BACKGROUND:Employers are increasingly seeking strategies to manage rising health care costs, including bundling or carving out specific benefits like pharmacy coverage. Although some studies suggest that integrating medical and pharmacy benefits leads to reduced medical costs, the mechanism remains unclear. OBJECTIVE:To evaluate the impact of bundling medical and pharmacy benefits on medical costs and utilization among self-funded employer groups and explore the potential role of population health management programs (PHMPs) as a mechanism for driving savings. METHODS:This retrospective, propensity score-matched, longitudinal cohort analysis used administrative claims data from a large health plan in Southeastern Pennsylvania. Self-funded group plan participants were included in the analysis if they had integrated medical and pharmacy benefits in both 2022 and 2023 (integrated group) or if they lacked integrated benefits in either year (comparison group). We additionally required that these plan participants did not experience major changes to their population health management benefits. Doubly robust models, adjusting for concurrent risk scores, were used to compare changes in per-member per-month (PMPM) medical costs and per-1,000-members per-year utilization between the integrated and nonintegrated groups. Propensity score matching was employed to create balanced comparison groups. RESULTS:Members with integrated pharmacy benefits experienced a statistically significant reduction of $32.48 PMPM (7.5%) in total medical cost growth relative to the nonintegrated benefits group. This reduction was largely driven by lower inpatient ($13.27 PMPM, 13.5%) and emergency department ($1.35 PMPM, 4.7%) spending. For members with a PHMP benefit, integrated pharmacy was associated with greater estimated savings ($39.28 PMPM, 9.0%) compared with those without integrated pharmacy. Additionally, members with integrated benefits were estimated to have a greater probability (10.9%) of outreach by a PHMP nurse compared with those without integrated pharmacy. CONCLUSIONS:Bundling medical and pharmacy benefits was associated with reduced medical cost growth, particularly in inpatient and outpatient settings. Coordination activities like PHMPs, enabled by data integration from bundled benefits, may be a key mechanism for achieving cost savings. These results support the consideration of benefit integration strategies for employers seeking to optimize health care spending and improve care management.

OBJECTIVES:To examine the determinants of unmet transcatheter aortic valve replacement (TAVR) needs and their impact on patient survival among Medicare beneficiaries with aortic stenosis. METHODS:We developed a county-level mismatch score measuring the gap between actual TAVR procedures performed and expected need based on population differences. Counties were classified as metropolitan, semiurban, or rural. Factors associated with larger mismatches were identified, and mortality rates among aortic stenosis (AS) patients were examined in relation to mismatch scores. We analyzed Medicare data from 2016 to 2022 across 3129 US counties. The mismatch score was developed to account for population differences and county urbanicity classification. Statistical analyses identified factors associated with TAVR mismatch and its relationship to mortality outcomes. RESULTS:We found substantial geographic variation in TAVR delivery. Counties with higher TAVR mismatch scores showed associations with fewer TAVR-providing hospitals, less market concentration, higher AS prevalence, and lower household incomes. Counties with greater gaps between needed and actual TAVR procedures were also associated with higher mortality rates. This relationship between mismatch and mortality was particularly strong in semiurban counties. CONCLUSIONS:Our findings identify associations between TAVR access gaps and patient outcomes, as well as factors linked to these access patterns. Counties with higher TAVR mismatch scores showed correlations with healthcare capacity constraints, geographic location, and socioeconomic factors. These associations suggest that mismatches may be addressed through targeted approaches based on local needs to improve care delivery for patients with AS in regions currently experiencing access challenges.

This study investigates the impact of geographic and socioeconomic barriers on access to transcatheter aortic valve replacement (TAVR). Utilizing Medicare data from the US Centers for Medicare and Medicaid Services, this study analyzed TAVR and surgical aortic valve replacement (SAVR) procedures among beneficiaries from 2017 to 2022. Geographic units were defined by 5-digit zip codes, categorized on the basis of TAVR/SAVR volume into four categories: (1) no TAVR or SAVR, (2) no-TAVR zone (SAVR present, no TAVR), (3) low-TAVR zone (TAVR/SAVR ratio ≤ 0.5), and (4) TAVR accessible (TAVR/SAVR ratio > 0.5). The differential distance index (DDI) was developed to measure travel hurdles, calculated as the difference in miles from a patient’s zip code center to the treatment hospital (TAVR versus SAVR, CABG (coronary artery bypass grafting), and PCI (percutaneous coronary intervention) comparators). This study maintained a continuous access variable to model outcomes such as the ratio or volume of TAVR/SAVR and the percentage share of TAVR/AVR within each zip code over biennial periods (2017–2018, 2019–2020, 2021–2022). Covariates in the model included population density, area deprivation index (ADI), and calendar time, with an exploration of the interaction between DDI and ADI. The analysis revealed significant geographic disparities in TAVR access across the USA, with no-TAVR zone and low-TAVR zone areas often featuring lower population densities, higher ADIs, and more rural settings. Increased travel distance (DDI) significantly correlated with lower TAVR utilization, emphasizing distance as a critical barrier. Furthermore, both ADI and DDI emerged as significant predictors of TAVR volume and share, underlining the compound effect of socioeconomic status and geographic distance on healthcare access. This study highlights the critical role of geographic and socioeconomic barriers in accessing advanced medical treatments like TAVR. Addressing these barriers may ensure equitable healthcare distribution, guiding policymakers and providers towards more accessible healthcare solutions for all populations.

Introduction We sought to measure the revenues, costs, and contribution margins (CMs) for major inpatient cardiovascular procedures in the Medicare population in years 2016-2019, evaluate the differences in CMs across procedures, and identify temporal trends in CMs. Methods Claim-level costs were calculated using cost-to-charge ratios and subsequently Winsorized to adjust for outliers, and CMs were assessed as the difference between revenue and costs. Results and Discussion We found that revenues, costs, and CMs vary widely across major inpatient cardiovascular procedures and that rapidly proliferating cardiovascular procedures contribute sizeable net CMs to US hospitals. (Am Heart J 2025;281:43-48.)

OBJECTIVE:To evaluate the impact of a digital platform that connects primary care providers and commercially insured adults to outpatient behavioral health services on behavioral health utilization and total medical costs. STUDY DESIGN:A matched difference-in-differences approach was used to assess the effects of the intervention. Data were obtained from administrative medical claims for commercially insured adults. METHODS:The intervention group consisted of members assigned to 735 practices that adopted the platform, and the comparison group included members from 516 practices that did not. Propensity score matching was employed to balance baseline characteristics, and doubly robust difference-in-differences analysis was applied to estimate the intervention's effects on outpatient behavioral health visits, emergency department (ED) visits, inpatient admissions, and total medical costs over 18 months. RESULTS:The intervention group had a 68% higher likelihood of receiving outpatient behavioral health services. They were 35% less likely to have a behavioral health-related ED visit and 43% less likely to be admitted for behavioral health-related inpatient care. Despite increased outpatient utilization, total medical costs were significantly lower in the intervention group (-$27.63 per member per month at 18 months post intervention). CONCLUSIONS:Connecting commercially insured adults to outpatient behavioral health services via a digital platform improves utilization of behavioral health care while reducing costly emergency and inpatient services. These findings suggest that enhancing access to outpatient behavioral health services can lead to better health outcomes and greater cost efficiency in managed care populations.

The COVID-19 pandemic disrupted surgical care delivery, yet the extent to which shifts from inpatient to outpatient settings have persisted remains unclear. Using medical claims data from Independence Blue Cross (2018-2022), we examined changes in surgery settings across 102 procedures before the pandemic and during the 2 years following the suspension of elective surgeries. After 2 years, inpatient volumes decreased for 9 of the 20 most common pre-pandemic inpatient procedures, with corresponding increases in outpatient utilization. Hip and knee replacements experienced the most pronounced shifts, with inpatient shares falling by more than 40 percentage points. Patients from lower-income census tracts saw greater declines in overall procedure volumes (-6.0%) compared to those from higher-income areas (+5.2%). Total allowed amounts decreased for procedures with outpatient migration, while out-of-pocket costs remained stable. These findings suggest durable, post-pandemic shifts in surgical care delivery patterns, with potential implications for access, costs, and equity.

Background: Opportunities to minimize inequities in accessing treatments for tricuspid regurgitation disease should be considered. Objective: The objective of this study was to explore how access to new tricuspid regurgitation technologies change when heart centers are restricted by payer coverage requirements. Methods: This case series study identified U.S. hospitals with a record of performing transcatheter aortic valve replacement, transcatheter edge-to-edge repair, and tricuspid and mitral valve procedures for the calendar year 2021. Population 65+ years of age and Area Deprivation Index (ADI), were identified by zip code. We created 10 scenarios based on low, medium, and high hospital volumes for combinations of transcatheter aortic valve replacement, transcatheter edge-to-edge repair, tricuspid and mitral valve procedures. Distance from a zip code to scenario eligible hospitals was determined; the closest hospital to a zip code was identified as the distance someone with tricuspid regurgitation would have to travel for care. Each scenario was modeled with the dependent variable as the distance to the nearest scenario eligible hospital by ADI, controlling for population size 65+ years of age. Results: A total of 929 U.S. hospitals met our study inclusion. ADI was statistically significant in every scenario—when ADI goes up (more deprivation), distance to the nearest hospital increases. Patients in zip codes with low ADI travel an average of 15 to 52 miles, medium ADI 31 to 67 miles, and high ADI 47 to 95 miles. Conclusions: Patients in higher socioeconomic deprivation areas travel longer distances to hospitals meeting procedure volume requirements. Policymakers and patient advocacy groups should consider this to ensure equitable access to potentially life-saving technologies.

Background To explore how differences in local socioeconomic deprivation impact access to aortic valve procedures and the treatment of aortic valve disease, in comparison to other open and minimally invasive surgical procedures. Methods and Results Procedure volume data were obtained from the Healthcare Cost and Utilization Project from 18 states from 2016 to 2019 and merged with area deprivation index data, an index of zip code‐level socioeconomic distress. We estimate the relationship between local deprivation ranking and differences in volumes of aortic valve replacement, which include transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), versus coronary artery bypass graft surgery and laparoscopic colectomy (LC). All regressions control for state and year fixed effects and an array of zip code‐level characteristics. TAVR procedures have increased over time across all zip codes. The rate of increase is negatively correlated with deprivation ranking, regardless of the higher share of hospitalizations per population in high deprivation areas. Distributional analysis further supports these findings, showing that lower area deprivation index areas account for a disproportionately large share of SAVR, TAVR, and LC procedures in our sample relative to their share of all hospitalizations in our sample. By comparison, the cumulative distribution of coronary artery bypass graft procedures was nearly identical to that of total hospitalizations, suggesting that this procedure is equitably distributed. Regressions show high area deprivation index areas have lower prevalence of SAVR ( β =−15.1%, [95% CI, −26.8 to −3.5]), TAVR ( β =−9.1%, [95% CI, −18.0 to −0.2]), and LC ( β =−19.9%, [95% CI, −35.4 to −4.4]), with no statistical difference in the prevalence of coronary artery bypass graft ( β =−2.5%, [95% CI, −12.7 to 7.6]), a widespread and commonly performed procedure. In the population aged ≥80 years, results show high area deprivation index areas have a lower prevalence of TAVR ( β =−11.9%, [95% CI, −18.7 to −5.2]) but not SAVR ( β =−0.8%, [95% CI, 8.1 to 6.3]), LC ( β =−3.5%, [95% CI, −13.4 to −6.4]), or coronary artery bypass graft ( β =5.2%, [95% CI, −1.1 to 1.1]). Conclusions People living in high deprivation areas have less access to life‐saving technologies, such as SAVR, and even moreso to device‐intensive minimally invasive procedures such as TAVR and LC.

Geographic disparities in access to inpatient procedures are a significant issue within the US healthcare system. This study introduces the Procedure Access Inequality (PAI) index, a standardized metric to quantify these disparities while adjusting for disease prevalence. Using data from the Healthcare Cost and Utilization Project State Inpatient Databases, we analyzed inpatient procedure data from 18 states between 2016 and 2019. The PAI index reveals notable variability in access inequality across different procedures, with minimally invasive and newer procedures exhibiting higher inequality. Key findings indicate that procedures such as skin grafts and minimally invasive gastrectomy have the highest PAI scores, while cesarean sections and percutaneous coronary interventions have the lowest. The study highlights that higher inequality is associated with greater market concentration and in particular, fewer hospitals offering these procedures. These findings emphasize the need for targeted policy interventions to address procedural access disparities to promote more equitable healthcare delivery across the United States.

Background:Opportunities to minimize inequities in accessing treatments for tricuspid regurgitation disease should be considered. Objective:The objective of this study was to explore how access to new tricuspid regurgitation technologies change when heart centers are restricted by payer coverage requirements. Methods:This case series study identified U.S. hospitals with a record of performing transcatheter aortic valve replacement, transcatheter edge-to-edge repair, and tricuspid and mitral valve procedures for the calendar year 2021. Population 65+ years of age and Area Deprivation Index (ADI), were identified by zip code. We created 10 scenarios based on low, medium, and high hospital volumes for combinations of transcatheter aortic valve replacement, transcatheter edge-to-edge repair, tricuspid and mitral valve procedures. Distance from a zip code to scenario eligible hospitals was determined; the closest hospital to a zip code was identified as the distance someone with tricuspid regurgitation would have to travel for care. Each scenario was modeled with the dependent variable as the distance to the nearest scenario eligible hospital by ADI, controlling for population size 65+ years of age. Results:A total of 929 U.S. hospitals met our study inclusion. ADI was statistically significant in every scenario-when ADI goes up (more deprivation), distance to the nearest hospital increases. Patients in zip codes with low ADI travel an average of 15 to 52 miles, medium ADI 31 to 67 miles, and high ADI 47 to 95 miles. Conclusions:Patients in higher socioeconomic deprivation areas travel longer distances to hospitals meeting procedure volume requirements. Policymakers and patient advocacy groups should consider this to ensure equitable access to potentially life-saving technologies.

Objective: In light of Department of Justice investigations of for-profit chains for over-admitting patients, we sought to evaluate whether for-profit hospitals are more likely to admit patients from the emergency department.Data Sources: We used statewide visit-level inpatient and emergency department records from Florida's Agency for Healthcare Administration for 2007-2019.Study Design: We calculated differences in admission rates between for-profit and other hospitals, adjusting for patient and hospital characteristics. We also estimated instrumental variables models using differential distance to a for-profit hospital as an instrument.Data Collection/Extraction Methods: Our main analysis focuses on patients ages 65 and older treated in hospitals that primarily serve adults.Principal Findings: Adjusted admission rates among patients ages 65 and older were 7.1 percentage points (95% CI: 5.1-9.1) higher at for-profit hospitals in 2019 (or 18.8% of the sample mean of 37.8%). Differences in admission rates have remained constant since 2009.Conclusion: Our results are consistent with allegations that for-profit hospitals maintain lower admission thresholds to increase occupancy levels.

Resource allocation generally involves a tension between efficiency and equity, particularly in health care. The growth in exclusive physician arrangements using non-linear prices is leading to consumer segmentation with theoretically ambiguous welfare implications. We study concierge medicine, in which physicians only provide care to patients paying a retainer fee. We find limited evidence of selection based on health and stronger evidence of selection based on income. Using a matching strategy that leverages the staggered adoption of concierge medicine, we find large spending increases and no average mortality effects for patients impacted by the switch to con-cierge medicine.

OBJECTIVE:To summarize the predictors and outcomes of empathy by health care personnel, methods used to study their empathy, and the effectiveness of interventions targeting their empathy, in order to advance understanding of the role of empathy in health care and facilitate additional research aimed at increasing positive patient care experiences and outcomes.DATA SOURCE:We searched MEDLINE, MEDLINE In-Process, PsycInfo, and Business Source Complete to identify empirical studies of empathy involving health care personnel in English-language publications up until April 20, 2021, covering the first five decades of research on empathy in health care (1971-2021).STUDY DESIGN:We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.DATA COLLECTION/EXTRACTION METHODS:Title and abstract screening for study eligibility was followed by full-text screening of relevant citations to extract study information (e.g., study design, sample size, empathy measure used, empathy assessor, intervention type if applicable, other variables evaluated, results, and significance). We classified study predictors and outcomes into categories, calculated descriptive statistics, and produced tables to summarize findings.PRINCIPAL FINDINGS:Of the 2270 articles screened, 455 reporting on 470 analyses satisfied the inclusion criteria. We found that most studies have been survey-based, cross-sectional examinations; greater empathy is associated with better clinical outcomes and patient care experiences; and empathy predictors are many and fall into five categories (provider demographics, provider characteristics, provider behavior during interactions, target characteristics, and organizational context). Of the 128 intervention studies, 103 (80%) found a positive and significant effect. With four exceptions, interventions were educational programs focused on individual clinicians or trainees. No organizational-level interventions (e.g., empathy-specific processes or roles) were identified.CONCLUSIONS:Empirical research provides evidence of the importance of empathy to health care outcomes and identifies multiple changeable predictors of empathy. Training can improve individuals' empathy; organizational-level interventions for systematic improvement are lacking.

Problem definition: Employers across many sectors of the economy have been fast to adopt variable work scheduling policies. The cost of this flexibility for employers is usually borne by employees, for whom unstable work schedules create several disruptions. In the context of home healthcare, we examine how employer-driven volatility in nurses’ schedules impacts their decision to voluntarily leave their job. Methodology/results: Using an instrumental variables approach, we causally identify the effect of schedule volatility on nurses’ voluntary turnover. We begin by constructing an operational measure of schedule volatility using time-stamped work log data from one of the largest home health agencies in the United States. Because this measure may be endogenous to the worker’s decision to quit, we instrument for schedule volatility using paid days off taken by other nurses in the same branch. We find that higher levels of schedule volatility substantially increase a worker’s likelihood of quitting. Specifically, a one-standard-deviation increase in schedule volatility increases the average worker’s propensity to quit on a given day by more than threefold. Translated into yearly terms, 30 days of high schedule volatility over the course of the year increases the average worker’s probability of quitting that year by 20%. Our policy simulations of counterfactual scheduling policies suggest that excess schedule volatility can explain a significant portion of voluntary turnover, and some interventions have the potential to substantially reduce workers’ daily propensity to quit. Managerial implications: This work contributes to the understanding of the extent to which employees value control over their own work schedules and are averse to volatile work schedules that are dictated by employers. Especially in the current environment where there is a growing emphasis on work-life balance and employee-driven flexibility, finding a way to support stable schedules could be important for employers to attract and retain workers. Funding: This work was supported by the National Research Service Award Postdoctoral Fellowship, the Wharton Dean's Research Fund, the Agency for Healthcare Research and Quality [T32 Grant 5T32HS26116], and the Claude Marion Endowed Faculty Scholar Award. Supplemental Material: The e-companion is available at https://doi.org/10.1287/msom.2023.1205 .

Purpose Nursing turnover is a leading cause of inefficiency in health care delivery. Few studies have examined turnover among nurses who work in rural areas. Methods We accessed human resources data that tracked hiring and terminations from a large health system operating in South Dakota, North Dakota, and Minnesota between January 2016 and December 2017. Our study sample included 7,634 registered nurses, 1,765 of whom worked in a rural community. Within the health system, there were 27 affiliated hospitals, 17 of which were designated critical access hospitals. We estimated nursing turnover rates overall and stratified turnover rates by available demographic and occupational characteristics, including whether the nurse worked in a community with an affiliated acute care hospital or critical access hospital. Findings Overall, 19% of nurses left their position between January 2016 and December 2017. Turnover rates were associated with state, nurse gender and age, and occupational tenure, but were similar in urban and rural areas. Of note, turnover rates were significantly higher in communities without an affiliated acute care hospital or critical access hospital. Conclusion Between 2016 and 2017, nearly 1 in 5 nurses working in this health system left their position. Turnover rates differed based on nurse demographics and selected occupational characteristics, including tenure. We also found higher turnover rates among nurses who worked in communities without an affiliated hospital, which points to a potential but unexplored benefit of hospitals in rural areas.

Value, a seemingly abstract and subjective concept, is acquiring more significance in the health care realm. In economic terms, value is a measure of the benefits obtained from a product, service, or experience relative to the cost incurred. In health care, value-based care (VBC) determines the worth of health care services on the basis of their benefits (that is, health outcomes) relative to their associated costs, encouraging the provision of high-value services and discouraging the provision of low-value services.

Objective: Nurse turnover can compromise the quality and continuity of home health care. Scope of practice laws, which determine the tasks nurses are allowed to perform and delegate, are an important element of autonomy and vary across states. In this study, we used human resource records from a multistate home health organization to examine the relationship between nurse turnover and whether nurses can delegate tasks to unlicensed aides. Design: A retrospective, cross-sectional analysis. Setting and Participants: The study sample included 1820 licensed practical nurses and 3309 registered nurses, who spanned 30 states. The study period was 2016 through 2018. Methods: We used weighted least squares to study the relationship between nurse turnover for registered and licensed practical nurses and task delegation across state-years. We measured task delegation continuously (0e16 tasks) and as a binary variable (14 or more tasks, which indicated the state was in the top half of the distribution). Results: Across state-years, the turnover rate was 30.8% for licensed practical nurses and 36.8% for registered nurses. Although there was no significant relationship between task delegation and turnover among registered nurses, we found that states in which nurses could delegate the most tasks had lower turnover rates among licensed practical nurses. Conclusion and Implications: The ability to delegate tasks to unlicensed aides was correlated with lower turnover rates among licensed practical nurses, but not among registered nurses. This suggests that the ability to delegate tasks is more likely to affect the workload of licensed practical nurses. This also points to a potential and unexplored element of expanding the scope of practice for nurses: reduced turnover. Given the added work-related hazards associated with home health care, including working in isolation, a lack of social recognition, and inadequate reimbursement, states should consider whether changes in their policy environment could benefit nurses working in home health. (C) 2023 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

Medicare has increased the use of performance pay incentives for hospitals, with the goal of increasing care coordination across providers, reducing market frictions, and ultimately to improve quality of care. This paper provides new empirical evidence by using novel operations and claims data from a large, independent home health care firm with the Hospital Readmissions Reduction Program (HRRP) penalty on hospitals providing identifying variation. We find that the penalty incentive to reduce re-hospitalizations passed through from hospitals to the firm at least for some types of patients, since it provided more care inputs for heart disease patients discharged from hospitals at greater penalty risk and that contributed more patients to the firm. This evidence suggests that HRRP helped increase coordination between hospitals and home health firms without formal integration. Greater home health effort does not appear to have led to lower patient readmissions.