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Objective: To estimate the impact of opting-out from Medicare supervision requirements for certified registered nurse anesthetists (CRNAs) on anesthesiologists' work patterns.Data Sources/study Setting: Secondary data from two national surveys of anesthesiologists and the Area Health Resource File.Study Design: We use a matching difference-in-difference regression which contrasts the change in work patterns for anesthesiologists in California, which dropped supervision requirements, to the change for similar anesthesiologists. Key outcome variables include the number of weekly hours worked, the type of work done, and type of care delivery teams.Data Collection/extraction Methods: Self-reported national survey data drawn from members of the American Society of Anesthesiologists.Principal Findings: Anesthesiologists in California saw no change in time spent working or time spent supervising CRNAs. There was a decrease in direct care clinical work hours along with a shift in working more in intraoperative care, a decrease in postoperative care, and an increase in the percentage of cases supervising residents.Conclusions: Anesthesiologists had small but real responses to California's decisions to opt-out of the physician supervision requirement for CRNAs, doing more work in intraoperative care and less outside of the operating room. Total hours worked saw no change. [ABSTRACT FROM AUTHOR]

Objective: To investigate the potential spillover effects of the Hospital Readmissions Reduction Program (HRRP) on readmissions for nontargeted conditions and patient populations. We examine HRRP effects on nontargeted conditions separately and on non-Medicare populations in Florida and California.Data Sources: From 2007-2013, 100 percent Medicare inpatient claims data, 2007-2013 State Inpatient Database (SID) for Florida, and 2007-2011 SID for California.Study Design: We conducted an interrupted time series analysis to estimate the change in 30-day all-cause unplanned readmission trends after the start of HRRP using logistic regression.Principal Findings: Hospitals with the largest reductions in targeted Medicare readmissions experienced higher reductions in nontargeted Medicare readmissions. Among nontargeted conditions, reductions were higher for neurology and surgery conditions than for the cardiovascular and cardiorespiratory conditions, which are clinically similar to the targeted conditions. For non-Medicare patients, readmission trends for targeted conditions in Florida and California did not change after HRRP.Conclusions: Our findings are consistent with positive spillover benefits associated with HRRP. The extent of these benefits, however, varies across condition and patient groups. The observed patterns suggest a complex response, including a role of nonfinancial factors, in driving lower readmissions. [ABSTRACT FROM AUTHOR]

Objective: Out-of-network emergency department (ED) use, or use that occurs outside the contracted network, may lead to increased care fragmentation and cost. We examined factors associated with out-of-network ED use among Medicaid beneficiaries.Data Sources and Study Setting: Enrollment, claims, and encounter data for adult Medi-Cal health plan members with 1+ ED visits and complete Medicaid eligibility during the study period from 2013 to 2014.Study Design: We analyzed the data to identify factors associated with out-of-network ED use classified by mode of arrival (ambulance vs. nonambulance).Data Extraction Methods: We extracted encounter, ambulance, and ED census data and linked them together based on ED visit date.Principal Findings: Of 11,143 ED visits, 6,808 (61.1 percent) were out-of-network. The number of hours the study ED was on ambulance diversion increased the odds of out-of-network visits for the 3,365 (30.2 percent) ED visits arriving by ambulance. For all visit types, assignment to a primary care clinic at the in-network hospital and having had any primary care visit during the study period decreased the odds of out-of-network ED care. Individuals were more likely to go out-of-network for ED care if they lived in neighborhoods containing out-of-network EDs.Conclusions: There are a number of factors related to out-of-network ED use, including the proximity and density of out-of-network EDs, race and ethnicity, a prior history of out-of-network ED use, and individuals' connection to primary care. EDs that serve Medicaid beneficiaries may need to explore alternative sites and modalities of care as alternatives to the ED, and consider their ability to absorb large numbers of out-of-network visits given already limited capacity. [ABSTRACT FROM AUTHOR]

Objective: To assess the effects on hospitals of early California actions to expand insurance coverage for low-income uninsured adults after passage of the Affordable Care Act.Data Sources/study Setting: Data from the California Office of Statewide Health Planning and Development and the California Department of Health were merged with U.S. census data for 294 short-term general hospitals during the period 2009-2012.Study Design: A difference-in-difference analysis was conducted with hospitals in counties that did not implement insurance expansions used as a comparison group. Variables examined included payer mix, costs of unreimbursed care, and hospital operating margin. Sensitivity analyses were conducted as well as a triple difference analysis. Effects were estimated for hospitals overall and by ownership type.Principal Findings: California insurance expansions primarily benefited for-profit hospitals, with these facilities experiencing significant decreases in self-pay patients, increases in county-covered patients, and reductions in charity care. Most models yielded no significant change in payer mix and conflicting changes in unreimbursed care for nonprofit hospitals.Conclusions: California hospitals that treated the most uninsured prior to insurance expansions did not as a group experience substantial benefit in terms of reduced uninsured burden or better financial performance after program expansions occurred. [ABSTRACT FROM AUTHOR]

Objective: To assess the coverage effects of California's 2011 Low-Income Health Program (LIHP), enacted as an "early expansion" under the Affordable Care Act (ACA), and to demonstrate the feasibility of using Census data to measure county-level coverage changes.Data Sources/study Setting: 2008-2012 American Community Survey (ACS). The sample contained California adults ages 19-64 years (n = 237,876) and children 0-18 years (n = 113,159) with incomes below 200 percent of the federal poverty level.Study Design: Differences-in-differences analysis comparing public coverage, private insurance, and the uninsured rate in counties that expanded the LIHP in 2011 versus California counties not expanding during this time. Additional analyses tested for heterogeneous impacts of the LIHP and spillover effects on children.Principal Findings: Compared to nonexpansion counties, public coverage for adults increased by 1.8 percentage points (p = .02) in expanding counties, while the uninsured rate declined by 2.1 percentage points (p = .01). There was no significant change in private coverage. Public coverage gains were largest for Latinos and those with limited English proficiency. The expansion produced a positive spillover effect on children's Medicaid enrollment.Conclusions: California's 2011 expansion produced significant increases in public coverage for low-income individuals, particularly Latinos. Substate coverage analyses with the ACS can add valuable detail to future assessments of the ACA. [ABSTRACT FROM AUTHOR]