Hospitals spend billions of dollars annually on major construction projects and facility upgrades, but limited research to date has examined whether this expenditure benefits patients. Using a novel dataset of California hospital construction projects opening between 2010 and 2019, we estimate the effect of project opening on patient experience and clinical measures using a difference-in-differences framework. We find sizable, statistically significant improvements in patient experience-cleanliness, quietness at night, and likelihood to recommend-with effects persisting for at least 2 years after opening. We find no measurable impact on clinical outcomes, 30-day mortality, and readmission for heart attacks and heart failure. These results suggest infrastructure investments meaningfully affect perceived care environments but may not translate into near-term changes in clinical performance. Policymakers and hospital leaders should weigh these returns when evaluating capital expenditures and potential support for hospital construction.
Nursing shortages in the United States (U.S.) have increased reliance on internationally educated nurses (IENs), yet their workplace outcomes remain poorly understood. This scoping review synthesized peer-reviewed empirical studies examining IEN workplace outcomes and associated individual characteristics and work conditions. Findings from 34 studies published between 2004 and 2025 showed that IENs generally reported moderate to high job satisfaction, while burnout findings suggested moderate to high occupational strain. Evidence on intention to leave was limited by inconsistent measurement and insufficient reporting. Workplace outcomes were most consistently associated with organizational conditions, particularly workload, discrimination, leadership support, orientation, and organizational commitment. Individual characteristics, including age, host-country tenure, and sociocultural adaptation, showed less consistent associations. Interpretation was limited by heterogeneity in study designs, outcome measures, and international settings. Future research using standardized measures and longitudinal or mixed-methods designs is needed to inform organizational practice and workforce policy supporting IEN well-being and retention.
We examined associations between hospital system market share, merger activity, 340B participation and operating margins using data for 2,226 U.S. hospitals. We calculated Metropolitan Statistical Area (MSA)-level health system market share, tracked merger activity from 2017 to 2022, and constructed a commercial price index for 1,336 hospitals with available prices. Hospitals with a greater share were significantly more likely to participate in the 340B Program. Among larger hospitals, a 20 percentage-point increase in MSA-level health system share was associated with a 7.6 percentage-point increase in the likelihood of participation. Recent mergers were linked to an 8.6 percentage-point higher likelihood of 340B participation; 340B participation was associated with 1.1-3.0 percentage-point higher margins for non-merged hospitals and 5.2-7.0 percentage-point higher margins for merged hospitals. Greater market share and outpatient revenues were associated with larger estimated 340B margin effects, consistent with the outpatient-focused design of the program.
We examined the effects of ownership and contracting relationships between primary care physicians (PCPs) and large health systems on care utilization and cost in Massachusetts from 2017 to 2021. Thirty-nine percent of treated patient-years were associated with ownership relationships and 61.0% with contracting relationships. A patient's PCP entering an ownership relationship increased the probability of admission to a within-system hospital by 0.75ppt (95% CI [0.54, 0.95]; p < .001) and to a top price hospital by 4.08ppt (95% CI [2.07, 6.08; p < .001); the effect of a contracting relationship was 0.52ppt (95% CI [0.39, 0.65]; p < . 001) and 2.98ppt (95% CI [1.26, 4.71]; p < .001), respectively. Ownership and contracting relationships increased the probability of outpatient follow-up with a within-system physician after hospitalization by 2.91ppt (95% CI [0.26, 5.56]; p = .032) and 2.61ppt (95% CI [0.57, 4.65]; p = .012), respectively. Our findings that both relationships exhibit similar effects suggest that policymaking and research on vertical consolidation may need to broaden beyond outright ownership.
This paper takes a critical look at the widespread belief that, compared to public regulation, competitive markets are increasingly less reliable as ways to limit inappropriate growth in hospital spending in the United States. Setting aside the population in rural areas and small cities where competition is very unlikely, the data presented show that the fraction of the remaining U.S. population in larger cities exposed to competition is large, ranging from 58% to 89%. The paper then considers the remaining areas that could support competition but currently do not do so. The literature on how to foster competition in such currently less competitive markets is reviewed. A combination of expanded markets and incentives for aggressive ("maverick") and disruptive hospital pricing behavior is shown to hold the most promise for a market-based solution.
The impact of safety-net hospital (SNH) acquisition by health systems on specialty care delivery remains unclear, with important implications for access and equity. We examined how SNH acquisitions affect oncology service availability, volumes, and patient characteristics among Medicare fee-for-service beneficiaries using claims data from 2008 to 2019. We identified 75 SNH acquisitions from 2011 to 2015 and 151 independently operated SNHs as controls, estimating changes using a weighted stacked event study design. Following acquisition, chemotherapy volumes increased significantly by 99.6 annual claims (95% CI: [21.9, 177.3]), representing an 84% increase from baseline, while advanced imaging, radiation therapy, and cancer-directed surgical volumes showed no significant changes. We observed no changes in service line availability or patient demographics including race and ethnicity, dual eligibility, or age. These findings suggest system integration may lead to selective expansion of scalable or financially favorable oncology services without markedly altering overall service offerings or Medicare populations served by SNHs.
Medicare site-dependent payments and the 340B Drug Pricing Program both incentivize vertical integration between hospitals and physician practices. Medicare pays higher rates to hospital outpatient departments (HOPDs) than to physician offices, incentivizing hospitals to acquire and convert standalone physician practices into off-campus HOPDs. 340B hospitals earn enhanced profits from outpatient drug delivery, which may further incentivize acquisition of new sites. We used Medicare fee-for-service claims to describe trends between 2016 and 2022 in services provided at off-campus HOPDs, an indicator of vertical integration, stratified by hospital 340B participation status. 340B hospitals delivered a higher and growing percentage of outpatient services at off-campus HOPDs than non-participating hospitals. Drugs accounted for a larger percentage of off-campus HOPD claims at 340B hospitals. At off-campus HOPDs paid site-neutral rates, service volume increased faster among 340B hospitals. Despite recent reforms, 340B hospitals may be more incentivized to pursue vertical integration than other hospitals.
The Patient Driven Payment Model (PDPM), a major reform in the way Medicare reimburses for skilled nursing facility (SNF) care, went into effect in October 2019, prioritizing intensity of nursing care provided over volume of therapy. The purpose of this study was to understand how the PDPM shaped SNF admissions and care delivery, using SNF administrator perspectives. Findings from this qualitative thematic analysis suggest that the PDPM created incentives for SNFs to prioritize more clinically complex patients over patients requiring less complex rehabilitation, improved care coordination between hospitals and SNFs, as well as within the SNF interdisciplinary care team, and emphasized the patient documentation review required for reimbursement. Findings suggest that these changes contributed to SNF care teams better understanding patients' care needs. When considering how best to balance efficiency and quality in patient care delivery, it is important to understand the nuanced changes the PDPM has on SNF operations.
Corporate employment of primary care physicians by hospitals and private equity-backed organizations has increased in recent years, raising concerns that the financial incentives of corporate employment will incentivize provision of low-value care. In this study, we use a difference-in-differences design to examine whether hospital and private equity (PE) acquisitions of primary care practices between 2018 and 2021 change the provision of low-value services within the Traditional Medicare population compared with independent primary care practices. Overall, one-third of Medicare beneficiaries with PE-affiliated primary care providers (PCPs) received low-value services relative to one-quarter of beneficiaries with hospital-affiliated or independent PCPs. We find that hospital and PE acquisitions in primary care did not result in significant changes to the likelihood or number of low-value services received by Medicare patients. As consolidation re-shapes the U.S. health care system, ongoing evaluation of hospitals, health systems and PE-backed organizations remains critical.
Care coordination is increasingly evidenced to improve outcomes for patients with complex conditions. Accordingly, the Veterans Health Administration (VA) is expanding care coordination for ~1.5 million Veterans nationally at the highest risk for hospitalization and mortality. One large nationally mandated initiative, Care Coordination & Integrated Case Management (CCICM), provides a practice framework and structure for local facilities to adopt and accelerate care coordination efforts. We sought to characterize the experiences of lead coordinators (LCs) at VA sites during early adoption of CCICM. LCs expressed a common understanding and believed in the goals of CCICM, with wide agreement that Veterans benefit. The level of buy-in to the framework varied. When local CCICM leaders facilitated a collaborative approach, LCs more often embraced the role. Enthusiasm waned when a directive, top-down approach was taken. Providers often lacked awareness or understanding of CCICM, hindering coordination efforts. System-wide education about goals and potential gains of CCICM needs to be expanded.
Geographic Primary Care Health Professional Shortage Area (HPSA) designations drive the allocation of government resources to improve access to care, but designations are based only on physicians and therefore obscure the available primary care workforce. In this cross-sectional study, we linked 2025 data from the National Plan and Provider Enumeration System and state licensure data to estimate active nurse practitioners (NPs) providing primary care. We then used data from the Health Resources and Services Administration to estimate the number of counties that would continue to meet the HPSA threshold after including NPs in population-to-provider ratios. Including NPs as primary care providers reduced the number of counties with an HPSA by nearly 80% under conservative inclusion criteria and employment and patient capacity assumptions. This finding highlights the need to reconsider HPSA scoring to reflect primary care provider availability and effectively allocate resources to address persistent shortages.
One of the major contributions of qualitative researchers working within the U.S. Veterans Health Administration (VA) has been the development and implementation of rapid qualitative methods. Rapid qualitative methods incorporate the rigor of conventional qualitative methods but have been adapted to the fast-paced environment of a learning health system. Rapid qualitative methods allow a qualitative research team to gather data, synthesize findings, and present results for leadership within a tight timeframe, providing insights that can be used to guide program delivery and policy. This article describes three innovations to rapid qualitative methods using examples from two VA quality improvement projects conducted within a 6-month period. These innovations not only aid in the efficiency of rapid qualitative methods but also may help to inform health care innovations to aid in the translation of findings into practice.
A service cascade refers conceptually to a multi-step process that occurs during the delivery of care as individuals proceed from one part of care to the next. Health care systems increasingly screen patients for unmet social needs and refer them to community-based organizations to address them, requiring a multi-step interaction between the health and social care systems, which we refer to as the social needs service cascade. This cascade is poorly understood beyond screening and referral. As part of an ongoing trial, we interviewed clinicians (n = 38), representatives from community-based organizations (n = 14), and patients with both uncontrolled type 2 diabetes and food insecurity (n = 39), to improve our understanding of the cascade. Qualitative data were analyzed thematically, and highlight key cascade steps including: (a) screening, (b) referral, (c) lag time, (d) linkage and engagement experience, and (e) resolution. These findings can inform future studies and policy approaches supporting integration between health and social care.Trial Registration: ClinicalTrials.gov NCT05472441
The dominant health policy perspective today appears to be that markets are over-consolidated and in need of anti-trust intervention. This commentary argues that the diagnosis is largely incorrect and the proposed treatment ineffective or, worse, effective but undesirable. The anti-trust ideal of a fragmented cottage industry of physician practices, hospitals, and other care organizations does not promise efficiency, even if the current industry configuration also is far from ideal. Many health care market are indeed competitive, and most are contestable, when one views provider organizations as multiproduct firms competing in overlapping geographic and customer markets. For example, many hospital systems compete in overlapping markets for primary care, specialty procedures, drug infusion, home health, subacute care, transplant surgery, telemedicine, population health management, and other services beyond traditional acute inpatient care. The anti-trust perspective should articulate its short-term and its long-term vision for the future of health care. What if it stopped all further mergers but left the status quo in place. What then? What if it not only stopped mergers but reversed them and brought us back to the health care industry of 1980? What then?
Health care consolidation continues to increase in the United States. Most of the evidence focuses on horizontal consolidation or vertical consolidation between hospitals and physician practices. The lack of comprehensive and longitudinal data identifying insurer and hospital vertical consolidation has limited study of the prevalence, variations, and impact of this form of consolidation. Therefore, we created a novel dataset of hospital-Medicare Advantage (MA) contract consolidation from 1980 to 2024. We illustrate the power of this novel dataset through analysis of annual trends in hospital-MA contract consolidation and state-level geographic variation in the share of hospitals consolidated with MA contracts. We also show that a quarter of hospital integrated MA contracts are owned by an MA insurer that owns other non-hospital integrated MA contracts. We make this dataset public to facilitate research on hospital-MA contract consolidation that can inform health care policy and anti-trust law.
All-payer claims databases (APCDs) comprise claims from multiple payers that can be traced to a single patient. To correctly estimate cost-sharing for an individual patient, we developed an algorithm to reconcile payments from secondary and tertiary payers to claims that are not fully covered by primary insurance. In a Colorado APCD cancer cohort (n = 70,100), reconciliation of claims across multiple payers markedly lowered estimated cost-sharing for patients with more than one source of coverage ($5,544 (no reconciliation); $5,013 (primary payer only) to $1,580). The largest reductions in cost-sharing after reconciliation were for individuals with Traditional Medicare with Medigap ($6,449→$1,123; Δ = -$5,326), dual Medicare-Medicaid ($4,439→$2,340; Δ = -$2,099), and Medicaid-commercial ($2,708→$2,009; Δ = -$699). Excluding secondary payments from estimates of cost-sharing systematically inflates cost-sharing estimates. A transparent reconciliation algorithm is necessary to correctly estimate cost-sharing and is recommended for researchers and policymakers who use the APCD for estimating costs across payers and to the patient.
Little is known about the sources of financing to offset the costs associated with operating hospital-based trauma centers (TCs). Research has documented separate trauma activation charges in hospital transparency databases, but the amounts that TCs bill to third-party payors have not been studied. We examined the association between trauma activation fees, an additional facility fee charged by TCs for trauma care, and the overall billed hospital charges between 2019 and 2022 using commercial administrative claims data for injury patients. Average hospital charges were US$41,601 (p < .001) higher for trauma injury patients relative to nontrauma injury patients. After controlling for patient, clinical, and hospital characteristics, the differential decreased to US$31,613 (p < .001) and further to US$12,793 (p < .001) after excluding the facility charge for trauma activation. Our findings indicate that TCs bill more for trauma injury patients - a premium that cannot be fully explained by patient case mix or the trauma activation charge.
The Centers for Medicare and Medicaid Services (CMS) and other policymakers have expressed interest in expanding rates of provider participation in accountable care organizations (ACOs), particularly among smaller physician group practices and independent providers. We described the extent to which clinician-level participation in ACOs varies as a function of both practice size and practice affiliations with health systems. We found that clinicians operating in larger practices and practices affiliated with health systems were more likely to participate in ACOs. Furthermore, engaging the approximately 800 largest practices not enrolled in ACOs as of 2022 in ACOs would increase clinician-level ACO participation rates by nearly 25 percentage points, while achieving the same gains in participation by engaging smaller practices would require engaging over 35,000 smaller practices. Our findings imply that prioritizing independent smaller practices for ACO engagement will yield smaller increases in clinician-level ACO participation rates compared to engaging larger system-affiliated practices.
More information is needed on how to recruit and retain rural health professionals, especially during times of crisis. In this article, we explore the experiences of rural health professionals during the COVID-19 pandemic. We conducted in-depth, semi-structured interviews with physicians, advanced practice providers, nurses, and allied health professionals in the state of Minnesota from 2023 to 2024 (n = 17) and used iterative thematic analysis to identify key themes. Two key themes emerged from our analysis as challenges during the COVID-19 pandemic: staffing shortages and the politicization of trust. Respondents also expressed satisfaction with rural life due to ease of social distancing and a strong sense of responsibility to their community. Despite the challenges presented by the COVID-19 pandemic for rural health professionals, respondents felt strongly about remaining in and serving their communities.
This study measured turnover of physical, occupational, and speech therapy staff in skilled nursing facilities (SNFs) from July 2020 through September 2023. We estimated associations between SNF characteristics and high therapy staff turnover and between turnover and therapy-relevant SNF-level patient outcomes. Average quarterly turnover of combined therapy staff was 13.0%, with higher turnover in for-profit SNFs, urban SNFs, and SNFs with lower therapy and nurse staffing and recent ownership changes. Periods of high therapy staff turnover within SNFs were associated with small increases in two adverse outcomes for long-term care residents: increasing need for assistance with activities of daily living and worsening ability to move independently. There was no association between turnover and falls for long-term residents or functional improvement for short-stay patients. Results suggest urban and for-profit SNFs could be targeted in efforts to reduce therapy staff turnover, with the potential for modest improvement in patient outcomes.
