Health affairs scholar最新文献

Introduction: Primary care attachment is the formal or informal affiliation with a regular primary care clinician. In countries with near-universal primary care, a physician's retirement typically results in the transition of care to another doctor. In many low- and middle-income countries, as well as the United States and Canada, this seamless transition often does not exist. A period of unattachment follows, during which the individual lacks primary care.

Methods: This population-based retrospective cohort study of 12 726 325 Ontarians uses health administrative data to examine how the duration of attachment and unattachment influences mortality, healthcare costs, and hospitalizations.

Results: A period of increased vulnerability was observed within the first 5 years of unattachment, associated with 85% higher odds of all-cause mortality compared with those attached for 15+ years. This association was amplified among multimorbid patients. Relative to long-term attached individuals without comorbidity, multimorbid patients exhibited approximately 5-fold higher all-cause mortality when stably attached, increasing to roughly 12-fold among those recently unattached. Cost and hospitalization outcomes exhibited similar patterns.

Conclusion: These findings carry crucial policy implications, underscoring the need for strategies that promote stable attachment, particularly for individuals with multimorbidity, and better patient support following the loss of a primary care physician.

Related to recent federal directives to strengthen physician nutrition education, this paper examines family medicine's leadership in nutrition counseling while identifying modifiable barriers limiting primary care's prevention potential. Family physicians, comprising over 109 000 certified clinicians, provide 20% of U.S. healthcare visits and deliver substantial nutrition counseling, particularly in underserved communities. The American Board of Family Medicine dedicates 5% of certification content to nutrition/obesity and 25% to chronic disease care. However, structural barriers significantly constrain implementation. Medicare only reimburses nutrition counseling for end-stage conditions (diabetes and kidney disease), frustrating key opportunities to help patients. Primary care receives <5% of national health spending and under 1% of federal research funding, despite handling half of all office visits. The workforce lacks integrated nutritionists and dietitians, with physicians 20 times more likely to address nutrition when services are covered. We propose federal actions to transform primary care's nutrition capacity: expanding Medicare coverage to earlier disease stages and obesity, increasing primary care investment, directing research investment to community practice settings, supporting workforce integration of nutrition professionals, and developing meaningful quality measures. These aligned policies could unleash primary care's prevention potential.

Introduction: Rapid increased utilization of GLP-1s by US patients has raised safety concerns, in addition to challenges related to supply shortfalls starting in March 2022.

Methods: We analyzed publicly available FDA Adverse Event Reporting System (FAERS) data from January 2015 through December 2024 to describe adverse events where GLP-1s were the primary suspect and compared them with events involving injectable insulin products.

Results: Among the 112 532 reports analyzed, GLP-1s were associated with a higher share of administration-related reactions (63%) compared to insulin (39%). Reports of dosing issues and administration errors increased for GLP-1s beginning in Q4 2022 and rose further in 2023 and 2024, patterns not seen for insulin. Increases coincided temporally with the period of national GLP-1 shortages. Increases in reporting volume may reflect increased utilization rather than increased risk as FAERS lacks exposure denominators.

Conclusion: The shift toward administration-related and dosing-related reports underscores the importance of patient and provider education and continued regulatory attention to the use of these drugs even as supply shortfalls resolve. Ongoing post-marketing surveillance remains essential to monitor safety signals.

Introduction: As of 2019, California requires healthcare providers to screen patients for mental health symptoms during prenatal care and postpartum care. This study examined perinatal mental health screening rates and perspectives of OBGYNs on screening outcomes following this mandate.

Methods: We analyzed electronic medical records data for patients who delivered in one California health system between 2019 and 2023 to assess prenatal and postpartum mental health screenings (N = 11 763). We also interviewed OBGYNs in the health system in 2023 about their perceptions of screening practice and patient outcomes since the mandate was implemented.

Results: Both prenatal and postpartum screening rates increased between 2019 and 2023; however, by 2023, only 80% of patients had documented screenings in prenatal care, 69% in postpartum care, and 57% in both time periods. In interviews, OBGYNs noted that while the mandate led to more consistent screening, they emphasized that patients continued to face substantial barriers to mental healthcare.

Conclusion: This study suggests that while the California perinatal mental health screening mandate led to incremental improvements in screening rates in the years following implementation, not all patients were screened within the study period. Further, OBGYNs indicated that screening alone did not substantially help patients access mental healthcare.

Introduction: To incentivize drug and vaccine development for neglected tropical diseases (NTDs), US Congress created the Priority Review Voucher (PRV) program in 2007. Sponsors that obtain Food and Drug Administration (FDA) approval for an eligible product receive a voucher redeemable to accelerate review of another product.

Methods: We reviewed the program's public health impact by examining all 14 vouchers awarded for NTD products between 2007 and 2024, including the timing of FDA approval relative to World Health Organization (WHO) Prequalification, Essential Medicines List inclusion, first use in endemic countries, and voucher disposition.

Results: Eight (57%) achieved WHO Prequalification, and 8 (57%) were listed in the Essential Medicines list. FDA approval occurred a median of 8.7 years after first regulatory approval or use in an endemic country and a median of 5.2 years after WHO Essential Medicines list inclusion.

Conclusion: Our findings suggest that the PRV program has primarily rewarded regulatory filings for long-established therapies rather than stimulating innovation or improving access. We propose reforms linking voucher eligibility to equitable pricing and endemic country registration.

Introduction: Financial strain is common in the United States and associated with substance use. We examined whether eligibility for the federal Earned Income Tax Credit (EITC), the largest US anti-poverty program, affected financial strain and drug use.

Methods: Using a difference-in-difference design with data from the Population Assessment on Tobacco and Health Wave 1 Adult Survey, a nationally representative survey of US adults, we estimated short-term EITC-associated changes in past-month financial strain, cannabis use, and central nervous system (CNS) depressant use for EITC-eligible people during the EITC disbursement period. Interview timing during/outside the disbursement period was independent of individual characteristics.

Results: Approximately 15.4% of adults were EITC-eligible with refunds ≥$500. Unadjusted prevalences of financial strain among EITC-eligible persons were 35.2% outside and 32.2% during the disbursement period. Refunds were associated with significantly lower financial strain (β = -4.5% [-8.9%, -0.1%]) vs EITC-ineligible individuals. Unadjusted prevalences of cannabis use in both periods were 10.7% and 9.8% in EITC-eligible vs 7.8% and 7.6% among EITC-ineligible; corresponding CNS depressant unadjusted prevalences were 6.3% and 6.6% in EITC-eligible and 4.9% and 4.7% among EITC-ineligible. There were no significant EITC-associated differences in drug use.

Conclusion: Findings support generous EITC refunds, with no evidence that financially supporting low-income people increased drug use.

Background: Hospitals make decisions about which services to provide based on a variety of factors. However, decisions to provide services based on financial or religious considerations have increasingly drawn public scrutiny. We conducted a national survey to assess public attitudes toward hospitals' financial or religious motivations for offering certain types of care.

Methods: We conducted a national, cross-sectional online survey of 1577 US adults. Respondents indicated on a 3-point, frequency-based Likert scale whether hospitals should "Never," "Sometimes," or "Always" be allowed to limit services for these reasons. Descriptive statistics and multivariable logistic regression analyses examined the demographic and experiential correlates of these attitudes.

Results: Most respondents opposed financially motivated restrictions (62%), while a plurality opposed religiously motivated restrictions (48%). Opposition differed across subgroups, with Republicans, individuals with public insurance, and health care employees more accepting of both types of restrictions, while older respondents and those with higher health literacy were more likely to oppose them.

Conclusion: Our findings reveal a notable divergence between how hospitals often operate and what the public believes hospitals should be permitted to do. Efforts to improve transparency around service limitations and ensure continuity of care may help maintain public trust when hospitals decline to provide certain services.

Millions will become uninsured when Affordable Care Act enhanced subsidies expire and new, stricter enrollment regulations take effect in 2026. Reductions in federal enrollment assistance that have helped coverage seekers navigate administrative burdens mean that health insurance brokers will be critical in mitigating Marketplace coverage losses. Brokers can be a strong force for maintaining Marketplace enrollment, particularly when the markets they operate in are structured to minimize bad behavior and to maximize outreach. This commentary argues that a robust broker infrastructure is necessary to help Marketplace enrollees retain coverage. We outline how brokers can help people navigate new administrative burdens to Marketplace enrollment and review 2 innovative models for maximizing outreach among people more likely to be uninsured.

CMS's new ACCESS payment model is a novel approach in how Medicare pays for chronic-disease management: recurring, condition-specific payments tied to clinical improvement, rather than billing for discrete encounters or tightly defined remote-monitoring activities. The promise is straightforward, more reimbursement for technology-enabled longitudinal care and more choice and competition for patient care. But ACCESS leaves many questions unanswered about payment levels, how quality is measured, risk adjusted, and how these patients' facing technology-enabled services coordinate care with the traditional delivery systems. Whether ACCESS strengthens primary care will depend on the details.