Medical Care[JOURNAL]
Sun
200 papers
Estimating Primary Care Spending in the United States: Toward a Common Method.
Zhan C, Liu L, Simpson M
Med Care · 2025 Jul · PMID 40396993 · Publisher ↗
BACKGROUND: The lack of common definition and methods, coupled with the scarcity of suitable data sources, have impeded efforts to track primary care spending in the United States. OBJECTIVES: Explore consistent approach...
BACKGROUND: The lack of common definition and methods, coupled with the scarcity of suitable data sources, have impeded efforts to track primary care spending in the United States. OBJECTIVES: Explore consistent approaches to estimating primary care spending. RESEARCH DESIGN: A recently developed framework for primary care services was applied to 2 datasets: the Medical Expenditure Panel Survey (MEPS), a survey of noninstitutionalized individuals and their families in the United States, and MarketScan, a database containing health insurance claims of employees and their dependents for a selection of major US companies, to estimate primary care spending per-person-per-year (PPPY) and as percentage of total health care spending (PTHS) covering 2010-2021. Cross-sectional and trend analyses were conducted, and key methodological issues were explored. RESULTS: In 2019, average primary care spending was $504 PPPY (95% CI: $469-$539), accounting for 8.07% PTHS (95% CI: 7.56%-8.58%), based on MEPS, and $378 PPPY (95% CI: $377-$379), accounting for 6.30% PTHS (95% CI: 6.28%-6.32%), based on MarketScan. There were steady increases between 2010 and 2021 in PPPY primary care spending (from $309 to $639 based on MEPS and from $343 to $433 based on MarketScan), but small fluctuations in PHTS primary care spending (between 6% and 9%). Misalignments between the definitions and the data were identified, and standard errors for the estimates were calculated. CONCLUSIONS: With explicit definitions, transparent methodologies and appropriate quantification of estimation uncertainty, comparable and reproducible estimates can be obtained to assess and track primary care spending in the United States.
Are Rates of Skin Procedures Higher in Veterans Health Administrations Purchased Care Than Veterans Health Administrations Delivered Care?
Dizon MP, Asch SM, Wagner TH
Med Care · 2025 Aug · PMID 40396991 · Publisher ↗
BACKGROUND: To improve access to care, the Department of Veterans Affairs (VA) implemented the Veterans Choice Program, allowing enrollees to receive care outside VA facilities if they met eligibility requirements tied t...
BACKGROUND: To improve access to care, the Department of Veterans Affairs (VA) implemented the Veterans Choice Program, allowing enrollees to receive care outside VA facilities if they met eligibility requirements tied to wait times, travel, and availability of services. VA-purchased care has grown significantly to more than $32 billion in 2024, representing 24% of VA's medical care budget. OBJECTIVES: To compare the annual utilization of skin procedures for Veterans who received only VA-purchased care versus any VA-delivered care. RESEARCH DESIGN: Using medical records and claims data, we conducted a retrospective cohort study of Veterans who received outpatient evaluation and management (E/M) services and skin procedures delivered or purchased by the VA during the era of the Veterans Choice Program (VCP) from January 1, 2015, to June 5, 2019. We examined the annual utilization of outpatient procedures and E/M services and adjusted for demographic and clinical characteristics using zero-inflated Poisson regression models and propensity score matching. RESULTS: VA-purchased care was associated with greater utilization for all skin procedures examined. For the most common procedures, destruction of premalignant lesions and biopsies, annual rates were 1.4-fold and 1.5-fold greater in the VA-purchased care group, respectively. CONCLUSIONS: The growth of purchased community care is a concern if it reflects a growth of low-value services. If the resource-intensive purchased care were unnecessary, it would pose risks for VA and Veterans, and alternative payment models should be explored to limit this risk.
Developing and Validating Models to Predict Suboptimal Early Glycemic Control Among Individuals With Younger Onset Type 2 Diabetes.
Gopalan A, Board CA, Alexeeff SE … +4 more , Nugent JR, Mishra P, Karter AJ, Grant RW
Med Care · 2025 Aug · PMID 40396990 · Full text
OBJECTIVE: Younger age at the time of type 2 diabetes onset increases individuals' future complication risk. Proactively identifying younger-onset individuals at increased risk of not achieving early glycemic goals can s...
OBJECTIVE: Younger age at the time of type 2 diabetes onset increases individuals' future complication risk. Proactively identifying younger-onset individuals at increased risk of not achieving early glycemic goals can support targeted initial care. DESIGN AND METHODS: Individuals (ages 21-44) newly diagnosed with type 2 diabetes were identified and randomly assigned to training (70%) and validation (30%) datasets. Least absolute shrinkage and selection operator regression models were specified to identify key predictors (assessed at diagnosis) of suboptimal glycemic control (HbA1c≥8%) within 1 year after diagnosis using the training dataset. The full model included 48 candidate predictors. We also developed additional more streamlined models using more widely available predictors (transferable model), a smaller number of available predictors (simplified transferable model), and a bivariate model with HbA1c as the sole predictor (HbA1c-only model). Model-based predicted risk scores were used to stratify individuals in the validation dataset. RESULTS: The cohort included 10,879 individuals. All of the models, including the HbA1c-only model, performed comparably. All had good discrimination (C-statistics ranging from 0.71 to 0.73) in the validation dataset. CONCLUSIONS: When predicting the risk of not achieving glycemic goals, the HbA1c-only model had comparable performance to the more complex prediction models. This simple risk stratification requires no computation and could be implemented simply by looking at the diagnosis HbA1c value. This practical approach can be used to identify newly diagnosed younger adults who may need extra attention during the critical early period after diagnosis.
The Effects of Three Forms of Provider Discrimination on Access to Health Care and Mental Health.
Call KT, Mac Arthur NS, Pando C … +2 more , Cha J, Jones-Webb R
Med Care · 2025 Jul · PMID 40396983 · Publisher ↗
BACKGROUND: Provider discrimination can diminish access to care and lead to poor health outcomes, especially in marginalized populations. We extend past research by exploring the combined or intersecting effects of 3 for...
BACKGROUND: Provider discrimination can diminish access to care and lead to poor health outcomes, especially in marginalized populations. We extend past research by exploring the combined or intersecting effects of 3 forms of provider discrimination and by looking beyond access to care to include the impact of provider discrimination on mental health. OBJECTIVES: To examine reports of multiple forms of provider discrimination, including the prevalence, associated characteristics, and effects on health care access and mental health. RESEARCH DESIGN: Secondary analysis of pooled 2021 and 2023 Minnesota Health Access survey data. SUBJECTS: Adults aged 18-64 who responded to the survey (unweighted sample size 11,908). MEASURES: Reports of 3 forms of provider discrimination based on: (1) race, ethnicity, or nationality; (2) gender or sexual orientation; or (3) insurance type or lack of insurance. RESULTS: Nearly 1 in 5 adult Minnesotans reported at least one form of provider discrimination (19.6%), with some populations of adults reporting disproportionately higher rates. Experiencing insurance-based discrimination or gender or sexual orientation-based discrimination alone, together, and in combination with race-based discrimination was associated with foregone mental or behavioral health care, diminished confidence in getting needed care, and mental distress. CONCLUSIONS: Provider discrimination comes in different forms, which intersect to impair access and mental health. Experiences of provider discrimination were concentrated among the most marginalized members of our communities based on their gender identity, sexual orientation, race, ethnicity, nationality, age, income, public insurance, and lack of insurance. We recommend several structural solutions.
Perinatal Resources and Wildfire Smoke.
Boudreaux M, Yoder M, Ellicott E … +2 more , Passarella M, Lorch SA
Med Care · 2025 Jun · PMID 40346810 · Full text
BACKGROUND: Pregnant people and infants are vulnerable to wildfire smoke. However, the availability of perinatal resources in communities impacted by smoke is unknown. OBJECTIVE: Describe perinatal resources in counties...
BACKGROUND: Pregnant people and infants are vulnerable to wildfire smoke. However, the availability of perinatal resources in communities impacted by smoke is unknown. OBJECTIVE: Describe perinatal resources in counties prone to wildfire smoke. RESEARCH STUDY DESIGN: Smoke data came from the Hazard Mapping System and perinatal resources were gathered from various sources. Choropleth maps described the geographic distribution of smoke. Unadjusted associations and multivariable regressions compared perinatal resource levels by smoke risk. Subgroup analysis of the most rural counties was conducted. SUBJECTS: Counties in the contiguous United States (n=3108) during the 2016-2020 period. MEASURES: Relative smoke risk was defined as the bottom, middle, and top third of the average annual smoke-days distribution. Perinatal resources included driving distance to the nearest maternity care hospital and NICU, the volume and geographic isolation of the nearest maternity care hospital, and county-based measures of OB-GYN and family medicine physicians. RESULTS: Average annual smoke-days ranged from 3.8 (SD=2.0) in low-risk to 15.3 (SD=5.5) in high-risk counties. Compared with low-risk counties, high-risk counties had fewer OB-GYNs per 10,000 births (-32.2, 95% CI: -45.7 to -20.6; P<0.001) and were farther to the nearest maternity hospital (10.1 miles, 95% CI: 8.7-11.5; P<0.001). High-risk counties were also farther to the nearest NICU. Associations were not explained by sociodemographics and were observed in the subset of the most rural counties. CONCLUSIONS: Communities prone to wildfire smoke often lack geographic access to the health care resources needed to treat pregnant people and infants in a timely manner.
Insights Into Perinatal Health Care Resources in United States Counties Affected by Wildfire Smoke.
Babin S
Med Care · 2025 Jun · PMID 40346809 · Publisher ↗
Abstract loading — click title to view on PubMed.
Effects of Expanding Medicaid Dental Coverage on General Health Status of Low-Income Adults.
Wehby GL, Lyu W, Reynolds J … +1 more , Levy SM
Med Care · 2025 Aug · PMID 40310287 · Publisher ↗
BACKGROUND: Oral health is considered a key component of general health. However, causal evidence examining the effects of dental coverage on general health is sparse. OBJECTIVES: To examine the effects of the Affordable...
BACKGROUND: Oral health is considered a key component of general health. However, causal evidence examining the effects of dental coverage on general health is sparse. OBJECTIVES: To examine the effects of the Affordable Care Act (ACA) Medicaid expansions with extensive dental benefits versus less generous dental benefits on the general health status of individuals with low income. RESEARCH DESIGN: A difference-in-differences design comparing states that expanded Medicaid eligibility in 2014 by whether they offered extensive or less generous dental benefits. SUBJECTS: Adults aged 18-64 years below 138% of the federal poverty level who participated in the 2011-2022 Behavioral Risk Factor Surveillance System surveys. OUTCOME MEASURES: Self-rated general health status and number of days not in good physical health or good mental health in the past 30 days. RESULTS: The likelihood of fair/poor rated health status declined with extensive dental benefits, including by 2.3 (95% CI: -3.90 to -0.69) percentage-points when aggregating 2014-2022, with declines first observed in 2015 and almost all years after. There were no statistically significant effects on days not in good physical or mental health when aggregating 2014-2022. There were fewer mentally unhealthy days with extensive dental benefits by 0.93 days in 2019 and 2021 (95% CI: -1.80 to -0.06 and -1.70 to -0.15, respectively). CONCLUSION: The findings suggest that extensive dental coverage improves self-rated general health status among low-income adults. There is suggestive evidence of improved mental health in 2 but not all years and no discernable effect on days not in good physical health.
Approaches to Identify Nursing Home Specialists Using Medicare Claims Data.
Riester MR, Ryskina KL, White EM … +3 more , Hayes KN, Harris DA, Zullo AR
Med Care · 2025 Jul · PMID 40307676 · Full text
BACKGROUND: Physicians and advanced practice clinicians who practice in nursing homes (NHs) are becoming increasingly specialized. Studies have identified clinicians as NH specialists using multiple data sources; yet, re...
BACKGROUND: Physicians and advanced practice clinicians who practice in nursing homes (NHs) are becoming increasingly specialized. Studies have identified clinicians as NH specialists using multiple data sources; yet, researchers' access to several sources may be limited due to required data purchases. OBJECTIVE: Examine the concordance of 2 approaches to measure NH specialization versus a standard approach using clinician-level Medicare Data on Provider Practice and Specialty (MD-PPAS). These alternative approaches leveraged: (1) publicly available clinician-level Medicare Part B data; and (2) patient-level Medicare Part D Event claims linked to publicly available clinician-level Medicare Part D prescribers data. RESEARCH DESIGN: Yearly cross-sections from 2016 to 2020. SUBJECTS: Physicians and advanced practice clinicians with at least one Medicare-paid service to NH residents and at least 100 total services in a given year. MEASURES: Nursing home specialists were classified as clinicians with ≥90% of annual services provided to NH residents. RESULTS: Between 2016 and 2020, NH specialists comprised 49,542 of 321,267 eligible clinician-years (15.4%) in MD-PPAS data; 35,983 of 189,992 eligible clinician-years (18.9%) in Part B data; and 31,148 of 1,101,484 eligible clinician-years (2.8%) in Part D data. Compared with the MD-PPAS approach, the concordance was greater for the Part B approach (sensitivity 71.8%, specificity 99.7%) than the Part D approach (39.4%, 97.6%). CONCLUSIONS: There were large differences in the numbers of eligible clinicians and NH specialists identified by 3 approaches. The Part B approach was reasonably concordant with the MD-PPAS approach and could be considered by researchers without the financial resources required to purchase MD-PPAS data.
Is a Distressed Birth Associated With Physical and Mental Health Problems as an Adult?: Evidence From Panel Data.
French MT, Mortensen K
Med Care · 2025 Aug · PMID 40307675 · Publisher ↗
BACKGROUND: A considerable amount of research has examined the short-term health outcomes associated with distressed births. Most studies have focused on the survival of the newborn, health complications, and medical car...
BACKGROUND: A considerable amount of research has examined the short-term health outcomes associated with distressed births. Most studies have focused on the survival of the newborn, health complications, and medical care utilization. Comparatively little research has considered the longer-term physical and mental health outcomes of distressed births that survive into adulthood. OBJECTIVES: The primary objective is to determine whether 3 common types of distressed births-low birth weight (LBW), preterm delivery, neonatal intensive care unit (NICU) admission-are significantly related to physical (ie, self-reported overall health status, number of chronic health conditions) and mental (ie, number of mental health disorders) health among young and middle-aged adults. SUBJECTS: Respondents to Waves IV (2008-2009; N=15,701) and V (2016-2018; N=12,300) of the National Longitudinal Survey of Adolescent to Adult Health (Add Health) provide the data for our research. RESEARCH DESIGN: Our empirical approach estimates numerous multivariate regression models for Waves IV and V separately, and mixed-effects models for both waves combined. Each subgroup (LBW, preterm delivery, and NICU admission) was analyzed separately in comparison to those without a distressed birth. RESULTS: All 3 distressed birth measures are negatively and significantly ( P <0.05) associated with physical and mental health status in adulthood. CONCLUSIONS: The primary implication is that clinicians, public health advocates, and policy makers at all levels of government can use these findings to secure additional resources for the prevention of future distressed births. Prevention initiatives can include teenage family planning, prenatal checkups and related care, and incentives for healthy behaviors during pregnancy.
The Impact of Racial/Ethnic Concordance in Patient-Reported Shared Decision-Making and Communication During the COVID-19 Era.
Eyring JB, Hemeyer BM, Wilson FA
Med Care · 2025 Aug · PMID 40307674 · Publisher ↗
BACKGROUND: Patient-provider racial/ethnic concordance may mitigate disparities, which is likely due in part to improved communication. The COVID-19 pandemic exacerbated disparities and raised questions on communication,...
BACKGROUND: Patient-provider racial/ethnic concordance may mitigate disparities, which is likely due in part to improved communication. The COVID-19 pandemic exacerbated disparities and raised questions on communication, warranting further exploration to inform equitable care. OBJECTIVES: This study aimed to investigate the influence of patient-provider racial/ethnic concordance on patient-reported shared decision-making and communication during the early stages of the pandemic. RESEARCH DESIGN: Stepwise logit models were constructed of short-term non-modifiable factors (race/ethnicity, education, age, marital status), modifiable factors (health insurance, poverty status), and self-reported health status predicting communication outcomes-whether the provider included the patient in decision-making and communicated treatment options. SUBJECTS: Adults from the 2020 US Medical Expenditure Panel Survey (N=9634), weighted consistent with complex sampling. MEASURES: Shared decision-making and communication of treatment options by the primary care provider were assessed by patient surveys. Demographic characteristics included race/ethnicity, poverty status, age, marital status, education, and insurance status. RESULTS: Concordance was associated with greater age and socioeconomic status, and being married, White, and in good health. Concordance was associated with patient-reported shared decision-making and communication of treatment options. The associations between demographic characteristics and communication outcomes differed significantly by concordance status, which further differed by race/ethnicity. For example, shared decision-making was predicted by education for discordant Hispanic patients and marital status for discordant White patients, but neither were predictive among concordant patients. CONCLUSIONS: The findings suggest a potential association between concordance on shared decision-making and communication dynamics, emphasizing the need for additional research to clarify how similarities and differences may influence health care interactions.
Improving Patient Experience With Provider Communication: Systematic Review of Interventions, Implementation Strategies, and Their Effectiveness.
Jesus TS, Zhang M, Lee D … +5 more , Stern BZ, Struhar J, Heinemann AW, Jordan N, Deutsch A
Med Care · 2025 Aug · PMID 40307673 · Publisher ↗
BACKGROUND: Provider communication with patients may be improved through training, shadow coaching, and other in-service interventions. We aim to synthesize these interventions, implementation strategies, and their impac...
BACKGROUND: Provider communication with patients may be improved through training, shadow coaching, and other in-service interventions. We aim to synthesize these interventions, implementation strategies, and their impact on the patient experience. METHODS: A systematic review of contemporary evidence (2015-2023). Six scientific databases, specialty journals, and snowballing searches identified training, shadow coaching, and other in-service interventions for improving provider communication with patients, evaluated by standardized patient experience measures. Studies without inferential statistics were excluded. Two independent reviewers assessed the studies' eligibility and methodological quality and mapped the implementation strategies against a widely used taxonomy of 73 strategies. RESULTS: Of 1237 papers screened, 14 were included: 10 controlled studies (5 randomized) and 4 prepost. Nine studies were on communication skills training and 3 on shadow coaching; all but one of these used a train-the-trainer implementation strategy. Eight studies (controlled n=4) used 5.5-8 hours of communication training and showed significant improvements in selected experience outcomes. Brief (45 min) communication training showed no significant results. Two controlled studies showed that shadow coaching and recoaching achieve short-term improvements but eroded without booster sessions. The use of transparent surgeon masks improved selected communication outcomes, but periodic reminders sent to clinicians on communication etiquette did not. DISCUSSION: In-service communication training (≥5.5 h) or shadow (re-)coaching by trained peers can improve patients' experience with provider-patient communication. To implement such interventions, organizations need to identify and train trainers/coaches, intentionally support the program, monitor effectiveness, and add boosters as needed. Brief communication etiquette training or simple reminders did not improve the patients' experiences with provider-patient communication.
"Sleep Is Not Getting the Attention It Deserves": A Qualitative Study of Patient and Provider Views on Sleep Management in the Veterans Health Administration.
Gaffey AE, Mattocks KM, Yaggi HK … +6 more , Marteeny V, Walker L, Brandt CA, Haskell SG, Bastian LA, Burg MM
Med Care · 2025 Jul · PMID 40307672 · Full text
BACKGROUND: Unique characteristics and service exposures of the post-9/11 cohort of U.S. Veterans can influence their sleep health and associated comorbidities. The objectives of this study were to learn about men and wo...
BACKGROUND: Unique characteristics and service exposures of the post-9/11 cohort of U.S. Veterans can influence their sleep health and associated comorbidities. The objectives of this study were to learn about men and women post-9/11 Veterans' and "front line" VA providers' knowledge about sleep and experiences with Veterans Health Administration (VA) sleep management. RESEARCH DESIGN: One sample included post-9/11 Veterans who received VA care (n=23; 60% women; Mage: 45 y). To complement those views, primary care and mental health providers were recruited from VA medical centers (n=27). Semistructured qualitative interviews were conducted using Microsoft Teams. Questions pertained to sleep knowledge, care practices, and perceived barriers to sleep-related VA care. Interview data were synthesized with content analysis and inductive coding to characterize major themes. RESULTS: Four main themes emerged: (1) Sleep is viewed as foundational but Veterans and providers often have limited related knowledge and more routine education is needed. (2) Men and women have distinct sleep management needs. Relative to men, women are more likely to advocate for sleep assessment and for behavioral versus pharmacological treatment. (3) Sleep management practices vary considerably between clinics and providers. (4) Veterans and their providers each experience unique barriers to sleep management. CONCLUSIONS: Post-9/11 Veterans and providers view sleep as critical. Yet, VA sleep management needs to be more uniform. Providers are motivated to assess sleep but require standardized education and low-burden opportunities to incorporate sleep into their practice, perhaps with mental health screening. Ultimately, more specialized care is required to meet the responsibility of Veterans' sleep health.
Differences in Initiation and Receipt of Home Health Care: Traditional Medicare Versus Medicare Advantage.
Chen AC, Spertus D, Fu CX … +2 more , Sterling MR, Grabowski DC
Med Care · 2025 Jul · PMID 40307669 · Full text
BACKGROUND: Because Traditional Medicare (TM) and Medicare Advantage (MA) have different reimbursement structures and incentives, it is important to understand differences in home health agency (HHA) use by payer type. O...
BACKGROUND: Because Traditional Medicare (TM) and Medicare Advantage (MA) have different reimbursement structures and incentives, it is important to understand differences in home health agency (HHA) use by payer type. OBJECTIVE: To quantify differences in care patterns and outcomes between TM and MA HHA users. RESEARCH DESIGN AND SUBJECTS: Medicare HHA claims were used to identify postacute HHA episodes among US adults aged 65 and older enrolled in MA or TM (2015-2019). Adjusted regression models with and without HHA fixed effects assessed whether TM and MA beneficiaries are treated differently within an HHA. MEASURES: We examined process (timely initiation of care, receipt of a skilled nursing visit, and length of stay) and quality measures (hospital readmission and healthy days at home). RESULTS: The study included 4,029,527 beneficiaries (3,034,452 TM and 995,075 MA). We identified large differences in the share of beneficiaries experiencing timely initiation of care (81.4% TM vs. 77.4% MA) and receipt of skilled nursing visits (86.8% TM vs. 81.9% MA). After including HHA fixed effects in the regression model, MA beneficiaries were 2.1 percentage points (pp) less likely to experience timely initiation of care and were 3.1 pp less likely to receive a skilled nursing visit (and 8.9 pp less likely to receive any type of skilled visit) within 2 days of starting HHA care compared with TM beneficiaries ( P <0.001). CONCLUSIONS: Our findings suggest differential treatment between MA and TM beneficiaries within the same HHA. Further research is needed to understand the mechanisms driving these within-agency differences.
Risk Adjustment in Capitation Payments to Primary Care Providers: Does It Matter How We Account for Patients' Socioeconomic Status?
Ellegård LM, Laberge M
Med Care · 2025 Jun · PMID 40272267 · Full text
BACKGROUND: One of the critical challenges with capitation payment to primary care providers is ensuring that the fixed payments are equitable and adjusted for expected care needs. Patients of lower socioeconomic status...
BACKGROUND: One of the critical challenges with capitation payment to primary care providers is ensuring that the fixed payments are equitable and adjusted for expected care needs. Patients of lower socioeconomic status (SES) generally have higher health care need. Sweden developed a Care Needs Index, which is used in the capitation payments to primary care providers to account for patient SES. OBJECTIVES: We aim to examine the potential value of collecting individual-level rather than geographic-level socioeconomic data to support an equitable payment to primary care providers. RESEARCH DESIGN: We used data from 3 regional administrative care registers, which cover all consultations in publicly funded health care, and Statistics Sweden's registers covering individual background characteristics. We estimated linear regression models and evaluated the model fit using the adjusted R2 with the Care Needs Index at the individual and at the district level. The population consisted of the 3,490,943 individuals residing in the 3 study regions for whom we had complete data. MEASURES: The main outcome variable was the number of face-to-face consultations with a GP or a nurse at a primary care practice. We use the R2 to compare the predictive power of the models. RESULTS: The share of the variation explained did not depend on whether the Care Needs Index was measured at the individual level or the small area level. CONCLUSIONS: SES explains very little variation in primary care visits, and there is no gain from having individual-level information about the individual's SES compared with having district-level information only.
Top-Rated Health Care and Ease of Access to Medications Linked to Lower Medicare and ADRD Costs.
Chen J, Jang S
Med Care · 2025 Jun · PMID 40272264 · Full text
IMPORTANCE: Little is known about the extent to which patient self-perception of care experience is associated with costs, especially for people with Alzheimer disease and related dementias (ADRD). OBJECTIVE: This study...
IMPORTANCE: Little is known about the extent to which patient self-perception of care experience is associated with costs, especially for people with Alzheimer disease and related dementias (ADRD). OBJECTIVE: This study explores the relationship between self-reported quality measures and Medicare costs and examines whether the ease of obtaining prescribed medications is associated with reduced overall Medicare costs, focusing on Medicare beneficiaries with ADRD. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study, Medicare Beneficiary Summary File data from 2018, 2019, and 2021 were linked to the Medicare Consumer Assessment of Health Care Providers and Systems (CAHPS) Survey using beneficiary IDs. The study sample included community-dwelling Medicare fee-for-service beneficiaries. EXPOSURES: Five quality measures were used as key exposure variables: (1) beneficiary's rating on health care; (2) ease of getting care/tests/treatment through the health plan; (3) whether the doctor always explained, listened, respected; and spent enough time with the patient; (4) ease of obtaining prescribed medications; and (5) whether doctor always talked about all the prescription medicines the beneficiary was taking. MAIN OUTCOME AND MEASURE: Annual total Medicare payments per person. RESULTS: The study included 230,617 Medicare fee-for-service beneficiaries aged 65 and older, including 16,452 beneficiaries with ADRD. Among the total beneficiaries, 53% were females (vs. 56% of ADRD beneficiaries), with a mean (SD) age of 75.8 (SD 7.27) years [vs. 82.5 (SD 7.97) years for ADRD beneficiaries]. Fully adjusted analyses showed significant negative associations between quality measures and total per-capita payments, with more pronounced cost reductions among patients with ADRD. Specifically, patients with ADRD who reported it was always easy to get care had reductions of $1,922.0 (95% CI, -$3304.8 to -$539.2), while those who reported it was always easy to get prescribed medications had reductions of $2964.5 (95% CI, -$4518.8 to -$1410.1). In addition, beneficiaries who reported that doctors always discussed the medicines experienced cost reductions of $2299.7 (95% CI, -$3800.5 to -$799.0) in medicare costs. CONCLUSION AND RELEVANCE: Our findings suggest that high-quality care is not necessarily associated with high costs. Meanwhile, focusing on the ease of access to needed care, obtaining prescription drugs, and effective communication about medication is critical in improving care quality while reducing costs.
The Impact of a Bidirectional Clinic to Community Social Care Referral Program.
Bolen SD, Lever J, Mundorf C … +16 more , Jenkins A, Waitzman R, Smith S, Finley M, Daprano J, Johnson E, Masotya M, Joshi S, Gunder A, Lohr ME, Bar-Shain D, Kaelber DC, Khaled T, Sumerauer D, Gullet H, Stange KC
Med Care · 2025 Jun · PMID 40266648 · Publisher ↗
BACKGROUND: Practical knowledge of how to address patients' social needs could have a large health impact. OBJECTIVE: Describe a scalable electronic health record (EHR)-facilitated, clinic-to-community linkage (CCL) prog...
BACKGROUND: Practical knowledge of how to address patients' social needs could have a large health impact. OBJECTIVE: Describe a scalable electronic health record (EHR)-facilitated, clinic-to-community linkage (CCL) program that addresses social needs at 6 clinics in 4 health systems. RESEARCH DESIGN: Primary care teams referred eligible patients to United Way 211 (UW 211) via a point-of-care EHR referral between 2018 and 2023. Patients were eligible if they were adults with uncontrolled blood pressure or blood sugar or 2-17 years old with overweight/obesity or asthma. UW 211 referred patients to assess and connect them with community resources and provided electronic feedback to the EHR. We conducted descriptive analyses of process measures (eg, patients referred, needs identified, need resolution). We then conducted pre-post analyses of selected health outcomes (ie, blood pressure, weight, and asthma exacerbations) versus comparison clinics. RESULTS: Referral ranges varied by clinic from 3% to 43%, with 1224 total patients referred and 38% (n=461) reached by UW 211. All 461 had at least one need, and 87% (n=400) had one need resolved or a resolution in progress. Reached patients had an average of 2.9 (SD 1.3) needs and an average of 10.1 resource referrals provided (SD 6.1). Top needs included food, physical activity, housing and utilities. No differences were found pre to post within the intervention clinics except for improvements in blood pressure control. However, comparison clinics had greater improvements in blood pressure control during the same time frame. CONCLUSIONS: An EHR-facilitated, closed-loop CCL program to address patients' social needs is feasible. Further research on the comparative effectiveness and sustainability of models to address social needs will be critical in advancing health equity.
Combining Machine Learning and Comparative Effectiveness Methodology to Study Primary Care Pharmacotherapy Pathways for Veterans With Depression.
Ozmen O, Rush E, Park BH … +7 more , Jones M, Trafton J, Brenner L, Rupper RW, Ward M, Nebeker JR, Pizer SD
Med Care · 2025 Jun · PMID 40266632 · Publisher ↗
OBJECTIVES: To demonstrate an innovative method combining machine learning with comparative effectiveness research techniques and to investigate a hitherto unstudied question about the effectiveness of common prescribing...
OBJECTIVES: To demonstrate an innovative method combining machine learning with comparative effectiveness research techniques and to investigate a hitherto unstudied question about the effectiveness of common prescribing patterns. DATA SOURCES: United States Veterans Health Administration Corporate Data Warehouse. STUDY DESIGN: For Operation Enduring Freedom/Operation Iraqi Freedom veterans with major depressive disorder, we generate pharmacotherapy pathways (of antidepressants) using process mining and machine learning. We select the medication episodes that were started at subtherapeutic doses by the first assigned primary care physician and observe the paths that those medication episodes follow. Using 2-stage least squares, we test the effectiveness of starting at a low dose and staying low for longer versus ramping up fast while balancing observable and unobservable characteristics of patients and providers through instrumental variables. We leverage predetermined provider practice patterns as instruments. DATA COLLECTION: We collected outpatient pharmacy data for selective serotonin reuptake inhibitors and selective norepinephrine reuptake inhibitors, patient and provider characteristics (as control variables), and the instruments for our cohort. All data were extracted for the period between 2006 and 2020. PRINCIPAL FINDINGS: There is a statistically significant positive effect (0.68, 95% CI 0.11-1.25) of "ramping up fast" on engagement in care. When we examine the effect of "ramping up slow", we see an insignificant negative impact on engagement in care (-0.82, 95% CI -1.89 to 0.25). As expected, the probability of drop-out also seems to have a negative effect on engagement in care (-0.39, 95% CI -0.94 to 0.17). We further validate these results by testing with medication possession ratios calculated periodically as an alternative engagement in care metric. CONCLUSIONS: Our findings contradict the "Start low, go slow" adage, indicating that ramping up the dose of an antidepressant faster has a significantly positive effect on engagement in care for our population.
Medicaid Managed Care Penetration and Mental Health Service Use Among Adults.
Hu JC, Cummings JR, Ji X … +1 more , Wilk AS
Med Care · 2025 May · PMID 40198265 · Publisher ↗
OBJECTIVE: To examine the association between Medicaid managed care (MMC) penetration and mental health (MH) service use among Medicaid-enrolled non-elderly adults, with a special focus on those with MH conditions. BACKG...
OBJECTIVE: To examine the association between Medicaid managed care (MMC) penetration and mental health (MH) service use among Medicaid-enrolled non-elderly adults, with a special focus on those with MH conditions. BACKGROUND: Medicaid covers over 9 million adults living with MH conditions, with many enrolled in MMC. Despite increases in MMC enrollment over the past decade, nationwide evidence of MMC's association with MH service use during this period is lacking. METHODS: Using 2015-2019 National Survey on Drug Use and Health data, we applied logistic and negative binomial regression models to examine the association between MMC penetration and MH service use among 35,500 non-elderly enrollees in 40 MMC states, and separately among 11,800 enrollees with MH conditions. Four dichotomous outcomes separately measured any MH service use in inpatient, outpatient, prescription medication, and any settings. Two additional count outcomes measured the number of inpatient MH stays and outpatient MH visits. RESULTS: A 2-percentage point higher level of MMC penetration was associated with a 9% reduction (adjusted incidence rate ratio = 0.91, 95% CI = 0.87, 0.94) in days of inpatient MH stays among all enrollees and a 7% reduction (adjusted incidence rate ratio= 0.93, 95% CI = 0.87, 0.99) among enrollees with MH conditions. MMC penetration was not associated with significant changes in other outcomes. CONCLUSIONS: Among non-elderly adults and those with MH conditions, increased MMC enrollment was associated with reduced inpatient MH services with no significant changes in the use in other settings. Ongoing monitoring is crucial to assess the potential impact of shortened inpatient stays on MH outcomes.
Learning Health Systems Research: Continued Progress and Ongoing Challenges.
Tisdale RL, Sarkar U
Med Care · 2025 May · PMID 40194918 · Publisher ↗
BACKGROUND: Learning health systems research (LHSR) builds on concepts of systems-based participatory research to form a new paradigm for partnered research. OBJECTIVE: Defines LHSR and its ongoing challenges and future...
BACKGROUND: Learning health systems research (LHSR) builds on concepts of systems-based participatory research to form a new paradigm for partnered research. OBJECTIVE: Defines LHSR and its ongoing challenges and future directions. RESEARCH DESIGN: Qualitative description of relevant dimensions of LHSR. RESULTS: In LHSR, researchers and health system stakeholders co-create research with dual aims of producing internal quality improvement and generalizable, disseminable knowledge. This approach aligns research priorities with community and health system needs, resulting in interventions that are both feasible and acceptable in real-world settings and effective. LHSR methods and outcomes reflect elements of implementation science, particularly participatory implementation science and the use of mixed methods, but the field is distinct in its emphasis on co-creation with health system leaders and the use of theory to inform rather than drive the work. Practitioners of LHSR face challenges related to the complex and multi-stakeholder nature of the field, including the time-intensive nature of building partnerships, conflicting project time horizons, imprecision inherent in real-world data, and barriers to publication of the smaller studies that typically result from LHSR. CONCLUSIONS: Continued advancement of the field requires confronting these challenges with a variety of interventions, including explicit institutional support and incentives for this type of work, training and career development opportunities, a diversity of funding sources, investment in data resources and expertise, and inclusive research governance structures.
Probabilistically Linkage of California's Birth Certificate and Hospital Discharge Data.
Garg B, Caughey AB, Darney BG
Med Care · 2025 Jun · PMID 40163323 · Publisher ↗
OBJECTIVE: To link California's birth certificate data with maternal and infant hospital discharge data to get a valuable database for epidemiological research. BACKGROUND: Secondary data sources are widely used for epid...
OBJECTIVE: To link California's birth certificate data with maternal and infant hospital discharge data to get a valuable database for epidemiological research. BACKGROUND: Secondary data sources are widely used for epidemiological research. Although California's birth certificate and patient discharge data (PDD) are readily available separately, the linked data are only available till 2012. We obtained birth certificate data from the California Department of Public Health and hospital discharge data from the Department of Health Care Access and Information. In this study, we propose a methodology to link these 2 datasets, which can be used for perinatal epidemiological research. We utilized data from 2008 to 2019. METHODS: We used probabilistic linkage methods to link birth certificates and hospital discharge data. Hospital discharge data was included as 2 datasets: maternal and infant discharge records. The linkage was a 2-step process: (1) Linkage of birth certificate with infant's hospital discharge data to form combined data. (2) Linkage of combined birth certificate-infant's discharge data with maternal discharge data. RESULTS: We included 5,661,695 births from birth certificates and 5,617,921 infant discharge files. After linkage, we were able to link 92.2% of the birth certificate records with the infant's discharge files using variables: maternity hospital, infant's birth date, infant's sex, mother's residence zip code, and birth Hospital County. When the combined vital statistics-infant's PDD data were linked with maternal PDD data, 90.0% of vital statistics data linked with both infant and maternal PDD, 2.5% linked to only infant PDD, and 1.5% linked to only maternal PDD. CONCLUSION: Our linkage algorithm produces effective linked data that can be used for epidemiological research. This process is complex and needs to be evaluated every year as some of the variables change, or some added information becomes available in some files.
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