This economic evaluation examines trends in enrollment, premiums, and advance premium tax credits for insurance plans.

IMPORTANCE Nonprofit hospitals are under increasing scrutiny to justify the generous tax benefit they receive due to their tax-exempt status. Quantifying the value of the tax benefit they receive at the federal, state, and local levels is critical for designing informed public health policies and ensuring nonprofit hospitals' taxpayer accountability. OBJECTIVE To estimate the financial benefit that nonprofit hospitals derive from their tax-exempt status and assess how the benefit is distributed across state and local communities. DESIGN, SETTING, AND PARTICIPANTS Using methodologies and measures consistent with current tax law and practice and data from 2021 Medicare Cost Reports, this study calculated the total financial benefit from nonprofit hospitals' tax-exempt status for all US nonprofit hospitals with the required Cost Reports data. MAIN OUTCOMES AND MEASURES Nonprofit hospitals' total tax benefit, which equals the sum of federal and state income tax, sales tax, property tax, the fair market value of charitable contributions from donors, savings from tax exemptions on issued bonds, and federal unemployment tax. RESULTS A total of 2927 US nonprofit hospitals received a $37.4 billion total tax benefit in 2021 from federal income tax ($11.5 billion; 31%), sales tax ($9.1 billion; 24%), property tax ($7.8 billion; 21%), state income tax ($3.7 billion; 10%), charitable contributions ($3.2 billion; 8%), bond financing ($2.1 billion; 6%), and federal unemployment tax ($200 million; <1%). Tax benefit varied substantially across states, from $25 098 (Delaware) to $159 464 (Massachusetts) per hospital bed and from $19 (Alabama) to $275 (Massachusetts) per capita. Tax benefit was highly concentrated, with 7% (n = 212) of hospitals accounting for half of the total amount. CONCLUSION AND RELEVANCE This study highlights the wide variation of nonprofit hospitals' tax benefit across states, its high concentration among a small number of hospitals, and the primary role played by state and local taxes. Policy efforts to strengthen nonprofit hospitals' taxpayer accountability are likely to be more effective when pursued at the local level. The detailed standardized estimation road map can be used by various stakeholders to estimate tax benefit for external valuation and reporting purposes, updated as laws change, and improved upon as better data sources become available.

This Viewpoint considers supply- instead of buy-side pressure to address the inflated cost of basic health services provided by hospitals.

Policymakers are increasingly interested in quantifying nonprofit hospitals’ tax benefits to assess whether hospitals’ nonprofit status is justified. Property taxes that nonprofits would otherwise pay are among the more difficult tax benefit to quantify. This paper aims to educate stakeholders on the issues with estimating nonprofit hospitals’ property tax benefits. We focus on Indiana because of relative advantages in its property tax record system. We first use a statewide database that identifies tax-exempt hospital properties to estimate property tax savings for all nonprofit hospitals in the state. We then examine five counties to quantify property tax benefits for specific hospitals. Using statewide data, we estimate a total property tax savings of $75.3 million in 2020 for all nonprofit hospitals in Indiana. However, upon closer examination of the five selected counties, we find that the state’s identification code for hospital properties fails to identify over 500 property accounts associated with the nonprofit hospitals. Allowing for these additional properties increases nonprofit hospitals’ tax savings in these counties by about 71%. These results suggest that our statewide estimate most likely understates nonprofit hospitals’ property tax benefits by a significant amount. If statewide estimates were comparably understated, property tax savings in 2020 for all nonprofit hospitals in Indiana would be closer to $128 million. We conclude with policy recommendations.

This cross-sectional study investigates commercial facility fee differences for colonoscopy procedures between US hospitals and ambulatory surgery centers located within the same county and contracting with the same insurers.

This study compares Medicare and patient spending for dual over-the-counter and prescription drugs with their over-the-counter cash prices.

This cross-sectional study compares commercial negotiated prices and cash prices between physician-owned hospitals and other hospitals in the same hospital referral region (HRR) using price information available through the Hospital Price Transparency Rule.

This cross-sectional study examines the purpose, revenues, profitability, and lobbying expenses of social welfare organizations in the US health care system.

This economic evaluation compares trends in premiums, claims, and enrollment among fully insured large group, small group, and individual health plans in the US from 2001 to 2021.

Objective: To assess the federal COVID-19 vaccine mandate's effects on nursing homes' nurse aide and licensed nurse staffing levels in states both with and without state-level vaccine mandates. Design: Cross-sectional study using data from Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, and Economic Innovation Group. Including nursing home facility fixed effects provides evidence on the intertemporal effects of the federal vaccine mandate within nursing homes. Setting and Participants: The sample contains 15,031 nursing homes, representing all US nursing homes with available data. Methods: On January 13, 2022, the US Supreme Court upheld the federal COVID-19 vaccine mandate for health care workers in Medicare-and Medicaid-eligible facilities, with workers generally required to be vaccinated by March 20, 2022 (ie, the compliance date). We examined actual nursing home staffing levels in 3 time periods: (1) pre-Court decision; (2) precompliance date; and (3) postcompliance date. We separately examined staffing levels for nurse aides and licensed nursing staff. Because 28% of nursing homes were in states with state-imposed vaccine mandates that predated the Supreme Court's ruling, we divided the sample into 2 groups (nursing homes in mandate states vs nonmandate states) and performed all analyses separately. Results: Staff vaccination rates and staffing levels were higher in mandate states than nonmandate states in all 3 time periods. After the Court's decision, staff vaccination rates increased 5% in nonmandate states and 1% in mandate states (on average). We find little evidence that the Court's vaccine mandate ruling materially affected nurse aide and licensed nurse staffing levels, or that nursing homes in mandate states and nonmandate states were differentially affected by the Court's ruling. Staffing levels over time were generally flat, with some evidence of a modestly greater increase for nurse aide staffing in mandate states than nonmandate states, and a modestly smaller decrease for licensed nurse staffing in mandate states than nonmandate states. Finally, regression results suggest that for both nurse aides and licensed nurses, staffing levels were lower in rural and for-profit nursing homes, and higher in Medicare-only, higher quality, and hospital-based nursing homes. Conclusions and Implications: Results suggest the federal COVID-19 vaccine mandate has not caused clinically material changes in nursing home's nurse aide and licensed nurse staffing levels, which continue to be primarily associated with factors that are well-known to researchers and practitioners. (c) 2023 AMDA -The Society for Post-Acute and Long-Term Care Medicine.

This economic evaluation examines the magnitude and trend of prescription drug rebates in commercial markets from 2015 to 2019 and identifies insurance plan factors associated with rebates.

The Quality Incentive Program (QIP) distributed US$2 billion to nursing homes (NHs) that met performance goals primarily related to their COVID-19 infection rates. We examine how QIP affected 15,331 NHs with different facility and community attributes, and the extent to which QIP payments per resident-week (QIP$) were associated with NHs’ COVID-related attributes. We find that QIP$ was primarily determined by county (not facility) infection rates. QIP distributed US$2 billion to NHs for months in which they experienced virtually no COVID-19 cases; US$0 was distributed for months in which they experienced more than 300,000 cases. We find that QIP$ was larger for smaller, nonprofit NHs located in more rural and economically distressed communities. Regression analyses reveal that recipients of larger QIP$ maintained greater supplies of personal protective equipment, conducted more staff testing, and limited admissions of infected residents, and that greater staff testing and limited admissions are also associated with NHs’ sustained success in receiving QIP payments. Policymakers should consider whether performance-based payment systems are optimal for addressing public health emergencies.

We use plan-level data to examine a reporting incentive unique to health insurers—the federal Affordable Care Act’s (ACA’s) Medical Loss Ratio (MLR) provisions—which require that health plans spend a specified percentage of premiums on claims or else pay policyholder rebates. While there are no penalties for noncompliance with the MLR provisions, incentives for insurers to comply include avoiding political and reputation costs, reducing administrative burdens, and eliminating rebate payments. We find that health plans with pre-managed MLRs— i.e., the MLRs that would be reported without reporting discretion—below the required MLR overstate claims, thereby increasing their MLRs and reducing or eliminating rebate payments. Overall, results suggest that overstating claims reduced rebate payments by approximately $190 million to $325 million for 20112013; i.e., about 10–17% of total rebates actually paid. We also find that plans with pre-managed MLRs significantly greater than the minimum required MLR understate claims, thereby improving plan earnings while still complying with the MLR provisions. These understatements average between 14–34% of plans’ pre-tax earnings.

ABSTRACT We examine whether skilled nursing facilities' (SNFs') cost structures vary based on their Medicaid payment systems: fixed-price (FXP) or cost-plus (C+). FXP systems—which tie payments to patient conditions, rather than costs—increase SNFs' operating risk by decreasing the association between revenues and costs. Results suggest that cost elasticities are greater in SNFs that operate primarily under FXP, with weaker results in non-profit SNFs compared with for-profit SNFs. We conclude that SNFs' cost structures are managed in part based on the operating risk resulting from their payment systems. We also find that, under FXP, managers of for-profit SNFs introduce more variable costs into their cost structures by deploying more contract labor. Finally, we show that greater use of contract labor by for-profit SNFs in FXP settings is concentrated below the registered nurse skill level. For non-profit SNFs, we find no differences in contract labor across payment types. Data Availability: All data are publicly available from sources indicated in the text.

Beginning January 1, 2020, Medicare’s Patient-Driven Groupings Model (PDGM) eliminated therapy as a direct determinant of Home Health Agencies’ (HHAs’) reimbursements. Instead, PDGM advances Medicare’s shift toward value-based payment models by directly linking HHAs’ reimbursements to patients’ medical conditions. We use 3 publicly-available datasets and ordered logistic regression to examine the associations between HHAs’ pre-PDGM provision of therapy and their other agency, patient, and quality characteristics. Our study therefore provides evidence on PDGM’s likely effects on HHA reimbursements assuming current patient populations and service levels do not change. We find that PDGM will likely increase payments to rural and facility-based HHAs, as well as HHAs serving greater proportions of non-white, dual-eligible, and seriously ill patients. Payments will also increase for HHAs scoring higher on quality surveys, but decrease for HHAs with higher outcome and process quality scores. We also use ordinary least squares regression to examine residual variation in HHAs’ expected reimbursement changes under PDGM, after accounting for any expected changes related to their pre-PDGM levels of therapy provision. We find that larger and rural HHAs will likely experience residual payment increases under PDGM, as will HHAs with greater numbers of seriously ill, younger, and non-white patients. HHAs with higher process quality, but lower outcome quality, will similarly benefit from PDGM. Understanding how PDGM affects HHAs is crucial as policymakers seek ways to increase equitable access to safe and affordable non-facility-provided healthcare that provides appropriate levels of therapy, nursing, and other care.

The Affordable Care Act's medical loss ratio (MLR) provisions require that health insurers spend a minimum percentage of premiums on medical costs, thereby limiting administrative costs and profits. Analyses of annual MLR changes indicate that plans both below and above the minimum MLR manage their ratios toward the minimum standard. Our finding that plans with excess MLR manage their MLRs downward suggests that compliant plans exploit their MLR "cushions," thus increasing profits while typically continuing to satisfy the MLR requirement. We show that 52 percent of noncompliant plans in a given year subsequently become compliant, while 14 percent of compliant plans subsequently become noncompliant.

The Affordable Care Act (ACA) imposed new restrictions on the formation and expansion of physician-owned hospitals. These restrictions provided incentives for the hospitals and their owners to take preemptive actions before the effective dates of ACA provisions and modify their operations thereafter. We studied 106 physician-owned hospitals in Texas to determine how they responded to ACA restrictions. We found that there were significant pre-ACA increases in the formation, physician ownership, and physical capacity of physician-owned hospitals, which suggests that they reacted quickly to the policy changes. After the ACA's provisions took effect, the hospitals improved the use of their assets to generate increased amounts of services, revenue, and profits. We found no evidence that existing physician-owned hospitals stopped accepting Medicare to avoid the ACA restrictions, although some investors adopted a seemingly unsuccessful strategy of not accepting Medicare at physician-owned hospitals formed after implementation of the ACA. We conclude that the ACA restrictions effectively eliminated the formation of new physician-owned hospitals, thus accomplishing what previous legislative efforts had failed to do.

This descriptive study shows how the government-wide financial statements can be used, with adjustments, to provide evidence on a state's fiscal sustainability. We compute “adjusted total net assets”(AdjTNA), which equals a state’s assets (not including its capital assets) minus the state's liabilities and obligations, including the UAAL for pension and OPEB not reported on the Statement of Net Assets.AdjTNAprovides information about a state’s ability to sustain its current fiscal structure, given its current financial resources. Primary results suggest that 40 states have a negativeAdjTNAvalue, with a median -$6.7 billion per state (-$5,230 per household). Sensitivity analysis suggests 48 states have a negativeAdjTNAvalue, with a median -$20.7 billion per state (-$16,200 per household). The paper discusses the important policy implications of these results.