The prevalence, acuity, and costs of behavioral health conditions in the US have risen sharply over the past decade. Over 40% of adults with mental illness report cost as a barrier to accessing care. The objective of this study was to evaluate patients’ sensitivity to out-of-pocket (OOP) costs for in-network behavioral health office visits, adjusting for patient acuity. We evaluated data from patients from all 50 states who received care from the largest outpatient behavioral health group in the US who had a first visit during 2024 and were followed for 12 months. For each visit, we assessed patient OOP cost. To assess the association between patient OOP cost and treatment, we used “difference-in-differences" linear regression models. Among the 425,423 commercially insured individuals included in this study, 68.7% identified as female and their mean age was 33.5 years (SD 11.2 years). Increased OOP costs were significantly associated with number of visits. For every $10 increase in OOP cost, patients had, on average, 0.50 fewer office visits. Number of office visits was not associated with clinical acuity, age, gender, or social vulnerability. Patients were more price sensitive for visits with a psychotherapist than with a psychiatric prescriber. These findings underscore the need for policy solutions that address the affordability and accessibility of outpatient mental health services. Anticipating financial barriers to care can inform expectation setting for providers and patients early in the course of mental health care.

Importance:Noneconomic damage caps, a form of medical malpractice law, remain controversial, as several states have enacted such laws since 2010, whereas others have repealed them. The clinical consequences of repealing these caps are poorly understood, and understanding these associations can inform the ongoing debate about medical malpractice reform. Objective:To examine whether repealing noneconomic damage caps is associated with changes in maternal care and infant health outcomes. Design, Setting, and Participants:This cross-sectional study adopted a difference-in-differences design, comparing between 2 treated states (Georgia and Illinois) that repealed their noneconomic damage caps in 2008 to 2009 and 16 control states that retained their caps during the entire study period between 2005 and 2019. The Centers for Disease Control and Prevention All-County Natality Files were used to estimate multivariate linear models, controlling for maternal and infant characteristics and county-level and state-level covariates. Estimates were stratified by county rurality and birth risk conditions. Data were analyzed from April 1, 2024, to April 9, 2026. Main Outcomes and Measures:The primary outcomes were 4 measures of maternal care and procedures (physician-attended births, inductions, cesarean delivery births, and prenatal visits) and 3 birth outcomes (low Apgar score, low birth weight, and preterm births). Difference-in-differences models with 2-way fixed effects were estimated, and linear models for the study outcomes were specified. Results:The sample included 20 426 267 live births (mean [SD] gestational age, 38.55 [1.35] weeks). Compared with their counterparts in the control states, rural counties in the treated states experienced a statistically significant increase of 2.92 percentage points (pp) (95% CI, 1.40-4.50 pp; Bonferroni-adjusted P = .01) in physician-attended births. The increase held for both low-risk (3.10 pp; 95% CI, 1.33-4.90 pp; P = .004) and high-risk (2.56 pp; 95% CI, 0.77-4.34 pp; P = .01) births in rural counties. There was no difference between treated and control states for physician-attended births overall or in urban counties. No statistically significant associations were observed for cesarean deliveries, inductions, prenatal visits, or infant health outcomes after adjusting for multiple comparisons. Conclusions and Relevance:In this cross-sectional study of 20 426 267 live births across 18 states, repealing noneconomic damage caps was associated with increased physician-attended births in rural counties but was not associated with statistically significant changes in other maternal care measures or infant health outcomes. These findings suggest that increased liability risk after repealing the caps may shift the composition of birth attendants in resource-constrained settings without demonstrable changes in infant health.

Direct-to-consumer advertising is pervasive in US healthcare markets, but little evidence exists on the effects of advertising by hospitals, second only to drug manufacturers in medical marketing. Advertising may help facilities increase market share by stealing existing patients, expand the market for hospital care, or do both. Regardless, it has important public finance implications due to the large sums of taxpayer funds spent by federal and state governments to subsidize hospital operations and finance care through public insurance programs. This paper provides the first causal evidence, to our knowledge, on the market expansion effects of hospital advertising. To obtain causal estimates, we leverage the fact that spikes in political advertising significantly crowd out hospital advertising in the same market, motivating an instrumental variables design. Using claims data on the universe of Traditional Medicare beneficiaries, we find that advertising expands aggregate patient volume and spending on inpatient care – though to a modest degree (implied elasticities of 0.06 and 0.05, respectively). Although the overall effect of advertising on hospital outpatient care is muted, for-profit hospitals obtain higher outpatient Medicare volume and revenue with greater advertising. Across both care settings, therefore, Medicare spending increases with hospital advertising. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

We combine 2021-2024 data on artificial intelligence (AI) adoption across U.S. shortterm general hospitals with national measures of hospital finances, volume, employment, and measured quality. Using synthetic difference-indifferences , we find that AI adoption is followed by approximately 3% higher net patient revenue, 3% higher total paid hours, and 7% higher patient volume. Total and clinical expenses also rise. By contrast, estimates for administrative expenses, administrative hours, and employee full-time equivalents are imprecise under inference clustered at the hospital-system level. Measured risk-adjusted mortality declines for several conditions, but unadjusted mortality and claims-based clinical-process measures do not show corresponding improvements, while documented severity increases. The results therefore point most clearly to operational expansion, throughput, and richer documentation; they do not establish administrative cost savings, per-unit productivity gains, or lower underlying mortality.

Importance:Cardiology services are among the most frequently used and costly services and procedures in US health care. Understanding price variation is essential for employers, patients, and policymakers to make informed decisions, contain costs, and promote value-based care. Objective:To assess the extent of variation in commercial insurance payment rates for common cardiology services across major US insurers and states using newly available Transparency in Coverage (TIC) data. Design, Setting, and Participants:This cross-sectional study used April 2025 TIC data from a third-party vendor reflecting 2023 contract year claims. The dataset included approximately 6.7 million professional and 104 563 facility price points for 32 common cardiology services across 4 major commercial insurers (Blue Cross Blue Shield, UnitedHealthcare, Aetna, and Cigna Healthcare), representing 78% of the commercial insurance market. The sample covered 51 568 physicians and 4128 facilities nationwide. Exposure:Negotiated allowed amounts paid by 4 major insurers for cardiology services, analyzed by Current Procedural Terminology code and grouped into categories such as diagnostic imaging, electrophysiology, and stress testing. Main Outcomes and Measures:Variation in allowed payment amounts for each cardiology service across insurers and states. Measures included median prices and IQRs, coefficients of variation, and volume-weighted price indices. Results:Facility negotiated price variation exceeded professional fee variation, with a median interquartile ratio of 2.56 across services. For example, median facility fees for implantable cardioverter-defibrillator (ICD) insertion ranged from $6674 (IQR, $3069-$11 402) to $36 269 (IQR, $18 673-$66 880) across insurers. Geographic variation was also substantial, with a median facility price for coronary angiography of $7683 (IQR, $4561-$10 101) across states. Blue Cross Blue Shield had the highest mean facility prices while Aetna had the lowest across most service categories. Conclusions and Relevance:In this cross-sectional study of commercial insurance payments for cardiology services, there was substantial variation across both insurers and states, particularly in facility fees. These findings reveal the influence of payer contracting strategies and market dynamics and underscore the need for greater transparency and regulatory oversight to promote efficient health care spending.

Importance:Private equity (PE) is one form of corporate investment that has rapidly expanded into primary care, with more than 2400 primary care physicians becoming PE-affiliated since 2019. There are concerns that profit incentives associated with PE investment might be detrimental to care quality and patient outcomes. Objective:To examine changes in patient outcomes for the traditional Medicare (TM) population after primary care practices are acquired by PE firms and to identify any changes in patient composition. Design, Setting, and Participants:This economic evaluation used a stacked difference-in-differences analysis with a 20% Medicare Part B sample from 2016 to 2022. Medicare beneficiaries with PE-acquired primary care physicians were matched to control patients based on age, risk score, sex, race and ethnicity, state of residence, and dual-eligibility status. Statistical analysis was performed from November 2024 to February 2026. Exposure:Primary care practice acquisition by a PE firm, identified using PitchBook data. Main Outcomes and Measures:Primary outcomes at the patient-quarter level include number of all-cause hospitalizations, number of potentially avoidable hospitalizations for ambulatory-sensitive conditions, and number of emergency department (ED) visits. Secondary outcomes include measures of patient composition, including patient age, sex, race and ethnicity, and hierarchical condition category score. Results:The analysis included 24 397 beneficiaries with PE-acquired primary care physicians, matched to 121 939 control patients. The mean (SD) age was 74 (10) years, and 56% of patients were female. After PE acquisition, the number of all-cause ED visits decreased by 1.36% (95% CI, -2.72% to -0.14%) per patient-quarter relative to baseline. Considering various sensitivity tests, there were no significant changes to the probability of or number of potentially preventable hospitalizations or all-cause hospitalizations. Patient composition remained unchanged. Conclusions and Relevance:In this national study of traditional Medicare beneficiaries, PE acquisitions of primary care practices were not associated with meaningful short-term changes in acute care outcomes. Overall, findings contribute to policy discourse on understanding the role of PE investments in shaping care quality, suggesting heterogeneity in outcomes across health care settings.

Vertical integration can both create efficiencies and harm competition through rival foreclosure. We examine these tensions through one of the most prominent forms of vertical integration in the United States: the acquisition of physician practices by the nation’s largest insurer, UnitedHealth Group. Using a difference-in-differences design and Medicare administrative data, we find minimal changes to acquired practice case mix or care quality, but do find evidence of increased patient risk score coding intensity, which translate into nearly \$300 million in annual increased spending. However, due the absence of rival foreclosure, the majority of this transfer payment accrues to rival firms.

BACKGROUND AND OBJECTIVE:Children with intellectual disabilities and related conditions (IDRC) and autism often require dental treatment in surgical settings. Studies of older adults suggest that ambulatory surgery centers (ASCs) can reduce costs without reducing quality, but it is unknown whether this is true for children with autism and IDRC and dental surgeries. This study compared outcomes among children with IDRC and autism receiving dental caries-related surgeries at ASCs and hospital outpatient departments (HOPDs). METHODS:This cross-sectional analysis used Medicaid data from 29 states (2016-2020) to examine 17 552 outpatient dental surgeries in ASCs and HOPDs for children with IDRC or autism. Regression models were used to examine whether outcomes varied by setting of care (ASC vs HOPD). The following outcomes were included: days from diagnosis to surgery, Medicaid payment, emergency department (ED) visits, and hospitalization after surgery. RESULTS:Multivariate regression results indicate time from diagnosis to surgery was, on average, 8.7 days sooner for a child with autism and 13.2 days sooner for a child with IDRC if furnished in an ASC compared with a HOPD (P < .001 for both). Average Medicaid payment was $419 and $363 less in an ASC than HOPD for a child with autism (P = .003) or IDRC (P = .02), respectively. The likelihood of an ED visit or hospitalization was lower in an ASC than HOPD for a child with IDRC (P < .001), but not autism (P > .05). CONCLUSIONS:Increasing use of ASCs for dental care may increase timely receipt of care and lower Medicaid costs without increasing adverse outcomes for children with autism and IDRC.

The diffusion of technological innovation depends on incentives, regulations, and firms’ strategic behaviors. We study these intersections within cardiac procedure markets following Medicare’s expansion of non-hospital facility options for treatment, enabled by clinical advancements. State-level regulations restrain federal pro-competition policy. Where market entry occurs, business stealing is concentrated among the lowest cost treatment settings, rather than high-cost hospitals––increasing Medicare spending by approximately $2.5 million. Medicare policy also generates externalities for untargeted procedures and other payers, except when hospitals and physicians are vertically integrated. Federal rulemaking interacts with and is mitigated by complex market dynamics––including in potentially unanticipated ways. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Mental illness exacts a heavy toll on the US healthcare system and strains general hospitals and their emergency departments. We study how psychiatric inpatient facility entry impacts the local hospital industry. We find that referrals, including from the legal system, are redirected to the specialized facilities––leaving general hospitals with approximately 60% fewer psychiatric admissions. General hospitals also discharge 50% more patients to psychiatric facilities and substitute away from high-skill psychiatric labor––consistent with specialization and market segmentation. Emergency department volumes do not change but care does. However, community-based crime, overdose deaths, and suicides do not decline in the short-run. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Importance:Despite need, children face access barriers to dental surgical procedures. Surgical procedures for older adults delivered in ambulatory surgical centers (ASCs) are less costly than and of comparable quality to care delivered in hospital outpatient departments (HOPDs), but it remains unknown whether this association extends to pediatric dental surgical procedures. Objective:To determine whether payment, time from diagnosis to care, and adverse events for pediatric surgical procedures for dental caries vary between ASCs and HOPDs paid by Medicaid. Design, Setting, and Participants:This cross-sectional study of Medicaid data (July 1, 2016, through January 31, 2020) used an instrumental variables regression approach and exploited a source of exogeneous variation influencing ASC supply. Analysis was conducted October 2024 to April 2025, using records from 29 states with high-quality Medicaid data. Participants were children aged 18 years or younger enrolled in Medicaid who underwent surgical procedures for dental caries in an ASC or HOPD. Exposure:Receipt of dental surgical care in an ASC or HOPD. Main Outcomes and Measures:The primary outcomes were Medicaid payment, days from diagnosis to surgery, and any emergency department visits and hospitalizations within 7 days after surgery. Results:Across 391 628 pediatric dental surgical procedures, patients had a mean (SD) age of 5.00 (3.05) years, and 211 819 (54.09%) were male. Medicaid payment was $604 (95% CI, $149-$1058; P < .009) less for a surgery occurring in an ASC vs an HOPD, corresponding to a 27% reduction in spending, and time from diagnosis to surgery was 8.9 days (95% CI, 5.5-12.3 days; P < .001) less for a surgery occurring in an ASC than HOPD. A surgery occurring in an ASC (vs HOPD) was statistically significantly less likely to be followed by an emergency department visit or hospitalization within 7 days after surgery (0.27 percentage points; 95% CI, 0.18-0.36 percentage points) and a hospitalization within 30 days after surgery (0.28 percentage points, 95% CI, 0.11-0.45 percentage points). Conclusions and Relevance:In this cross-sectional study of pediatric surgical procedures for dental caries paid by Medicaid, procedures performed in ASCs were less costly and had lower rates of adverse events compared with those performed in HOPDs. The time from diagnosis to surgery was shorter for surgical procedures in ASCs compared with HOPDs, suggesting that ASCs may improve access to care for children from low-income families needing for dental treatment. Increased use of ASCs for pediatric dental surgical procedures may reduce costs for Medicaid and improve patient experiences.

ImportanceConsolidation of physician practices by hospitals and private equity (PE) firms has increased rapidly. This trend is of particular importance within primary care. Despite its significance, there is no systematic evidence on the emerging trends in ownership affiliation of primary care physicians (PCPs) and its association with prices paid for physician services.ObjectiveTo describe trends in hospital affiliation and PE affiliation in primary care and examine variation in negotiated prices paid by commercial insurers to hospital-affiliated, PE-affiliated, and independent PCPs.Design, Setting, and ParticipantsData from PitchBook and IQVIA were used to examine hospital and PE affiliation PCPs. PCPs and their affiliations were linked to novel cross-sectional Transparency in Coverage data. A total of 226.6 million negotiated prices were analyzed for evaluation and management office visits (Current Procedural Terminology codes 99202 to 99205 and 99212 to 99215) across 4 national insurers (Aetna, Blue Cross Blue Shield, Cigna, and United Healthcare). Linear regressions were used to examine the association between hospital-affiliated, PE-affiliated, and independent PCPs and cross-sectional prices paid for physician services, with fixed effects for service, state, and insurers. Data were collected from January to June 2024, and data were analyzed from July to October 2024.Main Outcomes and MeasuresThe proportion of PCPs that are affiliated with hospitals and PE from 2009 to 2022. Using cross-sectional data from 2022, negotiated prices paid to physicians (physician professional fee) for office visits.ResultsA total of 198 097 PCPs were analyzed. PCPs affiliated with hospitals increased from 25.2% (28 216 of 111 793) in 2009 to 47.9% in 2022 (82 890 of 172 964). Over the same period, 1.5% (2483 of 172 964) of PCPs became affiliated with PE firms. Relative to independent PCPs, negotiated prices for office visits were $14.91 (95% CI, 8.92-27.64) or 10.7% (95% CI, 10.1-11.4) higher for hospital-affiliated PCPs (P < .001) and $9.56 (95% CI, 2.24-14.55) or 7.8% (95% CI, 4.7-10.8) higher for PE-affiliated PCPs (P < .001).Conclusions and RelevanceIn this cross-sectional study, nearly one-half of all PCPs were affiliated with hospitals, while PE-affiliated PCPs were growing and concentrated in certain regional markets. Relative to PCPs in independent settings, hospital-affiliated PCPs and PE-affiliated PCPs had higher prices for the same services.

PURPOSE:The consolidation of radiology practices by hospitals and private equity (PE) firms has accelerated in recent years, reshaping the landscape of radiology practice ownership. There is limited systematic evidence on the growing prevalence of hospital and PE ownership in radiology and its association with negotiated prices for imaging services. The aim of this study was to examine how commercial insurance negotiated prices for radiologic services vary by practice ownership structure, including independent, hospital, and PE-affiliated radiology practices. METHODS:A cross-sectional analysis was conducted of radiologists in the United States, categorizing them by practice ownership type. Data from PitchBook were used to identify practices affiliated with PE. Using novel cross-sectional transparency-in-coverage data, negotiated professional fees for radiologic services were compared across hospital, PE-affiliated, and independent radiology practices. Linear regressions were used to examine the association between hospital-employed, PE-affiliated, and independent radiologists and cross-sectional prices paid for physician services, with fixed effects for service, state, and insurers. RESULTS:Among 24,783 radiologists analyzed, 44% were affiliated with independent private practices, 41% were hospital employed, and 11% were PE employed as of 2022. Hospital-employed and PE-affiliated radiologists were concentrated in specific geographic markets. Negotiated professional fees for radiologic services were highest for hospital-employed radiologists, with fees $60.60 (95% confidence interval [CI], $59.53-$61.68) or 43.0% (95% CI, 42.2%-43.7%) higher for hospital-employed radiologists compared with independent radiologists (P < .001). Prices for PE-affiliated practices were $22.39 (95% CI, $20.77-$24.00) or 15.9% (95% CI, 14.7%-17.0%) higher than those for independent practices (P < .001). CONCLUSIONS:Hospital and PE-affiliated radiology practices have significantly higher prices for radiologic services compared with independent practices, with hospital-employed radiologists commanding the largest price differentials. These findings highlight the financial implications of ongoing consolidation in radiology and underscore the need for continued research into how these trends affect radiologists, patients, and radiology practices.

Certificate of Need (CON) laws regulate entry and capital investments in healthcare with the goal of containing costs while preserving access and quality. This paper examines the relationship between these laws and overall mortality as well as leading causes of mortality: cancer and cardiovascular disease. Using county-level death records, we conducted an event-study analysis comparing mortality rates in states that repealed their CON laws to states that did not between 1979 and 2004. The repeal of CON laws was associated with short-run reductions in cancer mortality, primarily from reductions in lung cancer mortality. Cardiovascular mortality and all-cause mortality rates were unchanged. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

This cohort study assessed changes in the amount and number of general payments received by ophthalmologists after private equity acquisition of practices.

Noneconomic damage caps are controversial because they seek to balance uncertain benefits through reductions in physician precautionary costs, against uncertain harms to patient welfare. Opposing policy actions at the state-level reflect this controversy as some states have enacted noneconomic damage caps over the past few decades while others repealed their caps. Our difference-in-differences analyses suggest that repeals increase premiums. These increases are larger after State Supreme Court decisions, affecting all cases in a state, compared with State Circuit Court decisions affecting only specific cases. Magnitudes differ by physician specialty, with larger effects observed in obstetrics/gynecology and general surgery, compared with internal medicine. Our estimates of these repeals are larger than estimates on enactments reported in the literature, suggesting a potential asymmetry between enacting and repealing damage caps.

Introduction:Commercial insurance payment rates for imaging studies have significant price variation, yet understanding this variation has been limited by lack of transparency and data limitations. Methods:Using newly available Transparency-in-Coverage insurer-posted data on negotiated rates, we analyzed price variation for the 2023 contract year across four major commercial insurers (Blue Cross Blue Shield, United, Cigna, and Aetna) for 30 imaging studies. Our analysis encompassed 12.7 million professional fee price points and 239 969 facility fee price points. Results:Our analysis revealed substantial variation in reimbursement rates. Key findings include greater variation in facility fees compared to professional fees, with facility coefficients of variation often 3 to 6 times higher than professional components. There was also substantial and inconsistent variation by payer. Geographic analysis revealed significant state-level variation, particularly in facility fees. Conclusion:These findings highlight the complex interplay of market dynamics and negotiating strategies in determining healthcare prices, with implications for policymakers, purchasers, and clinicians guiding patient care decisions.

Competition in health care markets should lead to lower prices and less dispersion, with consumer choice as the driving mechanism. Several studies document price variation, suggesting room for improvement; however, they relied on selected data from insurers who provide access to data, limiting generalizability. We document the nature of price variation in the private US market across geography, payer, and provider by leveraging a new dataset, implementing a descriptive analysis using the most comprehensive data available: Transparency-in-Coverage. We measured health care prices in 3 ways: percentile distribution prices for common services, state-level and insurer-level facility fee price indices, and regression-adjusted mean inpatient and outpatient prices. Variation is large: the mean facility fee for a foot X-ray, for example, is $86 at Anthem and $190 at UnitedHealth. Pricing does not appear to be uniform; there is just 22% correlation between an insurer's inpatient price and outpatient facility price. And there is little difference in ordering of high-price states depending on alternative measures, such as relative to Medicare. Results suggest greater consideration of policies to address high and variable prices for US health care.