Med Care Res Rev
· 2026 Jun · PMID 41474542
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Coverage gaps and periods of uninsurance are associated with decreased health care utilization, treatment nonadherence, and health-related work limitations. Yet little is known about long-term trajectories of insurance c...Coverage gaps and periods of uninsurance are associated with decreased health care utilization, treatment nonadherence, and health-related work limitations. Yet little is known about long-term trajectories of insurance coverage. We used sequence analysis and a nationally representative cohort study to identify and describe three trajectories of health insurance coverage from ages 25 to 37: stable private coverage (40%); stabilizing public coverage (16%); and recurrent uninsurance (44%). Estimated time exposed to uninsurance for each group was 0.2, 1.7, and 5.2 years, respectively. Those with recurrent uninsurance were more likely to be male, Black or Hispanic, working part-time, in poorer health, or living in the U.S. South or West. Prolonged and cyclical uninsurance is common in the years following the transition to adulthood, with disadvantaged adults more likely to experience recurrent uninsurance. Furthermore, examining insurance status cross-sectionally underestimates long-term exposure to coverage instability and may impede effective interventions aimed at securing long-term access to coverage.
Hartman A, Duran D, Ratto I
… +2 more, Young GJ, Post B
Med Care Res Rev
· 2025 Dec · PMID 41474540
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Hospital-physician vertical integration has become a defining feature of the health care landscape. While some evidence exists regarding integration's effect on clinical outcomes, little has examined patient-reported exp...Hospital-physician vertical integration has become a defining feature of the health care landscape. While some evidence exists regarding integration's effect on clinical outcomes, little has examined patient-reported experience. We used the 2021 Medicare Current Beneficiary Survey, constructing psychometric scales of care coordination and quality, communication, and accessibility from survey responses. We analyzed how patient experience with each scale differed by the proportion of care received from integrated physicians, adjusting for patients' characteristics. Integrated care was significantly and positively associated with patients' perceptions of coordination and quality. This relationship was driven by patients with high clinical complexity, with effects twice as large as for patients with low clinical complexity. However, integrated care was not significantly associated with communication or accessibility. These findings suggest a nuanced relationship between integration and patient experience. Policymakers, who often discuss integration in terms of outcomes and affordability, should also consider ways in which it shapes patients' experiences.
Madanay F, Campagna A, Tu K
… +4 more, Davis JK, Doerstling SS, Chen F, Ubel PA
Med Care Res Rev
· 2026 Jun · PMID 41420302
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Patients increasingly use online rating and review websites to share their clinical experiences, yet few studies have taxonomized how patients perceive their physicians. We developed a theoretical framework identifying t...Patients increasingly use online rating and review websites to share their clinical experiences, yet few studies have taxonomized how patients perceive their physicians. We developed a theoretical framework identifying the factors comprising patients' perceptions of their physicians' interpersonal manner and technical competence. We conducted a qualitative content analysis of 2,000 online reviews sampled from distinct physicians across the United States, balanced to represent primary care physicians and surgeons, males and females, and low- and high-star rated reviews. Reviews were received between 2015 and 2020 on a large commercial rating and review website. Our theoretical framework identifies 16 interpersonal manner factors and 10 technical competence factors. Interpersonal manner factors were grouped by physicians' attitude and character, behavior, and communication; technical competence factors were grouped by physicians' expertise, treatment approach, and outcomes. This framework may help physicians and health systems seeking to improve care quality, delivery, and patient satisfaction.
Liu J, O'Reilly-Jacob M, Zhu A
… +4 more, Borson S, Perloff J, DeGrazia M, Poghosyan L
Med Care Res Rev
· 2026 Jun · PMID 41388825
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To compare the performance of the Chronic Conditions Warehouse (CCW) and the 38-condition Elixhauser Comorbidity Index in predicting all-cause mortality among Medicare beneficiaries with dementia, we used a national samp...To compare the performance of the Chronic Conditions Warehouse (CCW) and the 38-condition Elixhauser Comorbidity Index in predicting all-cause mortality among Medicare beneficiaries with dementia, we used a national sample of 1,566,359 community-dwelling Medicare beneficiaries (age ≥65) with dementia, identified in 2018 claims data. Using elastic net logistic regression, we applied 30 CCW conditions and 38 Elixhauser comorbidities from 2018 to predict mortality at 30, 60, 180 days, and 1 year through December 31, 2019. Mortality rates were 2.42% (30 days), 4.27% (60 days), 10.77% (180 days), and 19.0% (1 year). All models demonstrated good discrimination (C-statistics: 0.696-0.731) and calibration, with no meaningful performance differences between the two measures. Elastic net models produced parsimonious predictors with performance comparable to traditional logistic regression. Both CCW and Elixhauser measures predicted all-cause mortality in dementia with similar accuracy. Elastic net offers a robust approach to claims-based mortality prediction.
Keohane LM, Keesee E, Fabius CD
… +1 more, Stevenson DG
Med Care Res Rev
· 2026 Jun · PMID 41355306
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Identifying dual-eligible beneficiaries who use Medicaid-funded long-term services and supports (LTSS) is difficult, hindering efforts to monitor use and improve quality. We demonstrate a strategy that uses only Medicare...Identifying dual-eligible beneficiaries who use Medicaid-funded long-term services and supports (LTSS) is difficult, hindering efforts to monitor use and improve quality. We demonstrate a strategy that uses only Medicare data to identify nursing home (NH) users and Medicaid home-and-community-based-service (HCBS) waiver participants by leveraging the fact that these groups exclusively qualify for zero cost-sharing in Part D. In a multistate cohort of low-income older adults, we identified Part D LTSS beneficiaries (dual-eligible beneficiaries with zero Part D cost-sharing) in Medicare enrollment records and verified LTSS use in NH assessments and Medicaid HCBS data. Over 96% of NH/HCBS waiver users in MDS or Medicaid data were correctly identified as Part D LTSS beneficiaries, and 93% of beneficiaries without NH or HCBS waiver use were accurately identified as not being Part D LTSS beneficiaries. Leveraging Part D data could support more timely evidence on quality and outcomes for dual-eligible LTSS users.
Chen AT, Saynisch PA, Song H
… +3 more, Smith-McLallen A, David G, Bergman A
Med Care Res Rev
· 2026 Apr · PMID 41351455
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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 (2018-20...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.
Kramer J, Johnson DJ, Wolf K
… +9 more, Gupta A, Ellis SD, Reed J, Pokharel Y, McWilliams A, Debinski B, Watson BN, Mavegam Tango Assoumou B, Taylor YJ
Med Care Res Rev
· 2026 Apr · PMID 41320995
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Social determinants of health contribute to disparities in cardiovascular outcomes, including hypertension. This study utilized a health equity framework to assess patient-level factors influencing hypertension managemen...Social determinants of health contribute to disparities in cardiovascular outcomes, including hypertension. This study utilized a health equity framework to assess patient-level factors influencing hypertension management across two health systems in North Carolina and Kansas. We interviewed 29 providers and 25 patients with hypertension from 14 clinics, including 13 primary care clinics-6 high-performing, 1 mid-performing, and 6 low-performing-and 1 cardiology clinic. Thematic analysis and open coding methodologies were used during analysis. Five salient patient-level themes emerged: patient resources, health literacy, lifestyle, intentionality, and patient-centered care. All providers identified health literacy as a critical barrier; however, those in low-performing clinics more regularly cited literacy-related challenges, with some associating patients' rurality with decreased understanding and intentionality. Mental health was also linked to hypertension management, as anxiety may exacerbate symptoms, while depression can reduce treatment motivation. Our findings underscore the need for individualized, equity-informed hypertension management strategies.
Ji X, Dougherty M, Lee Y
… +2 more, Poghosyan L, Lelutiu-Weinberger C
Med Care Res Rev
· 2026 Jun · PMID 41319108
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Primary care providers (PCPs) in the United States experience burnout more frequently than clinicians in other care settings. Interventions addressing PCP burnout are urgently needed. Organizational-level interventions i...Primary care providers (PCPs) in the United States experience burnout more frequently than clinicians in other care settings. Interventions addressing PCP burnout are urgently needed. Organizational-level interventions implemented in the workplace may help address burnout, as poor organizational conditions are primary contributors to burnout. This review synthesized existing evidence on organizational-level interventions' effects on PCP burnout in the United States. A comprehensive search was conducted in four databases and selected journals. Thirteen studies were included, and four overarching categories of interventions emerged. Interventions that addressed the workload, control, and community areas of worklife resulted in notable burnout reduction. Organizations considering using workload interventions to reduce PCP burnout should incorporate both human and time resources. PCP engagement in intervention design and implementation is crucial and may affect burnout. More studies are needed on interventions that target nurse practitioners and physician assistants who increasingly serve as PCPs.
Med Care Res Rev
· 2026 Apr · PMID 41237011
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Many regulated health insurance markets use prospective risk adjustment (RA) to mitigate risk selection incentives for insurers. However, prospective RA might underpay insurers for people diagnosed with a new chronic dis...Many regulated health insurance markets use prospective risk adjustment (RA) to mitigate risk selection incentives for insurers. However, prospective RA might underpay insurers for people diagnosed with a new chronic disease. By tracking spending and RA payments over the period -2 to +2 for individuals diagnosed with a new chronic disease in year , we find a substantial payment gap in year and, to a lesser extent, in prior and/or subsequent years. The extent to which these gaps stimulate selection incentives for insurers depends on the possibilities for insurers to distort consumers' choice of insurance products. Possibilities which-in turn-depend on whether and when consumers respond to the onset of the chronic disease when choosing an insurance product. By analyzing "insurer switching" in the period -2 to +2 we find that-on average-people first diagnosed with a chronic disease are more likely to switch insurer than others.
Wetzel M, Howard DH, Giordano NA
… +2 more, Patrick SW, Yarbrough CR
Med Care Res Rev
· 2026 Apr · PMID 41229161
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State policies requiring clinicians to review prescription drug monitoring program (PDMP) databases have proliferated. However, patient advocates suggest these policies may adversely affect patients with chronic pain. Th...State policies requiring clinicians to review prescription drug monitoring program (PDMP) databases have proliferated. However, patient advocates suggest these policies may adversely affect patients with chronic pain. This study aimed to quantify the effect of must-access PDMP implementation on pain and physical impairment. Using panel data on 34,431 older adults from the Health and Retirement Study (2002-2021), we conducted a heterogeneity-robust difference-in-differences analysis. Must-access PDMPs were associated with a 1.65 (95% CI: 0.43 to 2.87) percentage point increase in frequent pain during the two-year window surrounding policy implementation and a peak 3.52 (95% CI: 0.88 to 6.16) percentage point increase in the second post-policy period, after which the effect dissipated. Effects on impairment outcomes were positive but statistically insignificant. Findings suggest that must-access PDMP policies may increase numbers of older adults reporting frequent pain in the early policy implementation years, though they were not associated with statistically detectable changes in physical impairment.
Satterstrom P, Jung OS, Dementyev F
… +2 more, Danehey M, Singer SJ
Med Care Res Rev
· 2026 Apr · PMID 41220172
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This 24-month inductive study examined the practices provided by a variety of supporters to six frontline-led innovation teams. Analyzing 86 interviews with 35 team members and 17 supporters, we propose a comprehensive,...This 24-month inductive study examined the practices provided by a variety of supporters to six frontline-led innovation teams. Analyzing 86 interviews with 35 team members and 17 supporters, we propose a comprehensive, idealized framework of dynamic and multisource support. These practices offered critical aid as teams dealt with limited innovation experience, limited relationships, and limited contextual awareness. We categorized the practices we identified into six sets-Ensure Foundational Support, Transmit Knowledge and Skills, Nurture Teams and Teamwork, Cultivate Relationships with Decision-Makers, Scaffold Project Work, and Foster a Holistic View of Innovation Work-and discussed their benefits and boundaries of effectiveness. Our framework challenges the notion of "one-size-fits-all" support, emphasizing the value of adaptive support instead. We also highlight the critical role of coaches and identify significant roles unexpectedly played by the funder, insurer, student fellows, and research-observers that provided instruction, resources, and encouragement.
Joyce Wang X, Geng F, Kosar CM
… +3 more, Santostefano CM, Grabowski DC, Rahman M
Med Care Res Rev
· 2026 Feb · PMID 41139891
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Medicare and Medicaid dual-eligible beneficiaries (i.e., dual eligibles) have complex care needs and often experience poor outcomes in skilled nursing facilities (SNFs). The newly implemented patient-driven payment model...Medicare and Medicaid dual-eligible beneficiaries (i.e., dual eligibles) have complex care needs and often experience poor outcomes in skilled nursing facilities (SNFs). The newly implemented patient-driven payment model (PDPM) changed SNFs' postacute care delivery model and may differentially impact dual eligibles. This study describes the trend breaks due to the PDPM on therapy use, patient outcomes, SNF expenditures, and postacute care use, by dual eligibility status. We utilized health care administrative data and regression discontinuity analysis to examine the change in outcomes among 2 million SNF beneficiaries. We found that dual eligibles experienced greater increases in SNF expenditures than Medicare-only beneficiaries ($771.4 vs. $418.5). No meaningful differences were observed in the change in quality or postacute care use patterns. The increase in SNF expenditure could be due to upcoding or comorbidities not accounted for previously. Our results illustrate the heterogeneous effects of the PDPM.
Roberts ET, Macneal E, Johnston KJ
… +1 more, Figueroa JF
Med Care Res Rev
· 2026 Feb · PMID 41036777
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Medicare and Medicaid are separate programs that together cover 13 million low-income older adults and people with disabilities, known as dual-eligible individuals. Concern about a lack of coordination across Medicare an...Medicare and Medicaid are separate programs that together cover 13 million low-income older adults and people with disabilities, known as dual-eligible individuals. Concern about a lack of coordination across Medicare and Medicaid has prompted the development of Integrated Care Programs (ICPs). Although the primary goal of ICPs is to coordinate financing and care across Medicare and Medicaid, ICPs may also influence whether low-income individuals obtain or keep Medicaid. We evaluated whether the rollout of Medicare-Medicaid Plans (MMPs)-one of the largest ICPs-was associated with changes in Medicaid take-up and retention among Medicare beneficiaries residing in high-poverty zip codes. Using a stacked difference-in-differences design and variation in MMP rollouts across nine states, we found no evidence that MMPs increased monthly or continuous Medicaid enrollment in this population. These findings highlight the need for focused policies to address Medicaid enrollment gaps among low-income Medicare beneficiaries, which could complement broader integration efforts.
Med Care Res Rev
· 2026 Apr · PMID 40801357
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Organizational transformation in health care is critical to achieving systemic improvements, yet it lacks a cohesive body of empirical literature. Thirty-six articles met inclusion criteria in this systematic literature...Organizational transformation in health care is critical to achieving systemic improvements, yet it lacks a cohesive body of empirical literature. Thirty-six articles met inclusion criteria in this systematic literature review of empirical studies of whole-organization transformation describing the transformation process and measures of transformation. Studies had diverse analytic ( = 14) and descriptive ( = 22) aims and were published in many different journals. Few articles provided definitions of transformation. Most employed weak research designs, about half used models for evaluation, and no common measures of transformation were used across articles. Combinations of distributed leadership, staff engagement, and culture change were recurring themes contributing to successful transformation. Two-thirds of articles used models to guide the transformation process. There was no consistency across articles in which models were used for evaluating or guiding change. Most articles reported successful transformation. The literature is methodologically weak, highlighting the need for more rigorous, theory-driven research on health care transformation.
Spetz J, Dau KQ, Quan A
… +3 more, Bates T, DeLisser R, Muench U
Med Care Res Rev
· 2025 Dec · PMID 40801334
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Improving access to midwifery care has been identified as a strategy to address shortages of reproductive health clinicians and ensure person-centered, equitable care. This article describes findings from a new survey of...Improving access to midwifery care has been identified as a strategy to address shortages of reproductive health clinicians and ensure person-centered, equitable care. This article describes findings from a new survey of licensed midwives (LMs) in California, who enter the profession without a nursing background. The data offer new insights into LMs' demographics, training, client population, and practice experiences. LMs predominantly have their own practices, typically working with another midwife and/or an assistant or student, and have relatively small numbers of clients each year. Most of the births they attend occur in homes and birth centers. Many LMs report a lack of understanding of and support for their expertise by physicians and hospitals. Despite these challenges, most LMs are satisfied with their careers. LMs contribute to person-centered care, offering alternatives to hospital birth and expanding access to the midwifery model of care.
Stroupe KT, Markossian T, Etingen B
… +11 more, Hogan TP, Gonzalez B, Evans CT, Suda KJ, Osteen C, Kale I, Huo Z, Ippolito D, Burk M, Cunningham F, Smith BM
Med Care Res Rev
· 2026 Feb · PMID 40757635
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In February 2017, the Department of Veterans Affairs (VA) restructured outpatient medication copayments, creating three medication tiers comparable with private-sector value-based insurance designs (with copayments: US$5...In February 2017, the Department of Veterans Affairs (VA) restructured outpatient medication copayments, creating three medication tiers comparable with private-sector value-based insurance designs (with copayments: US$5, US$8, US$11 per 30-day supply for Tiers 1-3, respectively); however, Veteran medication management experiences have not been assessed following this change. We invited a random sample of Veterans with chronic conditions (e.g., diabetes, hypertension) who utilized VA services to complete a mailed survey about VA and non-VA pharmacy use and medication management experiences following this restructuring. There were 2,884 respondents (29% response rate). Veterans with the lowest proportion of medications from Tier 1 after the restructuring had the highest predicted probability of non-VA pharmacy use from regression analyses. Among respondents subject to VA copayments, 27% reported being better able to afford medications after the restructuring. However, 29% reported worrying about paying for medications, and 18% reported making tradeoffs (e.g., spending less on utilities, food) to pay for prescriptions.
Coates A, Probst J, Sarwal K
… +2 more, Riaz S, Grudniewicz A
Med Care Res Rev
· 2025 Oct · PMID 40705018
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Despite playing a pivotal role in rural community health services delivery and in local economies, rural hospitals in the United States have closed or merged with larger health networks at alarming rates. This scoping re...Despite playing a pivotal role in rural community health services delivery and in local economies, rural hospitals in the United States have closed or merged with larger health networks at alarming rates. This scoping review examines what is known about the impacts of rural hospital closures and mergers since 2010. Using the literature, we inductively derived a new Health System Ecologies Impact Matrix research tool to assess knowledge related to health system changes. Most of the included studies examined closures, primarily reporting on community impacts. Knowledge gaps remain related to financial-, workforce-, and utilization-related outcomes, and little is known about impacts on neighboring hospitals and communities. Few studies report effects of rural hospital mergers, primarily focusing on financial and utilization outcomes for the merged hospital. No studies examined the impacts of rural hospital mergers on patients or individuals and their social environments.
Schulte A, Staiger B, Rodriguez HP
… +1 more, Brewster AL
Med Care Res Rev
· 2025 Dec · PMID 40705003
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The number of Catholic hospitals grew by 28% between 2001 and 2020, and today almost one-fifth of U.S. nonprofit hospitals are Catholic. Catholic systems face conflicting institutional pressures to provide mission-orient...The number of Catholic hospitals grew by 28% between 2001 and 2020, and today almost one-fifth of U.S. nonprofit hospitals are Catholic. Catholic systems face conflicting institutional pressures to provide mission-oriented services while remaining financially competitive. Using 2009-2022 data from the American Hospital Association ( = 33,552 hospital-years), we applied difference-in-differences methods to compare changes in hospital operations after acquisition by Catholic and non-Catholic systems relative to the control group of never-acquired hospitals. Catholic-acquired hospitals were more likely to offer some mission-oriented services, including chaplaincy and charity care (average treatment effect on the treated, ATT, 10.41 percentage-point [pp] and 3.97 pp, respectively), while non-Catholic-acquired hospitals were less likely to operate an obstetrics unit (ATT -3.45 pp) after acquisition relative to the control group. Hospitals experienced similar cost-cutting measures after acquisition relative to the control group, including reduced operating expenses and employment, regardless of system ownership type. Our findings provide rigorous empirical evidence to inform ongoing policy debates regarding the expansion of Catholic health care.
Beckett MK, W Cohea C, Saliba D
… +3 more, Cleary PD, A Giordano L, Elliott MN
Med Care Res Rev
· 2025 Dec · PMID 40620127
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Adults age 75+ report worse inpatient experiences than patients 55 to 74. Older adults may have been especially vulnerable to changes such as family access and reduced staffing during the COVID-19 pandemic. We examined 2...Adults age 75+ report worse inpatient experiences than patients 55 to 74. Older adults may have been especially vulnerable to changes such as family access and reduced staffing during the COVID-19 pandemic. We examined 2018-2023 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys from 14,760,049 respondents discharged from 4,462 hospitals. We examined changes in an HCAHPS summary score (HCAHPS-SS), controlling for pre-pandemic quarterly and linear trends. HCAHPS-SS declined 4.1pp, a medium-to-large drop by Q3/2022, recovering only slightly by Q4/2023 (to -3.5pp). HCAHPS-SS decreased fastest for patients 75+ and least for maternity patients, even controlling for age. Differences by age may reflect older patients' greater need for instrumental support and differential impacts of visitor restrictions. Hospitals' quality improvement efforts should focus on understanding the need for patient support and on restoring prior patient experience gains. The failure to return to pre-pandemic levels points to the need to understand and address the residual factors that continue to alter patient experience.