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The Centers for Medicare and Medicaid Services (CMS) relies on the American Medical Association's Relative Value Scale Update Committee (RUC) to estimate the physician work and direct practice expense associated with the Medicare Physician Fee Schedule (MPFS). However, as CMS notes in the 2026 MPFS proposed rule, the RUC's processes, which rely heavily on surveys and expert panels of physicians who are members of specialty societies, create conflicts of interest and overvalue specialty services. Although CMS and the RUC regularly assess MPFS codes for misvaluation, significant distortions remain, in part because the RUC develops new values by simply repeating the survey and expert panel processes that created the misvaluation in the first place. To correct this longstanding program, CMS should implement a technical expert panel to provide unbiased recommendations on the fee schedule, and Congress should require CMS to validate work and direct practice expense values using alternative, empirical data sources.

Introduction: The rapidly ageing population and multimorbidity are associated with increased emergency department (ED) visits by older adults. In the ED, older adults have higher risk of hospitalization, functional and cognitive decline, and mortality. Boarding, holding admitted patients in the ED awaiting a hospital bed, exacerbates these negative outcomes, which disproportionately affect older adults.

Methods: We conducted a cross-sectional analysis to investigate US boarding trends by age using clinical administrative data from 5 health systems and publicly available NHAMCS data from 2018 to 2024.

Results: Boarding ≥3 h in the ED has increased across diverse hospital types, with oldest adults (85+) facing the greatest risk (System 4: IRR [95% CI] = 1.18 [1.15-1.20], System 5: IRR [95% CI] = 1.20 [1.17-1.23], System 3 [Community Hospital]: IRR [95% CI] = 1.25 [1.19-1.33]). These results were recapitulated at the national level in NHAMCS (IRR [95% CI] = 1.30 [1.05-1.61]).

Discussion: The trend of increased boarding has serious implications for patients, caregivers, and health systems. The 2025 CMS Age-Friendly Hospital Measure offers opportunities to improve processes and procedures to mitigate the negative effects of hospital boarding on older patients. We highlight opportunities to address this challenge, including ongoing quality improvement initiatives, bed prioritization algorithms, and alternate admission pathways.

Introduction: Hypertensive disorders in pregnancy, including chronic and pregnancy-induced hypertension, pose significant risks to maternal health. This study evaluated the association of New York State (NYS)'s Paid Family Leave (PFL) law, implemented in 2018, with postpartum healthcare utilization among women with hypertensive disorders in pregnancy.

Methods: Using commercial claims data (2017-2022) for 312 470 employed women aged 15-45 years with live births, we assessed postpartum outpatient visits, hospital admissions, and medication adherence.

Results: The PFL law was associated with a 3.7%-point increase in outpatient visits within 7 days postpartum for women with chronic hypertension (from 25.9% to 29.6% in NYS, P < 0.001) and an 8.6%-point increase for women with pregnancy-induced hypertension (from 26.3% to 35.0%) in NYS, P < 0.001). The PFL law was associated with a 1.5%-point reduction in inpatient admissions for women with chronic hypertension (from 3.6% to 2.1% in NYS, P < 0.001), and a 7.1%-point improvement in antihypertensive medication adherence for women with chronic hypertension (from 26.6% to 33.8% in NYS, P < 0.001).

Conclusion: Study findings suggest that PFL laws may enhance postpartum hypertension management, providing useful insights for policymakers aiming to improve maternal health outcomes through workplace policies.

Risk adjustment is used in healthcare payment to mitigate the payer incentive to select for healthier populations and to improve fairness of quality assessment. The Centers for Medicare and Medicaid Services (CMS) has used a spending-based metric, the CMS Hierarchical Condition Category (HCC) score, to determine risk. However, the HCC score is potentially confounded by access and utilization differences, which are related to income and rurality. In this study, we investigate how related HCC scores are to mortality, a more objective indicator of clinical risk state, and whether that relationship differs between rural and urban populations. We examined calibration of the HCC spending model by calculating the predicted-to-observed spending ratio within deciles of the HCC score. We then compared urban and rural beneficiaries' clinical risk by comparing observed mortality rates within deciles. Our results demonstrate that the HCC model underpredicts mortality, while overpredicting spending, for rural beneficiaries. In contrast, it is well-calibrated for urban beneficiaries. These findings suggest that risk models based on HCCs may systematically disadvantage rural beneficiaries because HCC-based risk-adjusted spending may not fully account for baseline clinical risk.

Introduction: Family caregiving is receiving increased attention in state and national policy, while caregivers face constrictions in workplace flexibility.

Methods: A survey of employed caregivers in Utah (n = 226) was used to assess how often they reported having trouble managing paid work and caregiving responsibilities, the challenges they encountered in finding balance between roles, and effective strategies for caregivers to manage both roles.

Results: Almost half (44%) experienced moderate to severe difficulties balancing paid work and caregiving. Based on open-ended responses, time burden was the most commonly difficult aspect of balancing. Caregivers who had difficulty managing caregiving and work were twice as likely to have made employment changes, including hybrid/remote work or reducing hours. Caregivers said flexibility in work schedule and help with caregiving from family and friends were important to helping them achieving balance.

Conclusion: Difficulties balancing caregiving with paid employment are common and span health, financial, and time challenges. Policies supporting caregivers in their dual roles should address the common difficulties that caregivers experience. These policies could benefit employers, workers, and people with chronic health conditions and disability.

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.