Health affairs scholar最新文献

More than 83 million people in the United States live in primary care shortage areas. As the US healthcare system faces a contracting primary care physician workforce, advanced practice providers are playing an increasingly important role in the delivery of primary care services. In parallel, public discourse regarding the differences in care delivery by advanced practice providers versus physicians has also expanded. In this commentary, we describe 3 main evidence gaps hindering optimal physician and advanced practice provider work organization in contemporary primary care delivery: (1) gaps in understanding the unique and overlapping competencies of each role group, (2) gaps in evaluating and defining optimal role delineation, and (3) gaps in payment models supporting effective collaboration. We subsequently present key needs in these 3 areas, including technology-based approaches to track physician and advanced practice provider competencies, increased empirical data on different clinical teaming structures, and exploration of novel models for primary care payment. We also note the need for an enhanced understanding of patient perspectives regarding primary care role types and teaming structures.

Consolidation of independent hospitals and physician practices into integrated health systems has reshaped the delivery of health care. While the literature suggests that provider consolidation raises prices, few studies have examined the interplay of health systems and insurers in relation to prices. Using negotiated price data that commercial insurers recently released under the Transparency in Coverage Final Rule, we examined the association between hospital concentration under health systems and prices for outpatient procedures in local health care markets with different levels of insurer concentration. We found that hospital prices are higher in more concentrated hospital markets, while lower in more concentrated insurer markets. However, the negative relationship between insurer concentration and hospital prices is attenuated in highly concentrated hospital markets, suggesting that insurers' bargaining leverage is lessened at greater levels of hospital consolidation. Considering the continued consolidation among hospitals and vertical integration of physician practices into health systems, our findings suggest that commercial payers may encounter increased challenges in controlling health care spending for their beneficiaries as providers' bargaining power continues to grow.

Enrollment in Medicare Advantage (MA) plans rose to over 50% of eligible Medicare patients in 2023. Payments to MA plans incorporate risk scores that are largely based on patient diagnoses from the prior year, which incentivizes MA plans to code diagnoses more intensively. We estimated coding inflation rates for individual MA contracts using a method that allows for differential selection into contracts based on patient health. We illustrate the method using data on MA risk scores and health conditions from the most recent year available, 2014. This approach could also be used beginning in 2022, when Medicare transitioned to MA risk scores based on MA Encounter records. Several existing methods assess coding intensity, but this study's approach is novel in its use of plan-level mortality rates to infer plan-level coding intensity. We found an enrollment-weighted mean coding inflation rate of 8.4%, with rates ranging from 3.4% to 12.7% for the largest 8 MA insurers and from 1.1% to 22.2% for the largest 20 MA contracts in 2014. We found higher coding intensity for health plans that were HMOs, provider-owned, large, older, or had high star ratings. Approximately 68.1% of MA enrollees were in contracts with coding inflation rates larger than Medicare's coding intensity adjustment.

Many older adults with personal care needs rely on paid caregivers to remain in the community ("home care"). Those without Medicaid or private long-term-care insurance must pay out-of-pocket for care. We used the Health and Retirement Study to identify the prevalence and financial burden of paying for home care out-of-pocket in 2002-2018, by income and dementia status. Over 600 000 people with personal care needs paid out-of-pocket for home care in a given year, 45% of whom have dementia. The quantity and cost of this care were substantial for people with dementia in particular: 51% of those with dementia paying out-of-pocket for home care spent ≥$1000/month. While the probability of paying out-of-pocket for home care increased sharply with income, 52% of people paying out-of-pocket for home care had incomes below 200% of the federal poverty line; this group faced high financial burdens of care. Policies aimed at easing the financial burden of home care are essential, particularly for low-income individuals with dementia who experience the greatest financial burden.

Naloxone is an opioid antagonist that can reverse opioid overdoses and save lives. In 2023, the California Department of Health Care Access and Information mobilized its affordable drug manufacturing program, CalRx, to develop a more affordable naloxone nasal product that could help increase access for all Californians. Partnering with a new market entrant, CalRx offered a stable demand forecast for an initial 3-year agreement. In exchange, the selected manufacturer launched a new generic over-the-counter naloxone nasal product at a transparent price 40% lower than the state's previously contracted rate. In its first 6 months, internal calculations suggest that the CalRx generic naloxone has saved the state over $2.6 million, which could be used to provide more than 108 000 additional units of naloxone free of charge to communities across California. Overall generic naloxone prices declined by 22% in a single quarter immediately following CalRx entry. The CalRx experience has helped disrupt the naloxone market by increasing competition and reducing prices. The experience also demonstrates that leveraging states' substantial purchasing power to negotiate lower prescription drug prices can have immediate market impact.

In 2001, the Centers for Medicare and Medicaid Services established the New Technology Add-On Payment (NTAP) program to incentivize access to costly new technologies for Medicare beneficiaries. These technologies, authorized by the Food and Drug Administration (FDA), must demonstrate "substantial clinical improvement" when compared to existing technologies. However, in FY2021, the FDA introduced two expedited authorization pathways, allowing technologies with either designation to bypass the "substantial clinical improvement" criterion. We describe the services and payments associated with NTAPs following this policy change.

The Program of All-Inclusive Care for the Elderly (PACE) is a managed care program financed by capitated government payments that primarily serves adults aged 55 or older requiring nursing home level of care who are dual-eligible for Medicare and Medicaid. While PACE programs have historically been nonprofit entities, in 2016, a regulation change allowed for-profit PACE programs to help expand the program. We describe PACE program growth from 2010 to 2022. Both the number of PACE programs and enrollees grew from 2010 to 2022. Yet, after allowing for-profits to enter the market, the enrollment rate of growth slowed overall (13.4% vs 7.0%), though for-profit program enrollment grew more rapidly compared to nonprofit programs (13.2% vs 5.7%). Entry of new programs drove for-profit growth primarily. Despite the growth of for-profit programs, most enrollees continued to receive care from nonprofit programs (78%) by 2022. Allowing for-profit programs did not increase PACE enrollment rates overall. Given emerging evidence that for-profit ownership in other health care sectors may reduce quality compared to nonprofits, policymakers should carefully monitor care quality and patient outcomes in PACE as for-profit entities increase.

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) individuals in the United States experience higher rates of discrimination and stressors that negatively impact health compared with their straight, cisgender counterparts. Using 2022 Behavioral Risk Factor Surveillance Survey (BRFSS) data, estimating multilevel mixed-effects logistic regressions, we examined the relationship between state LGBTQ+ policies and health among LGBT people. Findings reveal a statistically significant inverse link between protective (high) state policy scores and poor self-rated health, poor mental health days, and poor physical health days. Specifically, with each 1-point increase in policy score, the odds of poor self-rated health are reduced by 0.03%, high mental health burden by 0.02%, and high physical health burden by 0.02%. Inequalities in self-rated health, high mental health burden, and high physical health burden are greater in policy environments with fewer state-level protections, with LGBT individuals reporting better health where there are more protections. These results indicate that discriminatory state policies are linked to poorer health for LGBT individuals and suggest that protective policies could improve health. Further research with comprehensive data is needed to deepen understanding.

Behavioral health-related mortality-deaths from suicide, drug overdose, and acute alcohol injury-are leading causes of death among US adults. Crisis teams, trained behavioral health professionals who serve as first responders to assess and stabilize clients in crisis, as well as refer to treatment as necessary, have been shown to reduce psychiatric hospitalizations, but whether crisis teams reduce behavioral health mortality has not been studied. We assessed the association between changes in access to crisis team programs and changes in county-level suicide, drug overdose, and acute alcohol injury mortality from 2014 through 2019. We found that 250 (9%) of counties experienced crisis team program entry and another 237 (9%) experienced crisis team program closure. Access to crisis team programs was associated with significant changes in county-level drug overdose deaths, but not suicide or acute alcohol injury. Compared with counties with no change in access, crisis team program entry was associated with a 7% reduction in county-level drug overdose death rates, and crisis team program closure was associated with a 13% increase in drug overdose death rates. These findings may support the use of crisis teams as 1 intervention to address substance use disorder treatment gaps in the United States.