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Variation in Processes of Care for Total Hip Arthroplasty across High-Income Countries 高收入国家全髋关节置换术护理流程的差异

Health affairs scholar

Pub Date : 2024-04-24 DOI: 10.1093/haschl/qxae043

Laura Skopec, Robert A Berenson, Benedikt Simon, Irene Papanicolas

Total Hip Arthroplasty (THA) is among the most commonly performed elective surgeries in high-income countries, and wait times for THA have frequently been cited by US commentators as evidence that countries with universal insurance programs or national health systems “ration” care. This novel qualitative study explores processes of care for hip replacement in the US and six high-income countries with a focus on eligibility, wait-times, decision-making, post-operative care, and payment policies. We find no evidence of rationing or government interference in decision-making across high-income countries. Compared to the six other high-income countries in our study, the US has developed efficient care processes that often allow for a same-day discharge. In contrast, THA patients in Germany stay in the hospital 7-9 days and receive 2-3 weeks of inpatient rehabilitation. However, the payment per THA in the US remain far above other countries, despite far fewer inpatient days.

全髋关节置换术（THA）是高收入国家最常进行的选择性手术之一，美国评论家经常将全髋关节置换术的等待时间作为拥有全民保险计划或国家医疗系统的国家 "配给 "医疗服务的证据。这项新颖的定性研究探讨了美国和六个高收入国家的髋关节置换术护理流程，重点关注资格、等待时间、决策、术后护理和支付政策。我们发现，在高收入国家中，没有证据表明存在定量配给或政府干预决策的情况。与我们研究中的其他六个高收入国家相比，美国已经形成了高效的护理流程，通常可以实现当天出院。相比之下，德国的 THA 患者住院 7-9 天，并接受 2-3 周的住院康复治疗。然而，尽管住院天数少得多，美国每次 THA 的费用仍然远远高于其他国家。

引用次数: 0

Piloting racial bias training for hospital emergency department providers treating patients with opioid use disorder. 对治疗阿片类药物使用障碍患者的医院急诊科服务提供者进行种族偏见培训试点。

Health affairs scholar

Pub Date : 2024-04-24 eCollection Date: 2024-05-01 DOI: 10.1093/haschl/qxae049

Jason B Gibbons, Samantha J Harris, Olivia K Sugarman, Eric G Hulsey, Julie Rwan, Esther M Rosner, Brendan Saloner

Racial disparities in opioid overdose have increased in recent years. Several studies have linked these disparities to health care providers' inequitable delivery of opioid use disorder (OUD) services. In response, health care policymakers and systems have designed new programs to improve equitable OUD care delivery. Racial bias training has been 1 commonly utilized program. Racial bias training educates providers about the existence of racial disparities in the treatment of people who use drugs and the role of implicit bias. Our study evaluates a pilot racial bias training delivered to 25 hospital emergency providers treating patients with OUDs in 2 hospitals in Detroit, Michigan. We conducted a 3-part survey, including a baseline assessment, post-training assessment, and a 2-month follow-up to evaluate the acceptability and feasibility of scaling the racial bias training to larger audiences. We also investigate preliminary data on changes in self-awareness of implicit bias, knowledge of training content, and equity in care delivery to patients with OUD. Using qualitative survey response data, we found that training participants were satisfied with the content and quality of the training and especially valued the small-group discussions, motivational interviewing, and historical context.

近年来，阿片类药物过量的种族差异有所扩大。一些研究将这些差异与医疗服务提供者不公平地提供阿片类药物使用障碍（OUD）服务联系起来。为此，医疗政策制定者和医疗系统设计了新的计划，以改善阿片类药物使用障碍治疗服务的公平性。种族偏见培训是一项常用的计划。种族偏见培训让医疗服务提供者了解在治疗吸毒者方面存在的种族差异以及隐性偏见的作用。我们的研究评估了在密歇根州底特律市两家医院为 25 名治疗 OUD 患者的医院急诊服务提供者提供的种族偏见培训试点。我们进行了一项由三部分组成的调查，包括基线评估、培训后评估和为期 2 个月的跟踪调查，以评估向更多受众推广种族偏见培训的可接受性和可行性。我们还调查了隐性偏见的自我意识变化、培训内容知识以及向 OUD 患者提供护理服务的公平性等方面的初步数据。通过定性调查回复数据，我们发现培训参与者对培训的内容和质量感到满意，尤其重视小组讨论、动机访谈和历史背景。

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引用次数: 0

State Paid Sick Leave Mandates Associated with Increased Mental Health Disorder Prescriptions among Medicaid Enrollees 州带薪病假规定与医疗补助计划参保者精神疾病处方增加有关

Health affairs scholar

Pub Date : 2024-04-23 DOI: 10.1093/haschl/qxae045

Johanna Catherine Maclean, Ezra Golberstein, Bradley Stein

The United States does not have a federal paid sick leave policy. As a result, many workers, in particular lower wage workers, cannot take time off work to attend to health and family responsibilities. Fifteen states have adopted or announced paid sick leave mandates which offer employees approximately seven days of financially protected work-time each year. This time can facilitate health care use, including treatment related to mental health disorders, conditions for which treatment is time-consuming. We study the effect of state paid sick leave mandates on prescription medications dispensed for mental health disorders using the Medicaid State Drug Utilization Database 2011-2022. We find that medications dispensed for mental health disorders increased 6% per year following adoption of a state paid sick leave mandate.

美国没有联邦带薪病假政策。因此，许多工人，尤其是工资较低的工人，无法请假照顾健康和家庭。有 15 个州已经通过或宣布了带薪病假的规定，每年为雇员提供大约 7 天的经济保障工作时间。这段时间可以促进医疗保健的使用，包括与精神疾病有关的治疗，而精神疾病的治疗是非常耗时的。我们利用 2011-2022 年医疗补助州药物使用数据库研究了州带薪病假规定对精神疾病处方药的影响。我们发现，在州政府通过带薪病假规定后，用于治疗精神疾病的药物每年增加 6%。

引用次数: 0

Re-envisioning contributory health schemes to achieve equity in the design of financial protection mechanisms in low- and middle-income countries (LMICs) 重新审视缴费型医疗计划，在中低收入国家（LMICs）的财政保护机制设计中实现公平

Health affairs scholar

Pub Date : 2024-04-17 DOI: 10.1093/haschl/qxae044

Muyiwa Tegbe, Kyle J. Moon, Saira Nawaz

Universal health coverage has emerged as a global health priority, requiring financing strategies that ensure low-income and medically and financially at-risk individuals, can access health services without the threat of financial catastrophe. Contributory financing schemes and social health insurance (SHI) schemes, in particular, predominate in low- and middle-income countries (LMICs), despite evidence that suggests the most vulnerable remain excluded from such schemes. In this commentary, we discuss the need to re-envision schemes to prioritize equity, offering three concrete recommendations: adopt participatory designs for the co-design of schemes with beneficiaries, establish linkages between contributory financial protection schemes with economic empowerment initiatives, and prioritize the needs and preferences of beneficiaries over political expediency. Co-design alone does not necessarily translate into more equitable schemes, underscoring the need for greater monitoring and evaluation of these schemes that consider differential impacts across contexts and subgroups. In doing so, SHI schemes can be both attractive and accessible to populations that have long been excluded from financial protections in LMICs, acting as one channel in a broader financing strategy to achieve universal health coverage.

全民医保已成为全球健康领域的一个优先事项，这就需要制定筹资战略，确保低收入、有医疗和财务风险的个人能够在不受财务灾难威胁的情况下获得医疗服务。缴费型筹资计划和社会医疗保险（SHI）计划在中低收入国家（LMICs）尤其占主导地位，尽管有证据表明，最弱势群体仍被排除在这些计划之外。在这篇评论中，我们讨论了重新规划计划以优先考虑公平的必要性，并提出了三项具体建议：采用参与式设计，与受益人共同设计计划；在缴费型财务保护计划与经济赋权倡议之间建立联系；优先考虑受益人的需求和偏好，而不是政治权宜之计。仅靠共同设计并不一定能转化为更公平的计划，这就强调有必要加强对这些计划的监测和评估，以考虑不同环境和亚群体的不同影响。通过这样做，社会医疗保险计划对低收入与中等收入国家中长期被排除在财政保护之外的人群既有吸引力，又能为他们所用，成为实现全民医保的更广泛筹资战略中的一个渠道。

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引用次数: 0

Social Determinants of Health Z Code Documentation Practices in Mental Health Settings: A Scoping Review 心理健康机构中的健康社会决定因素 Z 代码文档实践：范围审查

Health affairs scholar

Pub Date : 2024-04-12 DOI: 10.1093/haschl/qxae046

Rachele M. Hendricks-Sturrup, Sandra Yankah, Christine Y Lu

Mental health remains an urgent global priority, alongside efforts to address underlying social determinants of health (SDoH) that contribute to the onset or exacerbate mental illness. SDoH factors can be captured in the form of International Classification of Disease, Tenth Revision, Clinical Modification [ICD-10 CM] SDoH Z codes. In this scoping review, we describe current SDoH Z code documentation practices, with a focus on mental health care contexts. Among 2,743,061,374 health care encounters noted across 12 studies in the United States, SDoH Z code documentation rates ranged from 0.5% to 2.4%. Documentation often involved patients under 64 years of age who are publicly insured and experience comorbidities, including depression, bipolar disorder and schizophrenia, chronic pulmonary disease, and substance abuse disorders. Documentation varied across hospital types, number of beds per facility, patient race/ethnicity, and geographic region. Variation was observed regarding patient sex/gender, although SDoH Z codes were more frequently documented for males. Documentation was most observed in government, nonfederal and private not-for-profit hospitals. From these insights, we offer policy and practice recommendations, as well as considerations for patient data privacy, security, and confidentiality, to incentivize more routine documentation of Z codes to better assist patients with complex mental health care needs.

精神健康仍然是全球的当务之急，同时还要努力解决导致精神疾病发病或加重的基本健康社会决定因素（SDoH）。SDoH因素可以通过国际疾病分类第十版临床修订版[ICD-10 CM] SDoH Z代码的形式来捕捉。在这篇范围综述中，我们描述了当前 SDoH Z 代码的记录实践，重点关注精神健康护理背景。在美国的 12 项研究记录的 2,743,061,374 次医疗护理中，SDoH Z 代码的记录率从 0.5% 到 2.4% 不等。记录的患者通常年龄在 64 岁以下，有公共保险，并患有抑郁症、双相情感障碍和精神分裂症、慢性肺病和药物滥用障碍等并发症。不同类型的医院、每家医院的床位数、患者的种族/民族以及地理区域的文件记录各不相同。在患者的性别方面也存在差异，但男性更常记录 SDoH Z 代码。在政府医院、非联邦医院和非营利性私立医院中，记录的情况最多。从这些洞察中，我们提出了政策和实践建议，以及对患者数据隐私、安全和保密性的考虑，以鼓励更多的常规 Z 代码记录，从而更好地帮助有复杂心理健康护理需求的患者。

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引用次数: 0

Life Cycle of Private Equity Investments in Physician Practices: An Overview of Private Equity Exits 私募股权投资在医生诊所的生命周期：私募股权投资退出概述

Health affairs scholar

Pub Date : 2024-04-10 DOI: 10.1093/haschl/qxae047

Yashaswini Singh, Megha Reddy, Jane M. Zhu

Private equity firms acquire and grow physician practices through add-on consolidation, generating outsized returns on the sale of the acquisition in 3-8 years (“exit”). PE’s abbreviated investment timeline and exit incentives may deter long-term investments in care delivery and workforce needed for high quality care. To our knowledge, there has been no published analyses of the nature or duration of PE exits from physician practices. We address this knowledge gap by using novel data to characterize PE exits from dermatology, ophthalmology, and gastroenterology, physician specialties with the largest number of acquisitions between 2016-2020. Of 807 acquisitions, over half (51.6%) of PE-acquired practices underwent an exit within 3 years of initial investment. In nearly all instances (97.8%), PE firms exited investments through secondary buyouts, where physician practices were resold to other PE firms with larger investment funds. Between investment and exit, PE firms increased the number of physician practices affiliated with the PE firm by an average of 595% in 3 years. Findings highlight the rapid scale of ownership change and consolidation under PE ownership and motivate evaluations by policymakers on the effects of PE ownership over the life cycle of PE investments.

私募股权公司通过附加合并的方式收购和发展医生诊所，在 3-8 年内通过出售收购获得超额回报（"退出"）。私募股权投资的投资期限缩短和退出激励可能会阻碍对医疗服务和高质量医疗服务所需的劳动力进行长期投资。据我们所知，目前还没有关于私募股权从医生诊所退出的性质或持续时间的公开分析。为了填补这一知识空白，我们利用新数据描述了 2016-2020 年间收购数量最多的皮肤科、眼科和消化科等医生专科的 PE 退出情况。在 807 项收购中，超过一半（51.6%）的私募股权收购诊所在初始投资后 3 年内完成了退出。几乎在所有情况下（97.8%），私募股权投资公司都是通过二次收购退出投资的，即医生诊所被转售给其他拥有更大投资基金的私募股权投资公司。从投资到退出，私募股权投资公司在 3 年内将隶属于该私募股权投资公司的医生诊所数量平均增加了 595%。研究结果凸显了在私募股权投资下所有权变化和整合的快速规模，并促使政策制定者对私募股权投资在其生命周期内的影响进行评估。

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引用次数: 0

National Trends in Billing Patient Portal Messages as E-Visit Services in Traditional Medicare 在传统医疗保险中将患者门户网站信息作为电子就诊服务计费的全国趋势

Health affairs scholar

Pub Date : 2024-04-03 DOI: 10.1093/haschl/qxae040

Terrence Liu, Ziwei Zhu, A. J. Holmgren, Chad Ellimoottil

引用次数: 0

Nursing home finances associated with real estate investment trust and private equity investments 与房地产投资信托和私募股权投资相关的养老院财务

Health affairs scholar

Pub Date : 2024-04-01 DOI: 10.1093/haschl/qxae037

Dunc Williams, Rahul Fernandez, David Stevenson, Mark Unruh, Robert Tyler Braun

In 2021, real estate investment trusts (REITs) and private equity (PE) held investments in 1915 (16%) and 1569 (13%) US nursing homes (NHs), respectively. We created a database of REIT and PE investments in NHs, merged it with Medicare Cost Report data (2011–2019), and used a difference-in-differences approach within an event-study framework to compare NH spending and financial performance before and after REIT or PE investment to NHs that did not receive REIT or PE investment. REIT investments were associated with higher total wages (3%), total nursing wages (3%; both logged, per resident day [PRD]), and current ratio (81%). PE investments were associated with lower net patient service revenue (7%), total expenses (7%), and total wages (8%; all logged, PRD). The impact of REIT and PE investments in NHs may vary in different market conditions, as may occur in the current environment of low, falling NH profits, potentially higher minimum staffing requirements, and rising interest rates. Therefore, it is important for stakeholders to understand the impact of these large, growing investments on the financial performance of NHs.

2021 年，房地产投资信托基金（REITs）和私募股权基金（PE）分别在 1915 家（16%）和 1569 家（13%）美国养老院（NHs）中持有投资。我们创建了一个房地产投资信托基金（REIT）和私募股权投资基金（PE）在养老院投资的数据库，将其与医疗保险成本报告数据（2011-2019 年）合并，并在事件研究框架内使用差分法，将房地产投资信托基金（REIT）或私募股权投资基金（PE）投资前后的养老院支出和财务表现与未获得房地产投资信托基金（REIT）或私募股权投资基金（PE）投资的养老院进行比较。房地产投资信托与较高的工资总额（3%）、护理工资总额（3%；均为对数，每住院日[PRD]）和流动比率（81%）相关。私募股权投资与较低的病人服务净收入（7%）、总支出（7%）和工资总额（8%；均按每住院日计算）相关。在不同的市场条件下，房地产投资信托基金和私募股权投资对公立医院的影响可能会有所不同，例如在当前公立医院利润低且不断下降、最低人员配备要求可能提高以及利率不断上升的环境下。因此，利益相关者必须了解这些不断增长的大型投资对养老院财务业绩的影响。

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引用次数: 0

Socioeconomic and fiscal returns of expanded investment in immunization: a case for life-course vaccination in Colombia 扩大免疫接种投资的社会经济和财政回报：哥伦比亚终生免疫接种案例

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Pub Date : 2024-04-01 DOI: 10.1093/haschl/qxae042

Jose Alejandro Soto-Moreno, Martha Coe, Cintia Parellada, Anupama Tantri, Maria Clara Angarita-Contreras, Paula Acosta

Despite the health, societal, and economic benefits of immunization, many countries focus primarily on childhood immunizations and lack robust policies and sufficient resources for immunizations that can benefit populations across the life course. While the benefits of childhood vaccination are well documented, there is limited evidence on the financial and social return on investment that policymakers can use to inform decisions around administering a life-course immunization program. We developed a cost-benefit model from a societal perspective to evaluate the inclusion of 5 vaccines across the life course in Colombia's national immunization program. This model estimated a return of US$1.3 per US$1.0 invested in the first 2 decades, increasing to US$3.9 after 60 years. Primary benefits were productivity gains, followed by fiscal savings and household averted expenditure on health care. Furthermore, vulnerable households are predicted to receive 3.2 times greater income protection than formally employed households under a life-course immunization program. Consequently, there is a potential to reduce Colombia's income inequality and poverty rate by increasing access to immunization for all ages.

尽管免疫接种对健康、社会和经济都有益处，但许多国家主要关注的是儿童免疫接种，缺乏健全的免疫接种政策和充足的免疫接种资源，从而使整个生命过程中的人群都能受益。虽然儿童接种疫苗的益处有据可查，但有关投资的经济和社会回报的证据却很有限，而决策者可以利用这些证据为实施终生免疫计划提供决策依据。我们从社会角度开发了一个成本效益模型，以评估将 5 种疫苗纳入哥伦比亚国家免疫计划的整个生命过程。该模型估计，在最初的 20 年中，每投资 1.0 美元可获得 1.3 美元的回报，60 年后将增至 3.9 美元。主要收益是生产率的提高，其次是财政节余和家庭避免的医疗支出。此外，根据预测，在终身免疫计划下，弱势家庭获得的收入保护是正式就业家庭的 3.2 倍。因此，通过增加所有年龄段的免疫接种机会，有可能减少哥伦比亚的收入不平等和贫困率。

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引用次数: 0

Decomposition of medical imaging spending growth between 2010 and 2021 in the US employer-insured population. 2010 年至 2021 年美国雇主参保人群医疗成像支出增长分解图。

Health affairs scholar

Pub Date : 2024-03-27 eCollection Date: 2024-03-01 DOI: 10.1093/haschl/qxae030

Michal Horný, Daniel Chang, Eric W Christensen, Elizabeth Y Rula, Richard Duszak

Medical imaging, identified as a potential driver of unsustainable US health care spending growth, was subject to policies to reduce prices and use in low-value settings. Meanwhile, the Affordable Care Act increased access to preventive services-many involving imaging-for employer-sponsored insurance (ESI) beneficiaries. We used a large insurance claims database to examine imaging spending trends in the ESI population between 2010 and 2021-a period of considerable policy and benefits changes. Nominal spending on imaging increased 35.9% between 2010 and 2021, but as a share of total health care spending fell from 10.5% to 8.9%. The 22.5% growth of nominal imaging prices was below inflation, 24.3%, as measured by the Consumer Price Index. Other key contributors to imaging spending growth were increased use (7.4 percentage points [pp]), shifts toward advanced modalities (4.0 pp), and demographic changes (3.5 pp). Shifts in care settings and provider network participation resulted in 2.5-pp and 0.3-pp imaging spending decreases, respectively. In sum, imaging spending decreased as a share of all health care spending and relative to inflation, as intended by concurrent cost-containment policies.

医学影像被认为是美国医疗支出不可持续增长的潜在驱动力，因此受到了降低价格和在低价值环境中使用的政策的影响。与此同时，《平价医疗法案》增加了雇主赞助保险（ESI）受益人获得预防性服务的机会，其中许多服务涉及影像检查。我们利用大型保险理赔数据库，研究了 2010 年至 2021 年期间 ESI 群体的影像学支出趋势--在此期间，政策和福利发生了巨大变化。2010 年至 2021 年期间，影像学的名义支出增长了 35.9%，但在医疗保健总支出中所占的比例却从 10.5% 降至 8.9%。成像名义价格增长 22.5%，低于消费价格指数衡量的通胀率 24.3%。造成成像支出增长的其他主要因素包括：使用量的增加（7.4 个百分点）、向先进模式的转变（4.0 个百分点）以及人口结构的变化（3.5 个百分点）。医疗机构和医疗服务提供者网络参与度的变化分别导致成像支出下降 2.5 个百分点和 0.3 个百分点。总之，影像学支出在所有医疗支出中所占的比例以及相对于通货膨胀率都有所下降，这也是同时实施的成本控制政策的初衷。

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