Medical Care Research and Review最新文献

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.

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.

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.

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.

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.

Many states' scope of practice laws limits the ability of nurse practitioners to deliver care by requiring physician supervision of their practices and prescribing activities. A robust literature has evolved around examining the role of these scope of practice laws in various contexts, including labor market outcomes, health care access, health care prices, and the delivery of care for specific diseases. Unfortunately, these studies use different, and sometimes conflicting, measures of scope of practice laws, limiting their comparability and overall usefulness to policymakers and future researchers. We address this salient problem by providing a recommended coding of nurse practitioner scope of practice laws over a 24-year period based on actual statutory and regulatory language. Our classification of scope of practice laws solves an important problem within this growing literature and provides a solid legal foundation for researchers as they continue to investigate the effects of these laws.

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.

As Medicare Advantage (MA) plans enroll an increasingly large share of Medicare beneficiaries, how much providers charge MA plans relative to Traditional Medicare (TM) has important policy implications. We used new price transparency data from hospitals-which contain the most up-to-date negotiated prices-to evaluate whether and how MA prices differed from TM for hospital outpatient services. We found that among the 1,135 hospitals in our sample, MA prices were close to TM at about half of them, but the other half reported MA prices that deviated considerably from TM, predominantly in the direction of higher rather than lower, and rural hospitals were more likely than urban ones to charge high MA markups. Our findings also suggest that hospital price transparency data hold promise for promoting price shopping among MA beneficiaries. But greater hospital compliance and more standardized reporting are necessary for the data to be a more useful tool.

This study asks: Does the empirical evidence support the conclusion that for-profit (FP) hospitals are more productive or efficient than private not-for-profit (NFP) hospitals or non-federal public (PUB) hospitals? Alternative theories of NFP behavior are described. Our review of individual empirical hospital studies of quality, service mix, community benefit, and cost/efficiency in the United States published since 2000 indicates that no systematic difference exists in cost/efficiency, provision of uncompensated care, and quality of care. But FPs are more likely to provide profitable services, higher service intensity, have lower shares of uninsured and Medicaid patients, and are more responsive to external financial incentives. That FP hospitals are not more efficient runs counter to property rights theory, but their relative responsiveness to financial incentives supports it. There is little evidence that FP market presence changes NFP behaviors. Observed differences between FP and NFP hospitals are mostly a "little deal."

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.