Health affairs scholar最新文献

While many Medicare beneficiaries are enrolling in Medicare Advantage (MA), some beneficiaries may want to return to traditional Medicare and purchase Medigap, especially beneficiaries who have greater medical needs. Beyond minimal federal regulations, states impose additional regulations that impact Medigap affordability. Beneficiaries in some states have greater difficulty obtaining Medigap coverage because the states where they live allow Medigap insurers to experience rate the beneficiary, which can make Medigap insurance prohibitively expensive. We examined beneficiaries who received physician-administered drugs, which can be expensive and subject to high cost sharing, to see if disenrollment from MA for these beneficiaries was greater in states with Medigap consumer protection policy levels. In 2020, we find a 1.0% average baseline average probability of MA disenrollment. For beneficiaries who received a physician-administered drug in our sample, the probability of MA disenrollment is 3.7 (95% CI, 2.6-4.8; P < .001) percentage points higher in Medigap-guaranteed issue states compared with states with no protections. We find a greater association between MA disenrollment and Medigap protection policies with higher cost drugs. These findings suggest that beneficiaries who receive a high-volume and high-spending physician-administered drug are more likely to disenroll from MA back to traditional Medicare when Medigap is more affordable.

Characterizing the value and equity of care delivered during the COVID-19 pandemic is crucial to uncovering health system vulnerabilities and informing postpandemic recovery. We used insurance claims to evaluate low-value (no clinical benefit, potentially harmful) and clinically indicated utilization of a subset of 11 ambulatory services within a cohort of ∼2 million Virginia adults during the first 2 years of the pandemic (March 1, 2020-December 31, 2021). In 2020, low-value and clinically indicated utilization decreased similarly, while in 2021, low-value and clinically indicated utilization were 7% higher and 4% lower, respectively, than prepandemic rates. Extrapolated to Virginia's population of insured adults, ∼$1.3 billion in spending was associated with low-value utilization of the 11 services during the study period, with 2021 spending rates 6% higher than prepandemic rates. During March 1, 2020-December 31, 2021, low-value and clinically indicated utilization were 15% and 16% lower, respectively, than pre-pandemic rates among patients with the greatest socioeconomic deprivation but similar to prepandemic rates among patients with the least socioeconomic deprivation. These results highlight widening healthcare disparities and underscore the need for policy-level efforts to address the complex drivers of low-value care and equitably redistribute expenditures to services that enhance health.

The United States does not have a federal policy offering employees paid leave. We study employer attitudes toward the Families First Coronavirus Response Act (FFCRA) federal emergency paid leave policies temporarily adopted during the COVID-19 pandemic to draw lessons for proposed permanent federal paid leave policies. We analyzed a 2021 survey of 300 San Francisco Bay Area employers to examine employers' experiences with paid sick leave (PSL) and paid family leave (PFL) policies during the COVID-19 pandemic, along with their attitudes regarding FFCRA paid leave. Most firms reported that it was not difficult to comply with or seek reimbursement for FFCRA leave. Nevertheless, most smaller firms did report difficulty in understanding policy details, and many reported being unaware of FFCRA paid leave availability. FFCRA paid leave was broadly popular among firms aware of it: 64% supported (9% opposed) the PSL provisions, and 52% supported (12% opposed) PFL. However, support for permanent extension dropped to just over 40%, despite this Bay Area sample having long familiarity with California's state paid leave policies. We conclude that federal pandemic paid leave offers a potential model that could be refined for future paid leave policies, but support is mixed.

The No Surprises Act banned surprise billing and established a final-offer arbitration system, independent dispute resolution (IDR), to resolve disagreements between health plans and providers. One factor that arbiters must consider in the IDR process is the qualifying payment amount (QPA), the median contracted rate for the same or similar service in the same market as computed by health plans. We analyzed public IDR data from 2023 for the most common disputed professional service: evaluation and management of a moderate to severe emergency medicine visit. Providers won 86% of cases, with mean decisions 2.7 times the QPA. Private equity-backed providers won more often and higher monetary awards than other providers. The mean QPA was 2.4 times Medicare payments. Disputes were dominated by a small group of health plans and providers, so payments may not reflect the overall market for emergency services.

The Washington Group Short Set (WGSS) questions are intended to measure the severity of disability and disability status in US federal surveys. We used data from the 2010-2018 National Health Interview Survey to examine the performance of the WGSS visual disability and hearing disability questions in capturing blindness and deafness. We found that the WGSS questions failed to capture 35.7% of blind adults and 43.7% of deaf respondents as having a severe disability, or, per their recommended cut point, as being disabled. Coupled with evidence demonstrating the poor performance of the WGSS questions in estimating the size of the overall disability population, we contend that results from this study necessitate a halt in the use of the WGSS questions to measure disability in US federal surveys.

[This corrects the article DOI: 10.1093/haschl/qxae098.].

[This corrects the article DOI: 10.1093/haschl/qxae103.].

HIV care continuum outcome disparities by health insurance status have been noted among people with HIV (PWH). We therefore examined associations between state Medicaid expansion and HIV outcomes in the United States. Adults (≥18 years) with ≥1 visit in NA-ACCORD clinical cohorts from 2012-2017 contributed person-time annually between first and final visit or death; in each calendar year, clinical retention was ≥2 completed visits > 90 days apart, antiretroviral therapy (ART) receipt was receipt of ≥3 antiretroviral agents, and viral suppression was last measured HIV-1 RNA < 200 copies/mL. CD4 at enrollment was obtained within 6 months of enrollment in cohort. Difference-in-difference (DID) models quantified associations between Medicaid expansion changes (by state of residence) and HIV outcomes. Across 50 states, 87 290 PWH contributed 325 113 person-years of follow-up. Medicaid expansion had a substantial positive effect on CD4 at enrollment (DID = 93.5, 95% CI: 52.9, 134 cells/mm³), a small negative effect on proportions clinically retained (DID = -0.19, 95% CI: -0.037, -0.01), and no effects on ART receipt (DID = 0.001, 95% CI: -0.003, 0.005) or viral suppression (DID = -0.14, 95% CI: -0.34, 0.07). Medicaid expansion had a positive effect on CD4 at entry, suggesting more timely HIV testing and care linkage, but generally null effects on downstream HIV care continuum measures.

Substance use remains a timely and important community need to understand and address. Nonprofit hospitals are in a unique position to identify needs and develop programs in response to substance use challenges in their communities. To better understand how nonprofit hospitals do this, we collected data from community health needs assessments and their corresponding implementation strategy (IS) to address these needs for a 20% random sample of hospitals in each state of the United States over 2 periods (2015-2018 and 2019-2021). The sample of nonprofit hospitals came from the American Hospital Association's (AHA) Annual Survey Database. Community health needs assessment and IS documents were coded for the inclusion of substance use programs using a systematic protocol and analyzed quantitatively. We found that the percentage of nonprofit hospitals in our sample with at least 1 substance use program increased from 66.5% in 2015-2018 to 73.6% in 2019-2021. Of the types of programs analyzed, harm reduction approaches saw the greatest increase in implementation in the time period studied, while primary care approaches decreased. This indicates that hospitals are continuing or even increasing their responses to community needs regarding substance use, but there is evidence that their approaches in doing so are shifting over time.

Venture capital (VC) firms fund biopharmaceutical research and development (R&D) while incurring substantial financial risk. VC firms seek to invest in clinical areas with the greatest potential for financial return. Using a combination of data for clinical trials and VC investment deals between January 2014 and March 2024, we found that approximately 75% of VC investments were allocated to clinical trials studying small-molecule drugs compared to biologics or gene therapies, without substantial changes over the study period. Most of VC firms' investment in biopharmaceutical R&D was concentrated in phase 1 and phase 2 clinical trials. This trend has increased in recent years, with phase 1 trials accounting for nearly half of total deals and capital investments in 2023. VC investments were concentrated in several therapeutic areas, including cancer.