost relative to lost office productivity for the physician. A significant disparity was still present even when modeling 30 patients per day. In sensitivity analyses, clinical productivity exceeded surgical compensation in 99% of modeled scenarios. In threshold analyses, the surgeon in the reference case would have to complete the surgery and all immediate perioperative care within 18 minutes to equal the total CMS valuation. Conclusions: CMS reimbursement for RD surgery resulted in a significant opportunity cost for the physician relative to office-based patient care, which was more pronounced for more efficient clinicians in the office. The sensitivity analyses supported the robustness of the model. Reductions in surgery reimbursements relative to office-based patient care might disincentivize busy clinicians.
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Affiliation(s)
| | | | - Shriji Patel
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rahul Reddy
- Department of Ophthalmology, University of Arizona College of Medicine, Phoenix, AZ, USA
| | | | | | - Jill Blim
- American Society of Retina Specialists, Chicago, IL, USA
| | - Carl Awh
- Tennessee Retina, Nashville, TN, USA
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13
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Potential Cost Savings Associated with a Multiuse Preoperative and Preinjection Eyedrop Protocol. Ophthalmology 2022; 129:1305-1312. [PMID: 35772659 DOI: 10.1016/j.ophtha.2022.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Calculate the cost savings associated with a multiuse preoperative and preinjection eyedrop protocol. DESIGN Economic analysis PARTICIPANTS: Adults undergoing ophthalmic surgical procedures requiring preoperative dilation and intravitreal injections. METHODS Economic modeling with scenario analysis was used to derive the value for cost-savings attributable to a protocol where perioperative mydriatic eyedrop bottles are used across multiple patients versus the current protocol where drop bottles are wasted after single patient use. Similar analyses were performed for a multiuse povidone-iodine protocol for intravitreal injections. Sensitivity analyses were used to test baseline model assumptions with varying degrees of waste and patient volume. RESULTS The multi-use mydriatic protocol allowed for a 97.1% reduction in the number of eyedrop bottles required for the single-use protocol (1037 bottles vs. 35850 bottles). This led to an estimated five year cost savings of approximately $240,000 (nominal) per institution (performing an average of 1434 cases/year) in the base case. This savings varied minimally in sensitivity analyses accounting for practical limitations (loss, expiration, or contamination) of multi-use containers, with savings of 97.54-95.00% for excess supply ranges from 0%-100% in the multiuse protocol. Likewise, the cost savings varied minimally in sensitivity analyses for eye drop sizes, with savings of 99.23-96.69% for mydriatic eye drop sizes of 15 microliter per drop to 65 microliter per drop, respectively, in the multi-use protocol. Over a five-year period, for povidone-iodine drops prior to performing intravitreal injection, the multi-use protocol required 153 bottles compared to 41,954 bottles (99.6% reduction) for the current single-use protocol, resulting in a nominal cost savings of $41,801, which varied minimally in sensitivity analyses. CONCLUSIONS Multiuse perioperative mydriatic eyedrops are a viable option for cost and environmental waste reduction for ophthalmologic procedures and surgeries requiring dilation. Likewise, multiuse povidone-iodine may allow for large relative cost reduction for in office procedures. The total potential savings over five years was estimated greater than $280,000 before adjusting for inflation.
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Berkowitz ST, Siktberg J, Gupta A, Portney D, Chen EM, Parikh R, Finn AP, Patel S. Economic Evaluation of the Merit-Based Incentive Payment System for Ophthalmologists: Analysis of 2019 Quality Payment Program Data. JAMA Ophthalmol 2022; 140:512-518. [PMID: 35420641 PMCID: PMC9011174 DOI: 10.1001/jamaophthalmol.2022.0798] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The Merit-Based Incentive Payment System (MIPS) is intended to promote high-value health care through quality-related Medicare payment adjustments. Objective To assess the economic evaluation of MIPS scoring and reporting on ophthalmologists. Design, Setting, and Participants In this retrospective, cross-sectional, multicenter economic evaluation conducted from October 10 to November 30, 2021, MIPS performance and related payment adjustments were evaluated using the US Centers for Medicare & Medicaid Service (CMS) public data files for ophthalmologists. Participants were stratified by reporting affiliation. Analysis of variance and summary statistics were used to characterize and compare total and subcategory MIPS scores and adjustments received by participants. Reported CMS methodology and performance year (PY) 2019 payment percentages were used to estimate payment adjustments for the following categories: positive MIPS adjustment plus potential additional adjustment for exceptional performance, positive MIPS adjustment, neutral payment adjustment, negative MIPS payment adjustment, and maximum negative MIPS payment adjustment. Study participants included ophthalmologists registered for Medicare Part B with participation in the Quality Payment Program (QPP) in PY 2019. Main Outcomes and Measures Proportion of ophthalmologists qualifying for payment adjustments and payment adjustments. Results For PY 2019, 76.5% of ophthalmologists (13 621) who registered for Medicare participated in the MIPS pathway of the QPP. Ophthalmologists practiced in a predominantly large metropolitan area (12 302; 90.3%). Roughly 99% of participants (11 182) received nonnegative reimbursement adjustments, and 92.6% (10 367) received positive adjustments. Ophthalmologists filing as individuals were less likely to achieve exceptional performance scores compared with those who had a filing category of advanced alternative payment model (APM; odds ratio [OR], 0.0003; 95% CI, 0.00002-0.00481) or group (OR, 0.21013; 95% CI, 0.19020-0.23215). When analyzing participating ophthalmologists with available Medicare payment data (11 193), a total of 8777 (78.4%) achieved exceptional MIPS scores corresponding to mean (SD) adjustments per physician of $244.60 ($217.36) to $4864.78 ($4323.08), or 0.07% ($2 146 835.21 of $3 212 011 252.88) to 1.33% ($42 698 166.89 of $3 212 011 252.88), of the total nondrug Medicare payment. Conclusions and Relevance Results of this economic evaluation showed that although 78.4% of ophthalmologists received exceptional positive payment adjustments, roughly 84% (798916 of 954615) of all health care professionals nationally achieved this benchmark. Exceptional MIPS was associated with filing as group or APM, resulting in, on average, a relatively small additional payment per participant; this suggests that ophthalmologists who file as individuals should consider an alternative filing approach. Changes in MIPS methodology may disproportionately affect certain ophthalmologists, which warrants further study.
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Affiliation(s)
- Sean T Berkowitz
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Siktberg
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Arulita Gupta
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Portney
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan, Ann Arbor
| | - Evan M Chen
- Department of Ophthalmology, University of California, San Francisco
| | - Ravi Parikh
- Department of Ophthalmology, NYU Grossman School of Medicine, New York, New York
| | - Avni P Finn
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shriji Patel
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
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Asahi MG, Pakhchanian H, Pham DT, Raiker R, Flynn EE, Khoo CTL, Patronas M. Medicare Reimbursement Trends for Vitreoretinal procedures: 2000 to 2020. Ophthalmol Retina 2021; 6:326-328. [PMID: 34902638 DOI: 10.1016/j.oret.2021.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 10/19/2022]
Abstract
Medicare reimbursements for vitreoretinal procedures have declined on average by 25% over the last two decades. Awareness of these trends is important for providers and future policy decisions. word count28 of 35.
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Affiliation(s)
- Masumi G Asahi
- George Washington University Department of Ophthalmology, 2150 Pennsylvania Ave, 2A, Washington, DC 20037
| | - Haig Pakhchanian
- George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC 20052
| | - Don T Pham
- Touro University Nevada, 874 American Pacific Drive, Henderson NV 89014
| | - Rahul Raiker
- West Virginia University School of Medicine, 1 Medical Center Dr, Morgantown, WV 26506
| | - Erin E Flynn
- George Washington University Department of Ophthalmology, 2150 Pennsylvania Ave, 2A, Washington, DC 20037
| | - Chloe T L Khoo
- George Washington University Department of Ophthalmology, 2150 Pennsylvania Ave, 2A, Washington, DC 20037
| | - Marena Patronas
- George Washington University Department of Ophthalmology, 2150 Pennsylvania Ave, 2A, Washington, DC 20037; Virgina Retina Center, 45 North Hill Drive #202, Warrenton, VA 20186
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Berkowitz ST, Siktberg J, Hamdan SA, Triana AJ, Patel SN. Health Care Price Transparency in Ophthalmology. JAMA Ophthalmol 2021; 139:1210-1216. [PMID: 34617970 DOI: 10.1001/jamaophthalmol.2021.3951] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Health care price transparency legislation is intended to reduce the ambiguity of hospital charges and the resultant financial stress faced by patients. Objective To evaluate the availability, usability, and variability of standard reported prices for ophthalmologic procedures at academic hospitals. Design, Setting, and Participants In this multicenter economic evaluation study, publicly available price transparency web pages from Association of American Medical Colleges affiliate hospitals were parsed for standard charges and usability metrics. Price transparency data were collected from hospital web pages that met the inclusion criteria. Geographic practice cost indices for work, practice expense, and malpractice were sourced from the Centers for Medicare & Medicaid Services. Data were sourced from February 1 to April 30, 2021. Multiple regression was used to study the geographic influence on standard charges and assess the correlation between standard charges. Main Outcomes and Measures Availability and variability of standard prices for Current Procedural Terminology (CPT) codes 66984 (removal of cataract with insertion of lens) and 66821 (removal of recurring cataract in lens capsule using laser). Results Of 247 hospitals included, 191 (77.3%) provided consumer-friendly shoppable services, most commonly in the form of a price estimator or online tool. For CPT code 66984, 102 hospital (53.4%) provided discount cash pay estimates with a mean (SD) price of $7818.86 ($5407.91). For CPT code 66821, 71 hospital (37.2%) provided discount cash pay estimates with a mean (SD) price of $2041.72 ($2106.44). The top quartile of hospitals, prices wise, listed included prices higher than $10 400 for CPT code 66984 and $2324 for CPT code 66821. Usability issues were noted for 36 hospitals (18.8%), including requirements for personal information or web page navigability barriers. Multiple regression analysis found minimal explanatory value for geographic practice cost indices for cash discount prices for CPT codes 66984 (adjusted R2 = 0.54; 95% CI, 0.41-0.67; P < .001) and 66821 (adjusted R2 = 0.64; 95% CI, 0.51-0.77; P < .001). Conclusions and Relevance Despite recent legislature that codified price transparency requirements, some current standard charges remain ambiguous, with substantial interhospital variability not explained by geographic variability in costs. Given the potential for ambiguous pricing to burden vulnerable, uninsured patients, additional legislation might consider allowing hospitals to defer price estimates or rigorously define standards for actionable cash discount percentages with provisions for displaying relevant benchmark prices.
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Affiliation(s)
| | | | - Saif A Hamdan
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Austin J Triana
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Shriji N Patel
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
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Abtahi SH, Nouri H, Moradian S, Yazdani S, Ahmadieh H. Eye Disorders in the Post-COVID Era. J Ophthalmic Vis Res 2021; 16:527-530. [PMID: 34840673 PMCID: PMC8593548 DOI: 10.18502/jovr.v16i4.9740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This is an Editorial and does not have an abstract. Please download the PDF or view the article HTML.
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Affiliation(s)
- Seyed-Hossein Abtahi
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hosein Nouri
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Siamak Moradian
- Ophthalmic Epidemiology Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahin Yazdani
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Ahmadieh
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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18
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Murray TG, Thompson JT. Do Health Care Institutions Deliver Retina Care at a Loss? Ophthalmol Retina 2021; 5:493-495. [PMID: 34099222 DOI: 10.1016/j.oret.2021.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 11/29/2022]
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