McMenamin A, Turi E, Schlak A
… +1 more, Poghosyan L
Med Care Res Rev
· 2023 Dec · PMID 37438917
·
Full text
Multiple chronic conditions (MCCs) are more common and costly than any individual health condition in the United States. The growing workforce of nurse practitioners (NPs) plays an active role in providing primary care t...Multiple chronic conditions (MCCs) are more common and costly than any individual health condition in the United States. The growing workforce of nurse practitioners (NPs) plays an active role in providing primary care to this patient population. This study identifies the effect of NP primary care models, compared with models without NP involvement, on cost, quality, and service utilization by patients with MCCs. We conducted a literature search of six databases and performed critical appraisal. Fifteen studies met inclusion criteria (years: 2003-2021). Overall, most studies showed reduced or similar costs, equivalent or better quality, and similar or lower rates of emergency department use and hospitalization associated with NP primary care models for patients with MCCs, compared with models without NP involvement. No studies found them associated with worse outcomes. Thus, NP primary care models, compared with models without NP involvement, have similar or positive impacts on MCC patient outcomes.
Med Care Res Rev
· 2023 Oct · PMID 37394818
·
Publisher ↗
More than 16 million people receive health care coverage through the Affordable Care Act's (ACA) individual health insurance marketplaces. Many enrollees receive premium subsidies that are tied to the premium of the seco...More than 16 million people receive health care coverage through the Affordable Care Act's (ACA) individual health insurance marketplaces. Many enrollees receive premium subsidies that are tied to the premium of the second least expensive silver plan available. This study investigates the consistency of the least expensive silver plan offered on Healthcare.gov from 2014 to 2021 and finds that on average, from one year to the next, the same insurer offered the least expensive silver plan in 63.1% of counties representing 54.7% of the population. However, even when the same insurer offers the least expensive plan, almost half the time, they introduce a new, less expensive plan in the next policy year. Consequently, ACA enrollees who previously purchased the least expensive silver plan may face incremental premium costs unless they spend time and effort to carefully reevaluate their choices each year. We estimate the potential premium cost of inattention and show how it varies over time and across states.
Grove LR, Berkowitz SA, Cuddeback G
… +4 more, Pink GH, Stearns SC, Stürmer T, Domino ME
Med Care Res Rev
· 2023 Dec · PMID 37366069
·
Full text
This study assessed whether permanent supportive housing (PSH) participation is associated with health service use among a population of adults with disabilities, including people transitioning into PSH from community an...This study assessed whether permanent supportive housing (PSH) participation is associated with health service use among a population of adults with disabilities, including people transitioning into PSH from community and institutional settings. Our primary data sources were 2014 to 2018 secondary data from a PSH program in North Carolina linked to Medicaid claims. We used propensity score weighting to estimate the average treatment effect on the treated of PSH participation. All models were stratified by whether individuals were in institutional or community settings prior to PSH. In weighted analyses, among individuals who were institutionalized prior to PSH, PSH participation was associated with greater hospitalizations and emergency department (ED) visits and fewer primary care visits during the follow-up period, compared with similar individuals who largely remained institutionalized. Individuals who entered PSH from community settings did not have significantly different health service use from similar comparison group members during the 12-month follow-up period.
Hollander MAG, Kennedy-Hendricks A, Schilling C
… +7 more, Meiselbach MK, Stuart EA, Huskamp HA, Busch AB, Eddelbuettel JCP, Barry CL, Eisenberg MD
Med Care Res Rev
· 2023 Oct · PMID 37345300
·
Full text
A high-deductible health plan (HDHP) may incentivize enrollees to limit health care use at the beginning of a plan year, when they are responsible for 100% of costs, or to increase the use of care at the end of the year,...A high-deductible health plan (HDHP) may incentivize enrollees to limit health care use at the beginning of a plan year, when they are responsible for 100% of costs, or to increase the use of care at the end of the year, when enrollees may have less cost exposure. We investigated both the impact of the deductible reset that occurs at the beginning of a plan year and the option to enroll in an HDHP on the use of substance use disorder (SUD) treatment services over the course of a health plan year. We found decreases in SUD treatment use following the increase in cost exposure related to a deductible reset. There was no variation in this behavior between HDHP offer enrollees and comparison enrollees who were not offered an HDHP. These findings reinforce that cost-sharing poses a barrier to SUD care and continuity of care, which can increase the risk of adverse clinical outcomes.
Med Care Res Rev
· 2023 Aug · PMID 37340800
·
Publisher ↗
High labor demand for physician assistants/associates (PA) has led to substantial PA workforce and wage growth. During this growth period, states have adopted reforms to reduce PA scope of practice restrictions and repor...High labor demand for physician assistants/associates (PA) has led to substantial PA workforce and wage growth. During this growth period, states have adopted reforms to reduce PA scope of practice restrictions and reports of significant gender and race wage disparities have emerged. This study examined data from the American Community Survey to investigate the influence of demographic characteristics, human capital, and scope of practice reforms on PA wages from 2008 to 2017. Using an ordinary least squares two-way fixed effects estimator, a significant association between reforms and PA wages could not be established. Rather, wages were found to be strongly associated with human capital and demographic characteristics. Gender and race wage disparities persist, with female PAs earning 7.5% lower wages than male PAs and White PAs earning 9.1% to 14.5% higher wages than racial and ethnic minority PAs. These findings suggest a minimal influence of prior scope of practice reforms on PA wages.
Med Care Res Rev
· 2023 Dec · PMID 37329285
·
Publisher ↗
Health insurance stability among children with adverse childhood experiences (ACEs) is essential for accessing health care services. This cross-sectional study used an extensive, multi-year, nationally representative dat...Health insurance stability among children with adverse childhood experiences (ACEs) is essential for accessing health care services. This cross-sectional study used an extensive, multi-year, nationally representative database of children aged 0 to 17 to examine the association between ACE scores and continuous or intermittent lack of health insurance over a 12-month period. Secondary outcomes were reported reasons for coverage gaps. Compared with children having 0 ACEs, those with 4+ ACEs had a higher likelihood of being part-year uninsured rather than year-round private insured (relative risk ratio [RRR]: 4.20; 95% CI: 3.25, 5.43), year-round public insured (RRR: 1.37; 95% CI: 1.06, 1.76), or year-round uninsured (RRR: 2.28; 95% confidence interval [CI]: 1.63, 3.21). Among children who experienced part-year or year-round uninsurance, a higher ACE score was associated with a greater likelihood of coverage gap due to difficulties with the application or renewal process. Policy changes to reduce administrative burdens may improve health insurance stability and access to health care among children who endure ACEs.
Kerrissey M, Jamakandi S, Alcusky M
… +2 more, Himmelstein J, Rosenthal M
Med Care Res Rev
· 2023 Oct · PMID 37232171
·
Publisher ↗
Amid enthusiasm about accountable care organizations (ACOs) in Medicaid, little is known about the primary care practices engaging in them. We leverage a survey of administrators within a random sample (stratified by ACO...Amid enthusiasm about accountable care organizations (ACOs) in Medicaid, little is known about the primary care practices engaging in them. We leverage a survey of administrators within a random sample (stratified by ACO) of 225 practices joining Massachusetts Medicaid ACOs (64% response rate; 225 responses). We measure the integration of processes with distinct entities: consulting clinicians, eye specialists for diabetes care, mental/behavioral care providers, and long-term and social services agencies. Using multivariable regression, we examine organizational correlates of integration and assess integration's relationships with care quality improvement, health equity, and satisfaction with the ACO. Integration varied across practices. Clinical integration was positively associated with perceived care quality improvement; social service integration was positively associated with addressing equity; and mental/behavioral and long-term service integration were positively associated with ACO satisfaction (all < .05). Understanding differences in integration at the practice level is vital for sharpening policy, setting expectations, and supporting improvement in Medicaid ACOs.
Med Care Res Rev
· 2023 Oct · PMID 37226668
·
Publisher ↗
Short-term health insurance policies-made available with longer durations during the Trump Administration-offer substantially fewer consumer protections than do Affordable Care Act ("ACA")-compliant policies. Federal reg...Short-term health insurance policies-made available with longer durations during the Trump Administration-offer substantially fewer consumer protections than do Affordable Care Act ("ACA")-compliant policies. Federal regulations require short-term policies' sellers to disclose possible ACA noncompliance to prospective buyers. This controlled experiment finds, however, that the federally required disclosure does not substantially improve consumer understanding of these policies' coverage limitations. The experiment also finds that an enhanced disclosure greatly improves this understanding. Importantly, consumers' preferences for ACA-compliant policies also increased with their comprehension of the coverage differences. Thus, the study demonstrates not only that easily implemented changes in the federally required disclosure would improve consumer understanding of the coverage differences but also that the improved understanding matters to consumers. However, even the enhanced disclosure left many respondents mistaken about some key limitations of short-term policies, suggesting that policymakers should consider other strategies to protect buyers of short-term health insurance.
Med Care Res Rev
· 2023 Dec · PMID 37191341
·
Publisher ↗
Noncitizen immigrants are often excluded from accessing critical safety-net programs, such as Medicaid. Access to health care plays a central role in current policy debates on maternal health. Yet, immigrant exclusions a...Noncitizen immigrants are often excluded from accessing critical safety-net programs, such as Medicaid. Access to health care plays a central role in current policy debates on maternal health. Yet, immigrant exclusions are rarely considered in maternal health policy research. Through open-ended interviews with 31 policymakers, researchers, and program administrators, we examined state variations in approaches to providing care for pregnant, post, and intrapartum immigrant women. We found four themes: (a) a patchwork safety-net exists that provides some access to immigrants ineligible for Medicaid; (b) patchwork coverage leads to patchwork care, which can contribute to maternal health inequities; (c) immigrant Medicaid policy is assembled along a hierarchy of deservingness based on documentation status; (d) Trump-era public charge rules and political climate may have a substantial chilling effect on benefit uptake regardless of eligibility. We discuss implications for efforts to expand Medicaid postpartum and address the maternal health crisis.
Med Care Res Rev
· 2023 Oct · PMID 37183707
·
Publisher ↗
In 2016, Minnesota implemented a new pay-for-performance reimbursement scheme for Medicaid residents in nursing homes, known as Value-Based Reimbursement (VBR). This study seeks to understand whether there is an associat...In 2016, Minnesota implemented a new pay-for-performance reimbursement scheme for Medicaid residents in nursing homes, known as Value-Based Reimbursement (VBR). This study seeks to understand whether there is an association between VBR and quality improvement. We use data from 2013 to 2019 including Centers for Medicare and Medicaid Services, Nursing Home Compare, and Long-term care Facts in the US. Using multivariate regression with commuting zone fixed effects, we compare five long-stay and two short-stay clinical quality metrics in Minnesota nursing homes to nursing homes bordering states, before and after VBR was implemented. We find minimal significant changes in quality in Minnesota nursing homes after VBR. Minnesota should reconsider its pay-for-performance efforts.
Med Care Res Rev
· 2023 Oct · PMID 37178015
·
Full text
Household surveys are an important source of information on medical spending and burden. We examine how recently implemented post-processing improvements to the Current Population Survey Annual Social and Economic Supple...Household surveys are an important source of information on medical spending and burden. We examine how recently implemented post-processing improvements to the Current Population Survey Annual Social and Economic Supplement (CPS ASEC) affected estimates of medical expenditures and medical burden. The revised data extraction and imputation procedures mark the second stage of the CPS ASEC redesign and the beginning of a new time series for studying household medical expenditures. Using data for the calendar year 2017, we find that median family medical expenditures are not statistically different from legacy methods; however, updated processing does significantly reduce the percentage of families estimated to have a high medical burden (medical expenses are at least 10% of family income). The updated processing system also changes the characteristics of families with high medical spending and is primarily driven by changes in imputation of health insurance and medical spending.
Gadbois EA, Brazier JF, Meehan A
… +5 more, Madrigal C, White EM, Rafat A, Grabowski D, Shield RR
Med Care Res Rev
· 2023 Dec · PMID 37170944
·
Full text
COVID-19 vaccinations are critical for mitigating outbreaks and reducing mortality for skilled nursing facility (SNF) residents and staff, yet uptake among SNF staff varies widely and remains suboptimal. Understanding wh...COVID-19 vaccinations are critical for mitigating outbreaks and reducing mortality for skilled nursing facility (SNF) residents and staff, yet uptake among SNF staff varies widely and remains suboptimal. Understanding which strategies are successful for promoting staff vaccination, and examining the relationship between vaccination policies and staff retention/turnover is key for identifying best practices. We conducted repeated interviews with SNF administrators at 3-month intervals between July 2020 and December 2021 ( = 156 interviews). We found that COVID-19 vaccines were initially met with both enthusiasm and skepticism by SNF staff. Administrators reported strategies to increase staff vaccine acceptance, including incentives, one-on-one education, and less stringent personal protective equipment requirements. Federal and state vaccination mandates further promoted vaccine uptake. This combination of mandates with prioritization of the vaccine by SNFs and their leadership was successful at increasing staff vaccination acceptance, which may be critical to increase staff booster uptake from its current suboptimal levels.
Kachoria AG, Sefton L, Miller F
… +5 more, Leary A, Goff SL, Nicholson J, Himmelstein J, Alcusky M
Med Care Res Rev
· 2023 Oct · PMID 37098858
·
Full text
Care coordination is central to health care delivery system reform efforts to control costs, improve quality, and enhance patient outcomes, especially for individuals with complex medical and social needs. The potential...Care coordination is central to health care delivery system reform efforts to control costs, improve quality, and enhance patient outcomes, especially for individuals with complex medical and social needs. The potential impact of addressing health-related social needs further illustrates the importance of coordinating health care services with community-based organizations that provide social services and support. This study offers early findings from a unique approach to care coordination delivered by 17 Medicaid Accountable Care Organizations and 27 partnering community-based organizations for individuals with behavioral health conditions and/or those needing long-term services and supports. Interview data from 54 key informants were qualitatively analyzed to understand factors affecting cross-sector integrated care. Key themes emerged, essential to implementing the new model statewide: clarifying roles and responsibilities; promoting communication; facilitating information exchange; developing workforce capacity; building essential relationships; and responsive, supportive program management through real-time feedback, financial incentives, technical assistance, and flexibility from the state Medicaid program.
Hamer MK, DeCamp M, Bradley CJ
… +2 more, Nease DE, Perraillon MC
Med Care Res Rev
· 2023 Aug · PMID 37098854
·
Full text
Medicare's Annual Wellness Visit (AWV) was introduced in 2011 to encourage the utilization of preventive services, but many clinicians and patients still do not participate in the visit. We qualitatively and quantitative...Medicare's Annual Wellness Visit (AWV) was introduced in 2011 to encourage the utilization of preventive services, but many clinicians and patients still do not participate in the visit. We qualitatively and quantitatively assessed motivations and clinical and financial value of AWVs from a primary care perspective using interviews and Medicare claims from 2012 to 2019. Primary care providers with the highest acuity patients had AWV utilization rates 11.2 percentage points lower than providers with the lowest acuity patients; utilization rates were 3.8 percentage points lower in rural counties. Adoption was motivated by patient needs and financial incentives. AWVs closed gaps in preventive care, strengthened patient-provider relationships, facilitated advance care planning, and provided an opportunity to improve quality metrics. Overall, the AWV has the potential to increase the use of high-value preventive services although not all clinics have an economic incentive to adopt the visit, which may explain some of the variability in utilization rates.
Meiselbach MK, Drake C, Zhu JM
… +6 more, Manibusan B, Nagy D, Sorbero MJ, Saloner B, Stein BD, Polsky D
Med Care Res Rev
· 2023 Aug · PMID 37083043
·
Full text
Provider networks in Medicaid Managed Care (MMC) play a crucial role in ensuring access to buprenorphine, a highly effective treatment for opioid use disorder. Using a difference-in-differences approach that compares net...Provider networks in Medicaid Managed Care (MMC) play a crucial role in ensuring access to buprenorphine, a highly effective treatment for opioid use disorder. Using a difference-in-differences approach that compares network breadth across provider specialties and market segments within the same state, we investigated the association between three Medicaid policies and the breadth of MMC networks for buprenorphine prescribers: Medicaid expansion, substance use disorder (SUD) network adequacy criteria, and SUD carveouts. We found that both Medicaid expansion and SUD network adequacy criteria were associated with substantially increased breadth in buprenorphine-prescriber networks in MMC. In both cases, we found that the associations were largely driven by increases in the network breadth of primary care physician prescribers. Our findings suggest that Medicaid expansion and SUD network adequacy criteria may be effective strategies at states' disposal to improve access to buprenorphine.
Miller-Rosales C, Busch SH, Meara ER
… +3 more, King A, D'Aunno TA, Colla CH
Med Care Res Rev
· 2023 Aug · PMID 37036056
·
Full text
Medications for opioid use disorder (MOUD) remain highly inaccessible despite demonstrated effectiveness. We examine the extent of screening for opioid use and availability of MOUD in a national cross-section of multi-ph...Medications for opioid use disorder (MOUD) remain highly inaccessible despite demonstrated effectiveness. We examine the extent of screening for opioid use and availability of MOUD in a national cross-section of multi-physician primary care and multispecialty practices. Drawing on an existing framework to characterize the internal and environmental context, we assess socio-technical, organizational-managerial, market-based, and state-regulation factors associated with the use of opioid screening and offering of MOUD in a practice. A total of 26.2% of practices offered MOUD, while 69.4% of practices screened for opioid use. Having advanced health information technology functionality was positively associated with both screening for opioid use and offering MOUD in a practice, while access to on-site behavioral clinicians was positively associated with offering MOUD in adjusted models. These results suggest that improving access to information and expertise may enable physician practices to respond more effectively to the nation's ongoing opioid epidemic.
Leao DLL, Cremers HP, van Veghel D
… +3 more, Pavlova M, Hafkamp FJ, Groot WNJ
Med Care Res Rev
· 2023 Oct · PMID 36951451
·
Full text
Evidence on the potential for value-based payment models to improve quality of care and ensure more efficient outcomes is limited and mixed. We aim to identify the factors that enhance or inhibit the design, implementati...Evidence on the potential for value-based payment models to improve quality of care and ensure more efficient outcomes is limited and mixed. We aim to identify the factors that enhance or inhibit the design, implementation, and application of these models through a systematic literature review. We used the PRISMA guidelines. The facilitating and inhibiting factors were divided into subcategories according to a theoretical framework. We included 143 publications, each reporting multiple factors. Facilitators on objectives and strategies, such as realistic/achievable targets, are reported in 56 studies. Barriers regarding dedicated time and resources (e.g., an excessive amount of time for improvements to manifest) are reported in 25 studies. Consensus within the network regarding objectives and strategies, trust, and good coordination is essential. Health care staff needs to be kept motivated, well-informed, and actively involved. In addition, stakeholders should manage expectations regarding when results are expected to be achieved.
Med Care Res Rev
· 2023 Aug · PMID 36951416
·
Publisher ↗
A possible unintended consequence of episode payment models is provider consolidation, which can, in turn, increase prices for commercially insured enrollees. We assess the effect of Medicare's Comprehensive Care for Joi...A possible unintended consequence of episode payment models is provider consolidation, which can, in turn, increase prices for commercially insured enrollees. We assess the effect of Medicare's Comprehensive Care for Joint Replacement (CJR) model on provider consolidation. Hospitals in randomly assigned metropolitan statistical areas were mandated to participate during the first 2 years of the model and a subset of hospitals were mandated for later years. We used a difference-in-differences approach to assess whether CJR affected consolidation, as measured by hospital ownership of practices, the number and size of practices, the Herfindahl-Hirschman Index, and the four-firm concentration ratio. Given limited sample sizes, our results are only suggestive that CJR was not associated with changes in consolidation. Our strongest results suggest null effects for changes in hospital ownership and practice size. These findings suggest that concerns regarding the role alternative payment models play in consolidation may have been overstated.
Med Care Res Rev
· 2023 Jun · PMID 36935565
·
Publisher ↗
Despite the substantial personal and economic implications of end-of-life decisions, many individuals fail to document their wishes, which often leads to patient dissatisfaction and unnecessary medical spending. We condu...Despite the substantial personal and economic implications of end-of-life decisions, many individuals fail to document their wishes, which often leads to patient dissatisfaction and unnecessary medical spending. We conducted a randomized trial of 1,200 patients aged 55 years and older to facilitate advance directive (AD) completion and better understand why patients fail to engage in high-value planning. We found that including a physical AD form with paper letters as a nudge to decrease hassle costs increased AD completion by 9.0 percentage points (95% confidence interval [CI] = [4.2, 13.9] percentage points). The intervention was especially effective for individuals aged 70 years and older, as AD completion increased by 17.5 percentage points (95% CI = [5.7, 9.4] percentage points). When compared with the impact of costless electronic reminders, each additional AD completion from the letter interventions costs as little as US$37. Our findings suggest that simple, inexpensive interventions with paper communication as behavioral nudges can be effective, especially in older populations.
Med Care Res Rev
· 2023 Aug · PMID 36800914
·
Full text
While cancer screening guidelines increasingly recommend incorporating life expectancy estimates to inform screening decisions for older adults, little is known about how this happens in practice. This review summarizes...While cancer screening guidelines increasingly recommend incorporating life expectancy estimates to inform screening decisions for older adults, little is known about how this happens in practice. This review summarizes current knowledge about primary care clinician and older adult (65+) perspectives about use of life expectancy to guide cancer screening decisions. Clinicians report operational barriers, uncertainty, and hesitation around use of life expectancy in screening decisions. They recognize it may help them more accurately weigh benefits and harms but are unsure how to estimate life expectancy for individual patients. Older adults face conceptual barriers and are generally unconvinced of the benefits of considering their life expectancy when making screening decisions. Life expectancy will always be a difficult topic for clinicians and patients, but there are advantages to incorporating it in cancer screening decisions. We highlight key takeaways from both clinician and older adult perspectives to guide future research.