Health affairs scholar最新文献

The arrival of bird flu (H5N1) is a poignant reminder of the need for public health leaders to understand Americans' evolving perspectives on pandemic mitigation policies. To guide response efforts, we conducted a nationally representative opinion survey among 1017 U.S. adults in 2024. Majorities said they would be likely to support each of 4 policies in a future pandemic scenario (related to masking requirements, school closures, restaurant closures, and healthcare worker vaccination requirements). About half (49%) were likely to support all 4 policies, while 32% expressed mixed support. Support varied by gender, age, race, ethnicity, income, metropolitan and parental status, political party, and COVID-specific comorbidities. Roughly 80% expressed concern that future pandemic policies would hurt the economy, be based on political or pharmaceutical company/business interests, pander to critics, or further polarize society. Results suggest public support for future pandemic policies may be wider than media reports suggest, though important divisions exist and concerns about design and implementation are widespread. The most appealing policies will explicitly consider economic impacts and target populations at risk during clear time frames, with scope for personal choice. Ensuring that policies are made without undue political or commercial influence will remain a central challenge for public health leaders.

[This corrects the article DOI: 10.1093/haschl/qxae017.].

[This corrects the article DOI: 10.1093/haschl/qxae117.].

[This corrects the article DOI: 10.1093/haschl/qxae133.].

The Medicaid program is the largest payer of opioid use disorder (OUD) treatment, including medications for OUD (MOUD). Because of budget neutrality requirements, some Medicaid programs use prescription drug caps to limit the monthly number of prescriptions an enrollee can fill. This study examined the association between Medicaid prescription drug caps and Medicaid-covered prescriptions for 2 forms of MOUD (buprenorphine and naltrexone) from 2017 to 2022 using fee-for-service and managed care data from Medicaid's State Drug Utilization Data. Ten states had monthly prescription drug caps, ranging from 3 to 6 prescriptions. Using multivariate linear regression, we estimated that enrollees in states with monthly drug caps filled 1489.3 fewer MOUD prescriptions per 100 000 enrollees. Further, compared with states with the smallest drug caps (3 drugs), enrollees in states with 4-, 5-, and 6-drug caps filled significantly more prescriptions per state-quarter (907.7, 562.6, and 438.9 more prescriptions, respectively). Our results were robust to sensitivity analyses. Monthly prescription drug caps were significantly associated with a reduction in Medicaid-covered MOUD prescriptions. Medicaid enrollees who need MOUD may be affected by indiscriminate prescription drug cap policies, potentially hindering ongoing efforts to mitigate the opioid crisis.

The public health workforce continues to atrophy due to mass and early retirement, under-funding, slow hiring processes, lack of advancement opportunities, and shifting policies. Organizational research into workforce sustainability is crucial for ensuring a robust, diverse staff capable of delivering essential public health services. We examined career ladders, a potential solution to workforce challenges, through interviews with 10 health departments (HDs) across seven states. Interview participants were recruited from HDs using or planning career ladders held administrative positions, and had a role in the hiring process. Many health department positions have traditionally included steps within certain job classifications that promote pay adjustments with increasing years of service. Career ladder approaches, however, specifically focus on providing opportunities for health continuing education, leadership development, or movement into formal leadership roles. Findings indicate that HDs have begun utilizing career ladders for professional development and critical role maintenance. Career ladders have been applied mostly for retention with limited impact on recruitment and increasing staff diversity. Challenges include civil service requirements, funding limitations, and complex recruitment that might exclude diverse candidates. This study emphasizes the importance of transparent development, engaging front-line staff, offering advancement pathways, and providing insights to enhance workforce recruitment and retention.

Health centers (sometimes referred to as "federally qualified health centers") can play an important role in addressing perinatal inequities. However, there is limited information on how different staffing models in health centers contribute to perinatal outcomes, including the availability of certified nurse midwives (CNMs). Using 2011-2021 Uniform Data System files, we examined 4 staffing models in 1385 health centers: those with no CNMs or obstetricians-gynecologists (OBs) ("non-CNM/OB"), CNM-only, OB-only, and both CNMs and OBs ("CNM/OB"). We predicted adjusted low birthweight (LBW) rates across these staffing types using a generalized linear model approach, adjusting for both time and center fixed effects as well as relevant patient, staffing, organizational, and community characteristics. We found that CNM-only health centers had the lowest LBW rates across all staffing models (7.6%) and non-CNM/OB centers had the highest (10.1%). Among Black births, LBW rates ranged from 10.1% (CNM-only) to 13.5% (non-CNM/OB). Findings indicate the importance of building and supporting the CNM workforce and ensuring adequate staffing at health centers, particularly as part of a comprehensive approach to addressing inequities in perinatal outcomes including addressing the scope of practice of CNMs, as more CNM-staff health centers were in areas with independent scope of practice.

The 340B program allows certain hospitals and clinics to use outpatient drugs purchased at substantial discounts on insured patients, generating profits to fund care. The size of these profits depends on the number of prescriptions filled by participating hospital or clinics' insured patients that also meet the Health Resources and Services Agency's definition of an eligible patient. A recent court case has challenged the Agency's longstanding definition of a patient, resulting in new definition that could significantly expand the size of the program and create conflicts when an insured patient satisfies the new definition for more than one hospital or clinic participating in the program. We use Medicare Part D data from 2018 to simulate the proportion of prescription drug fills eligible for 340B discounts and total program spending under both existing and new definitions. We found that the new definition could increase the share of 340B-eligible fills in Medicare Part D by 25%, from 12% of fills to 16%, and that the share of fills subject to a conflict could double, from 1% of fills to 1%-2%. Our results suggest that the new definition could increase covered entities' 340B profits by roughly a third.

How do referral networks and medical conditions determine where patients get care? We study this question in the US Hospice Industry, where for-profit hospice programs enroll more long-term care patients and more patients with Alzheimer's disease and related dementia. We find that for-profit hospice enrollees have 23% longer lifetime lengths-of-stay in hospice care than not for-profit hospice enrollees with the same medical conditions, institutional referral source, county of residence, and enrollment year. This and other differences in their end-of-life health care utilization suggest that hospice market segmentation is the result of a patient-specific selection mechanism that is partially independent of institutional barriers to hospice care.

There is strong interest among policymakers to adjust for area-level deprivation when making payments to providers because such areas have traditionally been underserved. The Medicare Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) model provides higher payments to ACOs serving areas with greater deprivation. Area Deprivation Index (ADI) is the primary component to measure deprivation for ACO REACH. The ADI is a commonly used deprivation index, but there are concerns about its methodology, primarily its use of nonstandardized deprivation factors. Prior research indicates the ADI is mainly determined by home values, which does not allow it to adequately capture deprivation in urban areas. This paper revises and updates the ADI, using American Community Survey data to compute a census block group deprivation index, the Community Deprivation Index (CDI). The CDI standardizes the deprivation factors to be unit neutral, applies statistical shrinkage to account for the imprecise measurement of the factors, updates several factors, and reweights the factors using the most recently available data. Validation tests suggest the CDI exhibits higher correlations with several health outcome/utilization measures than the ADI. The CDI will better serve policymakers by improving identification of urban areas with higher deprivation.