Jun H, Geng F, McGarry BE
… +4 more, Rahman M, White EM, Gadbois EA, Grabowski DC
Med Care Res Rev
· 2025 Dec · PMID 40583329
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The COVID-19 pandemic exacerbated staffing shortages in U.S. nursing homes. Staff who are immigrants may have stronger tendencies to remain in their jobs than U.S.-born staff, but evidence is lacking. In this study, we p...The COVID-19 pandemic exacerbated staffing shortages in U.S. nursing homes. Staff who are immigrants may have stronger tendencies to remain in their jobs than U.S.-born staff, but evidence is lacking. In this study, we predicted the share of immigrant staff and used a difference-in-differences regression to investigate whether nursing homes with a higher vs. lower proportion of immigrant certified nursing assistants (CNAs) experienced lesser declines in staff hours per resident day (HPRD) during the pandemic. We found that facilities with a larger-than-median predicted share of immigrant staff exhibited a relatively smaller decrease in CNA HPRD by 0.03 HPRD, equivalent to a 1.4% difference of the sample mean. We further found that CNA turnover rates during the pandemic were lower in facilities with relatively higher shares of immigrant staff. Our findings suggest that nursing homes with more immigrant staff may be more resilient in meeting staffing needs during crises.
Tyler DA, Gadbois EA, Brazier JF
… +1 more, Trivedi AN
Med Care Res Rev
· 2025 Oct · PMID 40580077
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The 21st Century Cures Act opened Medicare Advantage (MA) enrollment to people with end-stage renal disease (ESRD). Previously, most Medicare beneficiaries with ESRD were only permitted to enroll in traditional Medicare....The 21st Century Cures Act opened Medicare Advantage (MA) enrollment to people with end-stage renal disease (ESRD). Previously, most Medicare beneficiaries with ESRD were only permitted to enroll in traditional Medicare. The purpose of our study was to determine how MA plans responded to this policy change. We conducted 48 interviews with representatives from MA plans, dialysis provider organizations, and chronic kidney disease (CKD) care management companies. One major theme that emerged from our interviews was MA plans partnered with CKD care management companies to manage the care of ESRD patients. Plans partnered because they had little experience with and were wary of the costs of this population, and sought to improve the value and quality of services. MA plans varied in how they contracted with these organizations, and the CKD care management companies employed several methods for managing patients. Participants reported both benefits and challenges related to these partnerships.
Lenz C, Song M, Bandara S
… +5 more, Kennedy Hendricks A, Kramer C, Sufrin C, Fingerhood M, Saloner B
Med Care Res Rev
· 2025 Dec · PMID 40568792
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Provision of medications for opioid use disorder (MOUD) programs in carceral settings is critical to reducing overdose during the high-risk period following release from incarceration. Efforts to expand carceral MOUD pro...Provision of medications for opioid use disorder (MOUD) programs in carceral settings is critical to reducing overdose during the high-risk period following release from incarceration. Efforts to expand carceral MOUD programs have increased in recent years. We conducted a narrative review to synthesize evidence on the implementation of MOUD in U.S. carceral facilities. We analyzed 36 studies from 2019 to 2023 using the Exploration, Preparation, Implementation, Sustainment framework. Findings highlight that MOUD in carceral settings requires significant resources, infrastructure, and staffing. MOUD diversion is a common concern, with program responses varying widely. Stigma against MOUD remains a challenge, particularly when treating pregnant people with OUD. Effective coordination between carceral and community stakeholders is critical for MOUD implementation and continuity of treatment postrelease. COVID-19 spurred innovation, increasing telehealth in carceral MOUD programs. Future research should explore MOUD program transition from early adoption to wide-scale implementation, considering external factors, sustainability, and evolving policies.
Med Care Res Rev
· 2026 Feb · PMID 40448570
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This article studies the determinants and consequences of low-cost provider use for lab tests. Using all-payer claims data, I measure price variation across lab providers and link individual tests to referring providers,...This article studies the determinants and consequences of low-cost provider use for lab tests. Using all-payer claims data, I measure price variation across lab providers and link individual tests to referring providers, primary care providers, and clinician-hospital ownership information. I find that independent labs are 70% to 80% less expensive than hospital-based facilities, highlighting a path for considerable potential savings. Referring providers are overwhelmingly the strongest determinant of per-lab spending and hospital-based use, explaining 73% of the explained variance in site of care. Switching from a bottom-quintile independent-lab referrer to one in the top quintile is associated with a 39% drop in spending per test. Vertically integrated providers are less likely to be associated with independent lab use and are instead associated with higher spending per test. These findings suggest that clinician relationships, referral dynamics, and vertical integration are critical determinants of spending and site of care.
Med Care Res Rev
· 2025 Oct · PMID 40443140
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Contemporary practice guidelines recommend nonpharmacologic therapies instead of prescription opioids as first-line treatment for many pain types, including acute low back pain (aLBP). This serial cross-sectional study d...Contemporary practice guidelines recommend nonpharmacologic therapies instead of prescription opioids as first-line treatment for many pain types, including acute low back pain (aLBP). This serial cross-sectional study describes trends in the annual prevalence of physical therapy (PT), chiropractic care, gabapentinoids, and prescription opioid receipt among Medicare beneficiaries diagnosed with aLBP from 2016 to 2019, overall and within key demographic, clinical, and geographic subgroups. Overall, changes in PT (5.5%-6.7%), chiropractic care (11.0%-11.7%), and gabapentinoid (9.6%-8.9%) receipt were limited, whereas prescription opioid use substantially decreased (26.2%-17.8%). Prescription opioid receipt was higher among individuals under age 65, American Indian/Alaskan Native, non-Hispanic Black/African American, and Hispanic individuals, individuals with opioid use disorder, and in Southern states, while the use of nonpharmacologic pain therapies remained low among these subgroups. It is essential to promote equitable access to multimodal and guideline-recommended approaches for aLBP management including nonpharmacologic therapies.
Med Care Res Rev
· 2025 Oct · PMID 40433970
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We sought to understand stakeholder experience with telehealth services, through interviews with patients, providers, and health plans, to inform Medicaid policy after the COVID-19 public health emergency. Our primary ai...We sought to understand stakeholder experience with telehealth services, through interviews with patients, providers, and health plans, to inform Medicaid policy after the COVID-19 public health emergency. Our primary aim was to examine whether and how such telehealth policies affect equitable care delivery and to uncover any remaining policy gaps. Applying the Framework for Digital Health Equity our study identified digital determinants that operate at the individual, interpersonal, community and societal levels. Across respondents, telehealth expansion was viewed as overwhelmingly positive and noted as a significant contributor to increased access among marginalized, minoritized, and rural Medicaid participants in this study. Despite these strengths, patients and health care providers identified several challenges and recommendations.
Lê Cook B, McConnell KJ, Parry G
… +9 more, Flores M, Renfro S, Kumar A, Holmes C, Reddy A, Takalkar R, Mullin B, Normand ST, Horvitz-Lennon M
Med Care Res Rev
· 2025 Oct · PMID 40433969
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Racial and ethnic disparities in mental health care access are especially consequential for the health outcomes of Medicaid beneficiaries living with serious mental illness (SMI). This descriptive study of Oregon Medicai...Racial and ethnic disparities in mental health care access are especially consequential for the health outcomes of Medicaid beneficiaries living with serious mental illness (SMI). This descriptive study of Oregon Medicaid claims data assessed for disparities in access to SMI care for Oregon's adult Medicaid beneficiaries from 2010 to 2019, examining changes following the implementation of value-based payment (VBP) in 2012. Multivariable regression analyses compared changes in access to SMI care, pre- and post-VBP implementation, by race and ethnicity. Relative to White beneficiaries, VBP implementation was associated with net increases of 0.28% (95% confidence interval [CI]: [0.01%, 0.55%]) in the rate of access among Black beneficiaries (a complete reduction of the pre-VBP disparity) and 0.34% (95% CI: [0.17%, 0.51%]) among Latinx beneficiaries (narrowing but not closing the pre-VBP disparity). The Oregon policy's focus on access, equity, and beneficiaries with mental illness might have contributed to the observed reductions in disparities.
Med Care Res Rev
· 2026 Feb · PMID 40338021
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Health care providers participating in five accountable care organization (ACO) models designed, implemented, and evaluated by the Innovation Center at the Centers for Medicare & Medicaid Services have cared for almost s...Health care providers participating in five accountable care organization (ACO) models designed, implemented, and evaluated by the Innovation Center at the Centers for Medicare & Medicaid Services have cared for almost six million fee-for-service Medicare patients over the past decade. This systematic review summarizes the features and performance of these ACO models, capturing five major themes arising from their evaluation reports: spending performance by ACO organization type; the role of management companies in ACO structure and performance; financial risk and ACO participation; clinician incentives, waivers, and payment mechanisms; and patient engagement with ACOs. In difference-in-differences analyses, these 214 ACOs lowered spending by an estimated $2.8 billion, or $316.9 million after accounting for shared savings payouts derived from benchmarks, with no evident decrements in quality of care. ACOs' challenge in ongoing and future ACO models is to apply their accrued experience to reduce spending and improve quality within a fee-for-service payment system.
Korsberg A, Cornelius SL, Awa F
… +2 more, O'Malley J, Moen EL
Med Care Res Rev
· 2025 Jun · PMID 40271968
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Social network analysis is the study of the structure of relationships between social entities. Access to health care administrative datasets has facilitated use of "patient-sharing networks" to infer relationships betwe...Social network analysis is the study of the structure of relationships between social entities. Access to health care administrative datasets has facilitated use of "patient-sharing networks" to infer relationships between health care providers based on the extent to which they have encounters with common patients. The structure and nature of patient-sharing relationships can reflect observed or latent aspects of health care delivery systems, such as collaboration and influence. We conducted a scoping review of peer-reviewed studies that derived patient-sharing network measure(s) in the analyses. There were 134 papers included in the full-text review. We identified and created a centralized resource of 118 measures and uncovered three major themes captured by them: , and . Researchers may use this review to inform their use of patient-sharing network measures and to guide the development of novel measures.
Lombardi BM, Lombardi B, Galloway E
… +1 more, Zerden LS
Med Care Res Rev
· 2025 Jun · PMID 40271967
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This study used three national data sources to estimate the size and distribution of Community health workers (CHWS) in the United States. CHWs were identified in the National Plan and Provider Enumeration System (NPPES;...This study used three national data sources to estimate the size and distribution of Community health workers (CHWS) in the United States. CHWs were identified in the National Plan and Provider Enumeration System (NPPES; 2022), Bureau of Labor Statistics (BLS) data (2021), and American Community Survey (ACS; 2020). The rate of CHWs per 100,000 people was calculated and compared across states. Then, the study assessed if the rate of CHWS per the population varied in states with or without CHW certification or reimbursement in a series of one-way analyses of variance (ANOVAs). Nationally, the rate of CHWs per 100,000 people in NPPES is 7.44, 18.37 in the BLS, and 35.44 in the ACS. No significant differences in the mean number of CHWs per 100,0000 people in states with or without certification and/or reimbursement was found. Further exploration of available data sources is needed to provide new insights and potential solutions to employ, fund, and sustain the CHW workforce.
Med Care Res Rev
· 2025 Aug · PMID 40099701
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To analyze the determinants and effects of hospital entry, we compare entrants' quality of care to incumbent hospitals. Using national hospital-level patient mortality measures from July 2005 to June 2019 for Medicare pa...To analyze the determinants and effects of hospital entry, we compare entrants' quality of care to incumbent hospitals. Using national hospital-level patient mortality measures from July 2005 to June 2019 for Medicare patients with common medical conditions (heart attack, heart failure, and pneumonia), we establish that entrant hospitals experience 0.27 to 0.76 fewer deaths per 100 patients than incumbent hospitals in the same markets. We further show that new hospitals enter markets where they can provide higher quality care than incumbent hospitals.
Med Care Res Rev
· 2025 Aug · PMID 40099689
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Proposals to reduce the cost of health care services and improve the quality of care often involve ambitious expectations for the role of primary care clinics (PCCs). We systematically reviewed the literature to identify...Proposals to reduce the cost of health care services and improve the quality of care often involve ambitious expectations for the role of primary care clinics (PCCs). We systematically reviewed the literature to identify interventions PCCs could undertake to reduce avoidable emergency department visits and ambulatory care-sensitive admissions. Database searches resulted in only seven studies that met the inclusion criteria for this review. Very few studies identified interventions that primary care physicians could undertake to reduce total cost of care, possibly because relatively few PCCs are held responsible for total cost of care. Evidence-based interventions to reduce ACS admissions and ED use included case-management models, clinical decision-support tools, & care plans integrated into patients' electronic medical records. The interventions highlighted a heightened role for PCCs in care coordination and access to care that could lead to patients actively engaging in care management and consulting PCCs before seeking urgent care.
Smith LB, Waidmann TA, Caswell KJ
… +1 more, Wei K
Med Care Res Rev
· 2025 Aug · PMID 40099673
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Individuals dually enrolled in Medicare and Medicaid often experience fragmented care that fails to meet their health care needs and is unduly expensive due to a lack of coordination between Medicare and Medicaid program...Individuals dually enrolled in Medicare and Medicaid often experience fragmented care that fails to meet their health care needs and is unduly expensive due to a lack of coordination between Medicare and Medicaid programs. Washington state's Health Home Managed Fee-For-Service demonstration, part of the Financial Alignment Initiative, sought to improve care and reduce costs for high-cost, high-risk dual enrollees through care coordination. Using Medicare and Medicaid administrative claims data from 2016 to 2019, we evaluate the impact of the Washington demonstration on health care utilization using a modified regression discontinuity design. We find that for relatively healthy enrollees on the margin of eligibility for the demonstration, enrollment in the demonstration modestly reduced emergency department visits, ambulatory care visits, and some types of home and community-based service (HCBS) use and reduced nursing facility stays for older enrollees, but did not impact inpatient or skilled nursing facility admissions. Addressing the fragmentation of coverage, care, and financing for dual enrollees remains an important policy and research priority.
Med Care Res Rev
· 2025 Oct · PMID 40099657
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Empowering beneficiaries to choose a health plan that meets their health needs during the transition to Medicaid managed care is critical to promote informed decision-making. This study uses North Carolina's transition u...Empowering beneficiaries to choose a health plan that meets their health needs during the transition to Medicaid managed care is critical to promote informed decision-making. This study uses North Carolina's transition under the 1115 waiver to examine the role of the state, health plans, and providers in informing beneficiaries about the transition. We reviewed policy documents and interviewed 43 individuals representing provider practices and 10 representing the State Department of Health and Human Services and health plans between December 2020 and September 2021. Interviewees from the state described strategies to encourage beneficiaries to select a health plan. Participating practices shared that their patients were unaware or confused about the transition. These concerns led practices to engage beneficiaries and contract with all health plans to ensure continuity of care, contributing to administrative burdens. While the state made significant efforts to engage beneficiaries, the interaction between beneficiaries and providers was still critical.
Med Care Res Rev
· 2025 Aug · PMID 40079195
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This cross-sectional study examines shifts in health industry entry and sector choice among women, racially minoritized workers, and immigrants during the pandemic era. Using data from the Annual Social and Economic Supp...This cross-sectional study examines shifts in health industry entry and sector choice among women, racially minoritized workers, and immigrants during the pandemic era. Using data from the Annual Social and Economic Supplement of the Current Population Survey (2018-2023), we compare entrant characteristics before and during the pandemic era, focusing on demographic composition and sector choice. Results show minimal shifts by gender, race, or education but highlight a rise in entrants from outside the labor force, particularly among White women and racially minoritized men. There were changes in sector choice: ambulatory care saw the greatest increase in racially minoritized entrants, with small increases for hospitals and a decrease for long-term care. Despite these sector-specific shifts, overall opportunities for minoritized workers did not expand, nor did workforce diversity significantly improve. These findings underscore the need for research that examines how policies outside the workplace shape worker behavior, particularly among marginalized groups.
Med Care Res Rev
· 2025 Jun · PMID 39994828
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Using beneficiary reports of health care utilization from the 2019 Medicare Current Beneficiary Survey Cost Supplement, we compare the prevalence of home-based care and number of visits among Medicare beneficiaries aged...Using beneficiary reports of health care utilization from the 2019 Medicare Current Beneficiary Survey Cost Supplement, we compare the prevalence of home-based care and number of visits among Medicare beneficiaries aged 65 and older, by plan option, excluding dual-eligible beneficiaries. Traditional Medicare (TM) beneficiaries were significantly more likely to receive home-based medical visits (10.4% vs. 8.0%) with greater differences observed in vulnerable subgroups. While average number of visits were comparable for TM (35.6) and Medicare Advantage (MA) (34.9) beneficiaries, the distribution of the number of visits varied by plan option. Compared with TM beneficiaries, MA beneficiaries were 4.5 times more likely to receive a single home-based medical visit (17.5% vs. 3.9%) and roughly 1.5 times more likely to have the fewest (two to four visits; 12.2% vs. 8.0%) and greatest number of home visits (90+ visits; 11.1% vs. 7.7%). Access to, and number of, home-based medical care differs significantly by plan option.
Med Care Res Rev
· 2025 Jun · PMID 39972931
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Medicare home health coverage is an important resource for Medicare beneficiaries requiring health care at home. However, there have been changes in the United States health care system that might impact home health util...Medicare home health coverage is an important resource for Medicare beneficiaries requiring health care at home. However, there have been changes in the United States health care system that might impact home health utilization such as pressures to constrain Medicare spending, growth in Medicare Advantage (MA) plan enrollment, decline in institutional long-term care and growth of Medicaid home- and community-based services. Given these changes, we examined home health care use trends among beneficiaries enrolled in traditional Medicare (TM) and MA from 2010 to 2020. We separately examined home health episodes that were initiated after a hospital or skilled nursing facility discharge and those initiated within the community and among dually and non-dually eligible beneficiaries. Home health use decreased among TM enrollees for both community-initiated and post-discharge needs but increased among MA enrollees for community-initiated home health use. Increases in community-initiated home health use were concentrated in non-dually eligible beneficiaries.
Med Care Res Rev
· 2025 Jun · PMID 39936554
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This study examines the impact of legalizing fentanyl test strips (FTSs) on drug-related mortality in the United States from 2018 to 2022. Using a difference-in-differences approach with state-level data, we find that FT...This study examines the impact of legalizing fentanyl test strips (FTSs) on drug-related mortality in the United States from 2018 to 2022. Using a difference-in-differences approach with state-level data, we find that FTS legalization is associated with a significant reduction in drug-overdose deaths. Across the population, FTS legalization corresponds to a 7% decrease in overdose mortality, with an even more pronounced 13.5% reduction among Black individuals. Our analysis employs two-way fixed effects models and triple differences specifications to isolate the effect of FTS legalization from other factors. The results suggest that FTS legalization is particularly effective in reducing unintentional drug-overdose deaths. These findings underscore the potential of FTS as a critical harm reduction tool in addressing the opioid crisis, especially in mitigating racial disparities in overdose mortality. The study provides evidence to support expanding access to FTS as part of comprehensive public health strategies.
Neshan M, Padmanaban V, Fareed N
… +3 more, Ruff SM, Kelly EP, Pawlik TM
Med Care Res Rev
· 2025 Jun · PMID 39921421
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Decision control preferences (DCPs) refer to the degree of control patients' desire over their medical treatment. Several validated tools exist to evaluate a patient's DCPs, yet there is no universally used instrument an...Decision control preferences (DCPs) refer to the degree of control patients' desire over their medical treatment. Several validated tools exist to evaluate a patient's DCPs, yet there is no universally used instrument and their use in clinical settings is lacking. We provide a systematic comparative summary of available DCP tools. Following a systematic database search, English language studies across medical contexts and patient populations were eligible if a validated assessment tool to evaluate patient DCPs was reported. Among the 15 tools that met inclusion criteria, the autonomy preference index (API) and the control preference scale (CPS) were the most used tools (API: 40%, CPS: 26.6%). Most studies ( = 9) sought to identify the information-seeking preferences of patients as a critical component of decision-making. Only few studies evaluated providers' perceptions of patient preferences. Considering the variety of patients' DCPs, implementation of DCP tools can optimize shared decision-making and improve patient outcomes.
Achola EM, Trivedi AN, Kim D
… +3 more, Meyers DJ, Varma H, Keohane LM
Med Care Res Rev
· 2025 Apr · PMID 39849893
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Post-acute care users in Medicare Advantage (MA) plans may seek coverage changes if facing issues with plan benefits. In 2019, the Centers for Medicare and Medicaid Services extended the deadline to disenroll from an MA...Post-acute care users in Medicare Advantage (MA) plans may seek coverage changes if facing issues with plan benefits. In 2019, the Centers for Medicare and Medicaid Services extended the deadline to disenroll from an MA plan from February 14 to March 31 and, for the first time, permitted beneficiaries to switch to a different MA plan instead of traditional Medicare. Using 2016-2019 Medicare administrative data, we implemented a difference-in-differences approach to evaluate the impact of this policy on disenrollment from a plan within 1 month of initiating skilled nursing facility or home health services. When MA disenrollment rules became more flexible, overall rates of exiting MA plans did not change. Switching to a different MA plan increased after the policy change, but this outcome was so rare that this increase did not affect overall rates of exiting MA plans.