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Introduction: Routine screening for health-related social needs (HRSNs) is inconsistent, creating disparities in who gets identified and supported. Transgender patients, already facing structural stigma, may be especially affected.

Methods: We analyzed electronic health records from a large urban safety-net system (2018-2023). We identified 2639 transgender patients with at least one outpatient visit and created a ∼11:1 comparison cohort of 23 944 cisgender patients. Overall, 7.5% (n = 1997) completed a Social Needs Questionnaire (SNQ), including 1840 cisgender and 157 transgender patients. We compared screening rates using chi-square tests and assessed adjusted odds for HRSN with logistic regression.

Results: Transgender patients were screened less often than cisgender patients (5.9% vs 7.7%, P = 0.001). Among those screened, they had more than twice the odds of housing instability, poor-quality housing, and healthcare costs. Odds for interpersonal violence were th3ree times higher. Findings were consistent in sensitivity analyses adjusting for age, insurance, and neighborhood.

Conclusion: Transgender patients were underscreened yet faced greater HRSNs. Standardized screening and expanded supports are critical to support transgender communities.

Background: Accurate and complete patient race and ethnicity data are essential for informing health care quality and patient safety initiatives. However, missing data remain a persistent issue. We aimed to explore the utility of preferred language to impute patient race and ethnicity.

Methods: This was a retrospective analysis from 3 emergency departments in New York City, from June 1, 2023, to May 31, 2024. We leveraged a mapping schema for imputation of missing race and ethnicity data using preferred language for categorization into the Office of Management and Budget's 7 categories. We examined concordance between preferred language and predicted categories.

Results: The proportion of patients with missing race and ethnicity data decreased from 9.7% to 8.6%, reducing missingness by 11.1%. The greatest proportion of change with the use of preferred language was for Middle Eastern and North African patients (14.7%).

Conclusion: Our findings support that language-based imputation has the potential to reduce missing race and ethnicity data and may be a helpful tool in quality improvement and research efforts. For health systems where race and ethnicity fields may not be fully detailed or have a high rate of missing data, the use of language may serve as a valuable adjunct in improving the comprehensive picture of a population.

Introduction: While Medicare Allowable Bad Debt (MBD), defined as unpaid patient financial obligations Medicare partially reimburses to hospitals, represents only 0.12% of patient revenue, policymakers and executives should note the $1.7 billion reimbursed in 2022 affects hospitals of different types in various ways (see Appendix 1). The recent passage of the One Big Beautiful Bill Act did not eliminate MBD, but elimination has been proposed, supporting a need to understand what elimination could do to hospitals.

Methods: Using Medicare Cost Reports, we conducted a retrospective, longitudinal analysis of short-term general acute-care hospitals in 2022.Total margin was evaluated with and without MBD by Critical Access Hospital (CAH), rurality, state, and Hospital Referral Region.

Results: Elimination of this reimbursement would have impacted many hospitals; though findings highlight more adverse impacts on CAHs (accounting for a 0.3% point [PP] reduction in total margin), other rural hospitals (a 0.25PP reduction), states like Nevada (a 0.48PP reduction), and certain HRRs around the Appalachia region and parts of Texas.

Conclusion: Elimination of MBD may further jeopardize financial solvency for some rural hospitals that provide access to acute care across America's vast (mostly rural) land mass, particularly in rural and underserved communities.

The credibility of global health oversight mechanisms relies on their perceived independence. What truly constitutes "independent," however, remains ill-defined. Using a mixed-methods approach that includes a literature review and 54 key informant interviews, this paper outlines 4 pillars of independence: operational, political, economic, and knowledge/technical. It then proposes a practical tool for evaluating their application-the "OPEN Framework." We tested this framework by reviewing it against 3 so-called independent monitoring bodies: the Global Polio Eradication Initiative's Independent Monitoring Board, the Global Preparedness Monitoring Board, an independent monitoring and accountability body to ensure preparedness for global health crises, and the Independent Accountability Panel for Maternal, Newborn, and Child Health. Our findings reveal that, despite intentions of independence, pragmatic constraints and dependencies often compromise autonomy. The paper argues for a shift from rhetorical to operational independence by applying this framework, identifying conflicts of interest, and actively managing them. The OPEN Framework offers a replicable methodology for evaluating, comparing, and enhancing the independence of oversight bodies, thereby fostering stronger accountability and trust in global health governance.

Introduction: As Alzheimer's disease and related dementias (ADRD) progress, many individuals become homebound and increasingly depend on home-based medical care (HBMC), such as clinician house calls. The COVID-19 pandemic spurred a rapid expansion of telemedicine under Medicare, but its impact on outpatient care by modality-HBMC, telemedicine, and office-based-among enrollees with ADRD remains unclear.

Methods: Using national Medicare claims, we examined changes in primary care visits-categorized as office-based, HBMC, and telemedicine-between the pre-expansion period (March 2019-February 2020) and the late post-expansion period (March-November 2021), when telemedicine use had stabilized. Analyses were stratified by regions with low vs high HBMC provider availability.

Results: Regions with high HBMC availability saw a 13.6% greater increase in HBMC visits and a 5.0% greater increase in all visits compared to low-availability regions. Both groups had similar increases in telemedicine and declines in office-based visits. HBMC growth reflected broader access, with more beneficiaries receiving HBMC post-expansion. However, gains were concentrated among non-Hispanic White enrollees, with no significant changes for non-Hispanic Black or Hispanic enrollees.

Conclusion: These findings suggest that Medicare's telemedicine waivers expanded, rather than replaced, HBMC. Sustaining these policies may support aging in place for individuals with dementia, though disparities in access remain a critical concern.

The long-term services and supports (LTSS) system is intended to grant Americans, requiring care that extends beyond what can be provided in a hospital and/or primary care settings alone, access to the appropriate caretakers and facilities. Federal policy has struggled to ensure sustainable access to LTSS and the workforce that provides it. In particular, Medicaid beneficiaries are required to have access to these services but still face difficulties in obtaining them. Long term care provision has traditionally been institutionally based due to funding mandated through Medicaid, but the formalized workforce cannot keep pace with an aging population. Many rely instead on informal caregivers (ie, family, friends, etc.) for their care. While populations requiring long term care prefer to receive care from the comfort of their own communities, informal caregivers are rarely compensated and often forced to juggle employment and caregiving duties. This commentary explores how mandated funding for home and community-based services (HCBS) may improve access to LTSS by mobilizing an existing informal workforce.

The accountable care organization (ACO) model centers around primary care providers (PCPs) and undervalues the central role that specialists play for many beneficiaries with chronic conditions. This assumption informs beneficiary attribution methods for Medicare ACOs, which prioritize assignment of cost and quality accountability to PCPs over specialists. Yet, in 2023, many traditional Medicare beneficiaries with chronic conditions did not have a PCP as their predominant provider of care, limiting ACOs' ability to engage many beneficiaries with specialists as their predominant providers of care. To better engage specialists delivering chronic condition care, we recommend updating ACO policies to assign greater accountability for beneficiaries with chronic conditions to specialists.

Introduction: Medicaid provides access to care for low-income patients facing life-threatening illnesses who are cared for in intensive care units (ICUs). Despite the growth of Medicaid coverage with the Affordable Care Act, little is known about Medicaid's role in critical care for the Medicaid Expansion population, adults ages 19-64.

Methods: Using hospital discharge data from Virginia, we examined payer composition between 2016 and 2023 and analyzed 2023 demographic and clinical data for adults ages 19-64.

Results: Medicaid's share of ICU stays more than doubled from 2016 (14.1%) to 2023 (31.8%). While only 25.6% of Medicaid hospitalizations involved ICU care, these stays account disproportionately for charges (51.7%), hospital days (36.9%), and readmissions (32.3%). Common reasons for admission include potentially preventable conditions: sepsis, diabetes, heart failure, and alcohol use. Medicaid patients, despite being younger than their commercially insured counterparts, have more comorbidities (4+ comorbidities: 49.9% vs 38.9%) and are more likely to be readmitted in adjusted models (29.7% [95% Confidence Interval: 29.1-30.4] vs 24.3% [95% Confidence Interval: 23.6%-25.1%]).

Conclusions: This work demonstrates the crucial role of Medicaid as a payer for seriously ill adults and the need for increased attention by Medicaid programs to ICU patients before, during, and after hospitalization.