Abstract Medicare Advantage (MA) plans increasingly outsource core functions to third-party vendors, a trend termed the "vendorification" of MA. Vendors now play major roles in star-rating maximization, risk-code capture, and prior authorization, with evidence that vendor-conducted prior authorization yields higher denial rates and more appeal reversals than reviews conducted internally by insurers. This commentary examines three potential challenges that may be posed by vendorification: increased federal spending through non-budget-neutral risk adjustment and quality bonuses, opportunities to game medical loss ratio requirements, and weakened accountability to beneficiaries’ long-term health. Potential policy responses include mandatory reporting of vendor spending and, more fundamentally, reforming the payment incentives that make revenue-generating vendor services profitable.
Abstract Introduction Compared to metropolitan residents, rural residents face disparities in access to local mental health providers that are even larger than for other health care services. Telehealth appears to be a solution: patients should be able to more easily access providers from metro areas, reducing disparities in access. We consider how provider composition in telehealth or changes in provider behavior enabled by telehealth are associated with access to telehealth. Methods We present descriptive evidence from multivariate regressions using National Health Interview Survey and Medical Expenditure Panel Survey data. Results In recent years, rural and publicly insured patients have become relatively less likely to see a mental health provider. Simultaneously, access to any telehealth services is 8-9 percentage points lower for non-metro residents, even after accounting for potential differences in mental health care utilization and internet access. We also show that self-payment is associated with telehealth utilization. Conclusion We caution that telehealth in mental health may disproportionately benefit patients with higher insurance reimbursement or higher probability of self-pay and thus not reduce the mental health access gap for rural patients. Expansions in telehealth need to be combined with policies to promote equitable reimbursement and reduce barriers for providers to bill insurance.
Abstract Introduction Puerto Rico's Medicare Advantage market operates under a persistent yet fluctuating federal funding disparity, with reported benchmark payments approximately 38% below those in United States states. Health insurance industry representatives have argued that this disparity constrains their financial margins, warranting measures to reduce healthcare benefits and demand more federal funds for Medicare. Methods This study assessed the relationship between Puerto Rico’s Medicare funding disparity and medical loss ratio, administrative loss ratio and profit margins within the Medicare Advantage market. We analyzed insurer financial statements filed with the Puerto Rico Insurance Commissioner Office and Plan C plan payment data from the Centers for Medicare and Medicaid Services using descriptive trends and regression models. Results The funding disparity was not significantly associated with medical loss ratio or profit margin, but was associated with higher administrative loss ratio. Profit margins exhibit abrupt fluctuations coinciding with external shocks affecting healthcare utilization and the healthcare market. Conclusion Annual variation in the funding disparity alone does not explain insurer financial performance. Efforts to increase federal Medicare Advantage payments to Puerto Rico should be accompanied by oversight regarding how additional revenues are allocated among medical care, administrative activities, and profits.
Abstract Introduction States have expanded Medicaid waiver-based housing support programs, but evidence on outcomes in safety-net settings is limited. Methods We evaluated health care utilization and spending associated with Massachusetts Medicaid’s Flexible Services Program housing supports (FSP-H), provided to Accountable Care Organization (ACO) members with housing-related needs and qualifying health risks (2021-2024). Within a Boston-based safety-net health system, we linked FSP-H data to claims and electronic health records. Using staggered difference-in-differences, we compared monthly probability of inpatient and emergency department (ED) utilization and per-patient spending in FSP-H recipients (n=340) versus a contemporaneous comparison group with documented housing-related needs who were FSP-H-ineligible because they were in non-ACO plans (n=425). We conducted clinical risk-based subgroup analyses. Results Overall, FSP-H receipt was not associated with significant changes in monthly probability of inpatient utilization (-3.3 percentage points, p=0.223), ED utilization (-1.5 percentage points, p=0.569), or monthly spending (−$634, p=0.053). FSP-H was significantly associated with lower monthly inpatient utilization in the substance use disorder and frailty subgroups, and with lower monthly spending in the frailty subgroup. Conclusion Findings offer evidence for state Medicaid plans implementing or adapting housing programs.
Abstract Introduction Rural hospitals face unique financial challenges, prompting Congressional action including multiple Medicare-specific payment programs. Medicare’s programs to enhance rural hospital payment include: Critical Access, Sole Community, Medicare-Dependent, and Low-Volume Hospitals. Methods We examined the payments made through these programs and their resulting impact on hospitals’ finances for 2,942 rural hospitals from 1997 to 2024 using cost report data. Results Almost four-fifths (82.4%) of rural hospitals received payment from one of the programs. From 2015 to 2024, 14.7% of participating hospitals churned between programs. In 34.6% of hospital-years, hospitals received no special payments from programs they were eligible for. Furthermore, payments received by SCHs and MDHs fluctuated by more than 50% year-to-year for 16.0% of hospital-years. Financial reliance on these programs was larger in states that have not expanded Medicaid and for hospitals participating in two programs simultaneously. Conclusion Overall, many rural hospitals rely on Medicare’s special payment programs, but funding unpredictability, complicated and overlapping eligibility rules, and payment formulas based on historic costs create challenges for hospitals’ finances. There is a need to streamline Medicare payment and make existing programs more efficient before layering on dozens of differing state-level policies through the recently created Rural Health Transformation Program.
Extreme weather is a recurring source of stress on healthcare delivery, yet health systems remain largely reactive. Unlike an individual medical emergency, which the system absorbs one case at a time, a heat wave, wildfire smoke episode, or storm affects an entire population simultaneously. The resulting surge degrades care for every emergency patient, not only those the weather directly harmed. Primary care that anticipates weather-related risk and intervenes proactively can blunt that surge, but a central barrier to scaling such care is economic rather than clinical. Conventional prevention accounting counts only the benefit to the treated patient, and fee-for-service payment offers primary care practices only limited and poorly matched means to fund anticipatory care. Payment models that reward keeping patients healthy, such as global budgets, can address this, but only if risk adjustment accounts for environmental exposure so that providers serving vulnerable populations are not penalized. To address this, we outline 4 priorities: evaluations that capture system-wide costs; payment that rewards anticipatory care and adjusts for environmental risk; supply-side resilience in primary care, built jointly with public health agencies; and data infrastructure linking exposure to healthcare utilization.
The Centers for Medicare & Medicaid Services recently introduced 2 clinical quality measures that intend, in part, to disincentivize hospital boarding: a patient safety concern that involves holding admitted patients in the emergency department while an inpatient bed is unavailable. The Age-Friendly Hospital Measure (AFHM), a structural measure, asks hospitals to attest to having protocols in place to reduce boarding for older patients. The Emergency Care Access and Timeliness (ECAT) measure, an intermediate outcome measure, will require hospitals to report on the proportion of boarded patients. Each measure was developed under a different parent quality reporting program-1 inpatient and 1 outpatient-which has the unintended consequence of producing meaningful variation between the measures. We describe opportunities to standardize and synergize the AFHM and ECAT to capture the prevalence of boarding uniformly, prevent gamesmanship, and enhance their impact on hospital performance. In particular, we highlight the importance of stratifying ECAT by the older-adult patient population to complement AFHM and since older adults are uniquely vulnerable to boarding and its associated safety risks.
Introduction:Identifying social risk factors during the perinatal period may improve pregnancy-related outcomes. In 2018, the Massachusetts Medicaid program implemented an accountable care organization (ACO)-which required social risk factor screening-under 2 ACO model types: Model A (health system/Medicaid managed care plan partnership model) and Model B (primary care practice model). Methods:Using the 2016-2020 Massachusetts All Payer Claims Database and a difference-in-differences (DiD) design, we compared changes in any social risk factor documentation (ie, ICD-10 Z-codes) for Medicaid-enrolled deliveries in non-ACOs vs ACO Model A vs Model B, measured separately for the prenatal period, 60 days postpartum, 12 months postpartum, and the perinatal period. Secondary outcomes included documentation of specific Z-codes related to homelessness and food insecurity. Results:Both Model A (DiD = 1.03 percentage points [PP], P < .001) and Model B (DiD = 0.65 PP, P < .001) were associated with significant increases in Z-code documentation of food insecurity in the perinatal period. Model B was associated with a significant increase in Z-code documentation of homelessness in the perinatal period (DiD = 1.10 PP, P < .001) but not Model A. Conclusion:Massachusetts' Medicaid ACO was associated with modest increases in Z-code documentation during the perinatal period, with some variation by ACO model type.
Introduction:Medicaid programs have increasingly adopted value-based payment models, such as Accountable Care Organizations (ACOs), to improve quality of care and contain costs. Some evidence suggests that Medicaid ACOs have improved outcomes, but little is known about impacts on costs, including for maternity care, which comprises a large portion of Medicaid spending. Methods:Leveraging a natural experiment in Massachusetts, we evaluated the effects of Medicaid ACOs on total cost of care across the prenatal, delivery, and postpartum periods, including cost subcategories. Using claims data on 150 879 Medicaid-covered live deliveries, we used a difference-in-differences approach to compare costs before (quarter [Q] 1 2016 through Q4 2017) vs after (Q2 2018 through Q1 2023) Medicaid ACO implementation, among Medicaid ACO vs non-ACO deliveries, controlling for patient characteristics. Results:Results showed that the Medicaid ACO was not associated with statistical change in total cost of care across the perinatal period. Analysis of cost subcomponents found that the Medicaid ACO was associated with a 5% increase in inpatient delivery costs ($747) and a 21% decrease in emergency department costs (-$69). Conclusion:Expanding Medicaid ACOs may be a mechanism for improving care quality without increasing costs.
Introduction:Precision oncology biomarker testing informs prognosis and guides treatment selection. These tests represent a growing component of cancer care costs. Methods:We conducted a cross-sectional study of US commercial payer-negotiated rates for biomarker tests for breast, colon, and non-small cell lung cancer, using Turquoise Health hospital pricing database. Outcomes included geographically adjusted payer-negotiated rates, within- and between-hospital price variation, and differences by payer, rurality, and hospital size, assessed using generalized linear models adjusted for multiple comparisons. Results:We identified 422 515 negotiated rates for 28 biomarker tests across 2142 hospitals. Median proportion of hospitals reporting payer-negotiated rates was 18.3% (interquartile range [IQR]:17.2%-18.8%) for panel-based and 30.3% (IQR:22.2%-37.8%) for non-panel-based tests; median negotiated rates per test were $3704 (IQR: $3096-$4129) and $301 (IQR: $157-$485), respectively. Negotiated rates varied within hospitals (median within-hospital ratios: panel-based tests, 1.5 [IQR:1.4-1.5]; non-panel-based tests, 1.6 [IQR: 1.5-1.7]) and between hospitals (median between-hospital ratios: panel-based tests, 5.5 [IQR: 5.5-5.6]; non-panel-based tests, 5.2 [IQR: 5.1-5.4]). Negotiated rates varied significantly by payer for all tests. Conclusion:Our findings revealed wide variation in commercial payer-negotiated rates for oncology biomarker tests, underscoring the need for pricing transparency and efforts to reduce price variation to support equitable, affordable cancer care.
Introduction:Online sports betting has expanded rapidly in the United States following the 2018 Supreme Court decision in Murphy v. National Collegiate Athletic Association, with a growing body of research linking this expansion to increases in problem gambling, financial distress, bankruptcy filings, and intimate partner violence. Sportsbooks have invested heavily in advertising to acquire and engage customers. Podcasts may be a particularly attractive channel for sportsbook marketing, but little is known about the scale or targeting of this advertising. Methods:Using podcast advertising data from Podscribe for January 2024 through December 2025, we describe the podcast advertising estimated spending and volume for major online sportsbooks and compare them to the largest alcohol advertisers on podcasts. Results:In 2025, sports betting advertisers spent an estimated $63.4 million on podcast advertising, 2.9 times the $21.9 million spent by alcohol advertisers. DraftKings was estimated to have outspent all alcohol advertisers combined in 2025. DraftKings and FanDuel together accounted for 82% of estimated sports betting podcast spending, and The Joe Rogan Experience captured 13.9% of estimated sports betting podcast spending in 2025. Conclusion:The scale, format, and concentration of sportsbook podcast advertising merit attention from policymakers considering federal marketing regulations.
Abstract Introduction Oral health provider well-being is critical to sustaining the HRSA Health Center (HRSA-HC) workforce, yet limited evidence exists on the drivers of well-being outcomes specifically among dental assistants (DAs), dental hygienists (DHs), and dentists in safety-net settings. Methods This cross-sectional study used data from the 2022 HRSA Health Center Workforce Well-Being Survey among 2,671 oral health providers (DAs=1,385; DHs=564; dentists=722). Well-being outcomes for job satisfaction, engagement, and burnout were calculated as mean Likert scores and categorized into tertiles; intention to stay was dichotomized. Descriptive statistics, multinomial logistic regression, and multivariable logistic regression with backward stepwise selection were used to examine associations between 16 well-being drivers and four outcomes separately by provider type. Results DHs reported the most favorable well-being outcomes, with the highest levels of job satisfaction, engagement, and intention to stay, while burnout was similar across provider types. Work-life balance, meaningfulness, and professional growth were consistently associated with more favorable well-being outcomes and lower burnout, while workload and moral distress were related to higher burnout and poorer well-being across most provider types. Additional provider-specific drivers were also identified. Conclusion These findings underscore the need for both universal and provider-specific organizational strategies to strengthen oral health workforce well-being and retention at HRSA-HCs.
Introduction:Medicare Advantage (MA) enrollment is growing rapidly, yet less is known about how these plans impact health care access, affordability, and satisfaction for adults newly entering Medicare. Methods:Event study, difference-in-differences analysis comparing longitudinal changes in patient-reported outcomes among adults newly enrolled in MA (vs traditional Medicare [TM]) in the Health and Retirement Study (2010-2022). Results:There were 4247 adults who newly enrolled in Medicare between 65 and 67 years of age (34.2% MA; 65.8% TM). Following Medicare enrollment, health care access improved similarly in MA and TM, with no differential change between groups. However, MA enrollees experienced a greater reduction in the proportion of individuals reporting trouble affording medical care (difference-in-differences [DiD] estimate -5.3pp [95% CI, -9.7 to -0.9]). Additionally, the percentage of adults satisfied with their care increased for both groups; however, these gains were larger among MA enrollees and increased over time (DiD +13.3pp [95% CI, 7.9-18.6]). Conclusion:In this national, longitudinal study of adults entering Medicare, we found that enrollment in MA was associated with greater improvements in the affordability of care and higher satisfaction compared with enrollment in TM, without meaningful differences in health care access.
Introduction:Residential treatment is part of the care continuum for opioid use disorder (OUD). However, use of OUD medications (MOUD) has been historically low in this setting. The goal of this study was to assess changes in MOUD during residential treatment stays and the 12-month period surrounding them. Methods:We used national Medicaid claims data for the year 2017-2021 and descriptive as well as regression analyses. Results:Between 2017 and 2021, the rate of MOUD treatment in residential settings increased from 30.4 to 58.5 percentage points. By contrast, the rate of MOUD treatment 6 months before residential treatment stays and 5 months following residential treatment stays was low in 2017 and increased only slightly. Changes were similar in states that implemented a substance use disorder waiver compared to non-waiver states. Most states exhibited similar changes. New York was the only state where MOUD rates before and after residential treatment stays increased markedly. Conclusions:Our study suggests that use of MOUD during residential treatment stays increased substantially 2017-2021, but that this increase was not sustained during the months following stays. Improving retention in MOUD treatment following residential treatment stays could be an important future policy goal.
Introduction:Health care consolidation in the United States has yielded mixed outcomes for patients; however, little is known about the impact of integration between insurers and specialty pharmacies. Through improved data and clinical integration, integrated specialty pharmacy care models may improve health care access and reduce costs for beneficiaries. However, this type of vertical integration may allow increased market power, which could lead to higher costs for beneficiaries. Methods:Using Humana prescription claims, our cross-sectional study used adjusted regression analyses evaluating the association between the use of an integrated specialty pharmacy care model with pharmaceutical access and costs for beneficiaries managing complex specialty conditions in 2024. Results:After adjusting for demographic and clinical characteristics, the integrated specialty pharmacy care model was associated with fewer days from prescription to fill (absolute difference: -5.7 days; 95% CI: -6.7 to -4.7 days) and, reduced yearly beneficiary pharmacy costs (-$106; 95% CI: -$163 to -$49) and yearly beneficiary costs for the specialty drug (-$77; 95% CI: -$129 to -$27) compared with nonintegrated specialty pharmacies. We found additional benefits for beneficiaries who also used integrated primary care services. Conclusion:Integrated specialty pharmacy care models may deliver faster and less costly pharmaceutical care for beneficiaries.
Introduction:Public opinion on firearm legislation varies, though there is broader agreement on restricting guns in alcohol-serving venues. Methods:This study used a discrete choice experiment with 306 US adults in June 2025 to examine preferences for firearm restrictions across different conditions. Scenarios varied by who would be restricted (felons, currently intoxicated individuals, or those with prior alcohol-related offenses), venue size (small, medium, or large), and annual enforcement costs ranging from $0 to $300. Results:Results show that when no enforcement costs are included, a majority of the respondent sample weighted to voting-eligible Americans (56%-74%, depending on the restricted group and venue size) supports firearm restrictions, with support exceeding 65% for restrictions in large venues. However, introducing a $100 annual cost reduces support: significant majority support remains only for restricting combinations of felons, intoxicated people, or those with alcohol-related convictions and only in large venues. Support patterns differ by demographics: women show the strongest support regardless of political affiliation, Democratic men show moderate support, while Republican men and Independents are least supportive. Gun ownership did not independently affect preferences. Conclusions:While support for firearm restrictions in alcohol-serving venues is widespread, even modest implementation costs significantly reduce public backing.
Introduction:Increasing availability and wide geographic distribution of a skilled behavioral health/substance use (BH/SU) workforce is key to ensuring access to treatment for millions of individuals with BH/SU disorders. In many other healthcare sectors, there are state-regulated paraprofessional roles (ie, roles that require a bachelor's degree or less). Yet, the BH/SU field has historically lacked state-regulated paraprofessional roles, limiting workforce entry pathways. Methods:The purpose of this study was to examine policy provisions that states have adopted to formalize BH/SU paraprofessional roles using a formal legal mapping methodology. Results:As of September 2025, we identified a total of 94 BH/SU paraprofessional roles regulated by 36 states. Certification was the dominant level of regulation, and a majority of the BH/SUs certificates had a nondegree training pathway. From a financing perspective, explicit reimbursement references were common, with certification showing the clearest billing pathway. Conclusion:As the first systematic national legal mapping of state-regulated BH/SU paraprofessional roles, these insights can assist states considering the adoption or expansion of BH/SU paraprofessional roles.
