OBJECTIVE:To assess whether Medicare Advantage (MA) beneficiaries in socially vulnerable counties face more restrictive prior authorization (PA) requirements. STUDY DESIGN:Cross-sectional analysis of 2945 US counties in 2022. METHODS:The primary outcome was the mean percentage of Medicare-covered service categories requiring PA across all MA plans in a county, adjusted for service mix and plan enrollment and derived from the CMS MA benefit, landscape, and enrollment files. Secondary outcomes included county-level PA rates for selected service categories, the number of plans with more vs less restrictive PA policies, and mean monthly premiums. The exposure was the county-level Social Vulnerability Index (SVI) subdomains (socioeconomic status, household characteristics, racial/ethnic minority status, housing and transportation), categorized into deciles. Unadjusted linear regression models were used, weighted by county MA enrollment. RESULTS:Counties in the highest vs lowest SVI decile in the socioeconomic domain had overall PA rates that were 7.2 percentage points (PP) higher ( P  < .001), with the largest gap for psychiatric services (16.9 PP; P  < .001). Conversely, mean monthly premiums declined across socioeconomic deciles, from $29 in the first decile to $8 in the 10th ( P  < .001). Total plan counts were stable across deciles, but the composition differed: The most vulnerable counties offered 5 fewer plans with less restrictive PA policies and 4 more plans with more restrictive policies (both P  < .001). CONCLUSIONS:MA beneficiaries in socially vulnerable counties face more restrictive PA requirements, especially for psychiatric services. These disparities may compound existing structural barriers and warrant consideration in future MA policy reforms.

Low-value services (LVS) are those that “… provide little to no benefit to patients….”1 Among an existing set of 31 LVS are invasive procedures not typically performed by primary care physicians (PCPs), and other LVS that may be commonly provided by specialists. To facilitate research on the role of primary care physicians in low-value care, we sought to identify the reliability of two subsets of LVS measures that are more directly subject to PCPs’ decisions. We refer to these as primary care adjacent (“PCA”) LVS measures. Retrospective observational cohort study to identify which of a 31-item LVS measure set were most commonly performed, ordered, or referred by PCPs and examine the reliability of subsets of PCA-LVS measures. Setting was primary care practices in the Comprehensive Primary Care Plus (CPC+) model evaluation. 5,741,061 Medicare fee-for-service (FFS) beneficiaries attributed to 11,910 practices and 40,981 physicians in 2018 were observed. Based on percentages of LVS commonly performed, ordered, or referred by PCPs, we defined a 4-item and an 11-item PCA-LVS measure. We compared the reliability of the 4-item, 11-item, and 31-item LVS measure sets using Spearman ρ (rho) rank-order correlation and the Intra-Class correlation coefficient (ICC). Limitations included that PCP performing, ordering, and referring data are not available in all claims. Claims-based analyses of diagnosis codes may misclassify some appropriate services as PCA-LVS. The 4-item PCA-LVS measure has a significantly higher mean reliability estimate than the original 31-item measure in identifying PCPs who provide low versus high rates of LVS. The 11-item PCA-LVS measure also had significantly higher reliability than the 31-item measure but lower reliability than the 4-item measure. We identified two LVS subsets reflecting LVS events most influenced by PCPs. Further work will be required to ascertain how best to use this or related PCA-LVS measures to enhance the quality of primary care.

INTRODUCTION:To examine if Medicare beneficiaries attributed to Comprehensive Primary Care Plus (CPC+) practices had a greater decrease in the potential overuse of prescription opioids relative to beneficiaries attributed to other primary care practices. Primary care practices that participated in CPC+ received enhanced Medicare payment to support five functions: access and continuity of care, care management, comprehensiveness and coordination, patient and caregiver engagement, and planned care and population health. CPC+ practices participated within two tracks starting in 2017; Track 2 practices received larger payments to support more enhanced care delivery than Track 1 practices. METHODS:Employing difference-in-differences, we used Medicare claims and Part D data to examine changes in potential opioid overuse between 2016 (baseline) and 2021 (the fifth program year). Our measure of potential opioid overuse measure relies on specifications for an existing quality measure of the same name that is defined as filling opioid prescriptions at a daily dosage of 90 morphine milligram equivalents or more among beneficiaries who use opioids for at least 90 days of supply per year. A total of 40,219 Medicare fee-for-service beneficiaries used opioids long term and were attributed to 2888 CPC+ practices; 129,178 beneficiaries used opioids long term and were attributed to 6921 comparison practices. RESULTS:Across the combined treatment and comparison groups, potential opioid overuse decreased from 19 % in 2016 to 12 % in 2021. Relative to the comparison group, beneficiaries attributed to Track 1 CPC+ practices experienced an 0.8 percentage point greater decrease in potential opioid overuse (95 % CI = -1.4, -0.2) in the third program year compared to baseline. These findings persisted in the fourth and fifth years and were similar in magnitude to those in the third year. Track 2 results were similar to Track 1 results. The findings were likely driven by changes in CPC+ clinicians' prescribing behaviors: clinicians in CPC+ practices reduced the average dosage and the number of days' supply of prescription opioids more than clinicians in comparison practices. CONCLUSIONS:A large-scale primary care delivery transformation initiative was associated with reduced potential opioid overuse among Medicare beneficiaries.

IMPORTANCE Implemented in 18 regions, Comprehensive Primary Care Plus (CPC+) was the largest US primary care delivery model ever tested. Understanding its association with health outcomes is critical in designing future transformation models. OBJECTIVE To test whether CPC+ was associated with lower health care spending and utilization and improved quality of care. DESIGN, SETTING, AND PARTICIPANTS Difference-in-differences regression models compared changes in outcomes between the year before CPC+ and 5 intervention years for Medicare fee-for-service beneficiaries attributed to CPC+ and comparison practices. Participants included 1373 track 1 (1 549 585 beneficiaries) and 1515 track 2 (5 347 499 beneficiaries) primary care practices that applied to start CPC+ in 2017 and met minimum care delivery and other eligibility requirements. Comparison groups included 5243 track 1 (5 347 499 beneficiaries) and 3783 track 2 (4 507 499 beneficiaries) practices, matched, and weighted to have similar beneficiary-, practice-, and market-level characteristics as CPC+ practices. INTERVENTIONS Two-track design involving enhanced (higher for track 2) and alternative payments (track 2 only), care delivery requirements (greater for track 2), data feedback, learning, and health information technology support. MAIN OUTCOMES AND MEASURES The prespecified primary outcomewas annualized Medicare Part A and B expenditures per beneficiary per month (PBPM). Secondary outcomes included expenditure categories, utilization (eg, hospitalizations), and claims-based quality-of-care process and outcome measures (eg, recommended tests for patients with diabetes and unplanned readmissions). RESULTS Among the CPC+ patients, 5% were Black, 3% were Hispanic, 87% were White, and 5% were of other races (including Asian/Other Pacific Islander and American Indian); 85% of CPC+ patientswere older than 65 years and 58% were female. CPC+ was associated with no discernible changes in the total expenditures (track 1: $1.1 PBPM [90% CI, -$4.3 to $6.6], P =.74; track 2: $1.3 [90% CI, -$5 to $7.7], P =.73), and with increases in expenditures including enhanced payments (track 1: $13 [90% CI, $7 to $18], P <.001; track 2: $24 [90% CI, $18 to $31], P <.001). Among secondary outcomes, CPC+ was associated with decreases in emergency department visits starting in year 1, and in acute hospitalizations and acute inpatient expenditures in later years. Associationswere more favorable for practices also participating in the Medicare Shared Savings Program and independent practices. CPC+ was not associated with meaningful changes in claims-based quality-of-care measures. CONCLUSIONS AND RELEVANCE Although the timing of the associations of CPC+ with reduced utilization and acute inpatient expenditures was consistent with the theory of change and early focus on episodic care management of CPC+, CPC+ was not associated with a reduction in total expenditures over 5 years. Positive interaction between CPC+ and the Shared Savings Program suggests transformation models might be more successful when provider cost-reduction incentives are aligned across specialties. Further adaptations and testing of primary care transformation models, as well as consideration of the larger context in which they operate, are needed.

Objective To examine characteristics of beneficiaries, physicians, and their practice sites associated with greater use of low-value services (LVS) using LVS measures that reflect current care practices. Data Sources This study was conducted in the context of a large, nationwide primary care redesign initiative (Comprehensive Primary Care Plus), using Medicare claims data in 2018. Study Design We examined beneficiary-level total counts of LVS based on the existing 31 claims-based measures updated by excluding three services provided with diminishing frequency to Medicare beneficiaries and by replacing these with more recently identified LVS. We estimated hierarchical linear models with an extensive list of beneficiary, physician, and practice site characteristics to examine the contribution of characteristics at each level in predicting greater use of LVS. We also examined the proportion of variation in LVS use attributable to the set of characteristics at each level. Data Collection/Extraction Methods The study included 5,074,642 Medicare fee-for-service beneficiaries attributed to 32,406 primary care physicians in 11,009 primary care practice sites. Principal Findings Patients with disabilities, end-stage renal disease, and those in regions with higher poverty rates receive 10 (standard error [SE] = 3.0), 80 (SE = 14.0), and 10 (SE = 1.0) more LVS per 1000 beneficiaries across all 31 measures combined than patients without such attributes, respectively. Greater physician comprehensiveness and an increase in the number of primary care practitioners at a practice were associated with 40 (SE = 20.0) and 20 (SE = 6.0) fewer LVS per 1000 beneficiaries, respectively. Yet, the explanatory variables we examined only account for 11 percent of the variation in LVS use, with most of the variation (87 percent) being due to unobserved differences at the beneficiary level. Conclusions Unexplained residual variation, from underlying patient preferences and behavior of non-primary care providers, could be important determinants of LVS use.

BACKGROUND:States had flexibility in their implementation of the Patient Protection and Affordable Care Act (ACA) Medicaid expansions, which may have led to variation in coverage and changes in access to care for workers with disabilities. OBJECTIVE/HYPOTHESIS:To examine differential trends in health insurance coverage and access to care among workers with disabilities by states' decisions about expanding Medicaid under the ACA. METHODS:We aggregated data from the National Health Interview Survey into groups by time period relative to ACA implementation: pre-ACA (2006-2009), early ACA (2010-2013), and later ACA (2014-2017). We produced health insurance and access statistics for each time period, by state-level Medicaid expansion status. RESULTS:Uninsurance rates decreased after 2014 in all states, regardless of the state's decision whether to expand Medicaid. There was a substantial increase after 2014 in the share of workers with disabilities covered by Medicaid in states that expanded in that year; in other states, workers with disabilities experienced larger increases in privately purchased coverage. At the same time, the share of workers with disabilities reporting cost-related barriers to care declined markedly in 2014 Medicaid expansion states, but it increased slightly in the non-expansion states. Structural barriers to accessing care increased in all states, with the smallest increase in 2014 expansion states. CONCLUSIONS:Medicaid coverage and cost-related access to care improved significantly among workers with disabilities in 2014 Medicaid expansion states, both overall and relative to workers with disabilities in non-expansion states.

Under the prospective payment system (PPS), hospitals receive a bundled payment for an entire episode of treatment based on diagnosis-related groups (DRG). Although there is ample evidence regarding the impact of the introduction of the PPS, there is little research on the effects of the ensuing changes in payment levels under the PPS. In 2005, the Medicare PPS changed its definition of payment areas from the Metropolitan Statistical Areas to the Core-Based Statistical Areas, generating substantial area-specific price shocks. Using these exogenous price variations, this study examines hospital responses to price changes under the PPS. The results demonstrate that, while the average payment amount significantly increases in the affected areas, no parallel trend is observed in admission volume, treatment intensity, and quality of services. Conversely, hospitals facing a price increase are more liable to the perverse incentives that the PPS is known to encourage, namely, selecting or shifting patients into higher-paying DRGs. These results suggest that paying a higher price for a given service may not induce hospitals to offer services of better quality, but can rather prompt even higher payments through other behavioral responses.

Introduction: Scholarly interest in time preference as a potential predictor of risky health behaviors in adolescents has increased in recent years. However, most of the existing literature is limited due to the exclusive reliance on cross-sectional data, precluding the possibility of establishing the direction of causality. Using longitudinal data from the Korea Youth Panel Survey (2003-7), which followed up a nationally representative sample of 3449 adolescents aged 14 years for five years, this study examines a bidirectional relationship between time preference and smoking and drinking behaviors among adolescents.Methods: We used discrete time hazard models of smoking and drinking initiation as a function of time preference measured at the baseline and fixed-effects ordered logit model of time preference, respectively. Our measure of time preference was derived from the survey question on a hypothetical choice between immediate enjoyment today and likely higher scores on an exam tomorrow.Results: The overall results provide evidence on the bidirectional relationship; that is, higher time discounting (i.e., greater relative preference for present utility over future utility) results in an increased risk of engaging in smoking and drinking, and conversely, adopting such behaviors leads to a higher discount rate.Conclusions: The bidirectional relationship may function as a mechanism for adolescents to engage in increased smoking and drinking or additional negative health behaviors via gateway effects, strengthening the case for preventing the initiation of risky health behaviors among adolescents. (C) 2017 Elsevier Ltd. All rights reserved.

ABSTRACT South Korea's old-age poverty rate is among the highest in the developed world. Confronted with the increasing demand for a social safety net for older people, the South Korean government introduced the Basic Old-Age Pension (BOAP) in 2008. The BOAP is a non-contributory, means-tested pension covering 70 per cent of the elderly population, with monthly benefits amounting to 84 kW (thousand Korean won, approximately equivalent to US $1) for singles and 139 kW for couples. Little empirical research has been conducted, however, to evaluate the effectiveness of the new pension programme in supporting the financial wellbeing of older people. Using data from the 2008–2010 Korea Welfare Panel Study, a panel data analysis is conducted to estimate the effects of the BOAP on three sets of financial wellbeing measures: financial difficulty, monthly consumption and overall financial satisfaction. The results suggest that the BOAP has beneficial effects on the financial wellbeing of older people by improving affordability of basic subsistence items such as heating and nutritious meals, particularly among the older-old group. However, the effects are limited to these few outcomes only; overall financial wellbeing and other important indicators remain unchanged.

Objective: This study aimed to examine the associations of self-reported sleep duration with adolescent health outcomes, taking into account time spent on Internet use.Methods: We used data from the 2008-2009 Korea Youth Behavioral Risk Factor Survey, a cross-sectional online survey of middle and high school students aged 13-18 years in South Korea (N = 136,589) to examine the associations of self-reported sleep duration with four mental and physical health measures, e.g. self-report of depressive symptoms, suicidal ideation, weight status, and self-rated health. The binary logit and generalized ordered logit models controlled for time spent on Internet use for non-study purposes and other factors.Results: Shorter self-reported sleep duration was associated with a higher likelihood of reporting depressive symptoms, suicidal ideation, and overweight or obese status, and a lower likelihood of reporting better self-rated health, even after accounting for time spent on Internet use. Excessive Internet use was found to be an independent risk factor for these outcomes.Conclusions: Among in-school adolescents in South Korea, shorter sleep duration and excessive Internet use are independently and additively associated with multiple indicators of adverse health status. Excessive Internet use may have not only direct adverse health consequences, but also have indirect negative effects through sleep deprivation. (C) 2012 Elsevier B. V. All rights reserved.