Health Services Research最新文献

Objective: To examine the relationship between mental health provider productivity, staffing levels, and suicide-related events (SREs) among U.S. Veterans receiving care within the Veterans Health Administration (VHA), focusing on therapy and medication management providers.

Data sources/setting: We analyzed administrative data from the Department of Defense and VHA (2014-2018), encompassing 109,376 Veterans who separated from active duty between 2010 and 2017.

Design: A longitudinal design estimated the effects of facility-level provider work rate and staffing on SREs, adjusting for patient and facility characteristics. An instrumental variables (IV) approach addressed potential endogeneity.

Data collection/extraction methods: Data were obtained from the VHA Corporate Data Warehouse and the VHA Survey of Enrollees.

Principal findings: A 1% increase in therapy provider work rate led to a 12.1% increase in SRE probability, regardless of staffing levels. Conversely, a 1% increase in staffing levels led to a 1.6% reduction in SREs, with the largest effect in low-staffed facilities. For medication management providers, work rate had no overall impact on SREs, except in medium-staffed facilities. A 1% increase in staffing levels for medication management providers led to a 1.7% reduction in SREs.

Conclusions: Increased work rates, particularly in low-staffed VHA facilities, may elevate suicide-related risks. In contrast, staffing increases simultaneously improve access and reduce adverse outcomes. Where possible, policymakers should prioritize staffing growth over productivity gains to improve access to mental health clinics and ensure Veteran safety and care quality.

Objective: To test if state consumer protection policies reduce the share of consumers with medical debt in collections on their credit reports.

Study setting and design: This study uses a quasi-experimental research design to estimate the impact of consumer protection laws implemented between 2020 and 2022 in Illinois, Maryland, New Mexico, and Oregon on the share of consumers with medical debt in collections. These laws primarily aim to protect consumers against medical debt by expanding access to hospital financial assistance. We use a synthetic control approach to estimate changes in medical debt following the implementation of policies in treatment states relative to changes in select control states. We also assess the effects of earlier policies implemented between 2013 and 2019 in Washington, Utah, and North Carolina.

Data sources and analytic sample: This analysis relies on two extracts of credit bureau data from one of the country's three main credit bureau agencies. The first extract consists of random samples from June 2017 to June 2024 of approximately 125,000 consumers in each treatment state and 500,000 residents from the pool of 14 selected comparison states in each year. The second extract is based on a 2%-4% random sample of consumers in each year from 2011 to 2022.

Principal findings: We did not observe a statistically significant reduction in medical debt associated with policies implemented in these states within the study timeframe. In most states in our primary analysis, point estimates of the treatment effects are near zero, and in nearly all state-years, we can only rule out declines in medical debt larger than 1-3 percentage points following policy implementation.

Conclusions: Though we did not detect statistically significant effects of recent consumer protection policies on medical debt in collections, additional research is needed on whether these policies benefited consumers in ways that are not measured in this analysis and whether states that continue to move forward with similar laws can improve their effectiveness by extending consumer protections to a wider group of patients and providers and addressing implementation and enforcement challenges.

Objective: To assess the association between the implementation of 1115 Medicaid substance use disorder (SUD) waivers and changes in Medicaid-paid use of residential treatment and other types of services.

Study setting and design: We compared 20 states with SUD waivers to 14 non-waiver states using a staggered difference-in-differences design. Primary outcomes were Medicaid-paid opioid-use disorder (OUD) related residential treatment stays and length of stay (LOS). Secondary outcomes included admissions and LOS for all-cause and OUD-related inpatient stays, psychiatric hospital admissions, emergency department (ED) visits, outpatient visits, and primary care visits.

Data source and analytic sample: We used the 2016-2021 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF). The analytic sample included Medicaid enrollees ages 18-64 with OUD.

Principal findings: On average, waiver implementation was associated with an increase in residential treatment stays (estimate: 0.4%; 95% CI: 0.1%-0.7%), OUD-related inpatient visits LOS (estimate: 0.3 days; 95% CI: 0.0%-0.5%), psychiatric hospital LOS (estimate: 1.0 days; 95% CI: 0.6 days-1.4 days), primary care visits (estimate: 3.0%; 95% CI: 1.2%-4.7%), and OUD-related primary care visits (estimate: 2.7%; 95% CI: 0.9%-4.4%); and a decline in all-cause inpatient visits (estimate: -0.9%; 95% CI: -1.9% to -0.0%) and OUD-related inpatient visits (estimate: -0.8%; 95% CI: -1.6% to -0.0%). Results for psychiatric hospital LOS and OUD-related primary care visits were sensitive to adjusting for pre-trends. Among four early-adopting states (Indiana, Louisiana, New Jersey, Virginia), Medicaid-paid residential treatment increased 1-4 years following waiver implementation (e.g., 2-year estimate: 2.8%, 95% CI: 2.5%-3.0%), and inpatient visits declined 1-4 years following waiver implementation (e.g., 2-year estimate: -3.1%, 95% CI: -3.5% to -2.6%).

Conclusions: SUD waivers were associated with a small increase in Medicaid-paid residential treatment and a decline in inpatient visits across states, with changes being concentrated among early-adopting states.

Objective: To assess the impact of increased Medicaid income eligibility during pregnancy on payment source for prenatal care and birth and on gestational age at birth (GAb).

Study setting and design: We performed a quasi-experimental, difference-in-differences study comparing two increases in Medicaid income eligibility during pregnancy to two control states with data from 2007 to 2010: (Dyad 1) Ohio (expanded from 150% to 200% of the Federal Poverty level [FPL]) versus Pennsylvania and (Dyad 2) Wisconsin (185% to 250% FPL) versus Michigan. We performed multinomial logistic regression to assess the impact of increased Medicaid eligibility on the following key outcome variables: payment source for prenatal care and birth and GAb.

Data sources and analytic sample: We utilized CDC Pregnancy Risk Assessment Monitoring System (PRAMS) data (2007-2010) and limited analysis to singleton, in-state live births. After re-weighting for PRAMS survey design, our analytical sample represented about 540,000 births.

Principal findings: In the higher-income Wisconsin-Michigan dyad, increased Medicaid eligibility during pregnancy significantly increased exclusive Medicaid coverage for prenatal care (7.0%, 95% CI 2.9% to 11.1%) and birth (8.3%, 4.3% to 12.4%). Simultaneously, private insurance coverage dropped for prenatal care (-4.0%, -7.7% to -0.3%) and birth (-3.7%, -7.2% to -0.2%) while self-payment decreased only for birth (-1.8%, -3.5% to -0.2%). In the lower-income Ohio-Pennsylvania dyad, the only statistically significant effects on payment source were decreases in the likelihood of a payment source of other for prenatal care (-3.3%, -6.2% to -0.3%) and birth (-4.7%, -7.9% to -1.6%). There were no statistically significant effects on GAb across both dyads.

Conclusions: Increased Medicaid eligibility during pregnancy for individuals of higher income seems to improve utilization of exclusive Medicaid with diminished uninsurance but also less private insurance after accounting for indicators of socioeconomic advantage but has no clear impact on GAb. Medicaid policy should balance reducing uninsurance with directing scarce resources to high-risk individuals.

Objective: To examine associations between receipt of post-hospitalization care coordination and VA-delivered, VA-purchased, and Medicare fee-for-service hospital readmissions among Veterans at high risk for hospitalization and/or mortality.

Study setting and design: In this observational retrospective cohort study, we compared high-risk Veterans who received care coordination within one day after hospital discharge ("treated") with up to five matched high-risk Veterans who did not receive care coordination during this time ("comparators"). Competing risk models estimated adjusted sub-hazard ratios (aSHR) for 30-day all-cause and ambulatory care sensitive condition (ACSC) readmissions between treated and comparators, with death as a competing risk. In sensitivity analyses, we implemented inverse probability of censoring weights to account for censoring due to cross-over to treatment among comparators during follow-up.

Data sources and analytic sample: Data sources included the VA Vital Status File, VA Corporate Data Warehouse, and Centers for Medicare and Medicaid Services administrative files. Participants included 31,614 treated and 99,634 comparator high-risk Veterans initially hospitalized in fiscal year 2021.

Principal findings: Participants were primarily male sex, ≥ 65 years of age, and had initial hospitalizations in VA facilities; 15.9% and 2.3% of treated Veterans had 30-day all-cause and ACSC readmissions, respectively, compared with 13.5% and 2.1% of comparators. After accounting for the competing risk of death and covariates that remained imbalanced across groups after matching, post-hospitalization care coordination was associated with no difference in the risk of 30-day all-cause (aSHR 1.03, 95% CI 1.00, 1.07) and ACSC (aSHR 0.97, 95% CI 0.89, 1.05) readmission among high-risk Veterans. The risk of ACSC readmission was similar after including censoring weights (aSHR 1.00, 95% CI 0.92, 1.09); the increased risk of all-cause readmission was small in magnitude but statistically significant (aSHR 1.09, 95% CI 1.05, 1.13).

Conclusions: Receipt of post-hospitalization care coordination was largely associated with no difference in 30-day readmission risk, suggesting that alternative or additional services may be needed to address readmissions among high-risk Veterans.

Objective: To provide a conceptual framework for understanding ghost networks and propose a new methodology for estimating ghost physician prevalence in health plans' provider directories.

Study setting and design: We focused on providers listed as primary care physicians in Medicare Advantage (MA) plans' provider directories. Our framework categorizes ghost PCPs into general ghosts-those listed as PCPs but unavailable to any Medicare beneficiaries for primary care-and network-specific ghosts-those available to Medicare beneficiaries but inaccessible to enrollees with a certain MA network. We identified general ghosts with multiple data sources. In estimating network-specific ghost prevalence, to separate those who were truly unavailable from those who were accessible but saw no patients simply due to chance, we estimated a logistic model predicting being low-volume among the zero-volume and low-volume PCP-networks.

Data sources and analytic sample: We used the 2019 Ideon MA provider directory data. For physician information, we used the National Plan and Provider Enumeration System National Provider Identifier registry and OneKey Healthcare Industry Database. To estimate the patient volume of listed PCPs, we extracted from the 2019 MA encounter data carrier file beneficiaries' primary care visits to physicians in the office, hospital outpatient, or clinic setting.

Principal findings: We found that 17.5% of the listed PCPs in an average MA network were general ghosts and 11.5% were network-specific ghosts. Health maintenance organization networks listed more ghost PCPs than preferred provider organization (30.5% vs. 26.9%). Networks associated with high star rating contracts had substantially fewer ghost PCPs than those associated with low star rating contracts (26.5% vs. 37.2%). Our methodology for screening for ghost prevalence reduces the penalty on networks offering more choice, such as those serving urban markets.

Conclusions: Policymakers should ensure that provider directories reflect the physicians available to provide care. Our methodology may facilitate targeted network audits.

Objective: To evaluate the effects of physician and advanced practitioner specialization in skilled nursing facility (SNF)-based practice (SNFists) on the outcomes of patients with Alzheimer's disease and related dementias (ADRD) admitted to SNF for post-acute care.

Study setting and design: Taking advantage of the natural experiment provided by the growth of SNFists, we conducted a within-SNF difference-in-differences analysis with cross-temporal matching. Our primary outcome was functional improvement at SNF discharge, measured using a validated activities of daily living (ADL) score. Secondary outcomes included unplanned rehospitalization, emergency department (ED) visits, observational stays within 30 days of SNF admission, successful discharge to the community, SNF length of stay, admission into long-term nursing home care within 6 months of SNF discharge, and 30- and 60-day Medicare payments for professional and facility services.

Data sources and analytic sample: Medicare facility and professional claims and Nursing Home Minimum Data Set (MDS) data from 2012 and 2019 were used. The study sample included 338,574 community-dwelling fee-for-service Medicare beneficiaries with ADRD, age 65 or older, discharged from an acute care hospital to one of the 5196 SNFs that experienced an increase in patients treated by SNFists.

Principal findings: We did not observe an association between SNFist care and patient post-acute care outcomes or costs.

Conclusions: Specialization in SNF-based practice among physicians and advanced practitioners alone may not be an effective strategy to improve post-acute care outcomes or reduce costs to Medicare for patients with ADRD.

Objectives: The objective of this study is to examine whether potentially eligible individuals with Partnership Long-Term Care Insurance (PLTCI) program experience stronger social networks and improved interpersonal relationships compared to those without coverage.

Study setting and design: Our analysis utilizes data from the Health and Retirement Study (HRS), a longitudinal survey of U.S. adults aged 50 and older, incorporating responses from the Leave-Behind Questionnaire administered biennially from 2004 to 2018. We merge these data with a dataset tracking state-level implementation of the PLTCI program, enabling us to construct a binary indicator of policy exposure based on respondents' state of residence. Using ordinary least squares (OLS) regression with two-way fixed effects, we estimate the effect of the PLTCI program on the relational outcomes of aging individuals.

Data sources and analytic sample: The analytic sample includes HRS respondents potentially eligible for the PLTCI program at the time of its implementation, focusing on respondents and their spouse no more than 65 years without physical limitations per Activities of Daily Living (ADL) criteria. Depending on data availability, the sample size ranges from approximately 13,000 to 17,000 participants.

Principal findings: The PLTCI program improved perceived relationships with children and spouses. Older adults reported less frequent criticism (4.3% decrease with children, p = 0.04, 95% CI: 0.3%-8.3%; 3.4% with spouse, p = 0.04), feeling let down (3.9% decrease with children, p = 0.01; 3.8% with spouse, p = 0.009), or being annoyed (3.5% decrease with children, p = 0.03). They also felt more comfortable opening up about worries (2.1% increase with children) and relying on close family members during serious problems (3.0% increase with children, p = 0.01). These effects were strongest among individuals aged 55 and older compared to younger individuals, non-Hispanic White respondents compared to non-Hispanic Black respondents, and those with higher household wealth compared to those with lower household wealth.

Conclusions: Beyond financial security, the PLTCI program enhances older adults' social and emotional well-being by improving close relationships. These findings highlight the need to consider both economic and relational outcomes when evaluating long-term care policies.