State Medicaid programs vary in whether they cover glucagon-like peptide-1 receptor agonists (GLP-1s) for obesity treatment, creating an opportunity to examine how utilization differs across coverage environments. We combined 2024 KFF Medicaid coverage data with Medicaid State Drug Utilization Data from 2015 to 2024 across all 50 states and Washington, D.C. As of August 2024, 13 states covered GLP-1s for obesity, and prescriptions were concentrated in those states, reaching 16.2 per 1,000 Medicaid beneficiaries in Q4 2024. Prescription rates for obesity-indicated GLP-1s were higher in states with coverage and showed no consistent patterns across states with different utilization management requirements. GLP-1 prescriptions were more common in managed care than fee-for-service plans. GLP-1 prescribing varies substantially across state Medicaid coverage environments, underscoring the importance of monitoring how utilization evolves as state coverage policies change.
Background: Medicare payment models have adopted social risk adjustment, which adjusts benchmarks based on area-level indices of socioeconomic disadvantage, such as the Area Deprivation Index (ADI). Although the association between ADI and outcomes is well-established, it is unclear whether this association persists after performing clinical risk adjustment. Our objective was to determine whether Medicare beneficiaries living in disadvantaged neighborhoods have higher mortality than expected on the basis of clinical risk adjustment alone. Methods: We conducted a retrospective, cross-sectional study using a 20% sample of 2018 to 2019 Medicare claims. Exposures included beneficiary-level Hierarchical Condition Category (HCC) score components and ADI decile. The primary outcome was mortality. Results: The study included 4,477,014 Medicare beneficiaries. Excess mortality in the highest ADI decile (most disadvantaged) was significantly higher (0.5 percentage points; 95% CI, 0.4–0.6) compared to the middle decile. Conclusion: Socioeconomic disadvantage remained associated with mortality in excess of that expected after clinical risk adjustment.
With more than half of Medicare beneficiaries choosing to receive their coverage through private Medicare Advantage plans, more evidence is needed to understand Medicare Advantage enrollment of marginalized populations, including transgender beneficiaries. In this cross-sectional analysis of 60,797 transgender and 403,357 cisgender beneficiaries from 2012 to 2023, cisgender beneficiaries had a 3.14% higher probability of Medicare Advantage enrollment compared with transgender beneficiaries. In addition, we found significant variability in Medicare Advantage enrollment among transgender and cisgender beneficiaries by observed covariates (e.g., race, age, original reason for Medicare entitlement). Overall, there are differential trends in Medicare Advantage enrollment by gender identity and other characteristics, including race, ethnicity, age, and other demographics.
This article synthesizes findings from studies included in a special issue of Medical Care Research and Review ( MCRR) about consolidation in U.S. health care. Articles are grouped thematically, with findings discussed relative to the existing literature on the impact of consolidation on outcomes such as price, expenditures, access, and quality of care delivered. The article highlights key limitations and offers the following suggestions to better inform public policy, regulation, and new payment models: (a) traditional market definitions should be reconsidered given the evolution of consolidation and its impact on the contestability of markets; (b) fair and efficient pricing requires knowledge of production costs, which is currently limited; (c) payment, policy, and regulatory options should better account for the unique challenges in rural markets; (d) state policy change, including examination of existing provider licensing laws, could yield market improvements; and (e) continued investments in data infrastructure are needed to mitigate the potential negative effects of consolidation.
Hospital bypass by rural obstetric patients contributes to low patient volumes at rural hospitals, limiting revenues and eroding the viability of the obstetric service line. Bypass by commercially insured patients is particularly concerning for hospital finances because commercial insurers reimburse hospitals at higher rates than public insurers for obstetric services. Using commercial claims, we characterized bypass among rural obstetric patients with commercial insurance and calculated hospital payments generated by bypass admissions. Half of rural obstetric patients bypassed their nearest obstetric hospital between 2016 and 2021. Bypass rates were higher when the nearest obstetric hospital was in a noncore or urban-adjacent county, had low birth volumes, or lacked higher-level neonatal services. Bypass rates increased when patients had another nearby hospital option or higher clinical risk. However, bypass by low-risk patients was common and generated $536 million in payments to admitting hospitals, suggesting a meaningful role for obstetric bypass in influencing rural hospital finances.
