Health affairs scholar最新文献

Introduction: Zero-premium Medicare Advantage (MA) plans are increasingly popular, yet knowledge gaps exist regarding their distribution, enrollment, and quality, particularly in areas with greater socioeconomic vulnerability and clinical need.

Methods: We conducted a serial cross-sectional study of publicly available CMS data from 2019-2024, analyzing 2472 US counties. Annual plan counts and enrollment rates were examined, stratified by county-level socioeconomic and health characteristics (racial/ethnic minority percentage, poverty rate, and prevalence of fair/poor health). Counties were categorized into quartiles for comparison.

Results: Zero-premium MA plans expanded substantially from 2019-2024, rising from 46.02% of MA plans (9.12 million enrollees) to 66.3% (18.76 million). These plans were more likely to feature restrictive provider networks and showed disproportionate enrollment growth in counties with greater socioeconomic and health needs (higher proportions of racial/ethnic minority residents, poverty, and poor health status; P < 0.001). Across all county-characteristic subgroups, zero-premium plans consistently had lower star ratings (1-3.5).

Conclusion: Rapid zero-premium MA plan adoption raises concerns about the quality of care, especially among vulnerable populations. Further examination of plan quality standards and patient outcomes, transparency of enrollment incentives (eg, insurance broker commissions), and enrollee navigation and decision-making about plan options is warranted.

In 2024, the Centers for Medicare and Medicaid Services (CMS) added a novel Age-Friendly Hospital Inpatient Quality Reporting (IQR) Measure, composed of 10 attestation statements in 5 domains. The measure is designed to improve care for older adults through promoting care processes and structural capabilities drawn from evidence-based standards included in the 4Ms Framework (What Matters, Medication, Mentation, and Mobility) and operationalized in 3 programs: Geriatric Surgery Verification, Geriatric Emergency Department Accreditation, and the Institute for Healthcare Improvement's Age-Friendly Health System recognition. We highlight synergies and gaps between these programs and the CMS Age-Friendly IQR measure to guide hospital efforts as they prepare for their first attestation in 2026. In addition, we make recommendations to CMS to improve measure validity through better specifications that ensure meaningful impact on care for older adults and to reduce associated reporting burden. Notably, there is little overlap in the outcome measures incorporated into each program. Attending to these considerations is critical to maximize the potential of this new national quality measure to address persistent shortcomings in evidence-based care for older adults.

Introduction: Concerns about completing postmarketing requirements (PMRs) following accelerated approval (AA) of new drugs have been well documented. However, there has been little examination of specific barriers and facilitators to timely, rigorous PMRs (eg, blinded, randomized trials in the approved population) from the perspective of key stakeholders.

Methods: To understand these factors, especially for cancer and rare diseases, we interviewed 56 regulators, industry executives, patient advocates, and payers.

Results: Stakeholders focused on predictable PMR barriers and, except for payers, offered weak solutions, including those that would trade rigor for feasibility (eg, avoiding randomization, conducting PMRs outside approved indications), could raise other concerns (eg, conducting PMRs abroad), or are likely to fall short (eg, patient education). Stakeholders supported requiring that confirmatory studies begin before AA but were unsure how to retain rigor thereafter, emphasized tradeoffs, and sought rare disease exceptions. Although regulators and payers supported payment reforms for AA drugs, all stakeholder groups questioned practicability.

Conclusion: Stakeholders recognize PMR shortcomings but prioritize flexibility, raising questions about AA's foundations and suggesting that further documenting poor rigor is unlikely to change policy. Beyond recent reforms, future efforts should emphasize confirming benefit for rare disease AAs, encouraging PMR rigor, and exploring AA payment reform.

Introduction: This study examined the extent of provider consolidation across the outpatient sector overall and analyzed variation by ownership type, including vertically integrated health systems and large corporate owners.

Methods: Using data from the Agency for Healthcare Research and Quality (AHRQ) Compendium of US Health Systems and the IQVIA OneKey Database, we analyzed changes from 2020 to 2023 in the number and share of outpatient sites and outpatient physicians affiliated with health systems and corporate owners, overall and variation by profit status, owner size, and geographic scope.

Results: The number of outpatient physicians classified as independent or other type decreased by 34 770 (-7.0 percentage points) from 2020 to 2023. Outpatient consolidation into health systems and corporate owners was relatively high in 2020 and increased modestly from 2020 to 2023. Data validation identified some risk of misclassification of parent ownership status with a potential to bias upwards the prevalence of corporate ownership.

Conclusion: Our findings on changes in outpatient consolidation provide a baseline for tracking the growth in parent ownership across the outpatient sector overall and highlight the critical need for more accurate and standardized data on ownership and organization to address key policy issues related to competition, antitrust, and quality impacts.

Introduction: Low back pain is the leading cause of disability worldwide and Medicaid beneficiaries are disproportionally impacted. No studies have comprehensively examined patterns of treatment among Medicaid beneficiaries with low back pain.

Methods: We quantitatively described modalities of treatment and low-value care received following a low back pain diagnosis among Medicaid beneficiaries across the United States. We then qualitatively explored factors that influence treatment patterns by interviewing chronic pain experts.

Results: On average, 39.6% of patients received a prescription opioid in the 12 months following diagnosis and 41.2% received conservative therapies-noninvasive, nonpharmacological methods including physical, manual, or psychological therapies. Prescription nonopioid analgesic medications were the most common modality received first (57.8%) and across the 12 months following diagnosis (74.1%). On average, 8.9% of patients received high-dose, long-term opioid therapy (>120 morphine milligram equivalents/d for ≥90 days) and 31.7% received early imaging; both indicators for low-value care. Chronic pain experts highlighted challenges related to Medicaid coverage for conservative therapies, limited access to pain specialists, and social and economic factors influencing treatment access and utilization.

Conclusion: Barriers, including Medicaid coverage limitations, provider access challenges, and economic factors, likely impact patterns of low back pain treatment among individuals enrolled in Medicaid.

Introduction: This study aims to examine the extent to which health status, socioeconomic characteristics, and access to needed medications contribute to differences in total Medicare costs and drug spending among beneficiaries with and without Alzheimer's disease and related dementias (ADRD).

Methods: We used Medicare fee-for-service (FFS) claims data from 2018, 2019, 2021, and 2022, linked with the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, to examine factors associated with total Medicare spending, Part D drug spending, and Part B drug costs. Decomposition analysis was conducted to quantify the contribution of individual characteristics to observed cost differences by ADRD status.

Results: Our model explained 48% of the total Medicare spending difference and 80% of the Part D drug cost gap between beneficiaries with and without ADRD. Depression, heart disease, self-reported poor health, and functional limitations were major contributors to total spending differences. Dual eligibility was a primary driver of higher Part D costs. However, the model did not adequately explain differences in Part B drug costs.

Conclusion: These findings underscore the need for targeted interventions in mental health, cardiovascular care, and pharmaceutical policy. Further research is needed to better understand unmeasured drivers of Medicare spending, especially physician-administered drug costs under Part B, among beneficiaries with ADRD.

Introduction: In alignment with Centers for Medicare and Medicaid Services (CMS) requirements, hospitals increasingly screen for health-related social needs (HRSNs) such as housing, food, and transportation. However, these protocols often exclude instrumental social support-help with tasks like managing medications or attending appointments-which may influence post-discharge outcomes.

Methods: We analyzed social risk data from 5 medical-surgical units at a US quaternary academic medical center. Among 413 inpatients (mean age 48.9 years; 52.1% male; 85.5% non-Hispanic White), we examined whether patient-reported instrumental social support and unmet HRSNs were associated with 30-day emergency department (ED) visits or rehospitalizations. Models were adjusted for LACE scores, a validated index of length of stay, admission acuity, comorbidity burden, and ED visits.

Results: Within 30 days of discharge, 7.3% of patients had an ED visit, and 7.3% were rehospitalized. In adjusted models, higher instrumental social support was associated with lower odds of ED visits (OR = 0.76, 95% CI: 0.59-1.00). Unmet HRSNs were not significantly associated with either outcome. Higher LACE scores predicted increased utilization (ED visits, OR = 1.29, 95% CI: 1.15-1.45; rehospitalizations, OR = 1.21, 95% CI: 1.09-1.36).

Conclusion: Instrumental social support may influence short-term post-discharge outcomes. Expanding CMS-aligned screening to include support availability could improve discharge planning and reduce unplanned utilization.

Trial registration: Clinicaltrials.gov ID NCT04248738.

Introduction: The behavioral health (BH) needs of older adults are unique, increasing, and, too often, poorly understood.

Methods: Oregon established the first state-level center of excellence in the United States focused on the BH of older adults via a state-university-community partnership. Oregon's Center of Excellence for Behavioral Health and Aging (OCEBHA) was conceptualized by the state health authority and initially funded using a block grant from the Substance Abuse and Mental Health Services Administration.

Results: OCEBHA seeks to expand the capacity of health and social programs and providers to deliver BH services for older adults with serious mental illness and substance use disorders through translational research, workforce development, and policy innovation.

Conclusion: This review article describes the United States' and Oregon's BH and aging landscape, highlighting the disconnects between research evidence, clinical treatment/intervention, and policy implementation. It outlines the rationale for establishing centers like OCEBHA, which was designed to bridge these gaps. By detailing OCEBHA's structure and focus areas-translational research, workforce development, and policy innovation-the article shows how this model can help align evidence-based practices with service delivery and policy. It also offers a roadmap for other states seeking to strengthen support for older adults with BH needs.

Introduction: Burnout among clinicians can jeopardize their well-being, productivity, and quality of patient care. However, research on burnout of physician assistants/associates (PAs) is limited. This study investigates factors associated with burnout among PAs.

Methods: Using the Conservation of Resources theory as a framework and robust national data (N = 122 360), we examined factors associated with PA burnout. Analyses included descriptives, bivariate statistics, and multivariate logistic regression with marginal effects.

Results: A third (34.2%) reported experiencing at least one symptom of burnout; however, differences by specialty were observed, with emergency medicine PAs having the highest prevalence (42.2%) while dermatology PAs had the lowest (26.1%). Multivariate analysis revealed that the strongest factor associated with a 19.9 percentage point higher probability of burnout was a perceived decline in the quality of working conditions in the past year. PAs in emergency medicine were more likely than PAs in other specialties to report worsening conditions. Other factors associated with increased burnout included workload, understaffing, and educational debt.

Conclusion: The declining quality of working conditions among PAs was the strongest factor associated with increased burnout, while satisfaction with work-life balance was protective. Strategies and policies focusing on maintaining quality working environments to reduce burnout risk should be prioritized.