JAMA Health Forum最新文献

Importance: The home health agency (HHA) market has seen increasingly more change in ownership transactions. Little is known about the organizational characteristics and quality of care of HHAs after ownership has changed.

Objective: To examine whether an HHA change in ownership was associated with different quality-of-care outcomes, patient volume, and staffing levels.

Design, setting, and participants: Using current HHA change of ownership files linked to publicly available Medicare HHA data, this staggered difference-in-differences analysis evaluated ownership change transactions of Medicare-certified HHAs from quarter 1 of 2016 to quarter 4 of 2019. Pretransaction and posttransaction HHA characteristics and quality-of-care outcomes were compared between HHAs that changed ownership and up to 8 matched controls. The transactions in the main analysis included (1) when an HHA remained as for-profit with a change in ownership and (2) when an HHA changed from nonprofit/public to for-profit ownership. The data were analyzed between November 2023 and September 2024.

Main outcomes and measures: The primary outcomes were HHA-quarter measures of star ratings, the individual quality measures that compose the star ratings based on the Outcome and Assessment Information Set, and claims-based quality metrics, such as hospitalizations and emergency department visits. The secondary outcomes included HHA year measures of Medicare patient volume, per capita payments, and staffing levels (full-time equivalents and minutes per visit).

Results: The main dataset included 294 Medicare-certified HHAs that changed ownership, matched with 2330 controls. In 3 years after an ownership change, quarterly star ratings increased by 0.18 (95% CI, 0.05-0.31) relative to matched controls, with greater increases among HHAs that converted from nonprofit/public to for-profit. No significant improvement was observed in the 60-day rates of hospital admissions or outpatient emergency department visits. Further, no significant changes were observed in the number of Medicare beneficiaries, but per capita payments increased within 2 years post-ownership change. Significant reductions were observed in full-time equivalents of registered nurses (-17% [95% CI, -31% to -3%]) and home health aides (-26% [95% CI, -39% to -13%]), as well as per-visit minutes for skilled nursing care (-5% [95% CI, -9% to -1%]), physical therapy (-3% [95% CI, -5% to 0%]), and home health aide care (-11% [95% CI, -15% to -6%]).

Conclusions and relevance: In this difference-in-differences analysis of Medicare-certified HHAs, ownership change was associated with higher star ratings and Medicare per capita payments, but not with claims-based quality measures. Reduction in staffing levels after ownership change raises concerns about implications for quality of care.

Importance: In December 2023, the Biden-Harris Administration released a proposed framework for exercising government march-in rights (effectively granting compulsory licenses for those patents to generic drug makers) under the Bayh-Dole Act on patents on taxpayer-funded drugs, which has renewed questions about whether march-in rights could promote cost savings through generic competition or harm pharmaceutical innovation.

Objectives: To determine the feasibility of using march-in rights to remove patent barriers to generic competition.

Design, setting, and participants: This cross-sectional study examined government funding information from multiple sources for patents listed in the Food and Drug Administration (FDA) Orange Book from 1985 to 2023. Data analysis was completed in August 2024.

Exposures: New drug applications (NDAs) with Orange Book-listed patents, including (1) all new molecular entities (NMEs) approved from 1985 to 2022; (2) all NDAs with an Orange Book patent listed between 1985 and 2023; and (3) NDAs with unexpired patents listed in a recent (October 2023) edition of the Orange Book.

Main outcomes and measures: The main outcome was whether the drugs had any or all patents that were public-sector patents subject to the Bayh-Dole Act, based on combining different data sources for identifying patents that resulted from federal funding. Public-sector patents resulting from intramural research, which are not subject to march-in rights under the Bayh-Dole Act, were identified separately.

Results: Of 883 new molecular entities approved from 1985 to 2022, 68 (8%) had a Bayh-Dole patent, but only 18 (2%) had solely Bayh-Dole patents. Of 2832 drugs with patents listed for 1985 to 2023, 142 (5%) had a Bayh-Dole patent, but only 38 (1%) had solely Bayh-Dole patents. Of 1213 drugs with Orange Book patents listed in October 2023, 41 (3%) had a Bayh-Dole patent, but only 14 (1%) had solely Bayh-Dole patents.

Conclusion and relevance: This cross-sectional study found that, although Bayh-Dole march-in rights could remove patent barriers to generic entry for a few drugs, their overall effect would be limited.

Importance: Altruism-putting the patient first-is a fundamental component of physician professionalism. Evidence is lacking about the relationship between physician altruism, care quality, and spending.

Objective: To determine whether there is a relationship between physician altruism, measures of quality, and spending, hypothesizing that altruistic physicians have better results.

Design, setting, and participants: This cross-sectional study that used a validated economic experiment to measure altruism was carried out between October 2018 and November 2019 using a nationwide sample of US primary care physicians and cardiologists. Altruism data were linked to 2019 Medicare claims and multivariable regressions were used to examine the relationship between altruism and quality and spending measures. Overall, 250 physicians in 43 medical practices that varied in size, location, and ownership, and 7626 Medicare fee-for-service beneficiaries attributed to the physicians were included. The analysis was conducted from April 2022 to August 2024.

Exposure: Physicians completed a widely used modified dictator-game style web-based experiment; based on their responses, they were categorized as more or less altruistic.

Main measures: Potentially preventable hospital admissions, potentially preventable emergency department visits, and Medicare spending.

Results: In all, 1599 beneficiaries (21%) were attributed to the 45 physicians (18%) categorized as altruistic and 6027 patients were attributed to the 205 physicians not categorized as altruistic. Adjusting for patient, physician, and practice characteristics, patients of altruistic physicians had a lower likelihood of any potentially preventable admission (odds ratio [OR], 0.60; 95% CI, 0.38-0.97; P = .03) and any potentially preventable emergency department visit (OR, 0.64; CI, 0.43-0.94; P = .02). Adjusted spending was 9.26% lower (95% CI, -16.24% to -2.27%; P = .01).

Conclusions and relevance: This cross-sectional study found that Medicare patients treated by altruistic physicians had fewer potentially preventable hospitalizations and emergency department visits and lower spending. Policymakers and leaders of hospitals, medical practices, and medical schools may want to consider creating incentives, organizational structures, and cultures that may increase, or at least do not decrease, physician altruism. Further research should seek to identify these and other modifiable factors, such as physician selection and training, that may shape physician altruism. Research could also analyze the relationship between altruism and quality and spending in additional medical practices, specialties, and countries, and use additional measures of quality and of patient experience.