OBJECTIVE:To evaluate the impact of Veterans' urgent care use in non-Veterans Health Administration (VHA) clinics on their later use of specialty and emergency care. STUDY SETTING AND DESIGN:A retrospective cohort study analyzing urgent care, specialty care, and emergency department (ED) visits using VHA administrative and claims data. Veterans' first urgent care visit was the index visit, and subsequent utilization was tracked for up to 1 year. We used an instrumental variable (IV) approach to estimate the effect of non-VHA urgent care visits on the proportion of subsequent visits in non-VHA clinics. DATA SOURCES AND ANALYTIC SAMPLE:We used VHA administrative and community care claims data (2021-2022) obtained from the Corporate Data Warehouse. Our sample comprised VHA enrollees with at least one urgent care visit at a VHA or non-VHA urgent care clinic in 2021. PRINCIPAL FINDINGS:Of the 111,898 Veterans in the sample, 90,651 (81%) had their urgent care visit in the VHA, while 21,247 (19%) visited a non-VHA clinic. IV models showed that Veterans using non-VHA urgent care had 40 percentage points higher proportions of non-VHA specialty care within 30 days compared to those using VHA (95% CI: 37, 43). Effects stabilized at 28 percentage points within 365 days post urgent care visit (95% CI: 26, 30). In contrast, the effect of community urgent care on subsequent ED use outside the VHA system after 30 days of urgent care use was negligible and statistically insignificant. CONCLUSIONS:Veterans' use of non-VHA urgent care can lead to increased subsequent use of non-VHA specialty care but has no effect on non-VHA emergency care utilization within 60 to 365 days after urgent care visit. While expanded community care improves access in the short run, it also introduces care coordination challenges throughout an episode of care that may negatively affect health outcomes.
OBJECTIVE:To examine whether out-of-pocket costs during pregnancy and delivery affect use of postpartum care. STUDY SETTING AND DESIGN:Because health insurance deductibles and limits reset annually, the timing of childbirth within that year quasi-randomly assigns people to different levels of cost-sharing during pregnancy+delivery versus postpartum. We use a novel instrumental variable approach that leverages this variation to analyze whether higher maternity spending due to delivering early in the plan year affects postpartum care utilization. The exposure is maternity out-of-pocket spending, and the instrument is whether the delivery was in the first three versus last 3 months of the enrollee's health plan year; the primary outcome is use of any outpatient care postpartum. We analyze maternity episodes among Blue Cross Blue Shield of Massachusetts enrollees who gave birth, 2019-2023. DATA SOURCES AND ANALYTIC SAMPLE:Commercial health insurance enrollment and claims data for individuals with continuous enrollment during pregnancy, delivery, and 3-months postpartum (N = 51,337). PRINCIPAL FINDINGS:Out-of-pocket costs for those delivering at the start versus the end of their health plan year were, on average, 21% higher for pregnancy+delivery care and 58% lower for postpartum care. A $100 increase in pregnancy+delivery out-of-pocket spending led to a 0.53 percentage point (95% CI [0.28, 0.79]) increase in use of any outpatient postpartum care (sample mean: 82.5%). Higher pregnancy+delivery out-of-pocket costs also led to significant increases in the number of outpatient contact days, visits for preventive/well care, visits for mental health, and other visits. CONCLUSIONS:Higher pregnancy+delivery out-of-pocket costs due to delivering early in the plan year corresponded to lower postpartum out-of-pocket costs and led to modest increases in postpartum care. This suggests that lower postpartum cost-sharing may increase postpartum care use. Policies that lower those costs may be effective in increasing use of postpartum care.
OBJECTIVE:To assess the impact of primary care value-based payment implementation on low-value service use among Medicaid beneficiaries. STUDY SETTING AND DESIGN:On July 1, 2021, North Carolina Medicaid launched the Advanced Medical Home (AMH) program to improve care quality and coordination under managed care. Health plans are now required to include financial incentives for care coordination and performance in contracts with the highest-tier primary care practices (Tier 3 AMHs). Leveraging the tiered structure of the program and using a difference-in-differences design, we compared changes in low-value care utilization before and after the AMH rollout among beneficiaries attributed to Tier 3 AMHs versus those in lower-tier or non-AMH practices. DATA SOURCES AND ANALYTIC SAMPLE:We used North Carolina Medicaid institutional and professional claims, managed care encounters, and enrollment and provider files, supplemented with information on provider characteristics. The analytic sample included 33.6 million beneficiary-months, representing 1.34 million nonelderly adult beneficiaries and 7903 primary care practices. PRINCIPAL FINDINGS:Beneficiaries attributed to Tier 3 AMH practices and comparison practices had similar baseline rates of low-value care, with imaging for plantar fasciitis (31.2% vs. 28.9%), head imaging for uncomplicated headache (14.8% vs. 14.5%), and back imaging for nonspecific low back pain (13.8% vs. 13.8%) being the most commonly used low-value care services. Although rates for many low-value services declined over time, adjusted difference-in-differences estimates were small in magnitude and not statistically significant for low-value care outcomes included in the study. CONCLUSIONS:The results suggest limited effectiveness of value-based payment reform in curbing low-value service use among Medicaid beneficiaries in North Carolina. However, more time may be needed to observe substantial effects, given the gradual nature of practice transformation. Strengthening financial and quality-based incentives, including specific low-value care benchmarks, also could enhance the program's effectiveness in reducing unnecessary care.
OBJECTIVE:To determine if a change in how Medicare disproportionate share payments were calculated increased the amount of uncompensated care reported by hospitals. STUDY SETTING AND DESIGN:In 2018, Medicare changed the formula for determining disproportionate share payments to include uncompensated care. A difference-in-differences analysis was used to determine if different categories of hospitals altered their uncompensated care reporting and received higher disproportionate share payments following the change. DATA SOURCES AND ANALYTIC SAMPLE:We linked 2011-2023 hospital cost report data from RAND with hospital characteristics from the American Hospital Association (AHA)'s annual survey and state uninsurance rate data from KFF. PRINCIPAL FINDINGS:Only some categories of hospitals responded to the policy change. System affiliated hospitals saw an 11% rise in UC reporting and a 20% rise in UC payments relative to individual hospitals. For-profit hospitals saw a 41% rise in UC reporting and a 4% rise in UC payments relative to nonprofit hospitals. Relative to nonprofit individual hospitals, for-profit hospital systems reported a 49% increase in uncompensated care reporting and an 18% increase in additional disproportionate share payments. Among for-profit health systems, the main effect was driven by the two largest hospital systems. CONCLUSIONS:This change benefitted hospitals that reported higher levels of uncompensated care, including those that altered their reporting following the policy change. CMS could monitor the level of hospitals' uncompensated care and within this, charity care and bad debt, to ensure that hospitals are accurately and consistently reporting the data. More information is needed in order to ascertain whether hospitals' reporting changes are translated into practice or are limited to reporting. If limited to reporting, changes may be needed to ensure that large hospital systems with better reporting capacity do not receive the majority of Medicare disproportionate share and uncompensated care payments.
OBJECTIVE:To analyze associations between implementation of high reliability organization (HRO) programs at Veterans Health Administration (VA) medical centers (VAMC) and measures of employee turnover and retention. STUDY SETTING AND DESIGN:In 2018, VA began a phased multi-year national implementation of HRO principles to foster improvements in safety culture and quality of care. Interrupted time series analyses (ITSA) were used to estimate changes in employee turnover and retention pre- and post-HRO implementation. Primary analyses focused on each site's calendar time for program rollout. Secondary analyses estimated changes after training thresholds were attained based on the proportion of employees completing HRO training modules. DATA SOURCES AND ANALYTIC SAMPLE:A retrospective cohort of 723,290 VA employees working at 125 VAMCs between January 2018 through June 2024 was included. Baseline and post-implementation (intercept and slope) rates of employee turnover and retention were estimated. PRINCIPAL FINDINGS:ITSA model estimates showed prior to HRO rollout, VA turnover was increasing from 12.3% at baseline at an annual rate of +0.5% (95% CI: 0.2%, 1.0%, p < 0.001), and after HRO implementation the annual rate dropped by -1.04% (95% CI: -0.8%, -1.3%, p < 0.001). Similarly, retention across the VA was dropping from 86.8% at baseline at an annual rate of -0.8% (95% CI: -0.5%, -1.3%, p < 0.001), and after HRO implementation, the annual rate increased by +1.6% (95% CI: 1.0%, 2.1%, p < 0.001). For an "average" VAMC of 3056 employees at baseline, these changes in retention and turnover translated to 16 fewer positions lost and 24 additional employees retained per year. Models analyzing HRO training thresholds found similar results. CONCLUSIONS:HRO implementation was associated with temporary, modest but statistically significant reversals in the slope of employee turnover and retention rates. Although unobserved factors may have contributed to these results, this work provides initial information regarding potential associations between HRO implementation and workforce outcomes.
OBJECTIVE:To examine the role of insurance coverage of lung cancer screening in driving shifts in lung cancer stage at diagnosis. STUDY SETTING AND DESIGN:We performed difference-in-differences (DID) analyses to compare changes in the proportion of early-stage lung cancer diagnosis between pre-coverage (2007-2014) and post-coverage (2015-2019) periods across insurance groups. DATA SOURCES AND ANALYTIC SAMPLE:Using the National Cancer Institute's Surveillance, Epidemiology, and End Results database, we identified patients with non-small cell lung cancer aged 55-77 years and diagnosed between 2007 and 2019. Health insurance at diagnosis was categorized as private, Medicare (fee-for-service [FFS], FFS with supplemental private coverage, FFS with Medicaid, and Medicare Advantage with and without Medicaid), Medicaid (FFS and managed care), military health plans, and uninsured. PRINCIPAL FINDINGS:Among 227,112 patients, 63,676 (28.04%) had private insurance, 130,770 (57.58%) Medicare, 14,982 (6.60%) Medicaid, 5941 (2.62%) military health insurance, and 11,743 (5.17%) were uninsured. Compared with uninsured patients, a significantly greater increase in the proportion of early-stage lung cancer diagnosis between pre-coverage and post-coverage periods was observed among Medicaid patients (DID = 2.88 percentage points [ppt], 95% CI 0.73-5.02 ppt), but not patients with private insurance, Medicare, or military health insurance. Among Medicaid beneficiaries, those in managed care showed a significantly greater shift compared with those in FFS during 4-5 years post-coverage (DID = 8.22 ppt, 95% CI 4.51-11.93 ppt). Among Medicare FFS beneficiaries, dual enrollment in Medicaid was associated with a significantly smaller increase in the proportion of early-stage diagnosis compared with FFS-only enrollment during 4-5 years post-coverage (DID = -4.40 ppt, 95% CI [-6.40]-[-2.40] ppt). CONCLUSIONS:The results suggest that beneficial stage shifts following the recommendation for lung cancer screening varied by health insurance status and type. Addressing patient, provider, and system-level barriers to lung cancer screening and downstream care is essential to translate lung cancer screening coverage into earlier-stage diagnosis.
OBJECTIVE:To assess the utilization trends of authorized generics (AGs) within Medicare, evaluate differences in out-of-pocket (OOP) costs for Medicare beneficiaries between AGs and independent generics (IGs) when both were simultaneously available in the market, and estimate the adjusted mean difference in OOP costs between these generic types while controlling for potential confounders such as benefit phase and Medicare plan. STUDY SETTING AND DESIGN:This retrospective analysis examined Medicare Part D claims from 2012 to 2020, focusing on prescription-level OOP expenditures. Claims were limited to periods in which both AGs and IGs for the same product were concurrently available. Three measures of cost were used: per claim, per 30 units dispensed, and per 30-day supply. DATA SOURCES AND ANALYTIC SAMPLE:Using the 5% national Medicare Part D sample, linked to the FDA National Drug Code (NDC) Directory, AGs, IGs, and their market availability were identified. Plan information was retrieved from Medicare Plan Characteristics files. Sensitivity analyses applied winsorized OOP costs for outliers and a two-part model for excess zeros. PRINCIPAL FINDINGS:AGs comprised a small share of prescriptions and declined from 3.65% in 2012 to 2.30% in 2020. Compared to IGs, AGs incurred higher OOP costs across all measures. Median per 30-day supply costs were $3.19 for AGs and $1.96 for IGs. Multivariable regression showed IGs had lower adjusted mean OOP costs, with differences of $4.32 per claim, $8.99 per 30 units dispensed, and $6.49 per 30-day supply (all p < 0.0001). Results held across sensitivity analyses. CONCLUSIONS:Despite their smaller market share, AGs are associated with consistently higher OOP costs than IGs. These cost differences have important implications for Medicare affordability and generic market competition. Policies that ensure timely independent generic market entry and prevent anticompetitive delay tactics may help reduce beneficiary financial burden and improve access to lower-cost generics.
OBJECTIVE:To investigate whether eligibility for Veterans Health Administration (VA)-purchased community care, which expanded Veterans' access to care outside VA, was associated with increased polypharmacy or potentially inappropriate medication use among older adult Veterans. STUDY SETTING AND DESIGN:Regression discontinuity design, leveraging the distance threshold for community care eligibility (residing > 40 miles from the nearest VA facility with ≥ 1 or more full-time primary care physician), to examine the effects of community care eligibility on polypharmacy and potentially inappropriate medication use among Veterans aged ≥ 65 years. DATA SOURCES AND ANALYTIC SAMPLE:VA pharmacy data for all prescriptions filled at VA facilities, VA Program Integrity Tool files for prescriptions paid by VA and filled in community pharmacies, and Medicare Part D data. Analyses included annual cross-sectional samples of Veterans 36-39 miles or 41-44 miles from their nearest VA facility during FY 2016-2019. PRINCIPAL FINDINGS:The sample included 399,250 Veteran-year observations, of which 226,157 (56.6%) were 36-39 miles and 173,093 (43.4%) were 41-44 miles from the nearest eligible VA facility. Overall, we observed no discontinuities across the 40-mile threshold in the number of unique medications filled annually (-0.06 medications; 95% confidence interval [CI], -0.15 to 0.03). There were no discontinuities in proportions of Veterans filling ≥ 5 unique medications (-0.25 percentage points [pp]; 95% CI, -0.84 to 0.34), ≥ 10 medications (-0.55 pp.; 95% CI, -1.24 to 0.14), ≥ 1 medication on the Beers list (-0.02 pp.; 95% CI, -0.63 to 0.59), or ≥ 1 high-risk drug-drug interaction (-0.05 pp.; 95% CI, -0.17 to 0.07). Among Veterans with mental health conditions, exceeding the 40-mile threshold was associated with a higher likelihood of filling ≥ 10 unique medications annually (2.06 pp.; 95% CI, 0.42 to 3.70). We did not observe clinically or statistically significant discontinuities in other subgroups. CONCLUSIONS:Overall, eligibility for VA-purchased community care was not associated with increased polypharmacy or potentially inappropriate medication use among older adult Veterans.
OBJECTIVE:To evaluate whether centralized appointment scheduling and same-day virtual clinician evaluation improved appointment timeliness and follow-up after nurse triage. We also assessed whether these changes were associated with differences in downstream utilization, costs, reach, and Veteran experience. STUDY SETTING AND DESIGN:Retrospective quasi-experimental evaluation of Veteran Administration Health Connect (VAHC) modernization across 18 regions between October 1, 2018, and September 30, 2024. Staggered rollout enabled difference-in-differences and event-study analyses comparing outcomes before and after modernization. DATA SOURCES AND ANALYTIC SAMPLE:Data were drawn from the Veterans Administration Corporate Data Warehouse, Telecare Record Manager, and Customer Relationship Management platforms, and VSignals Veteran experience surveys. The analytic sample comprised 11,118,916 encounters (4,560,677 pre-modernization; 6,558,239 post-modernization). PRINCIPAL FINDINGS:Centralized scheduling was associated with modest and mixed improvements in appointment access. Same-day scheduling increased by 14.3 percentage points (95% CI, 10.1 to 18.5). Time from call to scheduled appointment decreased by 0.37 days (95% CI, -0.49 to -0.26), while time to completed appointment increased by 2.9 days (95% CI, 0.2 to 5.7). Following modernization, time from nurse triage to any subsequent care decreased by 0.28 days (95% CI, -0.45 to -0.11), and the proportion of callers receiving no follow-up care within 7 days declined by 2.3 points (95% CI, -4.0 to -0.5). Modernization was not associated with changes in the proportion of all emergency department (ED) visits preceded by a nurse triage call or in total ED visit volume. Seven-day ED visits, admissions, and total costs did not change meaningfully. Veteran satisfaction was high for post-modernization virtual encounters. CONCLUSIONS:VAHC modernization improved appointment access and follow-up after nurse triage but was not associated with short-term changes in ED use or costs, highlighting gains in navigation and experience without immediate shifts in downstream utilization.
OBJECTIVE:To assess the prevalence and financial impact of Sepsis-3 concordant vs. Sepsis-3 discordant sepsis hospitalizations in Traditional Medicare inpatient claims. STUDY DESIGN AND SETTING:This retrospective observational study used a 100% sample of Traditional Medicare inpatient claims from 2016 to 2022. The study population included acute care hospitals reimbursed under the Inpatient Prospective Payment System, excluding those in Maryland and U.S. territories. DATA SOURCES AND ANALYTIC SAMPLE:All Medicare beneficiaries with hospitalizations for sepsis, identified by DRGs 870-872, who were continuously enrolled in Medicare Parts A and B. Hospitalizations were classified as Sepsis-3 concordant vs. discordant based on the presence of diagnosis codes for acute organ dysfunction. PRINCIPAL FINDINGS:Among 4.2 million hospitalizations with a sepsis DRG from 2016-2022, 22.6% (95% CI: 22.3%, 22.9%) lacked a diagnosis code for acute organ dysfunction and were classified as Sepsis-3 discordant. These hospitalizations were most commonly associated with alternative diagnoses of pneumonia (27.4% (95% CI: 27.2%, 27.7%)), urinary tract infection (27.4% (95% CI: 27.2%, 27.6%)), and skin or subcutaneous tissue infections (9.7% (95% CI: 9.5%, 9.8%)). Thirty-day mortality was substantially lower among Sepsis-3 discordant (7.7% (95% CI: 7.6%, 7.8%)) versus concordant (33.4% (95% CI: 33.1%, 33.6%)) sepsis hospitalizations, suggesting meaningful clinical differences among patients with Sepsis-3 discordant sepsis diagnoses. Hospital payments for Sepsis-3 discordant sepsis hospitalizations averaged $839 (95% CI: $679, $999) more per hospitalization than alternative simple infections, leading to an estimated $114 (95% CI: $92, $136) million higher annual payments to hospitals. CONCLUSIONS:Nearly one in four inpatient sepsis hospitalizations in Traditional Medicare may be discordant with Sepsis-3, leading to substantial increases in spending. CMS could mitigate this by aligning ICD-10 coding guidelines with clinical definitions.
OBJECTIVE:To assess changes in methadone dosing practices among Opioid Treatment Program (OTP) and evaluate adherence to evidence-based guidelines recommending doses of at least 80 mg/day. STUDY SETTING AND DESIGN:This observational study used a national survey of OTPs to examine longitudinal changes in methadone dosing patterns between 2017 and 2023. Key outcomes included patterns in average dose levels and the relationships between program characteristics and dosing practices. DATA SOURCES AND ANALYTIC SAMPLE:Secondary data were analyzed from national OTP surveys conducted in 2017 and 2023. The sample included programs that provided data on dosing practices and program characteristics. PRINCIPAL FINDINGS:The proportion of OTPs offering the recommended maintenance dose of at least 80 mg/day remained stagnant, moving from 56% in 2017 to 58% in 2023. Concurrently, private-for-profit ownership of programs increased from 36% to 53%. Approximately 42% of patients in 2023 received doses below recommended clinical levels, highlighting a significant misalignment between evidence-based guidelines and actual practice. CONCLUSIONS:National methadone dosing levels stalled between 2017 and 2023. This pattern leaves a significant gap between evidence-based guidelines and clinical practice, which may limit the effectiveness of methadone maintenance treatment. Targeted interventions are needed to identify the systematic factors hindering the adoption of evidence-based care and to maximize treatment success.
OBJECTIVE:To estimate the prevalence of Medicaid estate recovery in North Carolina. STUDY SETTING AND DESIGN:We descriptively analyzed the number of estates, amount recovered, and hardship waiver applications using North Carolina public records data. DATA SOURCES AND ANALYTIC SAMPLE:The data contained information on the number of estates and amount recovered through Medicaid estate recovery between 2017 and 2021 (n = 2975). Additionally, we analyzed hardship waiver application data for residents who applied and had their application processed between 2018 and 2021 (n = 301). PRINCIPAL FINDINGS:We found approximately $83 billion was recovered from beneficiaries between 2017 and 2021, or 0.6% of the total cost of North Carolina's annual Medicaid program and just 0.9% of the fee-for-service annual long-term services and supports Medicaid budget. We found that Black homeowners were more likely to have lower value estates recovered, and overall, more money was recovered from white estates. CONCLUSION:While states hope Medicaid estate recovery may balance Medicaid spending through increased revenue, our findings demonstrate that these efforts may be insufficient. Policymakers should opt for strategies outside of the Medicaid program that can more precisely target high-net-worth individuals instead of policies like estate recovery that disproportionately impact low-income families.
OBJECTIVE:To determine whether personal responsibility incentives in Medicaid differentially affect enrollment and the comprehensiveness of plan benefits among members who are non-Hispanic Black and non-Hispanic White. STUDY SETTING AND DESIGN:We conducted an interrupted time series analysis to estimate trends in racial disparity ratios of enrollment across more comprehensive Healthy Indiana Plans (HIP) before and during the COVID-19 Public Health Emergency (PHE) when the state suspended personal responsibility incentives, including monthly premium contributions. DATA SOURCES AND ANALYTIC SAMPLE:We analyzed restricted-access administrative data from the Indiana Family and Social Services Administration from 2018 through 2023. The analytic cohort comprised 939,667 non-Hispanic Black and non-Hispanic White adults (19-64 years) enrolled in one of four HIP tiers, including HIP Plus or HIP Basic, and HIP State Plan Plus or HIP State Plan Basic in which presence of a qualifying health condition is required for eligibility. PRINCIPAL FINDINGS:Before the PHE, members who are non-Hispanic Black were approximately 23 percentage points less likely to be in the more comprehensive HIP Plus plan relative to members who are non-Hispanic White. An increase in the disparity ratio of 0.076 points toward parity (95% CI, 0.054-0.097 points) for HIP Plus recipients was observed following suspension of personal responsibility incentives during the PHE. After an administrative upgrade of all HIP Basic recipients to HIP Plus plans during July 2021, this disparity ratio increased an additional 0.146 points from the start of the PHE (95% CI, 0.141-0.151 points) to 0.994 (95% CI, 0.993-0.994). CONCLUSIONS:Personal responsibility incentives in Medicaid are associated with substantial and persistent racial disparities in enrollment and plan comprehensiveness. The study indicates that while the temporary removal of these incentives can reduce disparities, proactive policy interventions may be necessary to achieve and maintain equitable access to care.
OBJECTIVE:To assess documentation of social risk International Classification of Diseases, 10th Revision (ICD-10) Z-codes among hospitalized homeless shelter users in New York City (NYC). STUDY SETTING AND DESIGN:Cross-sectional analysis of hospitalizations among individuals experiencing homelessness using 2019 statewide administrative data from New York. DATA SOURCES AND ANALYTIC SAMPLE:New York Statewide Planning and Research Cooperative System (SPARCS) inpatient discharge data linked to NYC homeless shelter addresses. Hospitalizations were identified by matching geocoded discharge addresses to shelter locations (n = 13,105). PRINCIPAL FINDINGS:Among 13,105 hospitalizations, 27% had at least one Z-code documented and 23% included a homelessness Z-code. In adjusted analyses accounting for hospital-level clustering, documentation was highest for mental and behavioral health hospitalizations and lowest for maternal health admissions. Documentation was lower among women, younger patients, racial and ethnic minority groups, privately insured patients, and patients treated in private nonacademic hospitals. CONCLUSIONS:Z-code documentation among hospitalized individuals experiencing homelessness is low and varies across clinical, demographic, and institutional groups. Improving documentation completeness is important as reimbursement and equity-focused policies increasingly rely on accurate Z-code capture.
OBJECTIVE:To examine whether Medicare Advantage (MA) plans affiliated with health systems adopt less restrictive prior authorization (PA) policies than non-affiliated plans. STUDY SETTING AND DESIGN:We conducted a descriptive analysis comparing PA policies between system-affiliated and unaffiliated MA plans from 2016 to 2023. Using Plan Benefit Package data, we constructed enrollment-weighted measures of PA intensity based on the share of service categories requiring PA. We assessed robustness using alternative measures, including service-specific PA requirements, service mix-adjusted overall intensity, and measures without enrollment weights, and also examined results by plan type. DATA SOURCES AND ANALYTIC SAMPLE:Analyses included 6480 MA health maintenance organization and preferred provider organization plans operating during the study period. PRINCIPAL FINDINGS:Enrollees in system-affiliated MA plans faced fewer PA requirements than those in unaffiliated plans. In 2023, the difference was 31 percentage points (pp): among 23 service categories, enrollees in affiliated plans were enrolled in plans that required PA for 51% of categories, compared with 82% in unaffiliated plans. Differences were especially pronounced for behavioral and mental health services and dialysis (52-59 pp). CONCLUSIONS:System affiliation is associated with less restrictive PA policies in MA, highlighting organizational structure as an important dimension of utilization management.
OBJECTIVE:To examine whether Medicare Advantage (MA) plans' provision of expanded supplemental benefits reduces enrollees' acute care utilization. Expanded supplemental benefits included non-medical primarily health-related (PHR) benefits such as in-home support services, starting in 2019, and Special Supplemental Benefits for the Chronically Ill (SSBCI) such as food security and housing quality benefits, starting in 2020. STUDY SETTING AND DESIGN:Quasi-experimental design using staggered difference-in-differences models. We created indicators for offering the following benefits: Any expanded PHR, ≥ 2 expanded PHR, any SSBCI, and ≥ 2 SSBCI. Acute care utilization was measured by three binary indicators of adverse health events: annual emergency department (ED) use, hospitalizations, and re-admissions. DATA SOURCES AND ANALYTIC SAMPLE:We used 2017-2022 MA encounter data from a random 20% sample of enrollees. We estimated separate models for each benefit indicator, for all non-dual and all dual-eligible enrollees, and for highly frail patients within each non-dual and dual-eligible group. We used propensity score matching to balance baseline characteristics between treatment and control groups. PRINCIPAL FINDINGS:Offering expanded supplemental benefits did not generally reduce acute care utilization in all non-dual or all dual-eligible enrollees. A few significant effects were relatively small or were not robust to potential differential trends between benefit-offering and not-offering plans. However, among highly frail non-dual enrollees, offering any PHR reduced re-admissions by -2.82 percentage points (95% CI: -4.78, -0.86), offering ≥ 2 expanded PHR reduced hospitalizations by -1.79 percentage points (95% CI: -2.61, -0.98) and ED use by -1.76 percentage points (95% CI: -2.38, -1.14), and offering ≥ 2 SSBCI reduced ED use by -3.51 percentage points (95% CI: -4.96, -2.05) and hospitalizations by -2.05 percentage points (95% CI: -3.12, -0.099). CONCLUSIONS:Provision of expanded supplemental benefits may reduce acute care utilization for certain enrollees. As spending on MA supplemental benefits rises, continued efforts are needed to assess impacts of those benefits.
OBJECTIVE:To examine how patient engagement with SMS text reminder scan mediate cancer screening completion among patients at Federally Qualified Health Center clinics (FQHCs). STUDY SETTING AND DESIGN:Patients overdue for cancer screening were randomly assigned to one of two groups: a 3-week interactive SMS intervention or a 6-week theory-informed SMS intervention. The binary outcome was cancer screening completion after 90 days of SMS intervention. A mediation model was used to assess associations between text-message response rates and cancer screening completion. Exposure variables included sociodemographic characteristics, type of SMS intervention, type of cancer screening needed, and health status variables. DATA SOURCES AND ANALYTIC SAMPLE:Data were obtained from two large FQHC networks in Texas and California in 2023. We included 4,344 patients who participated in the 3-week or 6-week intervention groups, successfully received all interactive messages, had unique phone numbers, and did not opt out of the intervention. PRINCIPAL FINDINGS:Overall effects were statistically significant, indicating partial mediation. Full mediation was observed for insurance type: compared with Medicaid, private insurance was associated with a 5-percentage-point (PP) higher predicted probability of screening completion (Average marginal effect [AME] = 5.0 PP, 95% CI [0.01, 0.09]). Partial mediation was observed for Medicare (AME = 7.0 PP, 95% CI [0.02, 0.13]), uninsurance (AME = 5.0 PP, 95% CI [0.01, 0.09]), patient with diabetes (AME = -4.0 PP, 95% CI [-0.08, -0.01]), non-primary English language (AME = 8.0 PP, 95% CI [0.05, 0.10], p < 0.001), and large-city residence (AME = 9.0 PP, 95% CI [0.07, 0.10]), all of which were associated with higher predicted probabilities of screening completion. CONCLUSIONS:Engagement with SMS reminders was a significant mediator of cancer screening completion, suggesting that increasing message interactivity may improve cancer screening uptake. Theory-informed interactive messaging may promote greater patient engagement.
