BACKGROUND:For-profit hospital ownership has been associated with worse patient outcomes, but the mechanisms remain unclear. Underinvestment in nurse staffing is a plausible pathway linking for-profit ownership to performance. OBJECTIVES:To examine whether differences in nurse staffing mediate associations between for-profit hospital ownership and patient, nurse, and hospital outcomes. DESIGN:Cross-sectional study using 2024 data on hospital ownership, registered nurse survey responses, Medicare claims, and Hospital Compare measures. SUBJECTS:A total of 143 for-profit and 798 nonprofit adult, nonfederal, acute care hospitals across 10 US states; >1.17 million Medicare fee-for-service admissions; and 17,368 direct-care bedside registered nurses. MEASURES:Patient-level 30-day mortality and readmission (Medicare Provider Analysis and Review); hospital-level hybrid risk-standardized mortality and readmission and HCAHPS overall hospital rating (CMS Hospital Compare); nurse burnout (Maslach Burnout Inventory emotional exhaustion subscale) and related outcomes (Penn Nurses All survey). The hypothesized mediator was hospital-level nurse staffing. RESULTS:Among surgical patients, for-profit ownership was associated with a 0.48 percentage-point higher 30-day mortality (95% CI: 0.24-0.73), 45% mediated through staffing. Among medical patients, 1.13 percentage-point higher 30-day mortality (95% CI: 0.52-1.73), 40% mediated. Readmission findings were similar. For-profit status was associated with worse HCAHPS ratings (-4.45 percentage points; 95% CI: -5.20 to -3.60), 31% mediated. Nurse burnout was 9 percentage points higher (95% CI: 5.8-12.4), 67% mediated. CONCLUSIONS:For-profit hospital ownership is associated with worse patient and nurse outcomes, and differences in nurse staffing account for a share of these disparities.
BACKGROUND:Availability of childbirth services is declining nationally, especially in rural communities, where risks of maternal and infant mortality are elevated. OBJECTIVE:The study aims to describe the availability of hospital-based childbirth services and higher-level neonatal care in rural and urban US counties from 2010 to 2023 and to examine trends in availability. METHODS:Survey, administrative data, and primary sources were used to identify childbirth services (obstetric and basic well-infant services) and higher-level neonatal care (intermediate or intensive care) at short-term acute care hospitals in rural (n=1958) and urban (n=1186) US counties. For each year (2010-2023), counties were categorized into 3 mutually exclusive service categories: having (1) no childbirth services, (2) only childbirth services, or (3) both childbirth services and higher-level neonatal care. We estimated predicted percentages of rural and urban births occurring to residents of counties by service category using multinomial logistic regression models. RESULTS:The predicted percent of urban births occurring to residents of counties with both childbirth services and higher-level neonatal care increased from 87.0% in 2010 to 88.6% in 2023 (P=0.007), while this percent remained statistically stable among rural counties at 17.0% in 2010 and 16.6% in 2023 (P=0.762). In 2023, 83.4% of rural births occurred to residents of counties without higher-level neonatal care, compared with 11.4% of urban births. CONCLUSIONS:In 2023, 88.6% of urban births occurred to residents of counties with both childbirth services and higher-level neonatal care, compared with 16.6% of rural births. From 2010 to 2023, rural-urban differences in the availability of specialized care for high-risk infants widened.
Background: Racial and ethnic disparities in patient-reported experiences exist in the Veterans Health Administration (VA) and in VA-paid health care from non-VA providers (“community care”), but how these disparities compare is unknown. Objectives: We compared racial and ethnic disparities in patient-reported experiences between VA primary care and community care, and calculated differences in VA versus community care by patient race and ethnicity. Methods: Using cross-sectional data from the 2020 to 2023 VA Survey of Healthcare Experiences of Patients—VA Primary Care and Community Care surveys, we used linear and logistic regressions to assess patient-reported access, care coordination, communication, and provider satisfaction for each racial and ethnic group by setting, and calculated differences-in-differences by race and ethnicity and setting. Results: Primary care provided in community care had larger racial and ethnic disparities in patient-reported experiences of care than VA. Compared with White Veterans, age and sex-adjusted community care disparities exceeded VA disparities for communication among Black Veterans by 13 percentage points; care coordination for American Indian/Alaska Native, Black, and multirace Veterans by 22, 12, and 16 percentage points, respectively; and provider satisfaction for American Indian/Alaska Native Veterans by 34 percentage points. Conclusion: Our findings highlight potential unintended consequences of VA’s efforts to improve timely access by increasing reliance on community care, which may inadvertently widen disparities and contribute to worse care experiences. We suggest several policy implications, including tailoring existing patient tools to navigate community care to minoritized groups experiencing disparities, and providing VA and CC metrics to Veterans to support informed decisions.
BACKGROUND:Racial and ethnic disparities in patient-reported experiences exist in the Veterans Health Administration (VA) and in VA-paid health care from non-VA providers ("community care"), but how these disparities compare is unknown. OBJECTIVES:We compared racial and ethnic disparities in patient-reported experiences between VA primary care and community care, and calculated differences in VA versus community care by patient race and ethnicity. METHODS:Using cross-sectional data from the 2020 to 2023 VA Survey of Healthcare Experiences of Patients-VA Primary Care and Community Care surveys, we used linear and logistic regressions to assess patient-reported access, care coordination, communication, and provider satisfaction for each racial and ethnic group by setting, and calculated differences-in-differences by race and ethnicity and setting. RESULTS:Primary care provided in community care had larger racial and ethnic disparities in patient-reported experiences of care than VA. Compared with White Veterans, age and sex-adjusted community care disparities exceeded VA disparities for communication among Black Veterans by 13 percentage points; care coordination for American Indian/Alaska Native, Black, and multirace Veterans by 22, 12, and 16 percentage points, respectively; and provider satisfaction for American Indian/Alaska Native Veterans by 34 percentage points. CONCLUSION:Our findings highlight potential unintended consequences of VA's efforts to improve timely access by increasing reliance on community care, which may inadvertently widen disparities and contribute to worse care experiences. We suggest several policy implications, including tailoring existing patient tools to navigate community care to minoritized groups experiencing disparities, and providing VA and CC metrics to Veterans to support informed decisions.
BACKGROUND:Older injured patients are at risk for inappropriate pain management, including undertreatment of their pain and inappropriate medication use. The primary aim of this study was to examine the impact of geriatric comanagement on pain medication prescribing in hospitalized older adults. SETTING:Single-site urban academic hospital. PARTICIPANTS:Patients aged 65 years and older admitted to orthopedic trauma, general trauma, and neurosurgery services. METHODS:Pre-post intervention study from 2017 to 2020, using propensity score matching. We compared pain medication prescribing before and after implementation of a geriatric comanagement program. We tracked whether pain medications were received during hospitalization, and the total number of administrations per patient for each class of pain medications. RESULTS:A total of 2640 patients were included, and analytic sample sizes varied by outcome and subsample studied. Comanaged patients in the postintervention group were more likely to receive pain medications than the preintervention group (14.2%, 95% CI: 4.0-24.4, P=0.006), including opioids (20.1%, 95% CI: 2.5-37.6, P=0.025) and nonopioids (15.6%, 95% CI: 4.0-27.3, P=0.009). Comanaged patients had an increase in the administration of nonopioids (62.1%, P<0.001) without a significant increase in the administration of opioids. CONCLUSION:The introduction of geriatric comanagement was associated with changes in pain medication prescribing practices. While our study did not include pain outcome measures, the observed changes in pain medication prescribing add to the growing evidence supporting the benefits of geriatric comanagement models of care because appropriate prescribing facilitates pain management.
BACKGROUND:Federally Qualified Health Centers (FQHCs) are essential safety-net providers, but traditional payment mechanisms may focus on volume over quality-of-care. Alternative payment models (APMs) have been introduced to enhance value-based purchasing. It is hypothesized that APMs would improve flexibility and incentivize quality of care, but evidence remains limited, especially for maternal and child health and cardiovascular conditions. OBJECTIVES:We aim to evaluate the impact of APMs on quality-of-care in FQHCs in the United States. METHODS:We used a 2-stage difference-in-differences design to compare FQHCs in states adopting APMs with those that did not, using data from 2014 to 2024 in 695 FQHCs. Quality-of-care was measured using 6 indicators, including 2 associated with maternal and child services (early prenatal care and dental sealants), 2 with preventive care (depression screening and tobacco use screening), and 2 with cardiovascular disease management (cardiovascular and ischemic vascular disease treatment). To examine heterogeneity of the effects, the analysis stratified FQHCs into 3 groups based on patient volume. RESULTS:APM adoption was significantly associated with improvements in 4 quality measures: a 3.82-percentage-point increase in early prenatal care, a 9.12 percentage point increase in dental sealants, a 5.08 percentage point increase in depression screening, and a 3.50 percentage point increase in ischemic vascular disease treatment. Stratified analyses showed that large FQHCs in APM-adopting states experienced statistically significant improvements in 3 indicators. CONCLUSIONS:Overall, APMs were associated with positive but modest improvements in quality-of-care at FQHCs.
BACKGROUND:Identifying clinically intended medication discontinuations at scale may help generate evidence to inform deprescribing. We developed an algorithmic approach to identifying such discontinuations, combining text strings applied to clinical documentation with medication order data for 5 different drug groups: oral hypoglycemics, statins, antihypertensives, bladder antimuscarinics, and antithrombotics. DESIGN:The study population (n=1588) comprised individuals aged older than 65 with ≥90-day gaps in dispensing classified through manual review as having a clinically intended medication discontinuation or not. This gold-standard cohort was randomly divided into development and validation subsamples for each drug group. We developed text strings from clinical documentation reflecting clinical intent to discontinue a medication (or not). Text strings were usually simple [eg, "stop (medication)"], but required tailoring to drug groups [eg, temporarily "hold (antithrombotic)"]. Text strings queried clinical documentation and were supplemented with order discontinuation data, if available. We calculated sensitivity and specificity for identifying intended discontinuations for text alone, discrete data alone, and the full algorithm across validation samples. RESULTS:Sensitivity and specificity for the full algorithm were 80% and 85% for oral hypoglycemics (n=467), 75% and 95% for statins (n=282), 82%, 75% for antihypertensives (n=599), 77% and 80% for bladder antimuscarinics (n=80), and 74% and 78% for antithrombotics (n=160). The full algorithm had higher sensitivity than either text or order data alone. CONCLUSIONS:Text-based approaches supplemented by medication order data can identify clinically intended medication discontinuations at scale with moderate specificity and sensitivity. This may reduce misclassification relative to using claims data to generate evidence about deprescribing.
BACKGROUND:While payers and health systems are increasingly interested in addressing health-related social needs (HRSNs) to reduce health care use and align with value-based care incentives and regulatory requirements, limited evidence enables actionable strategies to manage and address social needs across population groups. OBJECTIVES:To understand the relationship between HRSNs and health care access and use for adults with Medicare, Medicaid, and private health insurance coverage. RESEARCH DESIGN:Survey data from adult participants from the All of Us Research Program (2017-2023; n=126,490) and logistic regression were used to examine the association between food insecurity and housing instability and having a usual source of care, seeing a health care provider, and forgoing care due to cost-stratified by payer type. RESULTS:The prevalence of HRSNs varied substantially by insurance: food insecurity affected 49.20% of Medicaid beneficiaries 18-64 years of age, 11.89% of privately insured adults 18-64 years of age, and 5.20% of Medicare beneficiaries 65 years of age and older; housing instability affected 54.61%, 25.18%, and 14.99%, respectively. Food insecurity was associated with lower odds of having a usual source of care for Medicaid and privately insured adults, lower odds of use for privately insured adults, and higher odds of forgone care for all 3 payer types. Housing instability was associated with lower odds of having a usual source of care for all 3 papers and with higher odds of forgone care for all groups. CONCLUSIONS:HRSNs like food insecurity and housing instability vary substantially by payer type and influence health care access and utilization in different ways. This can inform the design of payer-specific health management strategies that incorporate HRSNs.
BACKGROUND:A recent study reported that geographic access to cancer care was associated with guideline-recommended treatment for early-stage non-small cell lung cancer (NSCLC), particularly among uninsured and Medicaid patients. OBJECTIVE:To examine whether transportation resources modify the association between geographic access and treatment for early-stage NSCLC. METHODS:We used Surveillance, Epidemiology, and End Results data linked with Medicaid Analytic eXtracts Personal Summary files to identify patients aged 18 years or above with stage I/II NSCLC diagnosed during 2007-2019 who were uninsured or had Medicaid as primary/secondary payers at diagnosis. Geographic access to thoracic surgeons (TS) and radiation oncologists (RO) was calculated using the 2-step floating catchment area method and categorized into quartiles. Transportation resources were evaluated as county-level vehicle ownership and public transit availability, both dichotomized at the median level. Poisson regression with county-level clustering estimated rate ratios (RRs) for surgery and radiotherapy. RESULTS:Geographic access to TS was associated with surgery in both low (RR=0.92, 95% CI: 0.87-0.97 for lowest vs. highest access; P=0.66 for interaction) and high (RR=0.91, 95% CI 0.87-0.96) vehicle ownership counties. In contrast, geographic access to RO was associated with radiotherapy only among patients in counties with low vehicle ownership (RR=0.81, 95% CI: 0.74-0.89; P=0.01 for interaction), but not those in counties with high vehicle ownership (RR=0.96, 95% CI: 0.88-1.04). Similar patterns were observed in metropolitan counties with low vehicle ownership and limited public transit availability. CONCLUSIONS:Local transportation resources modified the association between geographic access and radiotherapy, but not surgery. Improving transportation access may enhance radiotherapy use for NSCLC.
BACKGROUND:Independent physician groups may develop novel revenue streams through ownership of services (eg, radiology equipment, ambulatory surgery centers), supplementing fee-for-service income. This form of entrepreneurial activity and its implied incentives for utilization may influence physician behavior and patient management. We developed an index measuring entrepreneurial activity of independent urology groups and assessed its association with diagnostic testing in men with benign prostatic hyperplasia (BPH). METHODS:We identified Traditional Medicare beneficiaries with BPH presenting to an independent urology group between 2017 and 2019. Using factor analysis of 9 unique ownership characteristics, we developed an index measuring entrepreneurial activity of independent urology groups (0-100-point scale). We assessed the relationship between the entrepreneurial index and 3 types of testing within 90 days of the initial new patient visit. At the patient level, we measured completion of a urinalysis (guideline-recommended), optional BPH testing (eg, ultrasound, cystoscopy), and testing unrelated to a BPH workup (ie, prostate-specific antigen, testosterone). RESULTS:The urology group entrepreneurial index ranged from 0 to 97.2, with 20.6% (n=706/3430) of groups owning at least 1 ancillary service (ie, index >0). Among 49,285 men, an increasing entrepreneurial index (per 10-point increase) was associated with greater odds of undergoing a urinalysis (OR=1.13; 95% CI: 1.09-1.18; P<0.001), optional BPH tests (OR=1.05; 95% CI: 1.02-1.09; P=0.002), and testing unrelated to BPH (OR=1.21; 95% CI: 1.15-1.27; P<0.001). CONCLUSIONS:Entrepreneurial activity in urology, through ownership of ancillary services, is concentrated in a subset of groups. Among men presenting with BPH, the index was associated with increased guideline-recommended, optional, and unrelated testing.
OBJECTIVE:To examine associations between social drivers of health and veteran-level reach of STRIDE, a supervised walking program implemented in the Veterans Health Administration (VA). STUDY SETTING AND DESIGN:We included 2527 patients across 5 facilities. We tested whether housing insecurity, rurality, race, and neighborhood deprivation were associated with reach, defined as any STRIDE walk during hospitalization. DATA SOURCES AND ANALYTICAL SAMPLE:We used the first 6 months of postimplementation data from a stepped-wedge implementation trial. PRINCIPAL FINDINGS:During the implementation period, 197 veterans (7.8%) received at least 1 STRIDE walk. In unadjusted models, patients residing rurally (vs. urban) and those who were White, non-Hispanic/Latino (NH) (vs. Black NH) were significantly more likely to receive ≥1 STRIDE walk. Unadjusted models showed large site differences in STRIDE reach, ranging from 3% to 26% probability by site. Reach differences coincided somewhat with facility-level racial composition: the lowest reach was observed at a site with a majority of Black NH admitted patients, whereas the highest reach was found at a site with a majority of White NH patients. In adjusted models, patient-level rurality remained associated with greater reach (probability 9% for rural veterans vs. 6% for urban veterans), but race was no longer associated (probability 6% among White NH veterans vs. 7% among Black NH veterans). CONCLUSIONS:Patient-level rurality was consistently positively associated with implementation outcomes. Patient-level race was associated with implementation outcomes in unadjusted but not adjusted models. Secondary analyses in implementation trials may help assess how social drivers of health are associated with implementation outcomes.
Background: The U.S. Department of Veterans Affairs (VA) has invested billions of dollars to address homelessness, but there has been limited analysis of long-term outcomes. Objectives: This retrospective study followed 2 cohorts of homeless veterans over 2 decades to identify long-term trajectories and predictors of mortality and continued VA homeless program use. Research Design: National VA administrative data were analyzed from 2004 to 2024. Subjects: A 2004 cohort of 85,533 homeless veterans and a 2014 cohort of 222,974 homeless veterans. Measures: Primary outcomes were mortality and continued use of VA homeless programs. Results: A total of 50% of the first cohort died within 20 years (mean=63.9 y old) and about one-quarter of the second cohort died within 10 years (mean=65.3 y old). Of surviving veterans, 25% in both cohorts used VA homeless programs, and 32%–36% used VA emergency department/urgent care in 2024. In both cohorts, predictors of mortality included being older, non-Hispanic White, male, having medical comorbidities, and alcohol use disorder. Predictors of continued use of VA homeless programs included non-Hispanic Black, male, unmarried, low-enrollment priority group, military sexual trauma, and drug use disorder. In both cohorts, 61%–81% with substance use disorders received substance use treatment, but generally of short duration. Conclusions: In a homeless population with access to comprehensive health care, there is a long-term need to address premature mortality, substance use disorders, and pathways to independence. These findings signal the work that remains in the VA, and the broader challenges that may lie ahead in other national efforts to address homelessness.
Background: The Pennsylvania legislature is considering limiting the number of patients nurses care for to promote safe care. Objective: To determine whether variation in nurse workloads is associated with adverse consequences for patients, nurses, and hospital costs in Pennsylvania. Methods: Observational study of 547,689 medical and surgical patients and 2782 direct care nurses in 132 Pennsylvania hospitals. The independent variable was medical-surgical nurse staffing ratios. Patient outcomes included 30-day mortality, 30-day readmissions, and length of stay. Nurse outcomes included burnout, job dissatisfaction, intent to leave, and evaluations of hospital management and patient care. Hospital outcomes were HCAHPS Star Ratings and cost offsets associated with better staffing. Results: Hospital nurse staffing ranged from 3 to 9 patients per nurse (average 5.9). Each additional patient per nurse was associated with higher odds of 30-day mortality (AOR: 1.08, 95% CI: 1.03, 1.13, P <0.001), longer length of stay (IRR: 1.02, 95% CI: 1.00, 1.04, P <0.05) and higher odds of readmission (AOR: 1.04, 95% CI: 1.01, 1.07, P <0.05). Worse staffing was associated with higher odds of nurse burnout, job dissatisfaction, and intent to leave, and lower patient satisfaction. Cost savings from patient outcomes and nurse retention were projected to offset costs of additional nurses needed for hospitals to meet a minimum safe nurse staffing level proposed in legislation. Conclusions: Large differences across Pennsylvania hospitals in the amount of nursing care patients receive are associated with negative consequences. A state policy establishing minimum safe nurse staffing requirements in hospitals is in the public’s interest.
Introduction: Black undocumented immigrants face dual barriers to care access based on their legal status and due to structural racism in US society. Prior work has shown that Black immigrants (and particularly undocumented immigrants) are less likely to be insured than the general population. However, less is known about other dimensions of health care access for Black undocumented immigrants. Methods: This study analyzes nationally representative data from the National Health Interview Survey (NHIS) from 1999 to 2018 to examine health care access and outcomes along the axes of legal status (undocumented, documented, naturalized citizen, and US-born citizen) among Black individuals aged 40 and above. We analyzed clinician visits over the past 2 years and overnight hospitalizations over the past year (the latter for individuals aged 40 y and older). Non-Hispanic White US-born citizens (NHWC) were used as the reference category. Results: Among Black individuals across legal strata, Black undocumented immigrants had higher odds of uninsurance (OR: 4.7 95% CI: 3.6, 6.0), having no recent physician encounters in the previous 2 years (OR: 1.7; 95% CI: 1.2, 2.3), including lower odds of emergency room visits (OR: 0.7, 95% CI: 0.5, 0.9) and overnight hospital visits (OR: 0.5; 95% CI: 0.4, 0.7) in the past year. They also had lower odds of any blood pressure measurements (OR: 0.5; 95% CI: 0.38, 0.77) in the past year, and women aged 40 had lower odds of ever having received cervical cancer screening (OR: 0.1; 95% CI: 0.1, 0.2). Across all categories, utilization decreased with less secure legal status. Causal mediation analysis showed that insurance status played an important role in the relationship between undocumented status and having had a recent physician visit, mediating 2.7 (95% CI: 1.2%, 4.0%) of the 5.1-point gap (95% CI: 1.7%, 8.7%) between Black undocumented adults and NHWC. Conclusions: The relationship between race and legal status is complex. Legal status is significantly associated with access to insurance and outpatient care among Black immigrants.
Background: Income is closely linked to morbidity and mortality in the United States, potentially due in part to differences in patient experience. However, existing studies on income and care experiences are outdated and have other important limitations. Methods: Using data from a recent national sample of adults (N=5016), we conducted a mixed-methods investigation of the relationship between income and primary care experiences. Patient experience was measured using the CAHPS Clinician and Group survey (CG-CAHPS) and its associated Narrative Item Set (NIS). Closed-ended responses were used to create 4 composite measures, for example, access to care, while open-ended NIS responses were coded for positive and negative mentions of 7 aspects of care: access, coordination, communication, office staff, efficiency, thoroughness, and emotional rapport. Results: Contingent on mentioning an aspect of care in their narratives, low-income participants had lower unadjusted odds of making positive mentions of access, coordination, communication, office staff, efficiency, and emotional rapport (all P- values ≤0.02). Conversely, they had higher unadjusted odds of making negative mentions of coordination, communication, efficiency, and thoroughness (all P -values ≤0.006). Patterns were similar after controlling for education and other characteristics. Low-income participants also had scores on all CG-CAHPS composite measures that were 3–5 points lower than scores for higher-income participants (all P- values <0.001). Conclusion: Low-income patients report fewer positive and more negative health care experiences than higher-income patients across multiple aspects of care. These deficits may contribute to their higher morbidity and mortality. Further research is needed to uncover underlying causes and inform policies and practices to ensure high-quality care for all patients.
Background: Studying delays in postacute care (PAC) rehabilitation using Medicare data is challenging due to the absence of a standardized definition of PAC access timeframes across rehabilitation provider types. Methods: We used 100% Medicare claims data for beneficiaries aged 66 and older discharged to PAC with one of 8 common medical conditions. PAC initiation was examined for inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs). Daily utilization curves were generated for each PAC setting. Joinpoint regression identified the time points where the rate of PAC initiation changed significantly, based on 2019 data. These joinpoints mark thresholds beyond which fewer patients accessed PAC at a slower pace and were used to define delayed access for each setting. We evaluated the stability of joinpoints using 2018 data. Results: Among over 8.9 million hospitalizations, IRFs and SNFs showed a consistent joinpoint at day 2 postdischarge. In contrast, HHA access increased more gradually, with a joinpoint at day 12. Conclusions: Patients typically access facility-based PAC (IRF and SNF) within 2 days, whereas initiation of home-based PAC (HHA) occurs around 12 days. These findings on the joinpoint provide empirical evidence to define PAC delay for each setting. However, it also indicates a systemic gap in defining timely postacute transitions, underscoring the need for standardizing the lengths of accessing postacute services with empirical evidence.
BACKGROUND:Subscription-based payment models (SBPMs) have been adopted to expand access to hepatitis C virus (HCV) treatment within Medicaid programs. OBJECTIVE:To evaluate the impact of SBPMs on HCV screening, RNA testing, and direct-acting antiviral (DAA) uptake among Medicaid Managed Care enrollees in Louisiana and Washington, and to identify factors associated with differential policy effects. RESEARCH DESIGN:Quasi-experimental study using the synthetic control method to compare outcomes in Louisiana and Washington-the only states implementing SBPMs in July 2019-with weighted combinations of 14 control states. SUBJECTS:Adults aged 18-64 years or older enrolled in Medicaid Managed Care between January 2018 and December 2022. MEASURES:Monthly HCV screening, RNA testing, DAA initiation, and refill rates identified from payer-complete closed claims. RESULTS:Louisiana SBPM was associated with significant increases in RNA testing (+35.2/100,000 persons/mo), DAA initiation (+7.8/1000 patients/mo), and DAA refills (+24.4/1000 patients/mo; all P=0.07). Gains were broad-based across subgroups and geographically consistent. Washington SBPM was associated with nonsignificant screening changes and significant declines in DAA initiation (-3.6/1000 patients/mo) and refills (-12.9/1000 patients/mo; P=0.07), with uniformly negative or null subgroup effects. CONCLUSIONS:SBPM yielded markedly different outcomes across states. Louisiana gains likely reflect convergence with recent Medicaid expansion and prior removal of DAA restrictions, generating a large treatment-eligible pool at implementation. Washington earlier expansion (2014) and fibrosis-restriction removal (2016) may have already addressed this demand. As the federal government invests $12.3 billion in HCV elimination with SBPM as a central mechanism, payment reform must be paired with comprehensive strategies-including provider engagement, screening infrastructure, and patient navigation-to achieve elimination goals.
BACKGROUND:Among traditional Medicare patients, discharge to home health agencies (HHAs) has become the most common postacute care (PAC) setting following hospitalization. OBJECTIVES:Estimate the effects of receiving care from home health agencies (HHAs) that specialize in providing PAC. RESEARCH DESIGN:Cross-sectional study using an instrumental variables approach with a differential distance between patients and specialized HHAs. SUBJECTS:Using 100% Medicare fee-for-service claims, we identified 853,780 traditional Medicare patients receiving postacute home health care in 2019. Postacute episodes were defined as home health starting within 14 days of hospital discharge. The sample averaged 56% female, 20% dual-eligible, and 84% White. Patient demographic and clinical characteristics were mostly similar between those who received care at PAC-specialized and nonspecialized HHAs. MEASURES:HHAs were categorized as PAC-specialized if they were in the 75th percentile nationally for share of postacute episodes. Main outcomes included hospitalization, skilled nursing facility (SNF) use, and mortality during the home health spell and within 6 weeks of HHA discharge. RESULTS:The instrument was strong (F-statistic=905.2), with each mile of differential distance reducing specialized HHA probability by 0.8 percentage points (pp). During home health spells, patients at specialized HHAs experienced significantly lower hospitalization risk (-2.1 pp) and SNF admissions (-0.3 pp). Postdischarge, we observed differences in hospitalizations (-0.8 pp during the discharge week and 0.9 pp at 6 wk post-HHA discharge). Mortality rates were consistently lower during the discharge week (-1.3 pp) and within 6 weeks postdischarge (-1.1 pp). CONCLUSIONS:Specialized HHAs appear to achieve better outcomes during treatment and have lower mortality rates both during and after care, suggesting important implications for postacute care delivery optimization.
BACKGROUND:The Surveillance, Epidemiology, and End Results (SEER) Program collects data on cancer incidence and treatments given as the first course of therapy. Medicare claims are another source of cancer treatment-related information. We assessed the agreement between these data sources to identify cancer surgery. METHODS:We used the SEER-Medicare data to create a female breast and bladder cancer cohort that included patients diagnosed from 2004 to 2019 and continuously enrolled in Parts A/B fee-for-service from 4 months before at least 12 months following diagnosis, the window for surgery assessment. The presence/absence of Medicare surgery treatment claims was compared with SEER surgery data. RESULTS:Of the 146,180 patients with breast cancer, 90.3% had surgery, and 6.4% did not have surgery per both SEER and Medicare. Surgery was identified in SEER only for 1.3% and in Medicare only for 1.6% (exact agreement=97%, κ=0.80). In the bladder cancer cohort (n=47,882), 90.9% had surgery and 1.8% did not, per both SEER and Medicare data. Surgery was recorded in SEER only for 2.2% and in Medicare only for 4.6% (exact agreement=93%, κ=0.31). For 0.1% of breast cancer patients and 0.3% of bladder cancer patients, surgery status was unknown per SEER, but Medicare surgery claims were present. CONCLUSIONS:Overall, there was high agreement between SEER and Medicare claims in identifying breast and bladder cancer surgery, but there were some patients who received bladder cancer surgery per Medicare but not per SEER. It is possible that patients received surgeries in the community setting, which were not reported to SEER.
